Do abnormalities in regional cerebral blood flow in anorexia nervosa resolve after weight restoration?

OBJECTIVE: Previous studies have demonstrated localised abnormalities of cerebral blood flow in anorexia nervosa, suggesting reduction of cerebral activity and function in specific regions. There is debate as to whether such findings are secondary to starvation or indicative of a primary abnormality predating the illness, representing an underlying biological substrate. This small study, the first in early onset anorexia nervosa, reports findings of regional cerebral blood flow (rCBF) at both baseline and follow up. METHOD: Nine participants who had previously undergone rCBF studies at the start of treatment, had a repeat scan at an average of 4.2 years later. RESULTS: Seven out of the nine had persisting reduced cerebral blood flow in one area of the brain, predominantly the medial temporal region. DISCUSSION: These data suggest that in the majority of cases rCBF does not return to normal following weight restoration. The implications for future research are explored.

Typology of obsessive-compulsive symptoms in children and adolescents with anorexia nervosa.

BACKGROUND: Previous studies have shown that symptoms of obsessive compulsive disorder are common in both adults and children and adolescents with anorexia nervosa. Until now, no study has explored the specific obsessive compulsive symptoms shown in children and adolescents with AN. METHOD: In this study we report types of symptoms displayed by young people with AN and explore similarities and differences with adults with AN and with people with OCD. RESULTS: Common obsessions concerned contamination, aggressive and somatic concerns, and common compulsions were related to ordering/arranging, and checking. CONCLUSION: It is important for clinicians to be aware of the obsessions and compulsions they are most likely to encounter when working with these patients. If missed or ignored, such symptoms may interact with eating disorder symptoms and impede treatment.

Classification of eating disturbance in children and adolescents: proposed changes for the DSM-V.

Childhood and adolescence are critical periods of neural development and physical growth. The malnutrition and related medical complications resulting from eating disorders such as anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified may have more severe and potentially more protracted consequences during youth than during other age periods. The consensus opinion of an international workgroup of experts on the diagnosis and treatment of child and adolescent eating disorders is that (a) lower and more developmentally sensitive thresholds of symptom severity (e.g. lower frequency of purging behaviours, significant deviations from growth curves as indicators of clinical severity) be used as diagnostic boundaries for children and adolescents, (b) behavioural indicators of psychological features of eating disorders be considered even in the absence of direct self-report of such symptoms and (c) multiple informants (e.g. parents) be used to ascertain symptom profiles. Collectively, these recommendations will permit earlier identification and intervention to prevent the exacerbation of eating disorder symptoms.

Classification of child and adolescent eating disturbances. Workgroup for Classification of Eating Disorders in Children and Adolescents (WCEDCA).

OBJECTIVE: : The purpose of this article is to summarize major conceptual and clinical variables related to age-appropriate and developmentally appropriate classification of eating problems and disorders in children and adolescents. METHOD: A review of current classifications and related literature in child development is provided. Problems with current classification schemes are identified and discussed. RESULTS: Current classifications are inadequate to address the clinical and research needs of children and adolescents with eating disturbances and disorders. CONCLUSION: A range of possible changes in classification strategies for eating disorders in children and adolescents are described.

Family functioning in adolescent anorexia nervosa: a comparison of family members' perceptions.

Abnormal patterns of family functioning have often been reported in anorexia nervosa. Moreover, members of families with an adult with eating disorders have different family functioning perspectives. This study investigated whether differences in family members' perspectives, similar to the ones found in families of adults with eating disorders, can be found in families of adolescents with anorexia nervosa. Perceived family functioning, measured with the Family Assessment Device, was compared between 49 control and 34 clinical families, and across family members. Differences were found between the two groups on a number of aspects of family functioning, with the clinical families showing most disturbances. There was a general agreement across family members in their perceptions of family functioning, with one notable exception. Clinical daughters disagreed with both their parents about the family level of communication, whereas control daughters disagreed only with their fathers. Disagreements between clinical adolescents and their mothers about the family communication style appear to be important in anorexia nervosa in this age group, although it is not possible to reach conclusions about the direction of causality. These findings support the use of family-oriented therapies that aim to identify and work with difficulties in communication within the family.

The nosological status of early onset anorexia nervosa.

BACKGROUND: Although cases of early onset anorexia nervosa have been described, there has been no systematic comparison of early onset cases with classic cases of later onset, or with other forms of early onset eating disturbance. METHOD: A consecutive series of patients referred to two specialist child and adolescent eating disorder services with a clinical diagnosis of eating disorder (N = 126) was systematically assessed using a child version of the Eating Disorder Examination (EDE) and the K-SADS interview. RESULTS: Of 86 patients with a diagnosis of eating disorder of early onset, 38 received a clinical diagnosis of anorexia nervosa (AN). The remainder were mainly diagnosed as having food avoidance emotional disorder (25 patients) and selective eating (17 patients). Six received other diagnoses (bulimia nervosa, or functional dysphasia). These 48 patients were combined to form a group of early onset non-AN eating disturbance. In terms of specific eating disorder psychopathology and general psychopathology, the early onset AN group was very similar to the late onset AN sample. When the two early onset groups were compared, there was a marked difference between them in terms of eating disorder psychopathology. A discriminant function analysis using the EDE information produced a clear discrimination, with the EDE restraint and shape concern subscales doing most of the discrimination work. CONCLUSIONS: The specific psychopathology of AN of early onset is very similar to that of classic adolescent onset AN. Other forms of early onset eating disorder do not evidence this specific psychopathology.

"Anorexia saved my life": coincidental anorexia nervosa and cerebral meningioma.

OBJECTIVE: We report on a 13-year-old girl with coincidental occult intracranial tumor and early-onset anorexia nervosa. METHOD: The cerebral meningioma was discovered fortuitously as the result of a research project using SPECT imaging to locate a neurobiological substrate in patients with anorexia nervosa. Without SPECT, the meningioma would have remained undiagnosed until it had become symptomatic. The two conditions appear to have been completely unrelated. RESULTS AND DISCUSSION: The case highlights two important points. First, intracranial pathology should also be considered however certain is the diagnosis of early-onset anorexia nervosa. Second, neuroimaging plays an important part in diagnosing early-onset anorexia nervosa, both from a clinical and a research prospective.

Clinical implications of brain imaging in eating disorders.

Imaging studies have greatly improved the understanding of the pathology and physiology of psychiatric disorders, such as schizophrenia, affective disorders, obsessive-compulsive disorder, and Tourette syndrome. In the past few years, several neuroimaging studies have concentrated on patients with eating disorders. Although the number of studies is small compared with studies of other psychiatric disorders, the results are beginning to highlight potential areas in the brain that may lead to a better understanding of these disorders. Much research still is needed, and replication of results across centers is needed. The brain is an extremely complex organ; that eating disorders are a result of abnormalities in one specific area of the brain is unlikely. More likely is that several components of the brain have a role, including cortex and subcortical regions and involvement of several neurochemical pathways and circuits within the brain. Further studies are needed in this exciting development of research about eating disorders.

Nasogastric feeding in children and adolescents with eating disorders: toward good practice.

OBJECTIVE: This study aimed to provide an insight into the subjective experiences of nasogastric feeding from the perspective of patients with eating disorders and their parents. METHOD: A semistructured self-report questionnaire was completed by patients from two specialist eating disorders units who had received nasogastric feeding. Parents' views were also assessed via a similar self-report questionnaire. RESULTS: Diverse views were expressed by both patients and parents. Some regarded the experience of nasogastric feeding as wholly negative, but acknowledged the lack of suitable alternatives. Others had a more positive view and identified several helpful aspects. CONCLUSION: Reactions were generally more positive than had been anticipated. A number of useful suggestions were made regarding how to improve the procedure. These have informed the development of guidelines for good practice.

Is physical illness a risk factor for eating disorders in children and adolescents? A preliminary investigation.

This study investigates the correlation between early-onset eating disorders and past history of physical illness. Subjects for this study were children and adolescents aged between 7 and 19 years, and were divided into two groups: those with anorexia nervosa (n=62) and those with "other eating disorders" (n=28). Data on medical history were obtained retrospectively from the patient's files and coded by a consultant psychiatrist. There was no significant difference between the two groups in relation to a history of prior physical illness. However, those with anorexia nervosa were significantly more likely to have suffered more than one serious physical illness prior to the onset of their eating disorder, and both groups were significantly more likely to have had a prior physical illness than an adult control group [Patton, G. C., Wood, K., & Johnson-Sabine. Br. J. Psychiatry 149 (1986) 756.]. Thus, it appears that a past history of physical illness is a significant risk factor for early-onset eating disorders in general, and for anorexia nervosa in particular when there has been more than one physical illness.

Enteric feeding in severe adolescent anorexia nervosa: a report of four cases.

OBJECTIVE: Refeeding patients with anorexia nervosa can be one of the more challenging aspects of their treatment, and particularly if all food and fluids are adamantly and persistently refused. METHOD: If the decision is made to augment or replace oral feeds, the most common intervention is nasogastric feeding. RESULTS: Although this is often successful, a subset of patients manage to sabotage feeding via this route. Other means of delivering nutrition such as intravenous feeds are often impractical for long-term use. Another alternative in such life-threatening situations is the use of enteric feeds via gastrostomy or jejunostomy. This paper presents the successful use of such enteric feeding in four cases of severe adolescent anorexia nervosa. DISCUSSION: The psychological, legal, and ethical issues involved are discussed, concluding that gastrostomy and jejunostomy are valid lifesaving methods to feed highly resistant anorectic patients.

Children into DSM don't go: a comparison of classification systems for eating disorders in childhood and early adolescence.

OBJECTIVE: To evaluate the reliability of diagnostic classification systems for eating disorders when applied to children and young adolescents. METHOD: Eighty-one patients were randomly selected from a population of 226 children (age 7-16) presenting with eating difficulties to a specialist clinic. Diagnoses were assigned according to three classification systems: the 10th edition of the International Classification of Diseases (ICD 10), the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), and Great Ormond Street (GOS) criteria. Ratings were performed by two clinicians blind to the diagnosis of the other. RESULTS: Interrater reliability values (kappa) for the three systems were 0.357 (ICD 10), 0.636 (DSM-IV), and 0.879 (GOS). Using DSM criteria, more than 50% of children were classified as eating disorder not otherwise classified (EDNOS) or could not be classified. DISCUSSION: DSM-IV and ICD 10 criteria are of little value in the classification of the eating difficulties of children. The GOS criteria, which were developed for this age range, are more reliable. The classification of eating disorders in childhood needs reevaluation.

Heart or heart-lung transplantation: psychosocial outcome.

The psychosocial outcome of 23 heart and 21 heart-lung transplant recipients, aged 5-17 yrs, was determined and compared with the psychosocial outcome of a group of 46 children and adolescents who underwent conventional cardiac surgery. Preoperatively, and 12 months post-operatively, the patients' physical health status, mental state (ICD-9) and level of psychosocial functioning (GAF scale, DSM-IIIR) were assessed. There was an improvement in physical health in all groups. Preoperatively, psychiatric disorder, including anxiety and phobic states, depression and adjustment reaction, was noted in 6/23 (26%) children assessed for heart transplantation, 6/21 (28.5%) children assessed for heart-lung transplantation, and 12/46 (26%) children undergoing conventional cardiac surgery. The prevalence of psychiatric disorder remained in the transplant group but decreased in the non-transplant comparison group (6.5%). Improvement in overall levels of psychosocial functioning were found in all groups, but over 40% of all the participants were still functioning below normal levels. In summary, children with end-stage cardio-respiratory disease benefit physically and psychologically from heart or heart-lung transplantation treatment but there is a need for systematic psychosocial support both before and after transplantation.

Paranoid psychosis in an 11-year-old boy following cardiac transplantation.

This is the first reported case of psychotic illness following pediatric cardiac transplantation. The case highlights diagnostic issues, and indicates a need for monitoring the psychological effects of cardiac transplantation in children.