Pervasive refusal syndrome (PRS) 21 years on: a re-conceptualisation and a renaming.

Twenty-one years ago, Lask and colleagues first described pervasive refusal syndrome (PRS) as a child's "dramatic social withdrawal and determined refusal to walk, talk, eat, drink, or care for themselves in any way for several months" in the absence of an organic explanation. PRS has been conceptualised in a variety of ways since then. These have included a form of post-traumatic stress disorder, learnt helplessness, 'lethal mothering', loss of the internal parent, apathy or the 'giving-up' syndrome, depressive devitalisation, primitive 'freeze', severe loss of activities of daily living and 'manipulative' illness, meaning the possibility that the children have been drugged to increase chances of asylum in asylum-seeking families. Others have insisted that PRS is simply depression, conversion disorder, catatonia or a factitious condition. This paper reviews these conceptualisations, explores some of the central complexities around PRS and proposes a neurobiological explanatory model, based upon autonomic system hyper-arousal. It touches upon the clinical implications and suggests a new name for the condition reflecting what we believe to be a more sophisticated understanding of the disorder than was available when it was first described.

Memory versus perception of body size in patients with anorexia nervosa and healthy controls.

The objective of this study was to compare body size estimation based on memory versus perception, in patients with anorexia nervosa (AN) and healthy controls, adjusting for possible confounders. Seventy-one women (AN: 37, controls: 35), aged 14-29 years, were assessed with a computerized body size estimation morphing program. Information was gathered on depression, anxiety, time since last meal, weight and height. Results showed that patients overestimated their body size significantly more than controls, both in the memory and perception condition. Further, patients overestimated their body size significantly more when estimation was based on perception than memory. When controlling for anxiety, the difference between patients and controls no longer reached significance. None of the other confounders contributed significantly to the model. The results suggest that anxiety plays a role in overestimation of body size in AN. This finding might inform treatment, suggesting that more focus should be aimed at the underlying anxiety.

Patient and parental self-reports of executive functioning in a sample of young female adolescents with anorexia nervosa before and after cognitive remediation therapy.

OBJECTIVE: Previous studies assessing the potency of cognitive remediation therapy (CRT) have largely focused on performance-based assessments and how these change during the course of the intervention. Little is known of behavioural manifestations of such changes, and no previous studies have studied parental reports before and after CRT. METHOD: Patient and parental self-reports of executive function using the Behaviour Rating Inventory of Executive Function (BRIEF) were obtained for 17 adolescent patients in treatment for anorexia nervosa before and after CRT. RESULTS: Results indicated that patients scored significantly lower on the BRIEF shift subscale after CRT, whereas parental reports revealed significantly lower scores on the shift and emotional control subscales, and on the two composite indices Behavioural Regulation Index and Global Executive Composite. Case-wise comparisons support variations in executive functions in adolescents with anorexia nervosa. DISCUSSION: Changes are evaluated in light of the relationship between patients and parents and with regard to the limitations of the study design.

Season of birth bias and anorexia nervosa: results from an international collaboration.

OBJECTIVE: Based on inconsistent findings in the literature, this study tested the hypothesis that "there is a season of birth bias for females with anorexia nervosa (AN)." METHOD: Females with AN, born in 1975 to 1996, were compared to females born in the same years and geographical regions by chi-square test for contingency tables with known population parameter testing for monthly deviations. Five groups were based on a priori power calculation and geographical location: Iceland, Norway and Sweden (N = 847), United Kingdom (N = 706), Oregon, USA (N = 394), Argentina and Brazil (N = 486), and Australia (N = 381). RESULTS: The hypothesis was not supported in any of the groups. The associations (Cramér's V) between month of birth and the differences in distributions of births ranged from 0.05 to 0.08, none of which were statistically significant. DISCUSSION: The main implication of these findings is that season of birth may not play a significant part in the aetiology of AN.

Neuropsychological functioning in adolescents with anorexia nervosa before and after cognitive remediation therapy: a feasibility trial.

OBJECTIVE: To investigate neuropsychological functioning in adolescents with anorexia nervosa (AN) before and after receiving cognitive remediation therapy (CRT). METHOD: Twenty young females with AN participated in an individually-delivered CRT treatment program. Neuropsychological and psychiatric assessments were administered before and after treatment. Weight, depression, anxiety, duration of illness, and level of eating disorder psychopathology were considered as covariates in statistical analyses. RESULTS: Significant changes in weight, depression, visio-spatial memory, perceptual disembedding abilities, and verbal fluency were observed. Changes in weight had a significant effect on improvements in visuo-spatial memory and verbal fluency. Results also revealed a significant effect of depressive symptoms on perceptual disembedding abilities. DISCUSSION: The results suggest improvements on a number of neuropsychological functions during the course of CRT. Future studies should explore the use of additional assessment instruments, and include control groups to assess the effectiveness of the intervention.

Season of birth bias and bulimia nervosa--results from a multi-centre collaboration.

BACKGROUND: Season of birth bias has been observed for people with a number of disorders, including women with bulimia nervosa. However, inconsistent results and methodological weaknesses render previous conclusions about such bias uncertain. With an enhanced methodology, this study aims to test whether there is a season of birth bias for women with bulimia nervosa. METHOD: Women with bulimia nervosa at five secondary and tertiary services in Norway, born between 1966 and 1988 (n = 549), were compared with women in the general population in a chi-square test for contingency tables, with known population parameters testing monthly deviations. RESULTS: There was no statistically significant association between month of birth and the distribution of births in the two groups (Cramer's V = .09). CONCLUSION: There appears not to be any season of birth bias in women with bulimia nervosa in Norway.

Verbal fluency in anorexia nervosa.

Verbal fluency performance is commonly evaluated in clinical neuropsychology, in particular for assessment of executive functioning. Fluency is usually assessed by the person's ability to produce as many words as possible from a given cue within a specific timeframe. The cues are typically phonemic, e.g. words beginning with a specific letter, or semantic, e.g. words within a given category. Important components underlying fluency performance include clustering (the production of words within subcategories) and switching (the switch between clusters). Previous studies have demonstrated good performance on verbal fluency tasks in patients with anorexia nervosa (AN), but have not investigated the underlying components of this performance. The aim of the present study was to compare phonemic fluency performance in patients with AN to healthy controls (HC) and to investigate the use of clustering and switching in the two groups. Fifty-two patients with AN were compared with 37 HC on a phonemic fluency task. The patient group produced more words in total but the results were not significantly different compared to the HC sample. There were no differences between the two groups with regard to clustering, but patients with AN performed significantly more switches. In addition, switching was significantly more related to total output score in the patient sample. In contrast with previous studies of other areas of cognitive flexibility in AN, patients with AN appear to have good verbal set-shifting skills.

An examination of the ravello profile--a neuropsychological test battery for anorexia nervosa.

The Ravello Profile test battery was developed to ensure a consistent methodology when researching neuropsychological functioning in anorexia nervosa (AN). To date, 157 patients with AN have been assessed with the full Ravello Profile. The present review is the first study to systematically investigate the tests included in the battery. Fifteen experimental studies, comparing AN patients with healthy control participants on at least one of the Ravello Profile tests, were identified, and effect sizes were calculated. Three of the tests, Verbal Fluency Test (VFT), Rey Complex Figure Test (RCFT) and Trail Making Test (TMT), were meta-analysed, and the pooled standardized effect size was significant for all three tests (0.25, -0.68 and 0.49, respectively). Patients with AN performed significantly better than healthy control participants on assessment of verbal fluency (VFT) and worse on tests of visual memory (RCFT) and set-shifting (TMT). The Ravello Profile test battery appears to consist of tests that are appropriate for assessing characteristic neuropsychological profiles specific in AN.

History of eating disorder in mothers of children with early onset eating disorder or disturbance.

The literature suggests that there is significant familial aggregation of eating disorders. A specific association has also been reported between childhood feeding problems and maternal eating disorder. This study investigates whether subgroups of children with early onset eating disturbance are distinguished by maternal eating disorder history. The mothers of 66 children with either anorexia nervosa (AN), food avoidance emotional disorder (FAED) or selective eating (SE) were interviewed to ascertain eating disorder history. Seventeen per cent of mothers reported a history of eating disorder, compared with 3%-5% reported for community samples. A history of eating disorder was reported by 5.9% of mothers of children with SE, 12.9% of mothers of children with AN and 33.3% of mothers of children with FAED. The findings, based on this small sample, suggest that children with FAED are especially likely to have grown up in a dysfunctional food environment.

A case series investigating distinct neuropsychological profiles in children and adolescents with anorexia nervosa.

A number of specific deficits in neuropsychological functioning in anorexia nervosa (AN) have been identified. However, it is not known whether these specific deficits cluster together to form one or more clear neuropsychological profiles. We present a case series of nine participants who were recruited as part of a wider, ongoing investigation of the neuropsychological profile of eating disorders (the Ravello Profile). Results show that there was a wide range of different neuropsychological profiles at initial assessment. This suggests a spectrum of neuropsychological strengths and weaknesses that would otherwise be masked in a cohort analysis. It is anticipated that factor and cluster analytic studies will establish one or more common profiles of neuropsychological deficits in AN.

Convergent validity of the eating disorder examination and the eating disorder examination-questionnaire among university women in Norway.

The present study compared the Eating Disorder Examination (EDE; 16.0) and the Eating Disorder Examination-Questionnaire (EDE-Q; 6.0) and investigated the psychometric properties of the Norwegian translation of the EDE. Fifty-eight university women aged 19-41 years (mean BMI = 23) were assessed with the EDE and EDE-Q. Satisfactory internal consistency and inter-rater reliability were demonstrated for the Norwegian translation of the EDE. Generally high convergent validity between the EDE and EDE-Q was found, with correlations ranging from 0.60 (Eating Concern) to 0.86 (Weight Concern). Agreement for OBEs and vomiting were excellent, while driven exercising generated lower levels of convergence. Consistent with prior studies, the EDE-Q generated significantly higher levels of psychopathology, although effect sizes were small. Owing to the significantly higher EDE-Q scores, it is ill advised to administer these two instruments interchangeably, as this may fail to produce meaningful data.

Reliability and validity of the Norwegian translation of the Child Eating Disorder Examination (ChEDE).

The Child Eating Disorder Examination (ChEDE) is a valid and reliable semi-structured interview, which measures eating-disorder specific psychopathology in children and young adolescents. The instrument is an adaptation of version 12.0D of the original Eating Disorder Examination (EDE 12.0) for adults. The Norwegian translation of the ChEDE is currently the only instrument for assessing eating disorder psychopathology in Norwegian children and adolescents. This study aimed to investigate the psychometric properties of the Norwegian translation of the ChEDE 12.0. The Norwegian version of ChEDE 12.0 was administered to 15 Norwegian children with anorexia nervosa (AN), 15 children with diabetes mellitus type 1 (DM) and two groups of 15 age-matched controls. The groups were compared using a matched pairs design. The results showed that the subscale scores of the AN group were significantly higher than those of the other groups, and the DM comparison group did not differ from its control group. The current AN group scored significantly higher on the Shape Concern subscale than the previous UK sample, with implications for construct validity or cross-cultural effects worthy of further study. Inter-rater reliability was generally high (r=0.91 to 1.00), although there were significant differences between raters on specific items for individual participants. Alpha coefficients for each of the ChEDE subscales indicated a high degree of internal consistency. It was concluded that the Norwegian version of the ChEDE 12 has adequate psychometric properties and can be recommended for clinical and research use with young people with eating disorders in Norway.

Psychometric properties of the clinical impairment assessment: norms for young adult women.

OBJECTIVE: This study aimed to investigate the initial psychometric properties and to establish norms for the Clinical Impairment Assessment (CIA v. 3.0) among a nonclinical sample of young adult women. METHOD: The CIA is a brief, 16-item self-report measure designed to assess psychosocial impairment due to eating disorder features over the past 28 days. We administered the CIA and the Eating Disorder Examination-Questionnaire (EDE-Q v. 6.0) to 438 university women (mean age = 25 years). RESULTS: Participants' mean global CIA score was 6.4 (SD = 7.5; range 0-40). Acceptable levels of internal consistency (Cronbach's alpha = 0.94) and 1-week test-retest reliability were observed. Significant correlations were found between the CIA and the EDE-Q total and subscale scores (Spearman rhos = 0.58-0.79), indicating that greater levels of impairment were associated with higher levels of eating disorder psychopathology. DISCUSSION: Results demonstrated satisfactory psychometric properties of the CIA among a sample of young adult women, suggesting the utility of the CIA to measure impairment due to eating disorder features in nonclinical samples.

Norms for the Eating Disorder Examination Questionnaire among female university students in Norway.

BACKGROUND: The Eating Disorder Examination (EDE) is a semi-structured interview used worldwide for diagnostic purposes and to assess the core psychopathology of an eating disorder. The Eating Disorder Examination Questionnaire 6.0 (EDE-Q) has been developed as a self-report questionnaire version of the full-length interview. AIM: This study was conducted to establish norms among female university students in Norway and to test the reliability of the Norwegian version of the EDE-Q. METHOD: The questionnaire was administered to 670 young adult women with a mean age (±standard deviation) of 24.8±6.9 years. RESULT: Participants' mean global EDE-Q score was 1.42±1.07 and subscales means were as follows: 1.44±1.23 for restraint, 0.63±0.88 for eating concern, 2.00±1.42 for shape concern, and 1.63±1.36 for weight concern. Acceptable levels of internal consistency were observed; Cronbach's alpha coefficients were 0.94 for the global EDE-Q score and 0.75-0.90 for the subscales. To evaluate the temporal stability of the EDE-Q, a total of 159 participants completed the measure 1 week later. Spearman's correlation coefficients were 0.93 for global EDE-Q and for the subscales 0.82-0.91, indicating a satisfactory level of test-retest reliability. CONCLUSION: The EDE-Q was easily administered and required only a few minutes to complete. This brief questionnaire provides a psychometrically established and cost-savings method of quickly assessing the core psychopathology of an eating disorder.

PANDAS and anorexia nervosa--a spotters' guide: suggestions for medical assessment.

OBJECTIVE: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection (PANDAS) should be considered in sudden onset, prepubertal Anorexia Nervosa (AN), arising shortly after an apparent streptococcal infection. However, the absence of a specific biological marker of PANDAS renders the diagnosis difficult. This paper critically reviews available tests for PANDAS and recommends a standardized approach to its investigation. METHOD: Medline database review between 1990 and 2008. RESULTS: Existing tests may be categorized as: (i) Non-specific markers of inflammation or immune response (Erythrocyte sedimentation rate, ESR; C-reactive protein, CRP; Neopterin), (ii) specific markers of streptococcal infection (throat swab and anti-streptococcal antibodies, Anti-streptolysin, ASO; Antideoxyribonuclease B, antiDNaseB), (iii) non-specific markers of auto-immune reaction (Antineuronal antibodies, AnAb; D8/17). No one test reliably identifies PANDAS. The lack of specificity and methodological problems may lead to errors of diagnosis. DISCUSSION: When PANDAS-Anorexia Nervosa (PANDAS-AN) is suspected clinically we recommend conducting all the above investigations. The more positive results there are the more likely is the diagnosis, but particular weighting should be given to AnAb and D8/17.

Predicting the weight gain required for recovery from anorexia nervosa with pelvic ultrasonography: an evidence-based approach.

Target weights are an arbitrary means of determining return to physical health in patients with anorexia nervosa (AN) and lack reliability and validity. Transabdominal pelvic ultrasound scanning (U/S) offers a more objective method of ascertaining physical well being by the ability to determine reproductive maturity. This study aimed to explore the correlations between the maturity grading on pelvic U/S and weight for height (WfH) ratios and body mass index (BMI) percentiles. Ultrasound studies were performed in 72 female adolescents (aged 11-17 years at intake) with AN. Scans were graded for maturity using published parameters of pelvic maturity and compared with the patient's WfH ratio and BMI percentile. In our sample was a wide variation of WfH ratios and BMI percentiles at each grade of maturity. This supports the view that arbitrary targets for weight, WfH ratio or BMI percentile are likely to be unnecessarily high for some patients and too low for others. We recommend that targets be based upon baseline pelvic U/S grading and follow-up scanning.

Anorexia nervosa--irony, misnomer and paradox.

Anorexia nervosa is a condition full of irony and paradox. Perhaps the most enigmatic of these is that professionals tend to hold the same morbid preoccupation with weight, BMI and targets as do our patients. In this article we outline why we believe that an over-emphasis on weight/BMI and targets is inappropriate, misleading and potentially harmful. Although this view is not always greeted with enormous enthusiasm by some, others are relieved that this particular 'holy cow' is at last being challenged. It is important that we should all have an open mind to the possibility that one of the main tenets of our practice may actually be unhelpful. Some ancient wisdom is drawn upon to support this view.

Pros and cons of using the Mental Health Act for severe eating disorders in adolescents.

BACKGROUND: In England and Wales the compulsory treatment of young people with severe eating disorders is controversial. There is a concern that such treatment may impair patient autonomy and negatively influence the outcome. In this study, based in a specialist hospital, we compared patients treated under parental consent with those detained under the Mental Health Act: their characteristics and outcome up to 12 months after discharge. RESULTS: 34 patients were informal (treated under parental consent) (age: 16.2 +/- 1.3 years) and 16 were treated under Section 3 of the Mental Health Act (age: 16.2 +/- 1) in a 3-year period. Detained patients had an earlier age of onset (12.2 +/- 5 vs. 14.3 +/- 1.8) and more previous hospitalisation. On admission, their psychosocial functioning (Children's Global Assessment Scale (C-GAS): 13.6 +/- 2 vs. 26.9 +/- 9; Health of the Nation Outcome Scale for Children and Adolescents (HONOSCA): 41.7 +/- 5 vs. 31.9 +/- 5) were worse than voluntary patients', they had a higher level of co-morbid depression (BDI: 38.1 +/- 15.6 vs. 26.6 +/- 12.4) and a higher rate of suicidal behaviour. All physical and psychosocial measures improved substantially and clinically significantly by discharge and there was no statistically significant difference at this stage between the two patient groups. Two informal patients died within a year after discharge (6.3%), but there were no deaths amongst the detained patients. COMMENTS: In contrast with previous findings in adults, the outcome for detained patients was similar to that for informal patients, despite the former having more severe presentation on admission. There was no evidence of higher mortality in the detained group.

Season of birth bias in eating disorders--fact or fiction?

OBJECTIVE: A season of birth (SoB) bias is said to be present if the SoB pattern for a particular group varies from the pattern within the normal population. Significant biases have been found for several disorders including eating disorders (EDs). This article critically reviews the existing literature on SoB in ED in order to inform future hypothesis-based research. METHOD: A literature search identified 12 papers investigating SoB in ED. RESULTS: Despite methodological differences, the studies consistently show a SoB bias for anorexia nervosa (AN) in the spring months, in both the northern and southern Hemispheres. This is especially strong for early-onset and restrictive subtype of AN. CONCLUSION: These findings suggest that SoB is a risk factor for AN. However, none of the studies have been methodologically satisfactory. Future research needs to overcome numerous methodological challenges and to explore specific hypotheses to explain this bias.

The fault is not in her parents but in her insula--a neurobiological hypothesis of anorexia nervosa.

The reported abnormalities of brain function in anorexia nervosa (AN) include impairment of neural circuits involving cortical (orbito-frontal, somatosensory and parietal) and sub-cortical (amygdala, hippocampus, thalamus, hypothalamus and striatum) structures. The insular cortex serves an integrative function for all the structures relevant to the features of AN and as such may be central to this impairment. We hypothesise that a rate limiting dysfunction of neural circuitry integrated by the insula can account for the clinical phenomena of AN. Such dysfunction could account for the known psychopathology, neuroimaging abnormalities and neuropsychological deficits. Proposals to test this hypothesis are made.