Transcript Child and Adolescent Psychopathology

Chapter 13:
Anorexia Nervosa
James Lock
Nina Kirz
Overview
 Features of Anorexia Nervosa (AN):
 Behavioral
• Refusal to maintain an acceptable weight
• Restrictive eating, excessive exercise, and purging in some
 Psychological
• Intense fear of fat or weight gain
• Body image distortion
 Physiological
• Malnutrition-related complications, for example osteoporosis,
lanugo, amenorrhea, hair loss
Significant Changes for Anorexia
Nervosa in DSM-5
 Elimination of the amenorrhea criteria
 Research suggests no difference in severity of illness
between patients with and without amenorrhea
 May allow more adolescents to receive diagnosis of AN,
rather than unspecified diagnosis
 Verbalization of fear of weight gain no longer
necessary
 Research suggests no difference between those
individuals who express fear of weight gain versus those
who do not
Indicates change from DSM-IV-TR criteria
DSM-5 Diagnostic Criteria for
Anorexia Nervosa
ANOREXIA NERVOSA
A. Restriction of energy intake below what is necessary to maintain a
healthy weight
B. Intense fear of fat, as evidenced by verbalizations or behaviors that
interfere with the maintenance of a healthy weight
C. Body image disturbance, undue influence of body shape/weight on
self-evaluation, or persistent denial of the seriousness of low weight
Two subtypes:
Restricting subtype: weight loss is accomplished exclusively through
caloric restriction (i.e. dieting, fasting) and/or excessive exercise; the
individual has not binged or purged in the last 3 months
Binge-eating/purging subtype: the individual has binged (subjective
or objective binge episodes) or purged in the last 3 months
Indicates change from DSM-IV-TR criteria
Rationale for Changes
 Elimination of the amenorrhea criteria
 Research suggests no difference in severity of illness
between patients with and without amenorrhea
 May allow more adolescents to receive diagnosis of AN,
rather than unspecified diagnosis
 Verbalization of fear of weight gain no longer
necessary
 Research suggests no difference between those
individuals who express fear of weight gain versus those
who do not
History of Anorexia Nervosa
Lasègue (1873) and
Gull (1873) both
described an illness
affecting girls and
young women
characterized by severe
weight loss, labeled
anorexia hystérique and
anorexia nervosa
Simmonds (1914) found
lesions in the pituitaries
of emaciated patients,
speculated that AN had
an endocrine etiology
Bruch (1973, 1978)
conceptualized AN in
terms of low selfesteem and body
distortion
Minuchin et al (1978)
and Palazzoli (1974)
view AN as an
expression of family
psychopathology
Epidemiology
 Prevalence of AN ~0.1% to 0.9%
 Rates of subthreshold AN higher
 Demographics
 ~5% to 10% of patients male, although true incidence
may be higher as males are less likely to be diagnosed
 Bimodal age of onset in females, ~14 and ~18 years of
age
 Similar rates across ethnic and socioeconomic lines
 Debate as to whether incidence is increasing
Neurobiological Dysfunction
 Serotonin
 Most popular neurotransmitter in AN research, given its
involvement in mood, obsessions, appetite regulation,
and impulse control
 Patients with AN have low levels of 5-HT metabolites
 Specific abnormalities have not yet been identified
 Dopamine
 Recent interest given its role in reward systems
 Suggest that hypersensitivity of dopaminergic system
may account for some of AN pathology
Neurobiological Dysfunction,
cont
 Neuroimaging
 Positron emission tomography (PET) and single-photon
emission computed tomography (SPECT) studies show
regional differences in patients with AN compared to
controls
 Functional magnetic resonance imaging (fMRI) studies
show differential activation in response to food stimuli in
patients with AN compared to controls
 Many studies find decreased brain mass and enlarged
sulci in acute phase of illness
• No consensus as to whether these changes can be reversed with
refeeding
Neurobiological Dysfunction,
continued
 Neurocognitive
 Problems with attention, executive functioning, working
memory, response inhibition, and mental flexibility in
patients with AN
 Deficits likely involved in etiology and maintenance of the
disorder, and may be obstacles to successful treatment
 Genetic risk
 Recent data suggests that genetic factors account for >
50% of the heritable risk
 Specific genetic mechanism unknown
Behavioral Dysfunction
 Behavioral course of illness
 Often starts with the desire to lose a little weight
 Weight loss gradually spirals out of control, perhaps due
to:
•
•
•
•
•
Restricted intake
Avoidance of certain foods
Elimination of certain meals
Excessive and compulsive exercise (e.g., exercise anorexia)
Purging behaviors and/or binge eating (in patients with binge/purge
subtype of AN)
 Patients in acute phase of illness typically extremely
preoccupied with food and eating
Cognitive Dysfunction
 Body image distortion
 Patient may recognize his/her overall thinness, but still
believe a part or parts of the body are grossly overweight
 Thinness is critical to self-worth
 Denial and deception
 Patients often have mixed feelings about recovery
 Disordered behaviors often kept secret and denied
 Perfectionism
 Drive and perfectionism lead to all-or-nothing thinking
 Failure to achieve perfection often leads to low selfesteem and low self-efficacy
Emotional Dysfunction
 Anxiety and depression
 Symptoms of anxiety and depression common and may
be a direct effect of starvation
 Eating disordered behaviors may lead to social isolation
and withdrawal, which contributes to anxiety/depression
 Premorbid anxiety disorders common in patients with AN
 Anxious and depressive symptoms may resolve with
weight restoration
Medical Complications in AN
 AN has highest mortality rate of any psychiatric
disorder
 Mortality rate is 5.6% per decade of illness
 Complications include:
 Growth retardation
 Pubetal delay
 Osteoporosis
 Structural abnormalities of the brain
 Cardiac dysfunction
 Electrolyte inbalance
 Bleeding in stomach/esophagus
Sociocultural Factors
 Social pressures to be thin may contribute to
development of AN, but are not the sole cause
 Rates of AN are highest after periods when beauty ideal
for women is thin
 Non-Western cultures and cultures that value plumpness
have lower rates of AN
 Extreme weight loss as in AN likely the product of an
interaction between overvaluation of thin ideal and
personality traits (e.g., perfectionism, obsessiveness,
emotional suppression)
Sociocultural Factors, cont
 Triggers for symptom onset
 AN a response to pubetal changes in some individuals
• Disordered behaviors and extreme weight loss return affected
individuals to preadolescent state and delay the developmental
challenges of adolescence
 Symptoms may be triggered by external stressors
• For example loss, move, abuse, or being teased about weight
 Familial attitudes about food, dieting, and appearance
may be relevant
• Acceptance of thin ideal and normalizing of dieting behavior may be
transmitted to children
• Unclear whether familial problems are the cause or effect of AN
Assessment:
Structured Interviews
 Eating Disorder Examination (EDE)
 Most commonly used measure in treatment studies
 Yields categorical data for DSM-IV diagnosis, continuous data on
four subscales (restraint, eating concern, shape concern, and weight
concern) and behavioral data on frequency of binge eating and
purging behaviors
 Requires intense training to achieve reliability
 Child version (ChEDE) also available
 Schedule for Affective Disorders and Schizophrenia for
School-Aged Children (K-SADS)
 Yields diagnostic information but not sufficiently detailed to assess
response to treatment
 Morgan-Russell Battery
 Assesses nutritional status, menstrual function, mental state, sexual
adjustment, and socioeconomic status over preceding 6 months
 Used in outcome research, but poor interrater reliability
Assessment:
Self-Report Measures
 Questionnaire version of EDE (EDE-Q)
 Assesses same domains as interview version with good
reliability
 Eating Attitudes Test (EAT)
 Assesses food preoccupation, thin body image,
vomiting/laxative abuse, dieting, slow eating, clandestine
eating, and perceived social pressure to gain weight
 Eating Disorders Inventory (EDI)
 Assesses drive for thinness, bulimia, body dissatisfaction,
ineffectiveness, perfectionism, interpersonal distrust,
interoceptive awareness, maturity fears, asceticism, impulse
regulation, and social insecurity
 Effective as screening measure and measure of symptom
severity and change, not able to differentiate between eating
disorder diagnoses
Intervention
 Outpatient therapy
 For adolescents, family therapy is superior
• In family-based treatment (FBT), parents are empowered and
taught to restore child’s weight at home
• Shown to be effective in treatment of adolescents with AN and BN
 Data in adults is hard to interpret, due to small sample
sizes and high drop-out rates
• No clear treatment of choice
• Cognitive behavioral therapy (CBT) for relapse and specialist
individual therapy have shown some promise
Intervention, cont
 Individual therapies
 Individual psychodynamic therapy for AN:
• Addresses maturational issues associated with
puberty/adolescence
 Ego-oriented individual therapy (EOIT):
• Corrects deficits in self-concept and individuation process
 Specialist supportive individual therapy (SSIT):
• Utilizes a supportive therapeutic relationship to effect behavioral
change
 Interpersonal therapy (IPT) not as promising as for other
eating disorders
Intervention, cont
 CBT
 Modified from CBT for depression to treat symptoms of AN,
including ego-syntonic nature, influence of physiological
symptoms on psychological functioning, distorted beliefs about
food/weight, and low self-esteem
 Goal is to move concerns away from food/eating/weight
 May be more useful for relapse prevention, after weight
restoration
 CBT-enhanced (CBT-E)
 New modification of CBT, includes modules that address
problems of eating disordered patients that interfere with
progress (e.g., perfectionism, interpersonal problems)
 Preliminary data is promising
Intervention, cont
 Inpatient, day-hospital, and residential treatment
 May be used in more severe cases
 Approaches based on behavioral principles to restore
weight
 Limited data suggests they are effective in promoting
recovery, but are costly
Intervention With Medication
 Psychopharmacologic
 A variety of medications have been tried, but none appear
to be systematically useful
 Some data suggests fluoxetine may be useful in relapse
prevention
 Other studies have evaluated antipsychotic medications,
with mixed results
Treatment Recommendations
 No consensus as to the best treatment approach
 In adolescents, FBT is the clear first-line treatment
 Treatment of adults less clear, largely due to high dropout rates
• Adults with AN generally more treatment resistant than adolescents
with AN or adults with other eating disorders
 Future directions in AN treatment research:
 Compare FBT to other treatments for adolescents with
AN
 Develop and study new treatments for adults, for example
couples therapy based on FBT principles, therapy to
address emotional avoidance in AN, and cognitive
remediation therapy