Food Refusal Secondary to Psychosis: A Case Series and Literature Review.

The aim of this article is to emphasize that starvation is an important potential consequence of psychosis and to provide recommendations for management of this condition. A review of the literature on food refusal and starvation in patients with psychotic illnesses was performed. Our search strategy returned 54 articles with one article meeting inclusion criteria. Additional independent research returned an additional four cases of patients with psychosis engaging in self-starvation. The cases of several patients from our institution who engaged in self-starvation behaviors as a result of psychosis are also presented. The management and outcomes of each of these 10 patients are discussed. Starvation secondary to psychosis is an important but underappreciated consequence of psychosis that can lead to serious adverse outcomes in these patients. Few cases have been reported in the literature. More study is warranted to develop evidence-based management guidelines.

FLP-18 Functions through the G-Protein-Coupled Receptors NPR-1 and NPR-4 to Modulate Reversal Length in Caenorhabditis elegans.

Animal behavior is critically dependent on the activity of neuropeptides. Reversals, one of the most conspicuous behaviors in Caenorhabditis elegans, plays an important role in determining the navigation strategy of the animal. Our experiments on hermaphrodite C. elegans show the involvement of a neuropeptide FLP-18 in modulating reversal length in these hermaphrodites. We show that FLP-18 controls the reversal length by regulating the activity of AVA interneurons through the G-protein-coupled neuropeptide receptors, NPR-4 and NPR-1. We go on to show that the site of action of these receptors is the AVA interneuron for NPR-4 and the ASE sensory neurons for NPR-1. We further show that mutants in the neuropeptide, flp-18, and its receptors show increased reversal lengths. Consistent with the behavioral data, calcium levels in the AVA neuron of freely reversing C. elegans were significantly higher and persisted for longer durations in flp-18, npr-1, npr-4, and npr-1 npr-4 genetic backgrounds compared with wild-type control animals. Finally, we show that increasing FLP-18 levels through genetic and physiological manipulations causes shorter reversal lengths. Together, our analysis suggests that the FLP-18/NPR-1/NPR-4 signaling is a pivotal point in the regulation of reversal length under varied genetic and environmental conditions.SIGNIFICANCE STATEMENT In this study, we elucidate the circuit and molecular machinery required for normal reversal behavior in hermaphrodite Caenorhabditis elegans We delineate the circuit and the neuropeptide receptors required for maintaining reversal length in C. elegans Our work sheds light on the importance of a single neuropeptide, FLP-18, and how change in levels in this one peptide could allow the animal to change the length of its reversal, thereby modulating how the C. elegans explores its environment. We also go on to show that FLP-18 functions to maintain reversal length through the neuropeptide receptors NPR-4 and NPR-1. Our study will allow for a better understanding of the complete repertoire of behaviors shown by freely moving animals as they explore their environment.

Early-life exposure to severe famine and subsequent risk of depressive symptoms in late adulthood: the China Health and Retirement Longitudinal Study.

BACKGROUND: The Chinese Great Famine caused widespread starvation in 1959-1961. Its long-term association with depressive symptoms has not been studied.AimsTo estimate the burden of depressive symptoms and the association of famine exposure with depressive symptoms. METHOD: The China Health and Retirement Longitudinal Study is a nationwide representative survey of 17 708 Chinese adults aged ≥45. Propensity score matching and modified Poisson regression were used to evaluate the association between self-reported famine exposure in early life and depressive symptoms among the overall participants. Such associations were also assessed by developmental stage using modified Poisson regression and logistic regression. RESULTS: The prevalence of depressive symptoms was 26.2% (95% CI 25.1-27.3%) in 2011. As defined by loss of family members because of starvation, 11.6% (95% CI 10.1-13.1%) of this population experienced severe famine. When compared with participants who did not experience starvation, those who had experienced severe famine during fetal, mid-childhood, young-teenage and early-adulthood stages had 1.87 (95% CI 1.36-2.55), 1.54 (95% CI 1.23-1.94), 1.47 (95% CI 1.09-2.00) and 1.77 (95% CI 1.42-2.21) times higher odds of having depressive symptoms in late adulthood, respectively. The first two trimesters of pregnancy were a critical time window during the fetal stage when severe famine had a stronger association with depressive symptoms. Famine during infant, toddler, preschool or teenage stages was not associated with depressive symptoms. Overall, famine contributed to 13.6% of the depressive symptom burden in this population. CONCLUSIONS: The Chinese Great Famine contributed substantially to the burden of depressive symptoms in China.Declaration of interestNone.

Hunger promotes acquisition of nonfood objects.

Hunger motivates people to consume food, for which finding and acquiring food is a prerequisite. We test whether the acquisition component spills over to nonfood objects: Are hungry people more likely to acquire objects that cannot satisfy their hunger? Five laboratory and field studies show that hunger increases the accessibility of acquisition-related concepts and the intention to acquire not only food but also nonfood objects. Moreover, people act on this intention and acquire more nonfood objects (e.g., binder clips) when they are hungry, both when these items are freely available and when they must be paid for. However, hunger does not influence how much they like nonfood objects. We conclude that a basic biologically based motivation can affect substantively unrelated behaviors that cannot satisfy the motivation. This presumably occurs because hunger renders acquisition-related concepts and behaviors more accessible, which influences decisions in situations to which they can be applied.

An Integrative Bio-Psycho-Social Theory of Anorexia Nervosa.

The need for novel approaches to understanding and treating anorexia nervosa (AN) is well recognized. The aim of this paper is to describe an integrative bio-psycho-social theory of maintaining factors in AN. We took a triangulation approach to develop a clinically relevant theory with face validity and internal consistency. We developed theoretical ideas from our clinical practice and reviewed theoretical ideas within the eating disorders and wider bio-psycho-social literature. The synthesis of these ideas and concepts into a clinically meaningful framework is described here. We suggest eight key factors central to understanding the maintenance and treatment resistance of anorexia nervosa: genetic or experiential predisposing factors; dysfunctional feelings processing and regulation systems; excessive vulnerable feelings; 'feared self' beliefs; starvation as a maladaptive physiological feelings regulation mechanism; maladaptive psychological coping modes; maladaptive social behaviour; and unmet physical and psychological core needs. Each of these factors serves to maintain the disorder. The concept of universal physical and psychological core needs can provide an underpinning integrative framework for working with this distinctly physical and psychological disorder. This framework could be used within any treatment model. We suggest that treatments which help address the profound lack of trust, emotional security and self-acceptance in this patient group will in turn address unmet needs and improve well-being. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: The concept of unmet physical and psychological needs can be used as an underlying integrative framework for understanding and working with this patient group, alongside any treatment model. A functional understanding of the neuro-biological, physiological and psychological mechanisms involved in anorexia nervosa can help patients reduce self-criticism and shame. Fears about being or becoming fat, greedy, needy, selfish and unacceptable ('Feared Self') drive over-compensatory self-depriving behaviour ('Anorexic Self'). Psychological treatment for anorexia nervosa should emphasize a focus on feelings and fostering experiences of acceptance and trust. Treatment for patients with anorexia nervosa needs to be longer than current clinical practice.

A systematic review of the effects of experimental fasting on cognition.

Numerous investigations have been conducted on the impact of short-term fasting on cognition in healthy individuals. Some studies have suggested that fasting is associated with executive function deficits; however, findings have been inconsistent. The lack of consensus regarding the impact of short-term fasting in healthy controls has impeded investigation of the impact of starvation or malnutrition in clinical groups, such as anorexia nervosa (AN). One method of disentangling these effects is to examine acute episodes of starvation experimentally. The present review systematically investigated the impact of short-term fasting on cognition. Studies investigating attentional bias to food-related stimuli were excluded so as to focus on general cognition. Ten articles were included in the review. The combined results are equivocal: several studies report no observable differences as a result of fasting and others show specific deficits on tasks designed to test psychomotor speed, executive function, and mental rotation. This inconsistent profile of fasting in healthy individuals demonstrates the complexity of the role of short-term fasting in cognition; the variety of tasks used, composition of the sample, and type and duration of fasting across studies may also have contributed to the inconsistent profile. Additional focused studies on neuropsychological profiles of healthy individuals are warranted in order to better develop an understanding of the role of hunger in cognition.

Alexithymia, emotional empathy, and self-regulation in anorexia nervosa.

BACKGROUND: Individuals with anorexia nervosa (AN) who are starved have poor awareness (alexithymia), reduced understanding of others' mental states (cognitive empathy), and difficulty regulating personal emotions (self-regulation). Despite its important role in social interaction, sympathy for others (emotional empathy) has not been measured in AN. Furthermore, it is unknown how restoring weight affects the relationship among alexithymia, empathy, and self-regulation in AN. METHODS: Women with AN were tested longitudinally during their starvation period (N = 26) and after weight was restored (N = 20) and compared with 16 age-matched healthy women. Alexithymia, empathy, and self-regulation were assessed with the Toronto Alexithymia Scale, the Interpersonal Reactivity Index, and items measuring self-regulation from the Minnesota Multiphasic Personality Inventory-2, respectively. RESULTS: Relative to comparison participants, individuals with AN during both starvation and weight restoration reported greater alexithymia and emotional empathy in one domain, personal distress (vicarious negative arousal to others' suffering). Among AN participants, personal distress was positively correlated with alexithymia and negatively correlated with self-regulation, when accounting for depression. CONCLUSIONS: High levels of alexithymia and personal distress may be persistent features of AN because they do not resolve upon weight restoration. Greater personal distress in AN may be a function of poor emotional awareness and regulation.

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.

[Physiological basis of survival and rehabilitation of the residents of blockaded Leningrad].

The authors attribute survival of certain residents of blockaded Leningrad under conditions ofcomplete starvation to activation of natural sanologic mechanisms of the body. Physiological psychoemotional stress is supposed to contribute to the formation of prerequisites for survival during subsequent starvation. Also, the survival is believed to be related to selected activation of apoptosis of renewable cells and utilization of their constituents in endogenous nutrition. The role of priority energetic and trophic support of brain and kidneys and the contribution of the psychosomatic factor are postulated. The mechanisms of rehabilitation after upset of vital activity involve partial reversibility of atrophic and metabolic processes and neural regulation of organs and their systems. The importance of the study of activation of natural sanologic mechanisms in extreme conditions is discussed

From famine to food crisis: what history can teach us about local and global subsistence crises.

The number of famine prone regions in the world has been shrinking for centuries. It is currently mainly limited to sub-Saharan Africa. Yet the impact of endemic hunger has not declined and the early twenty-first century seems to be faced with a new threat: global subsistence crises. In this essay I question the concepts of famine and food crisis from different analytical angles: historical and contemporary famine research, food regime theory, and peasant studies. I will argue that only a more integrated historical framework of analysis can surpass dualistic interpretations grounded in Eurocentric modernization paradigms. This article successively debates historical and contemporary famine research, the contemporary food regime and the new global food crisis, the lessons from Europe's 'grand escape' from hunger, and the peasantry and 'depeasantization' as central analytical concepts. Dualistic histories of food and famine have been dominating developmentalist stories for too long. This essay shows how a blending of historical and contemporary famine research, food regime theory and new peasant studies can foster a more integrated perspective.

The political economy of maize production and poverty reduction in Zambia: analysis of the last 50 years.

Poverty and food security are endemic issues in much of sub-Saharan Africa. To eradicate extreme poverty and hunger in the region remains a key Millennium Development Goal. Many African governments have pursued economic reforms and agricultural policy interventions in order to accelerate economic growth that reduces poverty faster. Agricultural policy regimes in Zambia in the last 50 years (1964­2008) are examined here to better understand their likely impact on food security and poverty, with an emphasis on the political economy of maize subsidy policies. The empirical work draws on secondary sources and an evaluation of farm household data from three villages in the Kasama District of Zambia from 1986/87 and 1992/93 to estimate a two-period econometric model to examine the impact on household welfare in a pre- and post-reform period. The analysis shows that past interventions had mixed effects on enhancing the production of food crops such as maize. While such reforms were politically popular, it did not necessarily translate into household-level productivity or welfare gains in the short term. The political economy of reforms needs to respond to the inherent diversity among the poor rural and urban households. The potential of agriculture to generate a more pro-poor growth process depends on the creation of new market opportunities that most benefit the rural poor. The state should encourage private sector investments for addressing infrastructure constraints to improve market access and accelerate more pro-poor growth through renewed investments in agriculture, rural infrastructure, gender inclusion, smarter subsidies and regional food trade. However, the financing of such investments poses significant challenges. There is a need to address impediments to the effective participation of public private investors to generate more effective poverty reduction and hunger eradication programmes. This article also explores the opportunities for new public­private investments through South­South cooperation and Asia-driven growth for reducing poverty in Zambia.

Between life and death: exploring the sociocultural context of antenatal mental distress in rural Ethiopia.

The high prevalence of antenatal common mental disorders in sub-Saharan Africa compared to high-income countries is poorly understood. This qualitative study explored the sociocultural context of antenatal mental distress in a rural Ethiopian community. Five focus group discussions and 25 in-depth interviews were conducted with purposively sampled community stakeholders. Inductive analysis was used to develop final themes. Worry about forthcoming delivery and fears for the woman's survival were prominent concerns of all participants, but only rarely perceived to be pathological in intensity. Sociocultural practices such as continuing physical labour, dietary restriction, prayer and rituals to protect against supernatural attack were geared towards safe delivery and managing vulnerability. Despite strong cultural norms to celebrate pregnancy, participants emphasised that many pregnancies were unwanted and an additional burden on top of pre-existing economic and marital difficulties. Short birth interval and pregnancy out of wedlock were both seen as shameful and potent sources of mental distress. The notion that pregnancy in traditional societies is uniformly a time of joy and happiness is misplaced. Although antenatal mental distress may be self-limiting for many women, in those with enduring life difficulties, including poverty and abusive relationships, poor maternal mental health may persist.

Starvation causes acute psychosis due to anterior thalamic infarction.

A 19-year-old female presented with acute onset of bizarre behavior, confusion, auditory hallucinations, and delusions after two weeks on a 100 kcal/day diet. She had a normal neurological examination. Urinalysis showed ketones 4+. She had elevated antinuclear antibody (ANA) (320) and positive heterozygous factor V Leiden mutation. Magnetic resonance imaging brain scan showed hyperintensity in the ventroanterior nucleus of the left thalamus. Ventroanterior thalamic stroke has been associated with personality changes. This is the first case of starvation-induced thalamic psychosis in the setting of factor V Leiden mutation and elevated ANA. The patient improved with risperidone in one month.

Behaviours indicating cannibalistic necrophagy in ants are modulated by the perception of pathogen infection level.

Cannibalistic necrophagy is rarely observed in social hymenopterans, although a lack of food could easily favour such behaviour. One of the main supposed reasons for the rarity of necrophagy is that eating of nestmate corpses carries the risk of rapid spread of pathogens or parasites. Here we present an experimental laboratory study on behaviour indicating consumption of nestmate corpses in the ant Formica polyctena. We examined whether starvation and the fungal infection level of the corpses affects the occurrence of cannibalistic necrophagy. Our results showed that the ants distinguished between corpses of different types and with different levels of infection risk, adjusting their behaviour accordingly. The frequency of behaviours indicating cannibalistic necrophagy increased during starvation, although these behaviours seem to be fairly common in F. polyctena even in the presence of other food sources. The occurrence and significance of cannibalistic necrophagy deserve further research because, in addition to providing additional food, it may be part of the hygienic behaviour repertoire. The ability to detect infections and handle pathogens are important behavioural adaptations for social insects, crucial for the fitness of both individual workers and the entire colony.

A developmental checkpoint directs metabolic remodelling as a strategy against starvation in Drosophila.

Steroid hormones are crucial regulators of life-stage transitions during development in animals. However, the molecular mechanisms by which developmental transition through these stages is coupled with optimal metabolic homeostasis remains poorly understood. Here, we demonstrate through mathematical modelling and experimental validation that ecdysteroid-induced metabolic remodelling from resource consumption to conservation can be a successful life-history strategy to maximize fitness in Drosophila larvae in a fluctuating environment. Specifically, the ecdysteroid-inducible protein ImpL2 protects against hydrolysis of circulating trehalose following pupal commitment in larvae. Stored glycogen and triglycerides in the fat body are also conserved, even under fasting conditions. Moreover, pupal commitment dictates reduced energy expenditure upon starvation to maintain available resources, thus negotiating trade-offs in resource allocation at the physiological and behavioural levels. The optimal stage-specific metabolic shift elucidated by our predictive and empirical approaches reveals that Drosophila has developed a highly controlled system for ensuring robust development that may be conserved among higher-order organisms in response to intrinsic and extrinsic cues.

Behavioral neuroendocrinology and treatment of anorexia nervosa.

Outcome in anorexia nervosa remains poor and a new way of looking at this condition is therefore needed. To this aim, we review the effects of food restriction and starvation in humans. It is suggested that body weight remains stable and relatively low when the access to food requires a considerable amount of physical activity. In this condition, the human homeostatic phenotype, body fat content is also low and as a consequence, the synthesis and release of brain neurotransmitters are modified. As an example, the role of neuropeptide Y is analyzed in rat models of this state. It is suggested that the normal behavioral role of neuropeptide Y is to facilitate the search for food and switch attention from sexual stimuli to food. Descriptive neuroendocrine studies on patients with anorexia nervosa have not contributed to the management of the patients and the few studies in which hormones have been administered have, at best, reversed an endocrine consequence secondary to starvation. In a modified framework for understanding the etiology and treatment of anorexia nervosa it is suggested that the condition emerges because neural mechanisms of reward and attention are engaged. The neural neuropeptide Y receptor system may be involved in the maintenance of the behavior of eating disorder patients because the localization of these receptors overlaps with the neural systems engaged in cue-conditioned eating in limbic and cortical areas. The eating behavior of patients with anorexia nervosa, and other eating disorders as well, is viewed as a cause of the psychological changes of the patients. Patients are trained to re-learn normal eating habits using external support and as they do, their symptoms, including the psychological symptoms, dissolve.

Starvation-induced true diabetic euglycemic ketoacidosis in severe depression.

True euglycemic diabetic ketoacidosis [blood glucose <200 mg/dl (11.1 mmol/l)] is relatively uncommon and in type 1 diabetes can be caused by starvation of any cause in conjunction with an intercurrent illness. We report a case of euglycemic diabetic ketoacidosis precipitated by starvation resulting from severe depression in a patient with type 1 diabetes. He was acidotic with ketonuria, but his blood glucose was only 105 mg/dl (5.8 mmol/l). He was rehydrated, the acidosis was corrected, and his depression was later treated. This case involves the complex interplay among type 1 diabetes, depression, ketoacidosis, and starvation physiology resulting in glucose concentrations in keeping with euglycemic diabetic ketoacidosis. The case also highlights that even in the absence of hyperglycemia, acid/base status should be assessed in an ill patient with diabetes, and in cases of euglycemic diabetic ketoacidosis, the diagnosis of depression should be considered as a cause for suppressed appetite and anorexia.

Saving lives, preserving livelihoods: understanding risk, decision-making and child health in a food crisis.

The purpose of this paper is to analyse household decision-making regarding resource allocation in the aftermath of a food crisis in rural Niger. International attention had resulted in humanitarian agencies launching emergency nutrition programmes to alleviate persistently high levels of acute child malnutrition. We conducted participant observation, 93 in-depth interviews, 15 focus groups, 44 feeding and illness histories for children under 5, and debriefing sessions with local humanitarian staff. The impetus for this study came from observations of marked intra-household differences in child growth and health status, despite the caregivers' ethos of treating children equally. Egalitarian input, however, does not always result in equal outcomes: vulnerable children become "victims of non-discrimination" through a form of benign neglect engendered by pervasive poverty. The ethos and practices of equal investment in children are rooted in a need to balance the perceived risks to children with the preservation of long-term livelihoods. We discuss the mismatch of views between external interventions, which focus on saving individual children's lives, and local priorities, aimed at spreading risk. This mismatch is rooted in the different ways in which humanitarian agencies and local communities weigh up risks and vulnerabilities in matters of child health.

Intracerebroventricular administration of leptin increases anxiety-like behavior in female rats after semi-starvation--implications for anxiety in eating disorders.

BACKGROUND: Patients with eating disorders often exhibit abnormal eating conditions like food restriction, adipocyte and body weight reduction, and pathologic anxiety-like behavior. The role of leptin, which is recognized as an adipocyte-derived hormone, on anxiety-like behavior in eating disorders is still unclear. METHODS: We investigated the role of leptin on anxiety-like behavior with or without semi-starvation using the elevated plus-maze test in adolescent female rats. In our first experiment, anxiety-like behavior was evaluated with the elevated plus-maze test 30 min after intracerebroventricular administration of 3 microg of leptin or vehicle. In our second experiment, the rats were allowed access to food for only 2 hr each day for 7 days. Then, leptin or vehicle was administered to the rats after the last 2 hr feeding period, and anxiety-like behaviors were evaluated in the same way as in the first experiment. RESULTS: In the first experiment, there was no difference between the anxiety-like behaviors observed after leptin administration and those seen after vehicle administration. Under the conditions of semi-starvation, however, the percentage of time spent in the open arms in the rats given leptin was lower than that in rats given vehicle. CONCLUSIONS: These results suggest that leptin administration causes anxiety-like behavior only after semistarvation. Leptin might play an important role in pathologic anxiety-like behavior in eating disorders.