Debra K. Katzman

Eating disorders in adolescents: A background paper

Although eating disorders primarily affect adolescents and young adults, much of the recent medical and psychiatric literature fails to consider the unique physiologic, psychologic, and developmental issues relevant to younger patients, more often describing older patients with more chronic and intractable disease. Pediatricians and adolescent medicine specialists see younger patients who have a shorter duration of illness and a different set of physiologic and psychologic responses to weight control. The Practice Guidelines for Eating Disorders, published in 1993 by the American Psychiatric Association (1), provide an excellent overview of the

The prevalence of high-level exercise in the eating disorders: Etiological implications

There is increasing evidence both from animal experimentation and from clinical field studies that physical activity can play a central role in the pathogenesis of some eating disorders. However, few studies have addressed the issue of prevalence or whether there are different rates of occurrence across diagnostic categories, and the estimates that do exist are not entirely satisfactory. The present study was designed to conduct a detailed examination of the physical activity history in patients with anorexia nervosa (AN) and bulimia nervosa (BN) both during and prior to the onset of their disorder. A sample of adult patients and a second sample of adolescent AN patients took part in the study. A series of chi-square analyses compared diagnostic groups on a number of variables related to sport/exercise behaviors both premorbidly and comorbidly. Data were obtained by means of a detailed structured interview with each patient. We found that a large proportion of eating disorder patients were exercising excessively during an acute phase of the disorder, overexercising is significantly more frequent among those with AN versus BN, and premorbid activity levels significantly predict excessive exercise comorbidity. These findings underscore the centrality of physical activity in the development and maintenance of some eating disorders. They also have important clinical implications in light of the large proportion of individuals who combine dieting and exercise in an attempt to lose weight, and the increasing recognition of the adverse effects of strenuous physical activity in malnourished individuals.

Physiologic Estrogen Replacement Increases Bone Density in Adolescent Girls with Anorexia Nervosa

Anorexia nervosa (AN) is prevalent in adolescents and is associated with decreased bone mineral accrual at a time critical for optimizing bone mass. Low BMD in AN is a consequence of nutritional and hormonal alterations, including hypogonadism and low estradiol levels. Effective therapeutic strategies to improve BMD in adolescents with AN have not been identified. Specifically, high estrogen doses given as an oral contraceptive do not improve BMD. The impact of physiologic estrogen doses that mimic puberty on BMD has not been examined. We enrolled 110 girls with AN and 40 normal‐weight controls 12 to 18 years of age of similar maturity. Subjects were studied for 18 months. Mature girls with AN (bone age [BA] ≥15 years, n = 96) were randomized to 100 µg of 17β‐estradiol (with cyclic progesterone) or placebo transdermally for 18 months. Immature girls with AN (BA < 15 years, n = 14) were randomized to incremental low‐dose oral ethinyl‐estradiol (3.75 µg daily from 0 to 6 months, 7.5 µg from 6 to 12 months, 11.25 µg from 12 to 18 months) to mimic pubertal estrogen increases or placebo for 18 months. All BMD measures assessed by dual‐energy X‐ray absorptiometry (DXA) were lower in girls with AN than in control girls. At baseline, girls with AN randomized to estrogen (AN E + ) did not differ from those randomized to placebo (AN E–) for age, maturity, height, BMI, amenorrhea duration, and BMD parameters. Spine and hip BMD Z‐scores increased over time in the AN E+ compared with the AN E– group, even after controlling for baseline age and weight. It is concluded that physiologic estradiol replacement increases spine and hip BMD in girls with AN.

Comparison of family therapy and family group psychoeducation in adolescents with anorexia nervosa.

Objective: To compare the effects of 4 months of 2 family-oriented treatments, family therapy and family psychoeducation, on female adolescents with newly diagnosed restrictive eating disorders. Method: Twenty-five female adolescents requiring hospitalization were randomized into either family therapy or family group psychoeducation. Outcome measures included medical (body weight) and psychosocial (specific and nonspecific eating disorder psychopathology) variables at baseline and after 4 months of treatments every 2 weeks. Results: A significant time effect was found in both treatment groups for the restoration of body weight (percentage of ideal body weight, P < 0.000 01). The group averages ranged from 75% to 77% ideal body weight before treatment to 91% to 96% after it. A time effect was also seen on the Family Assessment Measure (P < 0.018), in that the patients of both groups acknowledged more family psychopathology at the end of treatment. No significant group differences were found on any of the self-report measures of specific and nonspecific eating disorder pathology. Conclusions: Weight restoration was achieved following the 4-month period of treatment in both the family therapy and family psychoeducation groups, but no significant change was reported in psychological functioning by either adolescents or parents. Family group psychoeducation, the less expensive form of treatment, is an equally effective method of providing family-oriented treatment to newly diagnosed, medically compromised anorexia nervosa patients and their families.

Cerebral gray matter and white matter volume deficits in adolescent girls with anorexia nervosa.

OBJECTIVES This study was undertaken to determine whether the increased cerebrospinal fluid (CSF) volumes found in anorexia nervosa (AN) are the result of differences in gray matter or white matter volumes or both. METHODS Thirteen adolescent girls with AN who were receiving inpatient care at a tertiary-care university childrens hospital and eight healthy female control subjects were studied by using magnetic resonance imaging. Images were processed by means of software developed to classify all pixels as either CSF, gray matter, or white matter. Pixels of each class were then summed across all sections. RESULTS The AN group had larger total CSF volumes in association with deficits in both total gray matter and total white matter volumes. Lowest reported body mass index was inversely correlated with total CSF volume and positively correlated with total gray matter volume. Urinary free cortisol levels were positively correlated with total CSF volume and inversely correlated with central gray matter volume. CONCLUSIONS These findings add support to the view that the brain abnormalities found in AN are in large part the result of the effects of the illness. The extent to which these differences in gray matter and white matter volumes are reversible with recovery remains to be established.

Compulsive physical activity in adolescents with anorexia nervosa: a psychobehavioral spiral of pathology.

The excessive exercising that is frequently observed in anorexia nervosa (AN) has been viewed both as an addictive behavior and as a type of obsessive compulsive disorder. The present study tested a nonrecursive structural equation model that specified associations among personality factors, cognitions, and behavior in the development and progression of excessive exercise in adolescent patients with AN. As proposed, findings indicated that both addictive personality and obsessive-compulsive personality contributed to excessive exercising by means of their influence on obligatory/pathological cognitions about exercising. Childhood physical activity also predicted excessive exercising. The implications of these results are discussed from a psychobiological perspective.

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.

Cognitive Function and Brain Structure in Females With a History of Adolescent-Onset Anorexia Nervosa

OBJECTIVE. Abnormalities in cognitive function and brain structure have been reported in acutely ill adolescents with anorexia nervosa, but whether these abnormalities persist or are reversible in the context of weight restoration remains unclear. Brain structure and cognitive function in female subjects with adolescent-onset anorexia nervosa assessed at long-term follow-up were studied in comparison with healthy female subjects, and associations with clinical outcome were investigated. PATIENTS AND METHODS. Sixty-six female subjects (aged 21.3 ± 2.3 years) who had a diagnosis of adolescent-onset anorexia nervosa and treated 6.5 ± 1.7 years earlier in a tertiary care hospital and 42 healthy female control subjects (aged 20.7 ± 2.5 years) were assessed. All participants underwent a clinical examination, magnetic resonance brain scan, and cognitive evaluation. Clinical data were analyzed first as a function of weight recovery (n = 14, <85% ideal body weight; n = 52, ≥85% ideal body weight) and as a function of menstrual status (n = 18, absent/irregular menses; n = 29, oral contraceptive pill; n = 19, regular menses). Group comparisons were made across structural brain volumes and cognitive scores. RESULTS. Compared with control subjects, participants with anorexia nervosa who remained at low weight had larger lateral ventricles. Twenty-four–hour urinary free-cortisol levels were positively correlated with volumes of the temporal horns of the lateral ventricles and negatively correlated with volumes of the hippocampi in clinical participants. Participants who were amenorrheic or had irregular menses showed significant cognitive deficits across a broad range of many domains. CONCLUSIONS. Female subjects with adolescent-onset anorexia nervosa showed abnormal cognitive function and brain structure compared with healthy individuals despite an extended period since diagnosis. To our knowledge, this is the first study to report a specific relationship between menstrual function and cognitive function in this patient population. Possible mechanisms underlying neural and cognitive deficits with anorexia nervosa are discussed. Additional examination of the effects of estrogen on cognitive function in female subjects with anorexia nervosa is necessary.

Characteristics of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: A “New Disorder” in DSM-5

PURPOSE To evaluate the DSM-5 diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID) in children and adolescents with poor eating not associated with body image concerns. METHODS A retrospective case-control study of 8-18-year-olds, using a diagnostic algorithm, compared all cases with ARFID presenting to seven adolescent-medicine eating disorder programs in 2010 to a randomly selected sample with anorexia nervosa (AN) and bulimia nervosa (BN). Demographic and clinical information were recorded. RESULTS Of 712 individuals studied, 98 (13.8%) met ARFID criteria. Patients with ARFID were younger than those with AN (n = 98) or BN (n = 66), (12.9 vs. 15.6 vs. 16.5 years), had longer durations of illness (33.3 vs. 14.5 vs. 23.5 months), were more likely to be male (29% vs. 15% vs. 6%), and had a percent median body weight intermediate between those with AN or BN (86.5 vs. 81.0 and 107.5). Patients with ARFID included those with selective (picky) eating since early childhood (28.7%); generalized anxiety (21.4%); gastrointestinal symptoms (19.4%); a history of vomiting/choking (13.2%); and food allergies (4.1%). Patients with ARFID were more likely to have a comorbid medical condition (55% vs. 10% vs. 11%) or anxiety disorder (58% vs. 35% vs. 33%) and were less likely to have a mood disorder (19% vs. 31% vs. 58%). CONCLUSIONS Patients with ARFID were demographically and clinically distinct from those with AN or BN. They were significantly underweight with a longer duration of illness and had a greater likelihood of comorbid medical and/or psychiatric symptoms.

Bone Metabolism in Adolescent Boys with Anorexia Nervosa

BACKGROUND Anorexia nervosa (AN) is a condition of severe undernutrition associated with low bone mineral density (BMD) in adolescent females with this disorder. Although primarily a disease in females, AN is increasingly being recognized in males. However, there are few or no data regarding BMD, bone turnover markers or their predictors in adolescent AN boys. HYPOTHESES We hypothesized that BMD would be low in adolescent boys with AN compared with controls associated with a decrease in bone turnover markers, and that the gonadal steroids, testosterone and estradiol, and levels of IGF-I and the appetite regulatory hormones leptin, ghrelin, and peptide YY would predict BMD and bone turnover markers. METHODS We assessed BMD using dual-energy x-ray absorptiometry and measured fasting testosterone, estradiol, IGF-I, leptin, ghrelin, and peptide YY and a bone formation (aminoterminal propeptide of type 1 procollagen) and bone resorption (N-telopeptide of type 1 collagen) marker in 17 AN boys and 17 controls 12-19 yr old. RESULTS Boys with AN had lower BMD and corresponding Z-scores at the spine, hip, femoral neck, trochanter, intertrochanteric region, and whole body, compared with controls. Height-adjusted measures (lumbar bone mineral apparent density and whole body bone mineral content/height) were also lower. Bone formation and resorption markers were reduced in AN, indicating decreased bone turnover. Testosterone and lean mass predicted BMD. IGF-I was an important predictor of bone turnover markers. CONCLUSION AN boys have low BMD at multiple sites associated with decreased bone turnover markers at a time when bone mass accrual is critical for attainment of peak bone mass.