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Anorexia
Nervosa: 11 Areas of Advancement
Reprinted
from Eating Disorders Review
by Arnold E. Andersen, MD
March/April 2003 Volume 14, Number 2
©2003 Gürze Books
Although
the origin, treatment, course, and outlook of anorexia
nervosa (AN) have remained a puzzle, advances in at
least 11 areas have helped us better understand this
disease.
1:
Genetic Links
Important multicenter studies on the genetics of anorexia
nervosa are underway to compare vulnerable patients
with their siblings and parents, and to sort out clusters
of genes that increase vulnerability to anorexia nervosa.
Unlike Huntington's disease, for example, the genetics
of AN do not determine whether one gets the disease.
However, genetics probably do provide a crucial predisposition
to AN through abnormalities of serotonin and metabolism
and their effects on personality, reactivity, perseverance,
and perhaps weight control, hunger, and satiety.
2:
The Brain as a Mirror
The brain is clearly affected structurally and functionally
as a consequence of AN. Several studies have confirmed
the significant effects of self-starvation on the brain.
With starvation, the ventricles of the brain increase
in size and the cortical mass decreases. One matter
of concern is the fact that there is improvement, but
not complete normalization, of gray and white matter
as long as 6 to 12 months after weight restoration.
The very powerful imaging tools of functional MRI and
PET scans are demonstrating a change in the interaction
between the prefrontal cortex and components of the
limbic system in regard to the sensing and perpetuation
of emotional distress in active AN. These tools will
not only demonstrate the effects of eating disorders but will also document the relative benefits of a variety
of treatments.
3:
Critical Diagnostic Criteria
In another development, diagnostic criteria for anorexia are being reviewed with a goal of sorting out the critical
features and introducing more flexibility for traditional
but perhaps out-of-date criteria. Including amenorrhea
as a criterion for AN is less useful than noting abnormalities
of reproductive hormone function in general. Broader
recognition of medical consequences of starvation not
limited to levels of reproductive hormones is even more
useful. The key concept here is that AN involves self-starvation
to a substantial degree below the individual's usual
or healthy weight. Some people may be semi-starved even
if their hormone levels are normal and they are at their
normal weight. This means that amenorrhea is not as
important as are general measures of self-starvation,
and that a final lowest weight of 85% of normal healthy
weight is not as crucial as is a significant decline
in weight from an initial healthy weight.
4:
Men Develop AN, Too
A recent large epidemiologic study has substantiated
that males are probably underrepresented in both epidemiologic
and clinical studies. While earlier studies reported
ratios of as many as 10 females to 1 male, a ratio of
one male to three or four females may be more accurate.
This raises concerns that males are underrepresented
in clinical programs, and calls for better understanding
of the factors that may be keeping them from seeking
treatment.
5:
Axis I Comorbidities
The recognition that Anorexia Nervosa usually has associated comorbidities
on Axis I or II has been confirmed with awareness that
AN seldom presents by itself but there is a high probability
of Axis I diagnoses, including comorbid depression,
anxiety, and substance use disorders. On Axis II, there
is an overrepresentation of cluster C for restricting
AN and a mixture of clusters B and C for AN binge-purge
subtype. Recent studies from Denmark have highlighted
the especially deadly combination of AN with insulin-dependent
diabetes mellitus in young individuals. These studies
spell out an approximately tenfold increase in mortality
with this combination, compared to having either of
these disorders alone.
6:
The Rise of Neuroleptics
A number of trials are underway using atypical neuroleptics
such as risperidone and olanzapine. The hope is that
they will have an effect on the core psychopathology
of AN rather than merely stimulating weight gain, as
was the case with chlorpromazine in the 1960s.
7:
An Excellent Outcome May Be Possible for Many
Although AN is often considered a chronic disorder with
a poor prognosis, in fact the duration of AN is quite
variable, and more than 75% of patients will have an
excellent outcome. This is especially true for adolescent anorexics who are treated comprehensively to full weight
restoration with associated cognitive behavioral psychotherapy,
and then followed up carefully. A 10-year follow-up
study at UCLA documented complete improvement with absence
of any diagnostic features for any eating disorder in
76% of patients.
8:
Insurance Limitations
Despite improvements in outcome with modern treatment
modalities, many patients cannot get access to treatment
because of irrational insurance limitations. Decreasing
length of hospital stays, an increasingly common occurrence
with restrictive and irrational insurance limitations,
is leading to more frequent relapse and less sustained
improvement. Groups such as the Eating Disorders Coalition have been working to change this.
9:
Arguments Over Effectiveness of Prevention Efforts
Controversy exists between clinicians, between treatment
centers, and between countries on the possible effectiveness
of preventive efforts in AN. Several studies are now
suggesting there is a decrease in the prevalence or
severity of AN in vulnerable individuals when pressure
to lose and maintain an abnormal body weight is removed.
For example, there is evidence that the number of cases
of eating disorders declines when a strict ballet school
refuses to let a dancer participate below a certain
weight or when a collegiate wrestler is barred from
participating below a certain percent body fat or absolute
weight. The more adventurous approach toward empowering
young people with media skepticism, with assertiveness,
and with improved body image has not yet been tried
on a broad-enough population to comment on its effectiveness.
But the approach to "inoculating" the vulnerable subgroup
of young people with techniques to make their way through
a society obsessed with thinness merits continued work.
10:
A Disease That Stands on its Own
There has been some attempt to subsume AN into other
diagnostic categories, such as obsessive-compulsive
disorder (OCD), major depression, or psychosis. In fact,
AN "breeds true," with evidence that the core syndrome
has not changed in hundreds of years. There is ongoing
discussion about the presentation in different cultures
in regard to the content of the core psychopathology.
There is support for the concept that overvalued beliefs
are part of the core psychopathology of AN, and that
the overvalued beliefs vary from culture to culture.
For example, in the West, we overvalue thinness. To
further clarify this, overvalued beliefs are defined
as culturally normative beliefs that have been assigned
disproproportionate values in a particular individual
and that demonstrate that individual's thinking, emotional
life, and behavior. Nor are they the type of ego dystonic
thoughts or behaviors required for obsessive-compulsive
disorders. Although overvalued beliefs are not abnormal
themselves, what is abnormal is the excessive value
assigned to them. This diagnostic criterion is less
frequently used than it should be and helps to differentiate
the AN psychopathology from OCD or psychosis and also
explains some of the chronicity of the disease. It also
offers hope for change through stopping the abnormal
behavior and challenging the core overvalued belief
with cognitive behavioral techniques.
11.
Family Therapy
There's exciting evidence that the families of young
anorexics may be able to be empowered through teaching
techniques to keep the patient from ever being hospitalized,
even when very starved, when parents practice a stepwise
approach toward changing the self-starvation with caring
but firm techniques.
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