Chronotropic incompetence to exercise in anorexia nervosa patients during the body-weight recovery phase as an index of insufficient treatment.

Resting bradycardia is an important symptom for early diagnosis of anorexia nervosa (AN) during weight loss, and it improves with body-weight recovery. However, chronotropic incompetence (CI) in exercise is observed in some patients with AN despite amelioration of resting bradycardia in the recovery phase. We examined the relationship between CI in exercise and other parameters in patients with AN during the recovery phase. Ninety-two girls with AN (aged 13-20 years, median 15 years) performed cardiopulmonary exercise tolerance tests with a bicycle ergometer in the post-treatment recovery phase. Subjects with a peak-heart rate (HR) of < 160 beats/min (bpm) on subjective maximum loading were assigned to the CI+ group (n = 7), and those with a peak-HR of ≥ 160 bpm were assigned to the CI- group (n = 85). The peak-oxygen uptake (VO2) of both groups was below the normal range. Although there was no difference in peak-VO2 between these groups, both the resting-HR and ΔHR (peak-HR - resting-HR) were significantly lower in the CI+ group than in the CI- group (82 ± 8 vs. 93 ± 16 bpm, respectively; 72 ± 14 vs. 89 ± 13 bpm, respectively), suggesting lower exercise tolerance in patients with CI during the recovery phase of AN. Interestingly, the ΔVO2/ΔHR value was higher in the CI+ group than in the CI- group (0.31 ± 0.13 vs. 0.26 ± 0.06, respectively), suggesting excessive stroke volume for maintaining the cardiac output in patients with CI during their recovery phase. These data suggest that CI could be an index of insufficient recovery of AN and utilized for ideal exercise treatments of patients with AN during the recovery phase.

Harm minimization in severe and enduring anorexia nervosa.

For many sufferers of anorexia nervosa, the time course is long, and the prospect of disability and family burden great. This is all too often the case, even with early diagnosis and treatment. The term severe and enduring anorexia nervosa has been applied to these survivors. Yet, a majority of patients do eventually recover and, even where this is not the case, adaptive medical stability and function can be maintained despite alarming dilapidation. Managing the years of illness so as to have the best outcome physically and psychologically, even where full weight recovery does not occur, or has not yet occurred, is the topic of this article. Literature pertaining to harm minimization in chronic, severe, enduring, and long-standing anorexia nervosa was selectively reviewed using an Ovid data base and Google Scholar. The authors' own clinical experience over almost four decades in public and private hospital and community settings has also informed much of what has been written. The authors would like to think that it is possible to do better than the familiar injunction (variously attributed to Hippocrates, Galen, and others) of 'primum non nocere'-although this is a good place to start.

An Overview of Conceptualizations of Eating Disorder Recovery, Recent Findings, and Future Directions.

PURPOSE OF REVIEW: This review delineates issues in the conceptualization and operationalization of eating disorder recovery, highlights recent findings about recovery (since 2016), and proposes future directions. RECENT FINDINGS: A longstanding problem in the field is that there are almost as many different definitions of recovery in eating disorders as there are studies on the topic. Yet, there has been a general shift to accepting that psychological/cognitive symptoms are important to recovery in addition to physical and behavioral indices. Further, several operationalizations of recovery have been proposed over the past two decades, and some efforts to validate operationalizations exist. However, this work has had limited impact and uptake, such that the field is suffering from "broken record syndrome," where calls are made for universal definitions time and time again. It is critical that proposed operationalizations be compared empirically to help arrive at a consensus definition and that institutional/organizational support help facilitate this. Themes in recent recovery research include identifying predictors, examining biological/neuropsychological factors, and considering severe and enduring anorexia nervosa. From qualitative research, those who have experienced eating disorders highlight recovery as a journey, as well as factors such as hope, self-acceptance, and benefiting from support from others as integral to the process of recovery. The field urgently needs to implement a universal definition of recovery that is backed by evidence, that can parsimoniously be implemented in clinical practice, and that will lead to greater harmonization of scientific findings.

[Occupational therapy and eating disorders, a care case study]. / Ergothérapie et troubles du comportement alimentaire, récit d'une prise en charge.

Occupational therapy offers support through actuation via a suggested activity. It opens up a differentiated space, a space of experiences where patients can contemplate themselves through play. The therapeutic relationship, assured by the occupational therapist, offers flexibility and malleability to welcome, contain and support the person with an eating disorder. It aims to be compassionate without judgement to favour the experience of movement. 'Making do with oneself' to 'be with oneself' while respecting the temporality of the patient's possibilities.

Neuropsychological and Cognitive Correlates of Recovery in Anorexia Nervosa.

OBJECTIVE: To identify clinical or cognitive measures either predictive of illness trajectory or altered with sustained weight recovery in adult women with anorexia nervosa. METHODS: Participants were recruited from prior studies of women with anorexia nervosa (AN-C) and in weight-recovery following anorexia nervosa (AN-WR). Participants completed a neuropsychological battery at baseline and clinical assessments at both baseline and follow-up. Groups based on clinical outcome (continued eating disorder, AN-CC; newly in recovery, AN-CR; sustained weight-recovery, AN-WR) were compared by using one-way ANOVAs with Bonferroni-corrected post hoc comparisons. RESULTS: Women with continued eating disorder had poorer neuropsychological function and self-competence at baseline than AN-CR. AN-CR showed changes in depression and externalizing bias, a measure of self-related attributions. AN-WR differed from both AN-CC and AN-CR at baseline in externalizing bias, but only from AN-CC at outcome. DISCUSSION: Neuropsychological function when recently ill may be a prognostic factor, while externalizing bias may provide a clinical target for recovery. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Threat-Detection and Attentional Bias to Threat in Women Recovered from Anorexia Nervosa: Neural Alterations in Extrastriate and Medial Prefrontal Cortices.

OBJECTIVE: Behavioral studies have shown that anorexia nervosa (AN) is associated with attentional bias to general threat cues. The neurobiological underpinnings of attentional bias to threat in AN are unknown. This study investigated the neural responses associated with threat-detection and attentional bias to threat in AN. METHODS: We measured neural responses to a dot-probe task, involving pairs of angry and neutral face stimuli, in 22 adult women recovered from AN and 21 comparison women. RESULTS: Recovered AN women did not exhibit a behavioral attentional bias to threat. In response to angry faces, recovered women showed significant hypoactivation in the extrastriate cortex. During attentional bias to angry faces, recovered women showed significant hyperactivation in the medial prefrontal cortex. This was because of significant deactivation in comparison women, which was absent in recovered AN women. CONCLUSIONS: Women recovered from AN are characterized by altered neural responses to threat cues. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

The patient experience of illness, treatment, and change, during intensive community treatment for severe anorexia nervosa.

This study explores experiences of intensive community treatment, illness, and change among patients with severe anorexia nervosa (sAN), particularly seeking to understand the processes involved in change and inability to change. A qualitative design with purposive semi-stratified sampling, using semi-structured interviews and interpretive phenomenological analysis, investigated in detail the experiences of five participants. Participants all had sAN at the start of treatment and represented a spectrum of outcomes from deterioration to full recovery. Six super-ordinate themes emerged from the analysis: treatment experience, function of anorexia, self-criticism versus self-acceptance, isolation versus connection, hopelessness versus hope, and stuckness versus change. Results describe the valued function of the illness, barriers to change, the lengthy struggle for change, and how this can be supported by intensive community-based treatment. Necessary ingredients in the process of change, arising from the analysis, are proposed. We conclude that the experiences of these patients reflect the particular functions of AN for each individual, and that both clinical deterioration and full recovery can occur with prolonged intensive community treatment.

Increased Bone Mineral Content During Rapid Weight Gain Therapy in Anorexia Nervosa.

Patients with anorexia nervosa (AN) are at high risk of reduced bone mass. Osteocalcin (OC), a bone formation marker, has been proposed to act as a link between bone and energy metabolism. We investigated how the 3 forms of OC respond during a 12-week intensive nutrition therapy in AN patients, in whom large changes in energy metabolism are expected.Twenty-two female AN patients, mean 20.9 years of age, with a starting mean body mass index (BMI) 15.5 kg/m2 (minimum-maximum) (13.4-17.3 kg/m2) completed the study. Biochemical markers, body composition, bone mass by DXA, and pQCT were assessed. Subjects gained in median 9.9 kg (5.5-17.0 kg), and BMI increased from median 15.4 kg/m2 (13.4-17.3 kg/m2) to 19.0 kg/m2 (16.2-20.6 kg/m2), p<0.0001. Fat mass increased from median 11.4% (4.4-24.8%) to 26.7% (16.9-39.8%). Total OC, carboxylated OC (cOC), undercarboxylated OC (ucOC), and bone-specific alkaline phosphatase (BALP) increased during the study period. No change was observed for the resorption marker carboxy-terminal cross-linking telopeptide of type I collagen (CTX). Total body bone mineral content (BMC) increased, but no changes were found for whole body or lumbar spine bone mineral density. Tibial trabecular density measured by pQCT decreased. Total OC, cOC, and ucOC were not associated with BMI, insulin or body composition parameters. This prospective study demonstrates that all 3 forms of OC (total OC, cOC, ucOC) increase during rapid weight gain. BALP increased while the resorption marker CTX was unchanged, which corroborate with the increased total body BMC.

Normal gray matter volumes in women recovered from anorexia nervosa: a voxel-based morphometry study.

BACKGROUND: Anorexia nervosa (AN) has consistently been associated with reduced gray (GM) and white matter (WM) brain volumes. It is unclear whether GM alterations are present following recovery from AN, as previous findings are inconsistent. The aim of the present study was to determine if women recovered from AN exhibit reduced global or regional GM volumes. METHODS: Global GM and WM, as well as regional GM volumes, were investigated in 22 women recovered from AN and 22 age-matched healthy controls using magnetic resonance imaging. Women were considered recovered if they had maintained a body mass index above 18.0 and had not engaged in binge eating, purging, or restrictive eating behaviors during the past year. RESULTS: There were no significant differences between recovered AN women and healthy controls in terms of GM and WM volumes. There were also no significant differences between restricting and binging-purging AN subtypes. Lowest lifetime weight was positively correlated with regional GM volumes in the precuneus and insula. CONCLUSIONS: The present study showed that regional GM and global GM and WM volumes were similar for women long-term recovered from AN and age-matched healthy controls. Further research is needed to determine the extent to which illness severity affect regional GM volumes.

Temporal delay discounting in acutely ill and weight-recovered patients with anorexia nervosa.

BACKGROUND: Patients with anorexia nervosa (AN) are characterized by a very low body weight but readily give up immediate rewards (food) for long-term goals (slim figure), which might indicate an unusual level of self-control. This everyday clinical observation may be quantifiable in the framework of the anticipation-discounting dilemma. METHOD: Using a cross-sectional design, this study compared the capacity to delay reward in 34 patients suffering from acute AN (acAN), 33 weight-recovered AN patients (recAN) and 54 healthy controls. We also used a longitudinal study to reassess 21 acAN patients after short-term weight restoration. A validated intertemporal choice task and a hyperbolic model were used to estimate temporal discounting rates. RESULTS: Confirming the validity of the task used, decreased delay discounting was associated with age and low self-reported impulsivity. However, no group differences in key measures of temporal discounting of monetary rewards were found. CONCLUSIONS: Increased cognitive control, which has been suggested as a key characteristic of AN, does not seem to extend the capacity to wait for delayed monetary rewards. Differences between our study and the only previous study reporting decreased delay discounting in adult AN patients may be explained by the different age range and chronicity of acute patients, but the fact that weight recovery was not associated with changes in discount rates suggests that discounting behavior is not a trait marker in AN. Future studies using paradigms with disorder-specific stimuli may help to clarify the role of delay discounting in AN.

Using the theory of planned behaviour to measure motivation for recovery in anorexia nervosa.

Anorexia nervosa (AN) is a difficult to treat mental illness associated with low motivation for change. Despite criticisms of the transtheoretical stages of change model, both generally and in the eating disorders (EDs), this remains the only model to have been applied to the understanding of motivation to recover from AN. The aim of this pilot study was to determine whether the theory of planned behaviour (TPB) would provide a good fit for understanding and predicting motivation to recover from AN. Two studies were conducted - in the first study eight women who had recovered from chronic AN were interviewed about their experiences of recovery. The interview data were subsequently used to inform the development of a purpose-designed questionnaire to measure the components of the TPB in relation to recovery. In the second study, the resultant measure was administered to 67 females with a current diagnosis of AN, along with measures of eating disorder psychopathology, psychological symptoms, and an existing measure of motivation to recover (based on the transtheoretical model). Data from the interview study confirmed that the TPB is an appropriate model for understanding the factors that influence motivation to recover from AN. The results of the questionnaire study indicated that the pre-intention variables of the TPB accounted for large proportions of variance in the intention to recover (72%), and more specifically the intention to eat normally and gain weight (51%). Perceived behavioural control was the strongest predictor of intention to recover, while attitudes were more important in the prediction of the intention to eat normally/gain weight. The positive results suggest that the TPB is an appropriate model for understanding and predicting motivation in AN. Implications for theory and practice are discussed.

Dronabinol in severe, enduring anorexia nervosa: a randomized controlled trial.

OBJECTIVE: The evidence for pharmacological treatment of severe, longstanding anorexia nervosa (AN) is sparse and the few controlled pharmacologic studies have focused on a narrow range of drugs. The aim of the present study was to investigate the effects of treatment with a synthetic cannabinoid agonist on body weight and eating disorder-related psychopathological personality traits in women with severe, enduring AN. METHOD: This add-on, prospective, randomized, double blind, controlled crossover study was conducted between 2008 and 2011 at a specialized care center for eating disorders. Twenty-five women over 18 years with AN of at least 5 years duration were randomized to treatment with either dronabinol-placebo or placebo-dronabinol. In addition to the standardized baseline therapeutic regime, the participants received dronabinol, 2.5 mg twice daily for 4 weeks and matching placebo for 4 weeks, separated by a 4-week wash-out period. Primary outcome was the mean change in body weight. Secondary outcome was score changes on the Eating Disorder Inventory-2 (EDI-2). Data were analyzed for the 24 patients who completed the trial. RESULTS: During dronabinol treatment, participants gained 0.73 kg (t = 2.86, df = 22, p < 0.01) above placebo without significant psychotropic adverse events. Dronabinol significantly predicted weight gain in a multiple linear regression including EDI-2 body dissatisfaction score and leptin. EDI-2 subscale scores showed no significant changes over time. DISCUSSION: Dronabinol therapy was well tolerated. During four weeks of exposure it induced a small but significant weight gain in the absence of severe adverse events.

The recovery model and anorexia nervosa.

OBJECTIVE: Treatments in anorexia nervosa (AN) have not been wholly effective and, accordingly, practices need to be reviewed. The recovery model is an approach to treatment that has become a guiding principle for mental health policy worldwide that might provide promise for AN treatment. The model has received much attention in recent years; however, there is a dearth of literature exploring how useful this model is for AN. The aim of the current article was to consider the relevance of this model in AN. METHODS: This article provides a summary of the recovery model and reviews the literature to establish whether it is compatible with AN. The possible utility of the approach in AN is explored and suggestions are made as to how the model might be implemented in treatment. RESULTS: Qualitative studies examining the patient's perspective of AN support the recovery model. Many evidenced-based treatments currently used in AN have elements that are consistent with a recovery model approach. Treatments that are most consistent with recovery approaches have been effective for those with chronic AN. CONCLUSION: It is proposed that the model might offer a way in which to add to current practice and might have particular relevance for those with chronic AN. Future research is required to better understand how the model can best be utilised in AN.

[Hematological changes in adolescent anorexia nervosa]. / Hämatologische Veränderungen bei Anorexia nervosa im Kindes- und Jugendalter.

OBJECTIVE: Hematological changes often occur in patients with acute anorexia nervosa (AN). However, the relationship between these disturbances and other clinical parameters remains unclear. METHOD: Leucocyte, erythrocyte, and thrombocyte counts as well as hematocrit, hemoglobin, and differential blood counts were collected at admission and after weight restoration in 88 female adolescent patients with the diagnosis of AN according to DSM-IV. These were then compared to clinical parameters. RESULTS: At admission, there were mild changes in the blood count, most of which, however, were reversible after weight gain. Patients with a greater weight loss, a lower age-adjusted BMI, and a history of taking psychotropic drugs were more likely to develop hematological abnormalities. CONCLUSIONS: Although most of the hematological changes in adolescent patients with AN were mild, patients with high weight loss and/or low age-adjusted BMI as well as those on psychotropic medication should be monitored carefully in order to avoid severe medical complications. An altered immune function in adult patients with chronic AN might contribute to a higher rate of infections and thus to an increased mortality.

Physical fitness before and after weight restoration in anorexia nervosa.

AIM: The aims of this paper were: 1) to evaluate the feasibility of test for evaluating physical fitness (PF) in patients with anorexia nervosa (AN); 2) to investigate the effects of nutritional rehabilitation in this population of patients; and 3) to compare their level of fitness scores (at baseline and after weight restoration) with an age-matched healthy control group. METHODS: PF was assessed with an adapted version of the Eurofit Physical Fitness Test Battery (EPFTB) administered to 37 consecutive female AN patients, at baseline and after weight restoration, and to 57 healthy age-matched females. RESULTS: The inpatient treatment, based on cognitive behavior therapy, was associated with a significant improvement in BMI (from 14.5±1.5 to 18.8±1.1, P<0.001) and in 5 out of 6 EPFTB tests (P<0.05) in the AN group. However, both in pre and post, AN patients showed significant lower EPFTB than the control group (all P<0.001) with the exception of the Sit-Up score. CONCLUSION: Results indicated that PF is lower in AN patients than in controls both at baseline and after weight restoration. Future studies should evaluate if the inclusion of an individualized health-enhancing physical activity program might improve the restoration of physical fitness.

Structural brain abnormalities in adolescent anorexia nervosa before and after weight recovery and associated hormonal changes.

OBJECTIVE: The neurobiological mechanisms of structural brain abnormalities in patients with anorexia nervosa (AN) remain poorly understood. In particular, little is known about the changes in and the recovery of gray matter (GM) volumes after weight gain and the relation to hormonal normalization in adolescent patients with AN. METHODS: Nineteen female patients aged 12 to 17 years were assessed using magnetic resonance imaging at the time of admission to the hospital (T1) and after weight recovery (T2). Patients were compared with typically developing girls matched for age and intelligence quotient. Structural brain images were analyzed using a voxel-based morphometric approach. Circulating levels of cortisol and gonadotropins were assessed in blood samples. RESULTS: Compared with controls, patients with AN showed reduced GM in several brain regions along the cortical midline, reaching from the occipital cortex to the medial frontal areas. These GM reductions were mostly reversible at T1. Patients showed a GM increase from T1 to T2 along the cortical midline and in the occipital, temporal, parietal, and frontal lobes. GM increases at T2 correlated inversely with cortisol levels at T1 and positively with weight gain at T2. The strongest associations between regional GM increase and weight gain were found in the cerebellum. In addition, increases in GM volumes at T2 in the thalamus, hippocampus, and amygdala were associated with increases in follicle-stimulating hormone. CONCLUSIONS: Our data suggest that brain alterations in adolescents with acute AN are mostly reversible at T1 and that GM recovery in specific brain regions is associated with weight and hormonal normalization.

Cognitive flexibility in juvenile anorexia nervosa patients before and after weight recovery.

Deficits in set-shifting abilities have been robustly described in adult patients with anorexia nervosa (AN). These deficits are associated with behavioral traits, such as rigidity and perfectionism, and are independent of starvation. However, little is known about neurocognitive deficits in juvenile patients with AN. The brain circuits that support set shifting are not fully mature in these patients. One possibility is that neuroendocrinological changes, such as elevated cortisol levels, contributing to alterations in cognitive performance in individuals with AN. Set-shifting abilities (Visual Set-Shifting Task), cortisol levels, self-reported perfectionism and obsessive personality traits were assessed in 28 female adolescent patients with AN before (T0) and after (T1) weight rehabilitation and compared with 27 age- and IQ-matched healthy controls (CG). Compared with the CG, AN patients showed increased reaction times (RT) in shift trials (p < 0.001) and reduced error rates in both shift and non-shift trials across time points (p < 0.05). Across all subjects, perfectionism was associated with increased RTs during shift trials at T1 (r = 0.35, p < 0.05). Subjects with lower cortisol levels showed increased RTs and more errors in non-shift trials (p < 0.05). In contrast to the findings in adult patients, adolescent patients with AN did not display a marked deficit in set-shifting abilities. Instead, they demonstrated a perfectionistic cognitive style that was characterized by increased RTs in shift trials but improved accuracy. One could speculate that the shorter duration of illness and the incomplete maturation of the prefrontal cortices contribute to these findings.

Starvation and emotion regulation in anorexia nervosa.

Self-starvation, with concomitant weight loss, may serve as a dysfunctional behavior to attenuate negative affective states in anorexia nervosa (AN). A total of 91 participants composed of patients with acute AN, women recovered from AN, clinical controls with either depression or anxiety disorder, and healthy controls were tested on a measure of emotion regulation. Patients with acute AN as well as recovered patients with AN and clinical controls showed increased emotion regulation difficulties as compared with healthy controls. In patients with acute AN, a specific association between body weight and emotion regulation was found: the lower the body mass index in patients with acute AN, the lesser were their difficulties in emotion regulation. This association could only be found in the subsample of patients with acute AN but not in the control groups. Moreover, there were no confounding effects of depression or duration of illness. The findings are consistent with the hypothesis that self-starvation with accompanying low body weight serves as a dysfunctional behavior to regulate aversive emotions in AN.

Reluctance to recover in anorexia nervosa.

OBJECTIVE: Reluctance to recover may explain poor treatment outcome and high dropout and relapse rates in the treatment of anorexia nervosa (AN). This study systematically explored what AN patients describe as interfering with their wish to recover. METHOD: Two independent samples of women with AN (total N = 36) were interviewed in-depth using a phenomenological study design. Interviews were tape recorded, transcribed and analysed using QSR-NVivo7 (QSR International, Melbourne, Australia) software. RESULTS: Seven core obstacles were found to interfere with informants' wish to recover as follows: (i) 'perceiving judgements'; (ii) 'feeling stuck'; (iii) 'feeling distressed'; (iv) 'denying AN'; (v) 'eating'; (vi) 'gaining weight'; and (vii) 'appreciating the benefits'. CONCLUSION: The wish to recover is an autonomously based, fundamental motivational requirement for becoming ready to change. Understanding factors that contribute to this wish adds to the clinician's toolbox in motivational work with AN patients.

Becoming 'whole' again: a qualitative study of women's views of recovering from anorexia nervosa.

This study explored how women made sense of their recovery from Anorexia Nervosa (AN). Semi-structured telephone interviews were carried out with fifteen women who had received a diagnosis of AN and defined themselves as either recovered or in recovery. Data were analysed using interpretative phenomenological analysis (IPA). The women described their experiences in terms of three broad areas; being anorexic; the process of change; and being recovered. Transcending these themes was a series of dichotomies involving splits between their mind and body, AN behaviour and cognitions and their rational and irrational side. Further, they indicated that recovery reflects the time when these many different components of their selves are no longer divided and that this was often facilitated through therapy and close relationships which enabled them to find non bodily means to express their distress. Therapy should therefore aim to facilitate a sense of becoming 'whole' again.