# Anorexia nervosa

Annorexia nervosa is an eating disorder characterized by low weight, fear of gaining weight, and a strong desire to be thin, resulting in food restriction.
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## A

* Of the eating disorders, anorexia nervosa and bulimia nervosa are the ones that have made adolescent patients-often females and aged younger and younger-seek for help. This help is provided through a multidisciplinary treatment involving psychiatrists, psychologists and dietists. Psychotherapy has shown to be an efficient component for these patients' improvement.
** Abreu CN, Cangelli Filho R. "Anorexia nervosa and bulimia nervosa - a psychotherapeutic cognitive-constructivist approach", Int Rev Psychiatry. 2017 Jun;29(3):248-253. doi: 10.1080/09540261.2017.1285550. Epub 2017 Mar 2.
* Oxytocin is a peptide hormone important for social behavior and differences in psychological traits have been associated with variants of the oxytocin receptor gene in healthy people. We examined whether single nucleotide polymorphisms (SNPs) of the oxytocin receptor gene (OXTR) correlated with clinical symptoms in women with anorexia nervosa, bulimia nervosa, and healthy comparison (HC) women. Subjects completed clinical assessments and provided DNA for analysis. Subjects were divided into four groups: HC, subjects currently with anorexia nervosa (AN-C), subjects with a history of anorexia nervosa but in long-term weight recovery (AN-WR), and subjects with bulimia nervosa (BN). Five SNPs of the oxytocin receptor were examined. Minor allele carriers showed greater severity in most of the psychiatric symptoms. Importantly, the combination of having had anorexia and carrying either of the A alleles for two SNPS in the OXTR gene (rs53576, rs2254298) was associated with increased severity specifically for ED symptoms including cognitions and behaviors associated both with eating and appearance. A review of psychosocial data related to the OXTR polymorphisms examined is included in the discussion. OXTR polymorphisms may be a useful intermediate endophenotype to consider in the treatment of patients with anorexia nervosa.
** Acevedo SF, Valencia C, Lutter M, McAdams CJ, "Severity of eating disorder symptoms related to oxytocin receptor polymorphisms in anorexia nervosa", Psychiatry Res. 2015 Aug 30;228(3):641-8. doi: 10.1016/j.psychres.2015.05.040. Epub 2015 Jun 11.
* An 18-year-old white woman had nausea, vomiting, weight loss, and a diagnosis of anorexia nervosa. Copper-colored skin was noted on physical examination, and serum chemistry values were normal. Subsequent fever, disorientation, and confusion led to the discovery of Addison's disease, which responded well to corticosteroid replacement therapy. Addisonian and anorexic patients exhibit clinical similarities, including nausea, vomiting, weight loss, abdominal pain, cold intolerance, hypothermia, and orthostasis. Other commonalities include prolongation of electrocardiographic PR and QT intervals and generalized slowing on electroencephalogram. Important differences include a brown color to the skin in Addison's disease instead of a yellowish color in anorexia. Addisonian patients also display hypocortisolism, hypoglycemia, and hyperkalemia, in contrast to the hypercortisolism, hyperglycemia, and hypokalemia seen in anorexia.
** Adams, R; Hinkebein, MK; McQuillen, M; Sutherland, S (1998). "Prompt differentiation of Addison's disease from anorexia nervosa during weight loss and vomiting". Southern Medical Journal. 91 (2): 208–11. doi:10.1097/00007611-199802000-00017. PMID 9496878.
* While cerebral atrophy has been shown in patients with anorexia nervosa, cerebellar atrophy has never been reported in these patients. We report a case of cerebral atrophy with marked cerebellar atrophy in a 20-year-old woman with anorexia nervosa admitted to our hospital for severe weight loss. Neuroradiological examinations of the patient showed morphological brain alteration without focal parenchymal lesions. Cranial computerized tomography (CCT) showed an enlargement of the external cerebrospinal fluid spaces, especially those close to the cerebellar cistern. A brain magnetic resonance imaging (MRI) study confirmed the results of the CCT and dynamic single-photon emission tomography (d-SPECT) showed a reduced perfusion of the left brain areas. The reported case shows that some forms of anorexia nervosa have a concomitant presence of cerebral and cerebellar morphological anomalies. At present, it is not possible to demonstrate the whole correlation between the imaging reports and the clinical or neurological symptomatology. Some forms of brain alteration could be secondary to undernutrition; on the other hand, cerebral and cerebellar atrophy and eating disorders are far from clear and may also be an expression of an unknown common denominator.
** Addolorato, G; Taranto, C; Capristo, E; Gasbarrini, G (1998). "A case of marked cerebellar atrophy in a woman with anorexia nervosa and cerebral atrophy and a review of the literature". The International Journal of Eating Disorders. 24 (4): 443–7. doi:10.1002/(SICI)1098-108X(199812)24:4<443::AID-EAT13>3.0.CO;2-4. PMID 9813771.
* It is the position of the American Dietetic Association that nutrition intervention, including nutritional counseling, by a registered dietitian (RD) is an essential component of the team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating disorders during assessment and treatment across the continuum of care. Diagnostic criteria for eating disorders provide important guidelines for identification and treatment. However, it is thought that a continuum of disordered eating may exist that ranges from persistent dieting to subthreshold conditions and then to defined eating disorders, which include anorexia nervosa, bulimia nervosa, and binge eating disorder. Understanding the complexities of eating disorders, such as influencing factors, comorbid illness, medical and psychological complications, and boundary issues, is critical in the effective treatment of eating disorders. The nature of eating disorders requires a collaborative approach by an interdisciplinary team of psychological, nutritional, and medical specialists. The RD is an integral member of the treatment team and is uniquely qualified to provide medical nutrition therapy for the normalization of eating patterns and nutritional status. RDs provide nutritional counseling, recognize clinical signs related to eating disorders, and assist with medical monitoring while cognizant of psychotherapy and pharmacotherapy that are cornerstones of eating disorder treatment. Specialized resources are available for RDs to advance their level of expertise in the field of eating disorders. Further efforts with evidenced-based research must continue for improved treatment outcomes related to eating disorders along with identification of effective primary and secondary interventions.
** American Dietetic Association (2006). "Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders". Journal of the American Dietetic Association. 106 (12): 2073–82. doi:10.1016/j.jada.2006.09.007. PMID 17186637.
* Approximately two-thirds of the subjects with anorexia nervosa reported perfectionism and rigidity in childhood. This prevalence is consistent with that reported by Rastam (22) for premorbid obsessive-compulsive (or anankastic) personality disorder in anorexia nervosa. We are not aware of any similar studies conducted for patients with bulimia nervosa. However, previous findings that perfectionism, obsessionality, excessive concern about mistakes, and doubt about actions persist after recovery from both disorders suggest that they represent persistent traits (10, 13, 16).
** Anderluh, MB; Tchanturia, K; Rabe-Hesketh, S; Treasure, J (2003). "Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype". The American Journal of Psychiatry. 160(2): 242–7. doi:10.1176/appi.ajp.160.2.242. PMID 12562569.
* The findings suggest that childhood obsessive-compulsive personality traits are important risk factors for later development of eating disorders, particularly anorexia nervosa. Furthermore, the findings suggest that childhood perfectionism and rigidity may offer a more specific and homogenous phenotypic determination for genetic studies. Further studies are needed to determine whether these traits are specific for eating disorders or are also linked to other psychiatric disorders, such as depression or OCD. Personality traits may also act as maintaining factors and as such may have an important influence on the prognosis of the disorder. Studies of people who have recovered from an eating disorder would be needed to explore the influence of childhood obsessive-compulsive-personality traits on the length of illness and its severity. Female subjects were included in this study because the prevalence of eating disorders is approximately nine times higher in women than in men. However, further studies that include male subjects are needed to better understand the role of the assessed traits. To our knowledge, the interview scale described here is the first to measure these personality trait risk factors in a broad and comprehensive way. The finding that perfectionism and rigidity represent strong risk factors suggests that these items might also be also used to identify people at high risk for developing an eating disorder later in life. Prospective studies are needed to replicate these findings.
** Anderluh, MB; Tchanturia, K; Rabe-Hesketh, S; Treasure, J (2003). "Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype". The American Journal of Psychiatry. 160(2): 242–7. doi:10.1176/appi.ajp.160.2.242. PMID 12562569.
* Dancers, in general, had a higher risk of suffering from eating disorders in general, anorexia nervosa and EDNOS, but no higher risk of suffering from bulimia nervosa. The study concluded that as dancers had a three times higher risk of suffering from eating disorders, particularly anorexia nervosa and EDNOS, speciﬁcally designed services for this population should be considered
** Arcelus, J; Witcomb, GL; Mitchell, A (March 2014). "Prevalence of eating disorders amongst dancers: a systemic review and meta-analysis". European Eating Disorders Review. 22 (2): 92–101. doi:10.1002/erv.2271. PMID 24277724.
* At follow-up in girls, 3.6% (15 of 422) in control schools compared with 1.2% (4 of 327) in intervention schools reported engaging in disordered weight-control behaviors (P = .04). Multivariate analyses indicated that the odds of these behaviors in girls in intervention schools were reduced by two thirds compared with girls in control schools (odds ratio, 0.33; 95% confidence interval, 0.11-0.97). No intervention effect was observed in boys.
** Austin SB, Kim J, Wiecha J, Troped PJ, Feldman HA, Peterson KE, “School-based overweight preventive intervention lowers incidence of disordered weight-control behaviors in early adolescent girls.“, Arch Pediatr Adolesc Med. 2007 Sep;161(9):865-9.
* Results add compelling support for the effectiveness of an interdisciplinary, school-based obesity prevention intervention to prevent disordered weight-control behaviors in early adolescent girls.
** Austin SB, Kim J, Wiecha J, Troped PJ, Feldman HA, Peterson KE, “School-based overweight preventive intervention lowers incidence of disordered weight-control behaviors in early adolescent girls.“, Arch Pediatr Adolesc Med. 2007 Sep;161(9):865-9.

## B

* Several lines of evidence suggest that a disturbance of serotonin neuronal pathways may contribute to the pathogenesis of anorexia nervosa (AN) and bulimia nervosa (BN). This study applied positron emission tomography (PET) to investigate the brain serotonin 2A (5-HT(2A)) receptor, which could contribute to disturbances of appetite and behavior in AN and BN. To avoid the confounding effects of malnutrition, we studied 10 women recovered from bulimia-type AN (REC AN-BN, > 1 year normal weight, regular menstrual cycles, no binging, or purging) compared with 16 healthy control women (CW) using PET imaging and a specific 5-HT(2A) receptor antagonist, [18F]altanserin. REC AN-BN women had significantly reduced [18F]altanserin binding potential relative to CW in the left subgenual cingulate, the left parietal cortex, and the right occipital cortex. [18F]altanserin binding potential was positively related to harm avoidance and negatively related to novelty seeking in cingulate and temporal regions only in REC AN-BN subjects. In addition, REC AN-BN had negative relationships between [18F]altanserin binding potential and drive for thinness in several cortical regions. In conclusion, this study extends research suggesting that altered 5-HT neuronal system activity persists after recovery from bulimia-type AN, particularly in subgenual cingulate regions. Altered 5-HT neurotransmission after recovery also supports the possibility that this may be a trait-related disturbance that contributes to the pathophysiology of eating disorders. It is possible that subgenual cingulate findings are not specific for AN-BN, but may be related to the high incidence of lifetime major depressive disorder diagnosis in these subjects.
** Bailer, UF; Price, JC; Meltzer, CC; Mathis, CA; Frank, GK; Weissfeld, L; McConaha, CW; Henry, SE; Brooks-Achenbach, S; Barbarich, NC; Kaye, WH (2004). "Altered 5-HT(2A) receptor binding after recovery from bulimia-type anorexia nervosa: relationships to harm avoidance and drive for thinness". Neuropsychopharmacology. 29 (6): 1143–55. doi:10.1038/sj.npp.1300430. PMC 4301578. PMID 15054474.
* Because recent limitations in health care coverage have resulted in shorter lengths of inpatient stay, many patients with anorexia nervosa are discharged while still underweight. The authors' goal was to determine whether anorectic patients who were underweight when they were discharged had a worse outcome and a higher rate of rehospitalization than those who had achieved normal weight at discharge.
** Baran, SA; Weltzin, TE; Kaye, WH (1995). "Low discharge weight and outcome in anorexia nervosa". The American Journal of Psychiatry. 152 (7): 1070–2. doi:10.1176/ajp.152.7.1070. PMID 7793445.
* Anorectic patients who were discharged while severely underweight reported significantly higher rates of rehospitalization and endorsed more symptoms than those who had achieved normal weight before discharge.
** Baran, SA; Weltzin, TE; Kaye, WH (1995). "Low discharge weight and outcome in anorexia nervosa". The American Journal of Psychiatry. 152 (7): 1070–2. doi:10.1176/ajp.152.7.1070. PMID 7793445.
* These data suggest that brief hospitalization for severely underweight women with anorexia may not be cost effective because the majority are rehospitalized.
** Baran, SA; Weltzin, TE; Kaye, WH (1995). "Low discharge weight and outcome in anorexia nervosa". The American Journal of Psychiatry. 152 (7): 1070–2. doi:10.1176/ajp.152.7.1070. PMID 7793445.
* The latest studies and practice guidelines for the treatment of adolescent patients with anorexia nervosa agree in pointing out the key role played by parents in determining the young patients’ therapeutic possibilities and outcomes. Still family functioning has usually been studied using only self-reported instruments. The aim of the present study is therefore to investigate the triadic interactions within the families of adolescents with anorexia nervosa using a semi-standardized observational tool based on a recorded play session, the Lausanne Trilogue Play (LTP). Parents and adolescent daughters, consecutively referred to adolescent neuropsychiatric services, participated in the study and underwent the observational procedure (LTP). The 20 families of adolescent girls with anorexia nervosa (restricting type) were compared with 20 families of patients with internalizing disorders (anxiety and depression). The results showed different interactive patterns in the families of adolescents with anorexia nervosa: they had greater difficulties in respecting roles during the play, maintaining the joint attention and in sharing positive affect, especially in the three-together phase (third phase).
** Laura Balottin, Stefania Mannarini, Martina M. Mensi, Matteo Chiappedi, and Michela Gatta “Triadic Interactions in Families of Adolescents with Anorexia Nervosa and Families of Adolescents with Internalizing Disorders”, Front Psychol. 2016; 7: 2046. [10.3389/fpsyg.2016.02046]
* Evidence for the effectiveness of existing treatments of patients with eating disorders is weak. Here we describe and evaluate a method of treatment in a randomized controlled trial. Sixteen patients, randomly selected out of a group composed of 19 patients with anorexia nervosa and 13 with bulimia nervosa, were trained to eat and recognize satiety by using computer support. They rested in a warm room after eating, and their physical activity was restricted. The patients in the control group (n = 16) received no treatment. Remission was defined by normal body weight (anorexia), cessation of binge eating and purging (bulimia), a normal psychiatric profile, normal laboratory test values, normal eating behavior, and resumption of social activities. Fourteen patients went into remission after a median of 14.4 months (range 4.9-26.5) of treatment, but only one patient went into remission while waiting for treatment (P = 0.0057). Relapse is considered a major problem in patients who have been treated to remission. We therefore report results on a total of 168 patients who have entered our treatment program. The estimated rate of remission was 75%, and estimated time to remission was 14.7 months (quartile range 9.6 > or = 32). Six patients (7%) of 83 who were treated to remission relapsed, but the others (93%) have remained in remission for 12 months (quartile range 6-36). Because the risk of relapse is maximal in the first year after remission, we suggest that most patients treated with this method recover.
** Bergh, C; Brodin, U; Lindberg, G; Södersten, P (2002). "Randomized controlled trial of a treatment for anorexia and bulimia nervosa". Proceedings of the National Academy of Sciences of the United States of America. 99 (14): 9486–91. Bibcode:2002PNAS...99.9486B. doi:10.1073/pnas.142284799. PMC 123167. PMID 12082182.
* The aim of the present study was to evaluate the effectiveness of Acceptance and Commitment Therapy (ACT) for treatment of anorexia nervosa (AN) using a case series methodology among participants with a history of prior treatment for AN. Three participants enrolled; all completed the study. All participants had a history of 1-20 years of intensive eating disorder treatment prior to enrollment. Participants were seen for 17-19 twice-weekly sessions of manualized ACT. Symptoms were assessed at baseline, post-treatment and 1-year follow-up. All participants experienced clinically significant improvement on at least some measures; no participants worsened or lost weight even at 1-year follow-up. Simulation modelling analysis (SMA) revealed for some participants an increase in weight gain and a decrease in eating disorder symptoms during the treatment phase as compared to a baseline assessment phase. These data, although preliminary, suggest that ACT could be a promising treatment for subthreshold or clinical cases of AN, even with chronic participants or those with medical complications.
** Berman, MI; Boutelle, KN; Crow, SJ (2009). "A case series investigating acceptance and commitment therapy as a treatment for previously treated, unremitted patients with anorexia nervosa". European Eating Disorders Review. 17 (6): 426–34. doi:10.1002/erv.962. PMID 19760625.
* Anorexia nervosa often begins in adolescence, and there is a growing body of quantitative literature looking at the efficacy of treatment for adolescents. However, qualitative research has a valuable contribution to make to the understanding of treatment and recovery. This paper aims to review qualitative studies on the experience of treatment and recovery for adolescents with anorexia nervosa. Key themes from the 11 studies identified the role of family, peers and professionals, family therapy, the inpatient setting, emphasis on physical versus psychological and conceptualisation of recovery. Future studies would benefit from relating their findings to adolescent theory and considering reflexivity.
** Bezance J, Holliday J., "Adolescents with anorexia nervosa have their say: a review of qualitative studies on treatment and recovery from anorexia nervosa", Eur Eat Disord Rev. 2013 Sep;21(5):352-60. doi: 10.1002/erv.2239. Epub 2013 Jun 13.
* This literature search revealed only six randomised controlled trials investigating the use of family therapy in the treatment of adolescents with anorexia nervosa, and these all had small sample sizes. Some, but not all, of these trials suggest that family therapy may be advantageous over individual psychotherapy in terms of physical improvement (weight gain and resumption of menstruation) and reduction of cognitive distortions, particularly in younger patients. Due to the small sample sizes and the significant risk of bias (particularly information bias) in some of the studies the evidence in favour of family therapy over individual therapy is weak. In the future, larger randomised controlled trials with long term follow-up are required to assess whether family therapy is the most effective treatment for anorexia nervosa in adolescence.
** Bezance J, Holliday J., "Adolescents with anorexia nervosa have their say: a review of qualitative studies on treatment and recovery from anorexia nervosa", Eur Eat Disord Rev. 2013 Sep;21(5):352-60. doi: 10.1002/erv.2239. Epub 2013 Jun 13.
* A randomized controlled trial of zinc supplementation in anorexia nervosa (AN) reported a two-fold increase of the rate of increase of body mass index (BMI) in the zinc group. Zinc is inexpensive, readily available and free of significant side effects. However, oral zinc supplementation is infrequently prescribed as an adjunctive treatment for AN. Understanding the mechanism of action of zinc may increase its use.
** Birmingham, CL; Gritzner, S (2006). "How does zinc supplementation benefit anorexia nervosa?". Eating and Weight Disorders : EWD. 11 (4): e109–11. PMID 17272939.
* Low zinc intake, which is very common in AN, adversely affects neurotransmitters in various parts of the brain, including gamma-amino butyric acid (GABA) and the amygdala, which are abnormal in AN. Zinc supplementation corrects these abnormalities, resulting in clinical benefit in AN.
** Birmingham, CL; Gritzner, S (2006). "How does zinc supplementation benefit anorexia nervosa?". Eating and Weight Disorders : EWD. 11 (4): e109–11. PMID 17272939.
* Oral administration of 14 mg of elemental zinc daily for 2 months in all patients with AN should be routine.
** Birmingham, CL; Gritzner, S (2006). "How does zinc supplementation benefit anorexia nervosa?". Eating and Weight Disorders : EWD. 11 (4): e109–11. PMID 17272939.
* The Structured Clinical Interview for DSM-III-R (SCID and SCID II) was administered to 105 eating disorder in-patients in order to examine rates of comorbid psychiatric disorders and the chronological sequence in which these disorders developed. Eighty-six patients, 81.9% of the sample, had Axis I diagnoses in addition to their eating disorder. Depression, anxiety and substance dependence were the most common comorbid diagnoses. Anorexic restrictors were significantly more likely than bulimics (all subtypes) to develop their eating disorder before other Axis I comorbid conditions. Personality disorders were common among the subjects; 69% met criteria for at least one personality disorder diagnosis. Of the 72 patients with personality disorders, 93% also had Axis I comorbidity. Patients with at least one personality disorder were significantly more likely to have an affective disorder or substance dependence than those with no personality disorder.
** Braun, DL; Sunday, SR; Halmi, KA (1994). "Psychiatric comorbidity in patients with eating disorders". Psychological Medicine. 24 (4): 859–67. doi:10.1017/S0033291700028956. PMID 7892354.
* Alcohol use disorders were significantly more prevalent in women with ANBN and bulimia nervosa than in women with anorexia nervosa (p =.0001). The majority of individuals reported primary onset of the eating disorder, with only one third reporting the onset of the AUD first. After eating disorder subtype was controlled for, AUDs were associated with the presence of major depressive disorder, a range of anxiety disorders, and cluster B personality disorder symptoms. In addition, individuals with AUDs presented with personality profiles marked by impulsivity and perfectionism.
** Bulik, CM; Klump, KL; Thornton, L; Kaplan, AS; Devlin, B (2004). "Alcohol use disorder comorbidity in eating disorders: a multicenter study". The Journal of Clinical Psychiatry. 65 (7): 1000–6. doi:10.4088/JCP.v65n0718. PMID 15291691.
* Individuals with eating disorders and AUDs exhibit phenotypic profiles characterized by both anxious, perfectionistic traits and impulsive, dramatic dispositions. These traits mirror the pattern of control and dyscontrol seen in individuals with this comorbid profile and suggest that anxiety modulation may be related to alcohol use in this group.
** Bulik, CM; Klump, KL; Thornton, L; Kaplan, AS; Devlin, B (2004). "Alcohol use disorder comorbidity in eating disorders: a multicenter study". The Journal of Clinical Psychiatry. 65 (7): 1000–6. doi:10.4088/JCP.v65n0718. PMID 15291691.
* We searched six major databases for studies on the treatment of AN from 1980 to September 2005, in all languages against a priori inclusion/exclusion criteria focusing on eating, psychiatric or psychological, or biomarker outcomes.
** Bulik, CM; Berkman, ND; Brownley, KA; Sedway, JA; Lohr, KN (2007). "Anorexia nervosa treatment: a systematic review of randomized controlled trials". The International Journal of Eating Disorders. 40 (4): 310–20. doi:10.1002/eat.20367. PMID 17370290.
* Thirty-two treatment studies involved only medications, only behavioral interventions, and medication plus behavioral interventions for adults or adolescents. The literature on medication treatments and behavioral treatments for adults with AN is sparse and inconclusive. Cognitive behavioral therapy may reduce relapse risk for adults with AN after weight restoration, although its efficacy in the underweight state remains unknown. Variants of family therapy are efficacious in adolescents, but not in adults.
** Bulik, CM; Berkman, ND; Brownley, KA; Sedway, JA; Lohr, KN (2007). "Anorexia nervosa treatment: a systematic review of randomized controlled trials". The International Journal of Eating Disorders. 40 (4): 310–20. doi:10.1002/eat.20367. PMID 17370290.
* Evidence for AN treatment is weak; evidence for treatment-related harms and factors associated with efficacy of treatment are weak; and evidence for differential outcome by sociodemographic factors is nonexistent. Attention to sample size and statistical power, standardization of outcome measures, retention of patients in clinical trials, and developmental differences in treatment appropriateness and outcome is required.
** Bulik, CM; Berkman, ND; Brownley, KA; Sedway, JA; Lohr, KN (2007). "Anorexia nervosa treatment: a systematic review of randomized controlled trials". The International Journal of Eating Disorders. 40 (4): 310–20. doi:10.1002/eat.20367. PMID 17370290.
* Clinical signs of hypometabolism in anorexia nervosa may result from the "low triiodothyronine syndrome," in which thyroxine (T4) and thyroid stimulating hormone are usually normal, but triiodothyronine (T3) is in a range compatible with hypothyroidism. A case in which anorexia nervosa presented with unsuspected hyperthyroidism is reported.
** Byerley, B; Black, DW; Grosser, BI (1983). "Anorexia nervosa with hyperthyroidism: case report". The Journal of Clinical Psychiatry. 44 (8): 308–9. PMID 6874653.

## C

* The eating disorders anorexia nervosa (AN) and bulimia nervosa (BN) are multifactorial syndromes of unknown origin which occur typically in female adolescents or young women. Nowadays, AN and BN are most often triggered by dietary restriction. Both are treatable conditions. As in other psychiatric disorders, a lower comorbidity, a shorter duration of illness, less familial psychopathology, and, in AN, a higher minimal weight have been shown to be associated with a better outcome. So far, no abnormalities specific to AN or BN that would shed light on their etiology have been identified. Controlled and uncontrolled studies testing antipsychotic, antidepressant, weight-promoting, and prokinetic drugs have demonstrated that the core symptoms of AN are refractory to currently available psychotropic medication. For relapse prevention, however, antidepressant medication may be useful. Renutrition, psychotherapy, and family therapy remain the cornerstones of treatment for AN. Placebo-controlled studies with antidepressant drugs have been far more promising for treating BN in the short term. Recent studies have found that lasting symptomatic improvement and remission require the addition of psychological treatments in the form of cognitive and interpersonal psychotherapy. The steady stream of newly identified peptides and other molecules involved in appetite and body weight control may ultimately provide cues to better targeted treatments of eating disorders.
** Casper, RC (2002). "How useful are pharmacological treatments in eating disorders?". Psychopharmacology Bulletin. 36 (2): 88–104. PMID 12397843.
* Personality traits have been implicated in the onset, symptomatic expression, and maintenance of eating disorders (EDs). The present article reviews literature examining the link between personality and EDs published within the past decade, and presents a meta-analysis evaluating the prevalence of personality disorders (PDs) in anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) as assessed by self-report instruments versus diagnostic interviews. AN and BN are both consistently characterized by perfectionism, obsessive-compulsiveness, neuroticism, negative emotionality, harm avoidance, low self-directedness, low cooperativeness, and traits associated with avoidant PD. Consistent differences that emerge between ED groups are high constraint and persistence and low novelty seeking in AN and high impulsivity, sensation seeking, novelty seeking, and traits associated with borderline PD in BN. The meta-analysis, which found PD rates of 0 to 58% among individuals with AN and BN, documented that self-report instruments greatly overestimate the prevalence of every PD.
** Cassin SE, von Ranson KM, "Personality and eating disorders: a decade in review.", Clin Psychol Rev. 2005 Nov;25(7):895-916.
* We report the case of a 10-year-old girl with a mature teratoma in the hypothalamic region. The patient presented a 2-month history of anorexia, psychic disturbances and a 37% loss of body weight. These symptoms had led initially to a diagnosis of major depression and atypical anorexia nervosa. She also presented some signs and symptoms of diencephalic syndrome. This case illustrates the importance of considering a slow-growing mass as a rare but real possibility in the differential diagnosis of anorexia nervosa, mainly in atypical cases.
** Chipkevitch, E; Fernandes, AC (1993). "Hypothalamic tumor associated with atypical forms of anorexia nervosa and diencephalic syndrome". Arquivos de Neuro-psiquiatria. 51 (2): 270–4. doi:10.1590/S0004-282X1993000200022. PMID 8274094..
* We suggest that our case and further literature provide evidence for an involvement of specific thalamic structures, such as the dorsomedial nucleus, in the development of anorexia nervosa. Furthermore, the treatment of the patient by a combined psychotherapeutic and pharmacotherapeutic approach is described. We focus on the beneficial effect of the atypical antipsychotic olanzapine, which can induce weight gain by an increase of leptin levels.
** Conrad, R; Wegener, I; Geiser, F; Imbierowicz, K; Liedtke, R (2008). "Nature against nurture: calcification in the right thalamus in a young man with anorexia nervosa and obsessive-compulsive personality disorder". CNS Spectrums. 13 (10): 906–10. PMID 18955946.
* Obstetrical complications, based on parental recall, have been reported to be associated with development of anorexia nervosa. We used prospectively collected data about pregnancy and perinatal factors to examine the subsequent development of anorexia nervosa.
** Cnattingius, S; Hultman, CM; Dahl, M; Sparén, P (1999). "Very preterm birth, birth trauma, and the risk of anorexia nervosa among girls". Archives of General Psychiatry. 56 (7): 634–8. doi:10.1001/archpsyc.56.7.634. PMID 10401509
* Increased risk of anorexia nervosa was found for girls with a cephalhematoma (OR, 2.4; 95% CI, 1.4-4.1) and for very preterm birth (< or = 32 completed gestational weeks) (OR, 3.2; 95% CI, 1.6-6.2). In very preterm births, girls who were small for gestational age faced higher risks (OR, 5.7; 95% CI, 1.1-28.7) than girls with higher birth weight for gestational age (OR, 2.7; 95% CI, 1.2-5.8).
** Cnattingius, S; Hultman, CM; Dahl, M; Sparén, P (1999). "Very preterm birth, birth trauma, and the risk of anorexia nervosa among girls". Archives of General Psychiatry. 56 (7): 634–8. doi:10.1001/archpsyc.56.7.634. PMID 10401509
* Our results show that perinatal factors, possibly reflecting brain damage, had independent associations with anorexia nervosa. These risk factors may uncover the mechanisms underlying the development of the disorder, even if only a fraction of cases of anorexia nervosa may be attributable to perinatal factors.
** Cnattingius, S; Hultman, CM; Dahl, M; Sparén, P (1999). "Very preterm birth, birth trauma, and the risk of anorexia nervosa among girls". Archives of General Psychiatry. 56 (7): 634–8. doi:10.1001/archpsyc.56.7.634. PMID 10401509
* CRT cognitive training was performed. Eating Attitudes Test 26 (EAT - 26), Beck Depression Inwentory (BDI), Child Yale - Brown Obsessive - Compulsive Scale (CY - BOCS), Eating Disorders Belief Questionnaire (EDBQ), Wisconsin Card Sorting Test (WCST), Temperament and Character Inventory (TCI) and also Child Heath Questionnaire (CHQ) - assessed by parents, were used before and after the programme. After CRT completion, an improvement on the level ofpsychopathological symptoms was observed (especially in the EAT- 26 and BDI scales), in WCST some improvement was noticed. In TCI, no significant changes were found. In comparison to the initial assessment, an increased level of dysfunctional beliefs was observed. Cognitive Remediation Therapy can be used in adolescent patients with anorexia nervosa. This procedure may be related to cognitive and symptomatological improvement.
** Cwojdzińska, A; Markowska-Regulska, K; Rybakowski, F (2009). "Cognitive remediation therapy in adolescent anorexia nervosa—case report". Psychiatria Polska. 43 (1): 115–24. PMID 19694406.

## D

* The Stroop task has been adapted from cognitive psychology to be able to examine attentional biases in various forms of psychopathology, including the eating disorders. This paper reviews the research on the Stroop task in the eating disorders research area in both descriptive and meta-analytic fashions. Twenty-eight empirical studies are identified, which predominantly examine food and body/weight stimuli in bulimic, anorexic, or dieting/food-restricted samples. It is concluded that there is evidence of an attentional bias in bulimia for a range of stimuli but that the effect seems to be limited to body/weight stimuli in anorexia. The evidence to date is that there is no attentional bias in dieting samples.
** Dobson KS, Dozois DJ. "Attentional biases in eating disorders: a meta-analytic review of Stroop performance", Clin Psychol Rev. 2004 Jan;23(8):1001-22.
* Anorexia nervosa (AN), usually seen in young girls, is characterised by severe emaciation induced by self-imposed starvation. Enlargement of the ventricular system and sulci has been reported, as has high signal on T2-weighted images. We present a case with atrophic changes and high signal on T2-weighted images, which resolved completely following weight gain.
** Drevelengas, A; Chourmouzi, D; Pitsavas, G; Charitandi, A; Boulogianni, G (2001). "Reversible brain atrophy and subcortical high signal on MRI in a patient with anorexia nervosa". Neuroradiology. 43 (10): 838–40. doi:10.1007/s002340100589. PMID 11688699.
* Anorexia nervosa, which primarily affects adolescent girls and young women, is characterized by distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat. The criteria have several minor but important changes: • Criterion A focuses on behaviors, like restricting calorie intake, and no longer includes the word “refusal” in terms of weight maintenance since that implies intention on the part of the patient and can be difficult to assess. The DSM-IV Criterion D requiring amenorrhea, or the absence of at least three menstrual cycles, will be deleted. This criterion cannot be applied to males, pre-menarchal females, females taking oral contraceptives and post-menopausal females. In some cases, individuals exhibit all other symptoms and signs of anorexia nervosa but still report some menstrual activity.
** DSMV "Archived copy" (PDF). Archived from the original(PDF) on 2015-05-01. Retrieved 2015-04-09. “Eating Disorders Fact Sheet”, p.2.

## E

* Anorexia nervosa is originated from disturbances at various points of the cortico-hypothalamo-hypophyseal axis.
** Ehle, G; Wahlstab, A; Ott, J (1982). "Psychodiagnostic findings in anorexia nervosa and post-pill amenorrhea". Psychiatrie, Neurologie, und Medizinische Psychologie. 34 (11): 647–56. PMID 7170321.
* This paper reports the results of a randomised treatment trial of two forms of outpatient family intervention for anorexia nervosa. Forty adolescent patients with anorexia nervosa were randomly assigned to "conjoint family therapy" (CFT) or to "separated family therapy" (SFT) using a stratified design controlling for levels of critical comments using the Expressed Emotion index. The design required therapists to undertake both forms of treatment and the distinctiveness of the two therapies was ensured by separate supervisors conducting live supervision of the treatments. Measures were undertaken on admission to the study, at 3 months, at 6 months and at the end of treatment. Considerable improvement in nutritional and psychological state occurred across both treatment groups. On global measure of outcome, the two forms of therapy were associated with equivalent end of treatment results. However, for those patients with high levels of maternal criticism towards the patient, the SFT was shown to be superior to the CFT. When individual status measures were explored, there were further differences between the treatments. Symptomatic change was more marked in the SFT whereas there was considerably more psychological change in the CFT group. There were significant changes in family measures of Expressed Emotion. Critical comments between parents and patient were significantly reduced and that between parents was also diminished. Warmth between parents increased.
** Eisler, I; Dare, C; Hodes, M; Russell, G (2000). "Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions". Journal of Child Psychology and Psychiatry, and Allied Disciplines. 41 (6): 727–36. doi:10.1111/1469-7610.00660. PMID 11039685.
* The similarities between the mentalities of anorexia nervosa, bulimia, and sexual repression among young women are undeniable. Young women starve their bodies until they can no longer resist both physical and sexual hungers. But the guilt associated with indulging becomes overwhelming and purging and punishment ensues. Both biological and sexual hungers are natural. However the messages sent to young women by their culture are that neither of these hungers are normal and, in fact, are immoral and inexcusable.
** Essick, Ellen (2006). "Eating Disorders and Sexuality". In Steinberg, Shirley R.; Parmar, Priya; Richard, Birgit. Contemporary Youth Culture: An International Encyclopedia. Greenwood. p.276

## F

* Recent studies have hypothesized that perinatal complications might increase the risk of developing eating disorders. However, it is unclear which pathways might link obstetric complications and eating disorders. The present study aimed at exploring the relationship between obstetric complications and temperament in eating disordered subjects.
** Favaro, A; Tenconi, E; Santonastaso, P (2006). "Perinatal factors and the risk of developing anorexia nervosa and bulimia nervosa". Archives of General Psychiatry. 63 (1): 82–8. doi:10.1001/archpsyc.63.1.82. PMID 16389201.
* The sample was selected among subjects who took part in a prevalence study carried out on a representative sample of the general population and from among people with anorexia and bulimia nervosa referred to an outpatient specialist unit. Subjects who were born in the two obstetric wards of Padua Hospital between 1971 and 1979 and who completed the Tridimensional Personality Questionnaire were included. A blind analysis of the obstetric records of the whole sample was performed. The final sample was composed of 66 anorexia nervosa, 44 bulimia nervosa, and 257 control subjects.
** Favaro, A; Tenconi, E; Santonastaso, P (2006). "Perinatal factors and the risk of developing anorexia nervosa and bulimia nervosa". Archives of General Psychiatry. 63 (1): 82–8. doi:10.1001/archpsyc.63.1.82. PMID 16389201.
* Among the different groups of obstetric complications, only the group that included preterm birth and other signs of neonatal immaturity or dysmaturity displayed a significant relationship with harm avoidance. The use of a mediation path analytic model revealed a significant, but incomplete, mediation effect of harm avoidance in explaining the link between neonatal dysmaturity and the development of eating disorders. Maternal weight gain during pregnancy seemed to have a protective effect on harm avoidance.
** Favaro, A; Tenconi, E; Santonastaso, P (2006). "Perinatal factors and the risk of developing anorexia nervosa and bulimia nervosa". Archives of General Psychiatry. 63 (1): 82–8. doi:10.1001/archpsyc.63.1.82. PMID 16389201.
* The presence of signs of neonatal dysmaturity at birth seems to influence the development of high levels of harm avoidance in eating disorders.
** Favaro, A; Tenconi, E; Santonastaso, P (2006). "Perinatal factors and the risk of developing anorexia nervosa and bulimia nervosa". Archives of General Psychiatry. 63 (1): 82–8. doi:10.1001/archpsyc.63.1.82. PMID 16389201.
* Among the whole sample, the factor most strongly associated with suicide attempt or suicidal ideation was the diagnostic category, with the highest odds ratio for bulimia nervosa followed by anorexia nervosa of the binging/purging subtype. Among diagnostic subgroups, the strongest factors were drug use, alcohol use, and tobacco use.
** Fedorowicz VJ1, Falissard B, Foulon C, Dardennes R, Divac SM, Guelfi JD, Rouillon F., "Factors associated with suicidal behaviors in a large French sample of inpatients with eating disorders", Int J Eat Disord. 2007 Nov;40(7):589-95.
* Serum leptin levels in three groups of patients affected by severe eating disorders are not related to the specific pathology but are correlated with the individual BMI. The analysis of leptin values may be a useful index of assessing the adipose tissue stores in the clinical setting, but will be of no help for diagnosis nor prognosis of severe eating disorders.
** Ferron, F; Considine, R; Peino, R; Lado; I (1997). "Serum leptin concentrations in patients with anorexia nervosa, bulimia nervosa, and non-specific eating disorders correlate with the body mass index but are independent of the respective disease". Clinical Endocrinology. 46 (3): 289–293. doi:10.1046/j.1365-2265.1997.1260938.x. PMID 9156037.
* Previously, we identified that a majority of patients with anorexia nervosa (AN) and bulimia nervosa (BN) as well as some control subjects display autoantibodies (autoAbs) reacting with alpha-melanocyte-stimulating hormone (alpha-MSH) or adrenocorticotropic hormone, melanocortin peptides involved in appetite control and the stress response. In this work, we studied the relevance of such autoAbs to AN and BN. In addition to previously identified neuropeptide autoAbs, the current study revealed the presence of autoAbs reacting with oxytocin (OT) or vasopressin (VP) in both patients and controls. Analysis of serum levels of identified autoAbs showed an increase of IgM autoAbs against alpha-MSH, OT, and VP as well as of IgG autoAbs against VP in AN patients when compared with BN patients and controls. Further, we investigated whether levels of these autoAbs correlated with psychological traits characteristic for eating disorders. We found significantly altered correlations between alpha-MSH autoAb levels and the total Eating Disorder Inventory-2 score, as well as most of its subscale dimensions in AN and BN patients vs. controls. Remarkably, these correlations were opposite in AN vs. BN patients. In contrast, levels of autoAbs reacting with adrenocorticotropic hormone, OT, or VP had only few altered correlations with the Eating Disorder Inventory-2 subscale dimensions in AN and BN patients. Thus, our data reveal that core psychobehavioral abnormalities characteristic for eating disorders correlate with the levels of autoAbs against alpha-MSH, suggesting that AN and BN may be associated with autoAb-mediated dysfunctions of primarily the melanocortin system.
** Fetissov, SO; Harro, J; Jaanisk, M; Järv, A; Podar, I; Nilsson, I; Sakthivel, P; Lefvert, AK; et al. (2005). "Autoantibodies against neuropeptides are associated with psychological traits in eating disorders". Proceedings of the National Academy of Sciences of the United States of America. 102 (41): 14865–70. Bibcode:2005PNAS..10214865F. doi:10.1073/pnas.0507204102. PMC 1253594. PMID 16195379.
* With the apparent increase in prevalence of anorexic and bulimic eating disorders, the search for effective treatments for these disorders has been intensified in recent years. In this review the results of psychopharmacological studies of patients with anorexia or bulimia nervosa are presented and analysed. The focus of this review is on controlled studies. Although a variety of psychopharmacological substances has been tested in patients with anorexia nervosa, the outcome of controlled studies has been generally disappointing. A possible differential therapy effect of cyproheptadine needs replication: in one study it enhanced body weight gain in non-bulimic anorexics, while it appeared to hinder weight gain in bulimic anorexics. The issue of prophylaxis of osteoporosis in chronic low-weight anorexics has received increasing attention in recent years, and pharmacological prophylaxis appears indicated in this patient group. The results of psychopharmacological treatment studies of patients with bulimia nervosa have overall been more favourable than those of anorexic patients. Statistically significant effects concerning the reduction of bulimic or depressive symptoms in bulimia nervosa has been demonstrated for tricyclic antidepressants (imipramine, desipramine), serotonergic agents (fluoxetine, d-fenfluramine), non-selective monoamine-oxydase-inhibitors (isocarboxazide, phenelzine) and trazodone. The antibulimic effect appears not to be associated with the antidepressant effect. Theoretical, methodological and practical issues concerning pharmacological treatment of anorexic and bulimic eating disorders are presented and discussed.
** Fichter MM, “Drug treatment of anorexia nervosa and bulimia nervosa. A review”, Nervenarzt.1993 Jan;64(1):21-35.
* Franko et al’s results are also very interesting as they found that suicide attempts were more frequent among people with anorexia than among people with bulimia. This finding may have implications for clinical practice, both for treatment and for seeking confirmation of this evidence. The generalisability of Franko et al’s results will depend on further longitudinal studies with similar features. One of the authors’ aims was to identify predictors of suicide and suicide attempts. This should also be the aim of all mental health professionals involved in the treatment of people with eating disorders. However, future studies would benefit from a careful consideration of the diagnostic tools used, the evaluation of suicide risk and the recognition of comorbid Axis I disorders or personality disorders that may increase suicide risk dramatically.
** Franko, DL; Keel, PK; Dorer, DJ; Blais, MA; Delinsky, SS (2004). "What predicts suicide attempts in women with eating disorders?". Psychological Medicine. 34 (5): 843–53.
* Suicide is a common cause of death in anorexia nervosa and suicide attempts occur often in both anorexia nervosa and bulimia nervosa. No studies have examined predictors of suicide attempts in a longitudinal study of eating disorders with frequent follow-up intervals. The objective of this study was to determine predictors of serious suicide attempts in women with eating disorders. In a prospective longitudinal study, women diagnosed with either DSM-IV anorexia nervosa (n = 136) or bulimia nervosa (n = 110) were interviewed and assessed for suicide attempts and suicidal intent every 6-12 months over 8.6 years. Fifteen percent of subjects reported at least one prospective suicide attempt over the course of the study. Significantly more anorexic (22.1%) than bulimic subjects (10.9%) made a suicide attempt. Multivariate analyses indicated that the unique predictors of suicide attempts for anorexia nervosa included the severity of both depressive symptoms and drug use over the course of the study. For bulimia nervosa, a history of drug use disorder at intake and the use of laxatives during the study significantly predicted suicide attempts. Women with anorexia nervosa or bulimia nervosa are at considerable risk to attempt suicide. Clinicians should be aware of this risk, particularly in anorexic patients with substantial co-morbidity.
** Franko, DL; Keel, PK; Dorer, DJ; Blais, MA; Delinsky, SS (2004). "What predicts suicide attempts in women with eating disorders?". Psychological Medicine. 34 (5): 843–53. doi:10.1017/S0033291703001545. PMID 15500305.
* Studies of the role of leptin in patients with anorexia nervosa and bulimia nervosa have conflicted in their data and interpretation. Such differences may be a result of the assay methods used or the way results are compared with those from normal controls. To investigate these possibilities, we analyzed serum leptin levels in anorexic, bulimic, obese, and control individuals, thereby spanning the full range of human body weights, using three frequently employed commercial kits. Kits from Linco (St Louis, MO) and DSL (Webster, TX) employ a radioimmunoassay method, and the R&D Systems kit (Minneapolis, MN) uses an enzyme-linked immunosorbent assay. We found that the three kits provide results that are highly linearly correlated with each other and remarkably linearly related to percent ideal body weight (%IBW) over more than three orders of magnitude (Linco, r = 0.90; R&D, r = 0.87; DSL, r = 0.86). For very low leptin levels, the more sensitive kits from R&D and Linco appeared to give more reliable results. Measurement method does not appear to explain the literature conflicts. We found that patients with anorexia nervosa have serum leptin values that lie above the line extrapolated from the %IBW/leptin curve generated from analysis of all non-anorexic patients. Therefore, in anorexia nervosa, inappropriately high leptin levels for %IBW may contribute to a blunted physiologic response to underweight and consequent resistance to dietary treatment. By contrast, most bulimic patients have leptin levels significantly below those predicted from the same %IBW/leptin curve. The relative leptin deficiency in bulimic subjects may contribute to food-craving behavior. We propose that using the %IBW/ leptin curve can facilitate identification of true pathophysiologic abnormalities in eating-disordered individuals and provide a basis for the design of therapeutic interventions or monitoring of response to treatment.
** Frederich, R; Hu, S; Raymond, N; Pomeroy, C (2002). "Leptin in anorexia nervosa and bulimia nervosa: importance of assay technique and method of interpretation". The Journal of Laboratory and Clinical Medicine. 139 (2): 72–9. doi:10.1067/mlc.2002.121014. PMID 11919545.
* Disturbances of volume-regulating mechanisms have already been implicated in the pathophysiology of eating disorders like anorexia or bulimia nervosa with the peptide hormones vasopressin and atrial natriuretic peptide (ANP) being of special interest. Aim of the present study was to investigate, whether the expression of the corresponding genes was altered and if so, if these changes could be explained by epigenetic mechanisms such as DNA methylation. We analyzed blood samples of 46 women suffering from anorexia (n=22) or bulimia nervosa (n=24) as well as of 30 healthy controls. Peripheral mRNA expression and DNA methylation of the vasopressin and the ANP precursor genes were assessed using real-time PCR. We found significantly lower levels of ANP mRNA in patients with eating disorders. This downregulation was accompanied by a hypermethylation of the ANP gene promoter in the bulimic subgroup. We did not find differences regarding expression or methylation of the vasopressin gene. ANP mRNA expression was inversely associated with impaired impulse regulation. We conclude that epigenetic mechanisms may contribute to the known alterations of ANP homeostasis in women with eating disorders.
** Frieling H, Bleich S, Otten J, Römer KD, Kornhuber J, de Zwaan M, Jacoby GE, Wilhelm J, Hillemacher T., “Epigenetic downregulation of atrial natriuretic peptide but not vasopressin mRNA expression in females with eating disorders is related to impulsivity.” Neuropsychopharmacology. 2008 Oct;33(11):2605-9. doi: 10.1038/sj.npp.1301662. Epub 2008 Jan 2.
* The pathophysiology of eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) has been linked to an impaired dopaminergic neurotransmission, still the origin of this disturbance remains unknown. The aim of the present study was, therefore, to evaluate whether the expression of dopaminergic genes is altered in the blood of patients suffering from eating disorders and if these alterations can be explained by changes in the promoter specific DNA methylation of the genes.
** Frieling, H; Römer, KD; Scholz, S; Mittelbach, F; Wilhelm, J; De Zwaan, M; Jacoby, GE; Kornhuber, J; Hillemacher, T; Bleich, S (2010). "Epigenetic dysregulation of dopaminergic genes in eating disorders". The International Journal of Eating Disorders. 43 (7): 577–83. doi:10.1002/eat.20745. PMID 19728374.
* Our study shows a disturbed expression of dopaminergic genes that is accompanied by a dysregulation of the epigenetic DNA methylation. Further studies are necessary to provide more insight into the epigenetic dysregulation of the dopaminergic neurotransmission in the pathophysiology of eating disorders.
** Frieling, H; Römer, KD; Scholz, S; Mittelbach, F; Wilhelm, J; De Zwaan, M; Jacoby, GE; Kornhuber, J; Hillemacher, T; Bleich, S (2010). "Epigenetic dysregulation of dopaminergic genes in eating disorders". The International Journal of Eating Disorders. 43 (7): 577–83. doi:10.1002/eat.20745. PMID 19728374.

## G

* The media have been focusing on websites that are “pro-anorexic” to illustrate the pervasiveness of eating disorders in the US. This study focuses on the narratives of women who participate in “pro-ana” sites using Lyng’s (Am J Sociol 95:851–886, 1990) concept of edgework. Results indicate that women struggle with feelings of loss of control and through various skills are able to resume control. These data point to the intense emotive reactions fasting elicits, reactions which both reinforce and provide motivation to remain in the subculture. Findings contribute to the literature by focusing on women’s edgework and demonstrating the similarities between men and women edgeworkers.
** Gailey, J (2009). "Starving is the most fun a girl can have: The Pro-Ana subculture as edgework". Critical Criminology. 17 (2): 93–108. doi:10.1007/s10612-009-9074-z.
* Anorexia nervosa is a mental health disorder characterised by deliberate weight loss (through restrictive eating, excessive exercise and/or purging), disordered body image, and intrusive overvalued fears of gaining weight. The National Institute for Clinical Excellence recommends that family interventions that directly address the eating disorder should be offered to children and adolescents with anorexia nervosa.
** Gardner J, Wilkinson P, “Is family therapy the most effective treatment for anorexia nervosa?”, Psychiatr Danub. 2011 Sep;23 Suppl 1:S175-7.
* This literature search revealed only six randomised controlled trials investigating the use of family therapy in the treatment of adolescents with anorexia nervosa, and these all had small sample sizes. Some, but not all, of these trials suggest that family therapy may be advantageous over individual psychotherapy in terms of physical improvement (weight gain and resumption of menstruation) and reduction of cognitive distortions, particularly in younger patients. Due to the small sample sizes and the significant risk of bias (particularly information bias) in some of the studies the evidence in favour of family therapy over individual therapy is weak. In the future, larger randomised controlled trials with long term follow-up are required to assess whether family therapy is the most effective treatment for anorexia nervosa in adolescence.
** Gardner J, Wilkinson P, “Is family therapy the most effective treatment for anorexia nervosa?”, Psychiatr Danub. 2011 Sep;23 Suppl 1:S175-7.
* A population of professional dance (N = 183) and modelling (N = 56) students, who by career choice must focus increased attention and control over their body shapes, was studied. Height and weight data were obtained on all subjects. In addition, a questionnaire that is useful in assessing the symptoms of anorexia nervosa, the Eating Attitudes Test (EAT), was administered. Results of these tests were compared with those of normal female university students (N = 59), patients with anorexia nervosa (N = 68), and music students (N = 35). Anorexia nervosa and excessive dieting concerns were overrepresented in the dance and modelling students. Twelve cases (6.5%) of primary anorexia nervosa were detected in the dance group. All but one case developed the disorder while studying dance. Within the dance group those from the most competitive environments had the greatest frequency of anorexia nervosa. These data suggest that both pressures to be slim and achievement expectations are risk factors in the development of anorexia nervosa. The influence of socio-cultural determinants are discussed within the context of anorexia nervosa as a multidetermined disorder.
** Garner, DM; Garfinkel, PE (2009). "Socio-cultural factors in the development of anorexia nervosa". Psychological Medicine. 10 (4): 647–56. doi:10.1017/S0033291700054945. PMID 7208724.
* Eating disorders, such as anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorders (BED), are described as abnormal eating habits that usually involve insufficient or excessive food intake. Animal models have been developed that provide insight into certain aspects of eating disorders. Several drugs have been found efficacious in these animal models and some of them have eventually proven useful in the treatment of eating disorders. This review will cover the role of monoaminergic neurotransmitters in eating disorders and their pharmacological manipulations in animal models and humans. Dopamine, 5-HT (serotonin) and noradrenaline in hypothalamic and striatal regions regulate food intake by affecting hunger and satiety and by affecting rewarding and motivational aspects of feeding. Reduced neurotransmission by dopamine, 5-HT and noradrenaline and compensatory changes, at least in dopamine D2 and 5-HT(2C/2A) receptors, have been related to the pathophysiology of AN in humans and animal models. Also, in disorders and animal models of BN and BED, monoaminergic neurotransmission is down-regulated but receptor level changes are different from those seen in AN. A hypofunctional dopamine system or overactive α2-adrenoceptors may contribute to an attenuated response to (palatable) food and result in hedonic binge eating. Evidence for the efficacy of monoaminergic treatments for AN is limited, while more support exists for the treatment of BN or BED with monoaminergic drugs.
** Ivan Gestel MA, Kostrzewa E, Adan RA, Janhunen SK, “Pharmacological manipulations in animal models of anorexia and binge eating in relation to humans”, 2014 Oct;171(20):4767-84. doi: 10.1111/bph.12789. Epub 2014 Sep 5.
* In three hospitals 81 female patients satisfying rigorous diagnostic criteria for anorexia nervosa were randomly allocated to one of four treatment combinations of cyproheptadine and placebo with behaviour therapy and no behaviour therapy. Cyproheptadine was found to be effective in inducing weight gain in a subgroup of anorexia nervosa patients who (a) had a history of birth delivery complications, (b) had lost 41-52 per cent weight from norm and (c) had a history of prior outpatient treatment failure. This subgroup may represent a more severe form of anorexia nervosa.
** Goldberg, SC; Halmi, KA; Eckert, ED; Casper, RC; Davis, JM (1979). "Cyproheptadine in anorexia nervosa". The British Journal of Psychiatry. 134: 67–70. doi:10.1192/bjp.134.1.67. PMID 367480.
* The prevalence of body dysmorphic disorder in patients with anorexia nervosa is unknown. We hypothesized that body dysmorphic disorder would be underdiagnosed in patients with anorexia nervosa and that comorbidity with body dysmorphic disorder would result in greater overall dysfunction.
** Grant, JE; Kim, SW; Eckert, ED (November 2002). "Body dysmorphic disorder in patients with anorexia nervosa: prevalence, clinical features, and delusionality of body image". The International Journal of Eating Disorders. 32 (3): 291–300. doi:10.1002/eat.10091. PMID 12210643.
* Sixteen (39%) of the 41 patients with anorexia nervosa were diagnosed with comorbid body dysmorphic disorder unrelated to weight concerns. The anorexia nervosa patients with body dysmorphic disorder had significantly lower overall functioning and higher levels of delusionality than the anorexic patients without body dysmorphic disorder.
** Grant, JE; Kim, SW; Eckert, ED (November 2002). "Body dysmorphic disorder in patients with anorexia nervosa: prevalence, clinical features, and delusionality of body image". The International Journal of Eating Disorders. 32 (3): 291–300. doi:10.1002/eat.10091. PMID 12210643.
* These preliminary results suggest that body dysmorphic disorder may be relatively common among patients with anorexia nervosa. The presence of comorbid body dysmorphic disorder may indicate a more severe form of illness.
** Grant, JE; Kim, SW; Eckert, ED (November 2002). "Body dysmorphic disorder in patients with anorexia nervosa: prevalence, clinical features, and delusionality of body image". The International Journal of Eating Disorders. 32 (3): 291–300. doi:10.1002/eat.10091. PMID 12210643.
* The aim of this study is to obtain CRF (Corticotropin Releasing Factor) stimulation at a suprahypothalamic level with a psychological stressor and to evaluate its response in anorexia nervosa. CRF plays a major role in the mechanisms underlying the hypothalamo-pituitary-adrenal (HPA) system's response to stress. Animal studies clearly showed that CRF is involved both in the adaptation to a novel environment and the regulation of eating behaviour. CRF's staietogenic effect is mediated via the paraventricular nucleus. Three groups of age matched young women were studied: 8 patients meeting the DSM III-R criteria for anorexia nervosa, 8 underweight healthy volunteers and 10 normal weight volunteers. All subjects were submitted to an auditory stimulation test ("psychosocial stress test") consisting of an intellectual task in which maximal performance is impossible to achieve, the subjects being permanently disturbed by various meaningful noises. Subjects were asked to answer self-rating scales for anxiety and tension prior to and after the test. CRF reactivity was measured by salivary cortisol (RIA). After the test, anorexia nervosa patients exhibit a significantly higher salivary cortisol response compared to the normal weight volunteers. In most of cases, salivary cortisol response was not correlated with the psychological variables. The range of the response is very explosive in two anorectic patients. Our data are consistent with the hyperactivity of the corticotropic axis stress response in anorexia nervosa, but request further investigations to prove that.
** Gross, MJ; Kahn, JP; Laxenaire, M; Nicolas, JP; Burlet, C (1994). "Corticotropin-releasing factor and anorexia nervosa: reactions of the hypothalamus-pituitary-adrenal axis to neurotropic stress". Annales d'Endocrinologie. 55 (6): 221–8. PMID 7864577.
* There is no one sign of an eating disorder, however there are red flags. These can include excessive “fat, weight or calorie talk,” a pattern of eating a limited choice of low-calorie food or a pattern of occasional binge eating of calorie-dense foods. People with anorexia nervosa may excessively exercise or excessively stand, pace or fidget. Affected individuals may severely limit the amount of calories they consume or may avoid weight gain following meals by inducing vomiting or abusing laxative, diuretic and diet pills. Feeling self-conscious about one’s eating behavior is common. Affected individuals often avoid social eating settings and eat alone.
** Angela Guarda, M.D. "Eating Disorders". American Psychiatric Association. Archived from the original on 21 December 2014. Retrieved 4 December 2014.
* There is no single cause of an eating disorder. We know that genetics play a large role, but genetic vulnerability is only part of the story. Environment plays a role too, especially in triggering onset, which often occurs in adolescence. Pressure to diet or weight loss related to a medical condition can be the gateway to anorexia nervosa or bulimia. For those who are genetically vulnerable to anorexia nervosa, once they lose the first five to 10 lbs, dieting becomes increasingly compelling and rewarding. Looked at another way, if eating disorders were the result solely of social pressure for thinness we would expect eating disorder rates to have increased as obesity has in the past few decades, yet anorexia nervosa and bulimia remain relatively rare and often cluster in families.
** Angela Guarda, M.D. "Eating Disorders". American Psychiatric Association. Archived from the original on 21 December 2014. Retrieved 4 December 2014.
* Qigong is a mind-body intervention focusing on interoceptive awareness that appears to be a promising approach in anorexia nervosa (AN). In 2008, as part of our multidimensional treatment program for adolescent inpatients with AN, we began a weekly qigong workshop that turned out to be popular among our adolescent patients. Moreover psychiatrists perceived clinical benefits that deserved further exploration.
** Gueguen J, Piot M, Orri M1,2, Gutierre A, Le Moan J, Berthoz S, Falissard B, Godart N, “Group Qigong for Adolescent Inpatients with Anorexia Nervosa: Incentives and Barriers”, PLoS One. 2017 Feb 2;12(2):e0170885. doi: 10.1371/journal.pone.0170885. eCollection 2017.
* A qualitative study therefore sought to obtain a deeper understanding of how young patients with severe AN experience qigong and to determine the incentives and barriers to adherence to qigong, to understanding its meaning, and to applying it in other contexts. Data were collected through 16 individual semi-structured face-to-face interviews and analyzed with the interpretative phenomenological analysis method. Eleven themes emerged from the analysis, categorized in 3 superordinate themes describing the incentives and barriers related to the patients themselves (individual dimension), to others (relational dimension), and to the setting (organizational dimension). Individual dimensions associated with AN (such as excessive exercise and mind-body cleavage) may curb adherence, whereas relational and organizational dimensions appear to provide incentives to join the activity in the first place but may also limit its post-discharge continuation. Once barriers are overcome, patients reported positive effects: satisfaction associated with relaxation and with the experience of mind-body integration.
** Gueguen J, Piot M, Orri M1,2, Gutierre A, Le Moan J, Berthoz S, Falissard B, Godart N, “Group Qigong for Adolescent Inpatients with Anorexia Nervosa: Incentives and Barriers”, PLoS One. 2017 Feb 2;12(2):e0170885. doi: 10.1371/journal.pone.0170885. eCollection 2017.
* Qigong appears to be an interesting therapeutic tool that may potentiate psychotherapy and contribute to the recovery process of patients with AN. Further analysis of the best time window for initiating qigong and of its place in overall management might help to overcome some of the barriers, limit the risks, and maximize its benefits.
** Gueguen J, Piot M, Orri M1,2, Gutierre A, Le Moan J, Berthoz S, Falissard B, Godart N, “Group Qigong for Adolescent Inpatients with Anorexia Nervosa: Incentives and Barriers”, PLoS One. 2017 Feb 2;12(2):e0170885. doi: 10.1371/journal.pone.0170885. eCollection 2017.

## H

* A prospective, naturalistic, longitudinal design was used to map the course of AN and BN in 246 women. Follow-up data are presented in terms of full and partial recovery, predictors of time to recovery, and rates and predictors of relapse. The full recovery rate of women with BN was significantly higher than that of women with AN, with 74% of those with BN and 33% of those with AN achieving full recovery by a median of 90 months of follow-up. Intake diagnosis of AN was the strongest predictor of worse outcome. No predictors of recovery emerged among bulimic subjects. Eighty-three percent of women with AN and 99% of those with BN achieved partial recovery. Approximately one third of both women with AN and women with BN relapsed after full recovery. No predictors of relapse emerged. The findings suggest that the course of AN is characterized by high rates of partial recovery and low rates of full recovery, while the course of BN is characterized by higher rates of both partial and full recovery.
** Herzog, DB; Dorer, DJ; Keel, PK; Selwyn, SE; Ekeblad, ER (1999). "Recovery and relapse in anorexia and bulimia nervosa: a 7.5-year follow-up study". Journal of the American Academy of Child and Adolescent Psychiatry. 38 (7): 829–37. doi:10.1097/00004583-199907000-00012. PMID 10405500.
* The findings suggest that the course of AN is characterized by high rates of partial recovery and low rates of full recovery, while the course of BN is characterized by higher rates of both partial and full recovery.
** Herzog, DB; Dorer, DJ; Keel, PK; Selwyn, SE; Ekeblad, ER (1999). "Recovery and relapse in anorexia and bulimia nervosa: a 7.5-year follow-up study". Journal of the American Academy of Child and Adolescent Psychiatry. 38 (7): 829–37. doi:10.1097/00004583-199907000-00012. PMID 10405500.
* The purpose of this review is to evaluate the recent literature on the incidence and prevalence of and mortality associated with eating disorders.
** Hoek HW, “Incidence, prevalence and mortality of anorexia nervosa and other eating disorders”, Curr Opin Psychiatry. 2006 Jul;19(4):389-94.
* General-practice studies show that the overall incidence rates of anorexia nervosa remained stable during the 1990s, compared with the 1980s. Some evidence suggests that the occurrence of bulimia nervosa is decreasing. Anorexia nervosa is a common disorder among young white females, but is extremely rare among black females. Recent studies confirm previous findings of the high mortality rate within the anorexia nervosa population.
** Hoek HW, “Incidence, prevalence and mortality of anorexia nervosa and other eating disorders”, Curr Opin Psychiatry. 2006 Jul;19(4):389-94.
* The incidence of anorexia nervosa is around eight per 100,000 persons per year. An upward trend has been observed in the incidence of anorexia nervosa in the past century till the 1970s. The most substantial increase was among females aged 15-24 years, for whom a significant increase was observed from 1935 to 1999. The average prevalence rates for anorexia nervosa and bulimia nervosa among young females are 0.3 and 1%, respectively. Only a minority of people with eating disorders, especially with bulimia nervosa, are treated in mental healthcare.
** Hoek HW, “Incidence, prevalence and mortality of anorexia nervosa and other eating disorders”, Curr Opin Psychiatry. 2006 Jul;19(4):389-94.
* Evidence for organic brain contribution to anorexia nervosa is strong and can be illustrated by this case report of anorexia nervosa associated with cerebral tumour.
** Houy, E; Debono, B; Dechelotte, P; Thibaut, F (2007). "Anorexia nervosa associated with right frontal brain lesion". The International Journal of Eating Disorders. 40 (8): 758–61. doi:10.1002/eat.20439. PMID 17683096.

## I

* We examined the extent to which attachment insecurity was related to eating disorder (ED) symptoms, and predictive of treatment outcomes. Women diagnosed with anorexia nervosa (AN) restricting subtype (ANR), AN binge purge subtype (ANB), or bulimia nervosa (BN) completed an attachment scale pretreatment, and ED symptom scales pretreatment (N = 243) and post-treatment (N = 157). A comparison sample of 126 non-ED women completed attachment scales on 1 occasion. Those with EDs had significantly higher attachment insecurity than non-ED. ANB was associated with higher attachment avoidance compared with ANR and BN, and higher attachment anxiety compared with BN. Higher attachment anxiety was significantly related to greater ED symptom severity and poorer treatment outcome across all EDs even after controlling for ED diagnosis. Attachment dimensions substantially contribute to our understanding of ED symptoms and treatment outcome. Addressing attachment insecurity when treating those with EDs may improve treatment outcomes.
** Illing Vanessa A.; Tasca Giorgio; Balfour Louise; Bissada Hany (2010). "Attachment Insecurity Predicts Eating Disorder Symptoms and Treatment Outcomes in a Clinical Sample of Women". The Journal of Nervous and Mental Disease. 198 (9): 653–59. doi:10.1097/nmd.0b013e3181ef34b2. PMID 20823727.
* The aim of the article was an attempt to present selected theoretical motifs and moreover self experience in the adaptation of elements of psychodrama by Moreno in psychodynamic psychotherapy (individual and group psychotherapy) in a group of people with anorexia and bulimia nervosa. Psychodrama through own creativity, spontaneity and taking action on the "here and now" stage helps to attain and intensify therapeutic aims which concern the consciousness of inner conflict of persons with anorexia and bulimia nervosa, which is translocated on their body.
** Izydorczyk B, “Adaptation of psychodrama in psychotherapy of patients with anorexia nervosa and bulimia nervosa”, Psychiatr Pol. 2011 Mar-Apr;45(2):261-75.

## J

* Osteoporosis has been reported in anorexia nervosa (AN), but not in other eating disorders. Thirty-three patients, 8 AN, 17 bulimia nervosa (BN), and 8 eating disorder not otherwise specified (EDNOS), were evaluated by bone densitometry (radius, spine, femur) to determine the prevalence and distribution of osteoporosis and the role of physical parameters, exercise and estrogen. All three diagnostic subgroups had evidence of decreased bone density, worst in the EDNOS subgroup and least in the BN subgroup. The most affected site was the femur, least the spine; the radius was intermediate. Age, body surface area, age of onset, and length of illness weakly correlated with the femur and spine density in the BN and EDNOS subgroups. Exercise was related to bone density in the AN subgroup in the femur, moderate exercise having a protective effect and strenuous exercise being detrimental. No significant correlation of bone density measurements with estradiol levels and/or history of amenorrhea was identified. Eating disorder patients are at risk for osteoporosis, which has multiple contributing factors including physical parameters and exercise. Estrogen deficiency by itself may not be a major causative factor.
** Joyce, JM; Warren, DL; Humphries, LL; Smith, AJ; Coon, JS (1990), "Osteoporosis in women with eating disorders: comparison of physical parameters, exercise, and menstrual status with SPA and DPA evaluation", Journal of Nuclear Medicine. 31 (3): p. 325.

## K

* Although many women diet, relatively few develop the extreme weight loss and the clinical symptoms of anorexia nervosa. An underlying biological diathesis and temperament may place someone at risk for developing anorexia nervosa. Certain traits, such as negative affect, behavioral inhibition, compliance, high harm avoidance, and an obsessive concern with symmetry, exactness, and perfectionism, persist after recovery from anorexia nervosa. These persistent symptoms raise the possibility that such traits exist premorbidly and contribute to the pathogenesis of this disorder. Such traits could be associated with increased brain serotonin activity. After recovery, anorexics have increased levels of 5-HIAA, the major metabolite of serotonin, in the cerebrospinal fluid (CSF). Low CSF 5-HIAA levels have been associated with impulsive and aggressive behaviors, which are opposite to those typically found in anorexia nervosa. Increased serotonin activity could contribute to many behavioral symptoms, such as increased satiety. Moreover, recent data suggest that selective serotonin reuptake inhibitor (SSRI)-type medication improves outcome and prevents relapse in people with anorexia nervosa. These theoretical issues have important clinical implications in this era of diminished support for treatment of eating disorders. Anorexia nervosa, like other major psychiatric disorders, has contributory pathophysiology and can benefit from and deserves appropriate treatment resources.
** Kaye, WH (1997). "Anorexia nervosa, obsessional behavior, and serotonin". Psychopharmacology Bulletin. 33 (3): 335–44. PMID 9550876.
* Individuals with anorexia nervosa have a relentless preoccupation with dieting and weight loss that results in severe emaciation and sometimes death. It is controversial whether such symptoms are secondary to psychosocial influences, are a consequence of obsessions and anxiety or reflect a primary disturbance of brain appetitive circuits. New brain imaging technology provides insights into ventral and dorsal neural circuit dysfunction - perhaps related to altered serotonin and dopamine metabolism - that contributes to the puzzling symptoms found in people with eating disorders. For example, altered insula activity could explain interoceptive dysfunction, and altered striatal activity might shed light on altered reward modulation in people with anorexia nervosa.
** Kaye WH1, Fudge JL, Paulus M, “New insights into symptoms and neurocircuit function of anorexia nervosa”, Nat Rev Neurosci. 2009 Aug;10(8):573-84. doi: 10.1038/nrn2682. Epub 2009 Jul 15.
* Premorbid, childhood personality and temperament traits, which are thought to be genetically-determined, are thought to contribute to a vulnerability to develop AN. These include negative emotionality, harm avoidance, perfectionism, inhibition, a drive for thinness, altered interoceptive awareness and obsessive-compulsive personality traits. Individuals with AN seem to have a paradoxical response to eating; they engage in dietary restraint in order to reduce anxiety, because eating stimulates dysphoric mood. Several lines of evidence raise the possibility that altered serotonin (5-HT) function contributes to anxiety in subjects with AN, and starvation is a means of diminishing 5-HT functional activity. Individuals with AN might have a trait towards an imbalance between serotonin and dopamine pathways, which may have a role in an altered interaction between ventral (limbic) neurocircuits, which are important for identifying the emotional significance of stimuli and for generating an affective response to these stimuli, and dorsal (cognitive) neurocircuits that modulate selective attention, planning and effortful regulation of affective states. Recent functional MRI studies support the possibility that individuals with AN might be less able to precisely modulate affective responses to immediately salient stimuli but have increased activity in neurocircuits concerned with planning and consequences. Coding the awareness of pleasant sensation from the taste experience through the anterior insula might be altered in individuals with AN, tipping the balance of striatal processes away from normal, automatic reward responses mediated by the ventral striatum and towards a more 'strategic' approach mediated by the dorsal striatum. Perfectionism and obsessional personality traits could be related to exaggerated cognitive control by the dorsal lateral prefrontal cortex (which may have excessive inhibitory activity and thus dampen information processing through reward pathways) or to compensation for primary deficits in limbic function. When there are deficits in emotional regulation, overdependence upon cognitive rules is a reasonable strategy of self-management. <br. The temperament and personality traits that create a vulnerability to develop AN also persist after recovery. After recovery, these traits tend to have positive aspects, including attention to detail, concern about consequences and a drive to accomplish and succeed.
** Kaye WH, Fudge JL, Paulus M, “New insights into symptoms and neurocircuit function of anorexia nervosa”, Nat Rev Neurosci. 2009 Aug;10(8):573-84. doi: 10.1038/nrn2682. Epub 2009 Jul 15.
* Anorexia nervosa (AN) is a severe, usually relapsing, psychiatric disorder. It has the highest mortality rate of any psychiatric disorder with an estimated adult mortality rate of 5% per decade. It is most predominant among girls and young women with the average age at onset being 15 years. Estimated lifetime prevalence is approximately 2% in females and 0.3% in males although studies have reported rates of up to 4% in females. It is characterized by excessive weight loss due to self-starvation, body image distortion, and immense fear of gaining weight or being fat. There are two subtypes: (1) restricting (AN-R), characterized by restricting food intake with or without compulsive exercise, and (2) binge-eating/purging (AN-BP), characterized by episodes of consuming large portions of food (binging) followed by purging (eg, ipecac- or self-induced vomiting, and/or excessive use of laxatives, enemas, or diuretics). Comorbid psychiatric illnesses (eg, major depression, anxiety disorders, obsessive-compulsive disorder or behaviors) are common among individuals with AN.
** Kaye WH, Fudge JL, Paulus M, “New insights into symptoms and neurocircuit function of anorexia nervosa”, Nat Rev Neurosci. 2009 Aug;10(8):573-84. doi: 10.1038/nrn2682. Epub 2009 Jul 15.
* Anorexia nervosa can result in starvation status and nutritional deficiencies leading to reversible and irreversible medical complications of varying severity. These complications can affect nearly every body system and usually directly correlate to severity of the disease, degree of weight loss/starvation and/or purging.
** Kaye WH, Fudge JL, Paulus M, “New insights into symptoms and neurocircuit function of anorexia nervosa”, Nat Rev Neurosci. 2009 Aug;10(8):573-84. doi: 10.1038/nrn2682. Epub 2009 Jul 15.
* The use of antidepressants as the sole therapeutic intervention for AN is unsupported, and these agents should only be used as adjunctive treatment to nutritional restoration and psychotherapy. There is a general lack of evidence to support use of SSRIs or mirtazapine during the AN acute treatment phase in underweight individuals. As a result, clinicians should not use antidepressants during hospitalization while patients are undergoing initial weight and nutritional restoration. At this time, the data are inconclusive regarding the place of SSRIs and mirtazapine and for their benefits in individuals with AN during the maintenance treatment phase once the weight is at least partially restored. Health care professionals should use clinical judgment in recommending fluoxetine or possibly citalopram, sertraline, or mirtazapine as adjunctive treatment to psychotherapy for relapse prevention and/or improvement of symptoms of depression and anxiety and/or obsessive-compulsive behaviors that did not to resolve with nutritional rehabilitation and psychotherapy. A combination of psychotherapy and different pharmacologic modalities may be used under the rationale that the efficacy of these treatments might be additive or perhaps synergistic to increase treatment success in weight-restored anorexic patients.
** Kaye WH, Fudge JL, Paulus M, “New insights into symptoms and neurocircuit function of anorexia nervosa”, Nat Rev Neurosci. 2009 Aug;10(8):573-84. doi: 10.1038/nrn2682. Epub 2009 Jul 15.
* The prevalence of anxiety disorders in general and OCD in particular was much higher in people with anorexia nervosa and bulimia nervosa than in a nonclinical group of women in the community. Anxiety disorders commonly had their onset in childhood before the onset of an eating disorder, supporting the possibility they are a vulnerability factor for developing anorexia nervosa or bulimia nervosa.
** Kaye, WH; Bulik, CM; Thornton, L; Barbarich, N; Masters, K (2004). "Comorbidity of anxiety disorders with anorexia and bulimia nervosa". The American Journal of Psychiatry. 161 (12): 2215–21. doi:10.1176/appi.ajp.161.12.2215. PMID 15569892.
* Individuals with anorexia nervosa (AN) demonstrate a relentless engagement in behaviors aimed to reduce their weight, which leads to severe underweight status, and occasionally death. Neurobiological abnormalities, as a consequence of starvation are controversial: evidence, however, demonstrates abnormalities in the reward system of patients, and recovered individuals. Despite this, a unifying explanation for reward abnormalities observed in AN and their relevance to symptoms of the illness, remains incompletely understood. Theories explaining reward dysfunction have conventionally focused on anhedonia, describing that patients have an impaired ability to experience reward or pleasure. We review taste reward literature and propose that patients' reduced responses to conventional taste-reward tasks may reflect a fear of weight gain associated with the caloric nature of the tasks, rather than an impaired ability to experience reward. Consistent with this, we propose that patients are capable of 'liking' hedonic taste stimuli (e.g., identifying them), however, they do not 'want' or feel motivated for the stimuli in the same way that healthy controls report. Recent brain imaging data on more complex reward processing tasks provide insights into fronto-striatal neural circuit dysfunction related to altered reward processing in AN that challenges the relevance of anhedonia in explaining reward dysfunction in AN. In this way, altered activity of the anterior cingulate cortex and striatum could explain patients' pathological engagement in behaviors they consider rewarding (e.g., self-starvation) that are otherwise aversive or punishing, to those without the eating disorder. Such evidence for altered patterns of brain activity associated with reward processing tasks in patients and recovered individuals may provide important information about mechanisms underlying symptoms of AN, their future investigation, and the development of treatment approaches.
** Keating C, Tilbrook AJ, Rossell SL, Enticott PG, Fitzgerald PB, “Reward processing in anorexia nervosa” Neuropsychologia. 2012 Apr;50(5):567-75. doi: 10.1016/j.neuropsychologia.2012.01.036. Epub 2012 Feb 13.
* The authors explore the extent to which eating disorders, specifically anorexia nervosa (AN) and bulimia nervosa (BN), represent culture-bound syndromes and discuss implications for conceptualizing the role genes play in their etiology. The examination is divided into 3 sections: a quantitative meta-analysis of changes in incidence rates since the formal recognition of AN and BN, a qualitative summary of historical evidence of eating disorders before their formal recognition, and an evaluation of the presence of these disorders in non-Western cultures. Findings suggest that BN is a culture-bound syndrome and AN is not. Thus, heritability estimates for BN may show greater variability cross-culturally than heritability estimates for AN, and the genetic bases of these disorders may be associated with differential pathoplasticity.
** Keel, PK; Klump, KL (2003). "Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology". Psychological Bulletin. 129 (5): 747–69. CiteSeerX 10.1.1.524.4493. doi:10.1037/0033-2909.129.5.747. PMID 12956542.
* There is evidence for altered processing of taste in anorexia nervosa, particularly in the areas of reward processing and hedonic sensitivity. However, research on whether people with anorexia nervosa identify taste stimuli accurately, known as taste sensitivity, has yielded mixed findings.
** Kinnaird E1, Stewart C1,2, Tchanturia K1,2,3. “Taste sensitivity in anorexia nervosa: A systematic review”, Int J Eat Disord. 2018 Aug;51(8):771-784. doi: 10.1002/eat.22886. Epub 2018 Jul 8.
* The review of the findings suggest that individuals with AN may experience reduced taste sensitivity that may improve following recovery. However, there was a significant variability in results across studies, potentially reflecting methodological problems including low sample sizes, experimental designs, and uncontrolled confounding variables.
** Kinnaird E1, Stewart C1,2, Tchanturia K1,2,3. “Taste sensitivity in anorexia nervosa: A systematic review”, Int J Eat Disord. 2018 Aug;51(8):771-784. doi: 10.1002/eat.22886. Epub 2018 Jul 8.
* This review suggests that altered taste sensitivity could represent a component in the wider altered taste processing observed in anorexia nervosa. However, the heterogeneity of findings highlight the need for future research to consider methodological issues raised by this review.
** Kinnaird E1, Stewart C1,2, Tchanturia K1,2,3. “Taste sensitivity in anorexia nervosa: A systematic review”, Int J Eat Disord. 2018 Aug;51(8):771-784. doi: 10.1002/eat.22886. Epub 2018 Jul 8.
* Anorexia nervosa is an eating disorder defined by a symptomatic triad, anorexia, emaciation and amenorrhoea. This disease mainly affects young women. Besides these three symptoms, hyperactivity is often associated with anorexia nervosa. Hyperactivity can be considered as a strategy to lose weight, but studies on animal models have shown that it could be explained by more complicated mechanisms. Hyperactivity is defined by an excess of physical activity, which can induce social, professional and family consequences. Hyperactivity can take different forms, most striking is the restless one. Patients with anorexia nervosa are not all hyperactive. Brewerton et al. have compared patients with anorexia nervosa and hyperactivity to patients without hyperactivity. Hyperactive patients are more dissatisfied by their body image, they use less means of purging (laxatives, vomiting), and they start starving earlier than patients without hyperactivity. Many factors can promote the emergence and maintenance of hyperactivity, especially social and cultural requirements, sports environment, family influences. Various models can explain the links between excessive exercise and anorexia nervosa. Epling and Pierce have exposed a behavioural model which shows how hyperactivity can lead to starvation, creating a self-maintained cycle. Eisler and Le Grande have described four models to explain the links between hyperactivity and anorexia nervosa. First, excessive exercise can be considered as a symptom of anorexia nervosa. It can also promote the development of eating disorders. Anorexia nervosa and hyperactivity can be a manifestation of an other psychiatric disorder. At least, hyperactivity can be a variant of anorexia nervosa, which has the same effects, as weight loss. Hyperactivity can also be considered as a kind of obsessive compulsive disorder. Hyperactivity and obsessive compulsive disorders actually share some clinical and neurochemical characteristics. An other model consists in comparing excessive exercise in anorexia nervosa to an addictive behaviour. Self-starvation exacerbated by hyperactivity can be considered as an addiction to endogenous opioid.
** Kohl M1, Foulon C, Guelfi JD, “Hyperactivity and anorexia nervosa: behavioural and biological perspective”, Encephale. 2004 Sep-Oct;30(5):492-9.
* Few studies are carried out in order to estimate the prevalence of high level exercise in the eating disorders. Davis et al. have achieved a prevalence study. The results indicate that a large majority of patients with anorexia nervosa (80,8%) were exercising excessively during an acute phase of the disorder. Research on animals, specially on rats, brings us an interesting model explaining interactions between anorexia nervosa and hyperactivity. With animal models, we have noticed that, when rats with access to a running wheel, are restricted in their food intake, they become excessively active, and paradoxically reduce food consumption. Many searchers have tried to explain this phenomenon. Morse et al. have pointed from animal models that the level of hyperactivity was linked to the severity of food restriction. This result can be explained by a failure of a part of the brain involved in rest and activity regulation. Animal research brings us explanations about the effects of starvation on the endocrine system and the neurotransmitters. Broocks et al. have shown that corticosterone concentration in plasma was synergistically increased by semi starvation and exercise, and the reduction of triiodothyronine by semi starvation was significantly greater in the running wheel group. An other study of Broocks et al. has revealed an increased hypothalamic serotonin metabolism with the combined effect of hyperactivity and food restriction. Tryptophan, an amid acid involved in serotonin synthesis, can also play a role in the maintenance of anorexia nervosa. In starvation conditions, opioid releasing caused by physical exercise would decrease food intake. Exner's study and Adan's one have shown that leptin would be involved in semi starvation induced hyperactivity mechanisms. In spite of animal models can not be entirely generalized to human, they are useful to try to explain biological supports of hyperactivity. Hyperactivity is not only a strategy to lose weight, but also a specific symptom which completes the clinical triad. Animal studies have led to promising results; we might use medicine, such as serotonin reuptake inhibitors or opioid antagonists in the treatment of hyperactivity in anorexia nervosa.
** Kohl M1, Foulon C, Guelfi JD, “Hyperactivity and anorexia nervosa: behavioural and biological perspective”, Encephale. 2004 Sep-Oct;30(5):492-9.

## L

* Studies examining the function of the hypothalamic-pituitary-adrenal (HPA) axis in anorexia nervosa are reviewed. A principal finding is that of hypercortisolism, associated with increased central corticotropin-releasing hormone levels and normal circulating levels of adrenocorticotropic hormone. Similarities between neuroendocrine findings in anorexia nervosa and in affective disorder are reviewed. The contribution of circadian rhythm disturbances and malnutrition to observed HPA axis abnormalities in anorexia nervosa is also considered. Directions for future research are discussed.
** Licinio, J; Wong, ML; Gold, PW (1996). "The hypothalamic-pituitary-adrenal axis in anorexia nervosa". Psychiatry Research. 62 (1): 75–83. doi:10.1016/0165-1781(96)02991-5. PMID 8739117.
* This case suggests that an intracranial tumor near the hypothalamus should be included in the differential diagnosis of AN. Any male adolescent with the clinical impression of AN should receive periodic re-evaluation, including neurological, endocrinological and, if necessary, neuroimaging study.
** Lin, L; Liao, SC; Lee, YJ; Tseng, MC; Lee, MB (2003). "Brain tumor presenting as anorexia nervosa in a 19-year-old man". Journal of the Formosan Medical Association, Taiwan Yi Zhi. 102 (10): 737–40. PMID 14691602.
* After the conducted investigation and observation, the characteristics of the forming incorrect personality were observed in 80% of examined children. According to DSM IV classification, in 50%--from the cluster C, and in 30% cases--the cluster B. According to ICD-10 classification: 26.6% attributes of dependent personality, 16.6%--histrionic personality, 13.3% avoiding personality, 10%--anancastic personality, 6.7% borderline personality and 6.7% antisocial personality.
** Lucka, I; Cebella, A (2004). "Characteristics of the forming personality in children suffering from anorexia nervosa". Psychiatria Polska. 38 (6): 1011–8. PMID 15779665.
* There is predominating opinion in literature, connecting restrictive type of psychical anorexia, with disorders of personality of anxiety type--the cluster C, and the figure bulimic--with personality the cluster B. Those results were confirmed with statistical significance in the conducted examinations.
** Lucka, I; Cebella, A (2004). "Characteristics of the forming personality in children suffering from anorexia nervosa". Psychiatria Polska. 38 (6): 1011–8. PMID 15779665.

## M

* Bulimia and anorexia nervosa are the main diagnostic categories of eating disorders, affecting up to 1.5% of people in the USA at any one time. Both conditions are associated with physical (eg, reduced body mass index, percentage of body fat) and psychosocial (eg, depression, anxiety, quality of life) impairments, as well as high risk of death. Anorexia nervosa is specifically characterised by an excessive exercise engagement with fear of weight gain and aversion of fat, whereas people with bulimia nervosa present with binge eating and purging. These eating disorders are considered one of the most challenging psychiatric conditions to treat, and treatment usually comprises of cognitive–behavioural therapy and pharmacological management. Exercise is usually not recommended for patients with these conditions, mainly due to the belief that it might aggravate the progress of the disorder. However, there is evidence that exercise increases body mass index and reduce depression in people with binge eating. What is uncertain is whether physiotherapy interventions are effective in treating bulimia and anorexia nervosa.
** Machado GC, Ferreira ML “Physiotherapy improves eating disorders and quality of life in bulimia and anorexia nervosa”, Br J Sports Med, 2014;48:1519-1520.
* The role and utility of antidepressants in AN were published in double-blind, placebo-controlled studies; open-label trials; and a retrospective study. Antidepressants should not be used as sole therapy for AN although their use for confounding symptomatology makes discerning efficacy difficult as they are given together with other therapies. Neurobiological changes due to starvation and AN itself complicate results interpretation. For safety, tricyclic antidepressants and monoamine oxidase inhibitors are not recommended, and bupropion is contraindicated. Use of SSRIs during acute treatment lacks efficacy. Use of SSRIs-primarily fluoxetine and to some extent citalopram, sertraline, or mirtazapine-may aid in relapse prevention and improvement of psychiatric symptomatology in weight-restored anorexic patients.
** Marvanova M1, Gramith K2. “Role of antidepressants in the treatment of adults with anorexia nervosa”, Ment Health Clin. 2018 Apr 26;8(3):127-137. doi: 10.9740/mhc.2018.05.127. eCollection 2018 May.
* Health care professionals should use clinical judgment regarding fluoxetine or possibly citalopram, sertraline or mirtazapine as adjunctive treatment to psychotherapy for relapse prevention, improvement of depressive and anxiety symptoms, and/or obsessive-compulsive behaviors unresolved with nutritional rehabilitation and psychotherapy.
** Marvanova M1, Gramith K2. “Role of antidepressants in the treatment of adults with anorexia nervosa”, Ment Health Clin. 2018 Apr 26;8(3):127-137. doi: 10.9740/mhc.2018.05.127. eCollection 2018 May.
* Etiological theories emphasize interpersonal and family dysfunction in the development of anorexia nervosa. Research supports the notion that families of individuals with anorexia nervosa have dysfunctional patterns of communication. The history of treatment for anorexia nervosa emphasizes the need for resolution of interpersonal dysfunction, within the traditions of psychodynamic, family therapy, and multidimensional therapies.
** McIntosh, VV; Bulik, CM; McKenzie, JM; Luty, SE; Jordan, J (2000). "Interpersonal psychotherapy for anorexia nervosa", The International Journal of Eating Disorders. 27 (2): 125–39. doi:10.1002/(SICI)1098-108X(200003)27:2<125::AID-EAT1>3.0.CO;2-4. PMID 10657886.
* Interpersonal psychotherapy is a time-limited psychotherapy based on the notion that regardless of etiology, interpersonal relationships are intertwined with symptomatology. The goals of the therapy are to improve interpersonal functioning and thereby decrease symptomatology. Factors identified as important in the development of anorexia nervosa are readily conceptualized within the interpersonal psychotherapy problem areas of grief, interpersonal disputes, interpersonal deficits, and role transitions.
** McIntosh, VV; Bulik, CM; McKenzie, JM; Luty, SE; Jordan, J (2000). "Interpersonal psychotherapy for anorexia nervosa", The International Journal of Eating Disorders. 27 (2): 125–39. doi:10.1002/(SICI)1098-108X(200003)27:2<125::AID-EAT1>3.0.CO;2-4. PMID 10657886.

## N

* In recent years, anorexia and bulimia nervosa, whether combined into a single clinical picture or considered as distinct syndromes, have reached epidemic proportions among adolescents. Professionals in the educational and physical and mental health care fields need to be aware of the influence of social pressures on teenagers' perceptions of body image and appearance. This article reviews the sociocultural, socioeconomic, and sex-related factors which contribute to the development of eating disorders. It is recommended that professionals help adolescents resist societal pressure to conform to unrealistic standards of appearance, and provide guidance on nutrition, realistic body ideals, and achievement of self-esteem, self-efficacy, interpersonal relations and coping skills.
** Nagel KL, Jones KH, “Sociological factors in the development of eating disorders”, Adolescence. 1992 Spring;27(105):107-13.
* Purging can include self-induced vomiting, over-exercising, and the use of diuretics, enemas, and laxatives. Anorexia nervosa is characterized by extreme food restriction and excessive weight loss, accompanied by the fear of being fat.
** Nationaleatingdisorders.org, "Anorexia Nervosa", Archived from the original on 2013-02-04. Retrieved 2013-02-13.
* Prior research on non-clinical samples has lent support to the sexual competition hypothesis for eating disorders (SCH) where the drive for thinness can be seen as an originally adaptive strategy for women to preserve a nubile female shape, which, when driven to an extreme, may cause eating disorders. Restrictive versus impulsive eating behavior may also be relevant for individual differences in allocation of resources to either mating effort or somatic growth, reflected in an evolutionary concept called "Life History Theory" (LHT). In this study, we aimed to test the SCH and predictions from LHT in female patients with clinically manifest eating disorders. Accordingly, 20 women diagnosed with anorexia nervosa (AN), 20 with bulimia nervosa (BN), and 29 age-matched controls completed a package of questionnaires comprising measures for behavioral features and attitudes related to eating behavior, intrasexual competition, life history strategy, executive functioning and mating effort. In line with predictions, we found that relatively faster life history strategies were associated with poorer executive functioning, lower perceived own mate value, greater intrasexual competition for mates but not for status, and, in part, with greater disordered eating behavior. Comparisons between AN and BN revealed that individuals with BN tended to pursue a "fast" life history strategy, whereas people with AN were more similar to controls in pursuing a "slow" life history strategy. Moreover, intrasexual competition for mates was significantly predicted by the severity of disordered eating behavior. Together, our findings lend partial support to the SCH for eating disorders. We discuss the implications and limitations of our study findings.
** Nettersheim J, Gerlach G, Herpertz S, Abed R, Figueredo AJ, Brüne M, “Evolutionary Psychology of Eating Disorders: An Explorative Study in Patients With Anorexia Nervosa and Bulimia Nervosa.”, Front Psychol. 2018 Oct 31;9:2122. doi: 10.3389/fpsyg.2018.02122. eCollection 2018.
* Annorexia can cause menstruation to stop, and often leads to bone loss, loss of skin integrity, etc. It greatly stresses the heart, increasing the risk of heart attacks and related heart problems. The risk of death is greatly increased in individuals with this disease.
** Neumaker, K.J. (2000). "Morality rates and causes of death". European Eating Disorders Review. 8(2): 181–187. doi:10.1002/(SICI)1099-0968(200003)8:2<181::AID-ERV336>3.0.CO;2-#.

## P

* The speculation about whether there may be a positive association between sexual abuse in childhood and the later development of clinical eating disorder has been widely considered over the past 15 years. It has sometimes been accepted uncritically as established truth. It is certainly plausible. After all, bulimia and anorexia nervosa differentially affect girls and seem to involve complex feelings about the body which might well have originated in adverse early sexual experience. Furthermore, many patients disclose such experiences in the clinic. The evidence from early research studies, however, does not consistently support all of the clinical speculation. More than one review reached broadly negative conclusions.1,2 The study by Wonderlich et al systematically re-examines publications up to the end of 1994. The authors of this review had to grapple with studies employing a wide variety of methods and samples. They used predetermined criteria of quality but not meta-analysis to sort out which studies could contribute to their conclusions. They were appropriately strict in applying their criteria. This review supports the position of clinicians who consider that a history of childhood sexual abuse is worth seeking and may be an important consideration in their patients with eating disorders, but no more important than in many other patients. It may be especially relevant for those who have bulimia nervosa with comorbidity. Patients with such complex problems require careful thought. Finding a background of sexual abuse may prove to be important but should not lead to the conclusion that “all is now explained”. Furthermore, most studies show that only a minority of patients with eating disorders report abuse and inferring past abuse from the fact of present eating disorder is unjustified.
** Robert L Palmer, Aetiology, "Review: childhood sexual abuse is associated with bulimia nervosa especially when there is psychiatric comorbidity", vol. 1, issue 2; Wonderlich SA, Brewerton TD, Jocic Z, et al. "Relationship of childhood sexual abuse and eating disorders". J Am Acad Child Adolesc Psychiatry, 1997 Aug; 36 : 1107 –15 CrossRefPubMedWeb of Science
* There is good evidence that children of parents with psychological disorders are themselves at increased risk of disturbances in their development. Although there has been considerable research on a variety of disorders such as depression and alcohol, research on the children of parents with eating disorders has been relatively recent. This paper aims to review the evidence and covers a number of areas, including genetic factors, pregnancy, the perinatal and postpartum period, infancy, and the early years of life, focusing on feeding and mealtimes, general parenting functions, and growth. This is followed by a consideration of psychopathology in the children, parental attitudes to children's weight and shape, and adolescence. What is clear is that although there are numerous case reports and case series, the number of systematic controlled studies is relatively small, and almost nothing has been written about the children of fathers with eating disorders. What is evident from the available evidence is that children of mothers with eating disorders are at increased risk of disturbance, but that the risk depends on a variety of factors, and that difficulties in the children are far from invariable. The paper concludes by summarizing five broad categories of putative mechanisms, based on the evidence to date, by which eating disturbance in parents can influence child development.
** Patel, P; Wheatcroft, R; Park, R; Stein, A (2002). "The Children of Mothers With Eating Disorders". Clinical Child and Family Psychology Review. 5 (1): 1–19. doi:10.1023/A:1014524207660. PMID 11993543.
* This study explored friendship variables in relation to body image, dietary restraint, extreme weight-loss behaviors (EWEBs), and binge eating in adolescent girls. From 523 girls, 79 friendship cliques were identified using social network analysis. Participants completed questionnaires that assessed body image concerns, eating, friendship relations, and psychological family, and media variables. Similarity was greater for within than for between friendship cliques for body image concerns, dietary restraint, and EWLBs, but not for binge eating. Cliques high in body image concerns and dieting manifested these concerns in ways consistent with a high weight/shape-preoccupied subculture. Friendship attitudes contributed significantly to the prediction of individual body image concern and eating behaviors. Use of EWLBs by friends predicted an individual's own level of use.
** Paxton, SJ; Schutz, HK; Wertheim, EH; Muir, SL (1999).[ https://www.ncbi.nlm.nih.gov/pubmed/10369035 "Friendship clique and peer influences on body image concerns, dietary restraint, extreme weight-loss behaviors, and binge eating in adolescent girls"], Journal of Abnormal Psychology. 108 (2): 255–66. doi:10.1037/0021-843X.108.2.255. PMID 10369035.
* In the literature, no review concerning the family comorbidity of mood and anxiety disorders of anorexic subjects exists. However, this data can be important for the comprehension of this disorder and for the assumption of responsibility.
** Perdereau F1, Faucher S, Jeammet P, Godart NT. “Mood and anxiety disorders in relatives of anorexia nervosa patients: a review”, Encephale. 2007 Mar-Apr;33(2):144-55.
* The group receiving nutritional counseling relapsed significantly earlier and at a higher rate than the group receiving cognitive behavior therapy (53% versus 22%). The overall treatment failure rate (relapse and dropping out combined) was significantly lower for cognitive behavior therapy (22%) than for nutritional counseling (73%). The criteria for "good outcome" were met by significantly more of the patients receiving cognitive behavior therapy (44%) than nutritional counseling (7%).
** Pike, KM; Walsh, BT; Vitousek, K; Wilson, GT; Bauer, J (2003). "Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa". The American Journal of Psychiatry. 160 (11): 2046–9. doi:10.1176/appi.ajp.160.11.2046. PMID 14594754.
* Cognitive behavior therapy was significantly more effective than nutritional counseling in improving outcome and preventing relapse. To the authors' knowledge, these data provide the first empirical documentation of the efficacy of any psychotherapy, and cognitive behavior therapy in particular, in posthospitalization care and relapse prevention of adult anorexia nervosa.
** Pike, KM; Walsh, BT; Vitousek, K; Wilson, GT; Bauer, J (2003). "Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa". The American Journal of Psychiatry. 160 (11): 2046–9. doi:10.1176/appi.ajp.160.11.2046. PMID 14594754.
* The purpose of this study was to assess the relative contribution of personality and emotional experience to self-reported eating attitudes in a group of patients with clinically diagnosed eating disorders, a weight-reduction training group (Weight Watchers), and a control group without body weight problems. Participants in this study (N = 114) completed Estonian versions of the Eating Disorder Inventory-2 (EDI-2; Garner, 1991), NEO Personality Inventory (Costa & McCrae, 1989), and Positive Affect and Negative Affect Schedule, Expanded Form (Watson & Clark, 1994). Data demonstrated validity of the Estonian version of EDI-2 in its ability to identify problems on a continuum of disordered eating behavior. Among the Big Five personality dimensions, Neuroticism made the largest contribution to EDI-2 subscales. Two other dimensions, Openness to Experience and Conscientiousness, also predispose individuals to eating problems. Personality traits made a larger contribution to the self-reported eating pathology than the self-rated effects experienced during the last few weeks. It was argued that personality dispositions have a larger relevancy in the etiology of eating disorders than emotional state.
** Podar, I; Hannus, A; Allik, J (1999). "Personality and affectivity characteristics associated with eating disorders: a comparison of eating disordered, weight-preoccupied, and normal samples". Journal of Personality Assessment. 73 (1): 133–47. doi:10.1207/S15327752JPA730109. PMID 10497805.
* Some contributory factors appear to be necessary for the appearance of eating disorders, but none is sufficient. Eating disorders may represent a way of coping with problems of identity and personal control.
** Polivy, J; Herman, CP (2002). "Causes of eating disorders". Annual Review of Psychology. 53: 187–213. doi:10.1146/annurev.psych.53.100901.135103. PMID 11752484.
* Suicide in anorexia nervosa and bulimia nervosa is a major cause of death. Risk factors for suicide and attempted suicide (which in many cases results in successful suicide) in anorexia nervosa include: purging type, chronic disease, and during treatment, obsessive symptoms and drug abuse, major depression, and for anorexia nervosa low body mass index (BMI) at presentation. In anorexia nervosa suicide has been considered the first cause of death and attempted suicide is a serious threat to these individuals. Data concerning suicide in bulimia nervosa has still scarce whereas attempted suicides are easily found in clinical histories of patients. No doubt suicidal behavior is underestimated amongst patients with anorexia nervosa and bulimia nervosa. An effort to reconcile with subject of suicide and a better evaluation of these patients' psychopathology should improve suicide prevention strategies amongst these individuals.
** Pompili, M; Mancinelli, I; Girardi, P; Accorrà, D; Ruberto, A; Tatarelli, R (2003). "Suicide and attempted suicide in anorexia nervosa and bulimia nervosa". Annali dell'Istituto Superiore di Sanità. 39 (2): 275–81. PMID 14587228.
* Although it remains unclear whether the prevalence of eating disorders is higher in those with DRCHCs compared with the general population, overall findings suggest that young people with DRCHCs may be at risk of endorsing disordered eating behaviors that may lead to diagnosis of an eating disorder and other health problems over the course of their treatment. Thus, health care providers should be aware that young people with DRCHCs may be at risk of eating disorders and carefully monitor psychological changes and the use of unhealthy weight control methods. It is also important to develop and evaluate theory-based interventions and disease-specific eating disorder risk screening tools that are effective in halting the progression of eating disorders and negative health outcomes in young people with chronic health conditions.
** Quick VM, Byrd-Bredbenner C, Neumark-Sztainer D (May 1, 2013). "Chronic illness and disordered eating: a discussion of the literature". Adv Nutr (Review). 4 (3): 277–86. doi:10.3945/an.112.003608. PMC 3650496. PMID 23674793.

## R

* The development of eating disorders including anorexia nervosa, bulimia nervosa, binge eating disorder, and atypical eating disorders that affect many young women and even men in the productive period of their lives is complex and varied. While numbers of presumed risk factors contributing to the development of eating disorders are increasing, previous evidence for biological, psychological, developmental, and sociocultural effects on the development of eating disorders have not been conclusive. Despite the fact that a huge body of research has carefully examined the possible risk factors associated with the eating disorders, they have failed not only to uncover the exact etiology of eating disorders, but also to understand the interaction between different causes of eating disorders. This failure may be due complexities of eating disorders, limitations of the studies or combination of two factors. In this review, some risk factors including biological, psychological, developmental, and sociocultural are discussed.
** Rikani, AA; Choudhry, Z; Choudhry, AM; Ikram, H; Asghar, MW; Kajal, D; Waheed, A; Mobassarah, NJ (October 2013). "A critique of the literature on etiology of eating disorders". Annals of Neurosciences. 20 (4): 157–61. doi:10.5214/ans.0972.7531.200409. PMC 4117136. PMID 25206042.
* It has been hypothesized that eating disorders have multiple and often shared etiologies including biological, psychological, developmental, and sociocultural. A tightly woven network of causes, symptoms, and outcomes of eating disorders makes the study of etiology of these disorders very challenging. Some suggested risk factors for eating disorders require to be defined as either integral parts of eating disorders syndrome such as body dissatisfaction, and perfectionism or outcome of prolonged disordered eating such as functional alterations in serotonin, and some mood disturbances. Researchers should structure their thought processes around this concept that some of currently well-known risk factors for eating disorders are concurrent symptoms of eating disorders. Hence paying special attention to the new and evolved concepts is highly recommended while studying the etiology of eating disorders.
** Rikani, AA; Choudhry, Z; Choudhry, AM; Ikram, H; Asghar, MW; Kajal, D; Waheed, A; Mobassarah, NJ (October 2013). "A critique of the literature on etiology of eating disorders". Annals of Neurosciences. 20 (4): 157–61. doi:10.5214/ans.0972.7531.200409. PMC 4117136. PMID 25206042.
* This article describes the qualitative analysis of a randomized control trial that explores the use of parent-to-parent consultations as an augmentation to the Maudsley model of family-based treatment for anorexia. Twenty families were randomized into two groups, 10 receiving standard treatment and 10 receiving an additional parent-to-parent consultation. Parents of all families were interviewed regarding their experience of treatment and transcripts were analyzed with the assistance of QSR N-Vivo. Parents described parent-to-parent consultations as an intense emotional experience that helped them to feel less alone, to feel empowered to progress, and to reflect on changes in family interactions. These results suggest that parent-to-parent consultations are seen as a useful augmentation to the Maudsley model of family-based treatment for anorexia nervosa.
** Rhodes, P; Brown, J; Madden, S (2009). "The Maudsley model of family-based treatment for anorexia nervosa: a qualitative evaluation of parent-to-parent consultation". Journal of Marital and Family Therapy. 35 (2): 181–92. doi:10.1111/j.1752-0606.2009.00115.x. PMID 19302516.
* Tumours of the central nervous system mostly present with neurological symptoms and signs of intracranial hypertension. Several reports of cerebral tumors in adolescents outline initial symptoms of anorexia and emaciation, leading to the diagnosis of anorexia nervosa.
** Rohrer, TR; Fahlbusch, R; Buchfelder, M; Dörr, HG (2006). "Craniopharyngioma in a female adolescent presenting with symptoms of anorexia nervosa", Klinische Pädiatrie. 218 (2): 67–71. doi:10.1055/s-2006-921506. PMID 16506105.
* We report on a 15.5-year-old girl with a craniopharyngioma. The girl had a 2 year history of weight loss, dystrophy, no onset of puberty, and a 6 year history of headache. These symptoms had led initially to the clinical diagnoses of migraine and anorexia nervosa, since unenhanced computed tomography of the brain was normal. At presentation, physical examination showed short stature (height SDS - 3.6) and Tanner stage I. Bone age delay was about four years. Laboratory analyses showed hypopituitarism. The diagnosis of craniopharyngioma was made by repeated imaging, depicting an intrasellar and parasellar mass, which was totally removed by neurosurgery. Hormonal substitution with hGH, L-thyroxine, hydrocortisone, and estrogens led to normal physiological development and final height within upper target height.
** Rohrer, TR; Fahlbusch, R; Buchfelder, M; Dörr, HG (2006). "Craniopharyngioma in a female adolescent presenting with symptoms of anorexia nervosa", Klinische Pädiatrie. 218 (2): 67–71. doi:10.1055/s-2006-921506. PMID 16506105.
* The reported case illustrates that the diagnosis of craniopharyngioma is often delayed due to unspecific clinical symptoms. Careful evaluation of anthropometrics, ophthalmologic, and endocrine data in patients with suspected eating disorders may give additional clues to the diagnosis of a craniopharyngioma.
** Rohrer, TR; Fahlbusch, R; Buchfelder, M; Dörr, HG (2006). "Craniopharyngioma in a female adolescent presenting with symptoms of anorexia nervosa", Klinische Pädiatrie. 218 (2): 67–71. doi:10.1055/s-2006-921506. PMID 16506105.
* Studies have reported that the oral health status is jeopardized in patients with eating disorders. The aim was to review the oro-facial manifestations in patients with eating disorders. The address the focused question was "What is the oro-dental health status in patients with eating disorders?" MEDLINE/PubMed and Google Scholar databases were searched from 1948 to March 2012 using the following terms in various combinations: "Anorexia nervosa", "bulimia nervosa", "eating disorders", "dental", "oral health status". Letters to the editor, unpublished data and articles published in languages other than English were excluded. Dry lips, burning tongue and parotid gland swelling are common manifestations in patients with eating disorders as compared to medically healthy controls. The association of dental caries and periodontal disease in patients with eating disorders remains debatable. Temporomandibular disorders have also been reported to be more prevalent in patients with eating disorders as compared to healthy controls. A critical oral-dental examination during routine dental check-ups may reveal valuable information regarding the presence or absence of eating disorders in routine dental patients. This may be important information, updating the medical history, supporting the role of the physician.
** Romanos, GE; Javed, F; Romanos, EB; Williams, RC (October 2012). "Oro-facial manifestations in patients with eating disorders". Appetite. 59 (2): 499–504. doi:10.1016/j.appet.2012.06.016. PMID 22750232.
* Comorbid personality disorders in eating disordered patients may seriously affect the treatment and course of their illness. Several studies show such a comorbidity, though with inconsistent findings. Qualitative reviews attribute this to methodological shortcomings, but the qualitative method may itself create new shortcomings. To circumvent this, the present, more extensive review applies a meta-analytic approach. Using the databases MEDLINE and PSYCHLIT, the 28 articles published between 1983 and 1998 that presented empirical evidence for an eating disorder and personality disorder comorbidity suitable for meta-analysis were included. We found a higher proportion of eating disordered patients with any personality disorder (average proportion = 0.58) related to comparison groups (average proportion = 0.28). Compared with anorexia nervosa patients, a higher proportion of patients with bulimia nervosa had a concurrent cluster B personality (average proportion = 0.44) and a borderline personality disorder (average proportion = 0.31). However, no differences between anorexia nervosa and bulimia nervosa patients in proportions of cluster C were found (average proportion = 0.45 and 0.44 respectively). Patients with eating disorders and patients with bulimia nervosa in particular, should be routinely assessed for a concurrent personality disorder using structured clinical interviews. In future research, more stringent assessment procedures are highly recommended to address the question of causality between eating disorders and personality disorders, and how eating disorder symptoms and personality disorder symptoms are related to treatment effects.
** Rosenvinge, JH; Martinussen, M; Ostensen, E (2000). "The comorbidity of eating disorders and personality disorders: a meta-analytic review of studies published between 1983 and 1998". Eating and Weight Disorders. 5 (2): 52–61. doi:10.1007/bf03327480. PMID 10941603.
* The aim of this investigation was to study the relationship between unhealthy eating habits and behaviors, perception and acceptance of societal standards regarding thinness, body dissatisfaction, and family and peer pressure to be thin. One hundred and twentythree high school girls from Rijeka (Croatia) were surveyed using Eating Attitudes Test (EAT- 26), Sociocultural Attitudes Towards Appearance Questionnaire (SATAQ), Body Esteem Questionnaire for Adolescents and Adults (BES), and Scale of perceived pressure to be thin from family and peers. The results of path analyses showed that social pressure from family and peers, experience of weight-related teasing and criticism by family members, contributed to development of eating disturbance. The acceptance of social standards related to appearance, contributed to onset of disturbed eating habits. Weight satisfaction alone influences the development of some eating disorder symptoms, but it is also a mediator of higher body mass index (BMI) and internalization of societal appearance standards. Girls with higher BMI, who accepted societal standards of thin-ideal, perceived major social pressure to be thin through direct and persuasive comments designed to establish the importance of dieting, and probably develop eating disturbed habits, or some symptoms of anorexia (AN) or bulimia nervosa (BN).
** Rukavina, T; Pokrajac-Bulian, A (2006). "Thin-ideal internalization, body dissatisfaction and symptoms of eating disorders in Croatian adolescent girls". Eating and Weight Disorders : EWD. 11 (1): 31–7. doi:10.1007/bf03327741. PMID 16801743.
* The development of eating disorders including anorexia nervosa, bulimia nervosa, binge eating disorder, and atypical eating disorders that affect many young women and even men in the productive period of their lives is complex and varied. While numbers of presumed risk factors contributing to the development of eating disorders are increasing, previous evidence for biological, psychological, developmental, and sociocultural effects on the development of eating disorders have not been conclusive. Despite the fact that a huge body of research has carefully examined the possible risk factors associated with the eating disorders, they have failed not only to uncover the exact etiology of eating disorders, but also to understand the interaction between different causes of eating disorders. This failure may be due complexities of eating disorders, limitations of the studies or combination of two factors. In this review, some risk factors including biological, psychological, developmental, and sociocultural are discussed.
** Romanos, GE; Javed, F; Romanos, EB; Williams, RC (October 2012). "Oro-facial manifestations in patients with eating disorders". Appetite. 59 (2): 499–504. doi:10.1016/j.appet.2012.06.016. PMID 22750232.
* Studies have reported that the oral health status is jeopardized in patients with eating disorders. The aim was to review the oro-facial manifestations in patients with eating disorders. The address the focused question was "What is the oro-dental health status in patients with eating disorders?" MEDLINE/PubMed and Google Scholar databases were searched from 1948 to March 2012 using the following terms in various combinations: "Anorexia nervosa", "bulimia nervosa", "eating disorders", "dental", "oral health status". Letters to the editor, unpublished data and articles published in languages other than English were excluded. Dry lips, burning tongue and parotid gland swelling are common manifestations in patients with eating disorders as compared to medically healthy controls. The association of dental caries and periodontal disease in patients with eating disorders remains debatable. Temporomandibular disorders have also been reported to be more prevalent in patients with eating disorders as compared to healthy controls. A critical oral-dental examination during routine dental check-ups may reveal valuable information regarding the presence or absence of eating disorders in routine dental patients. This may be important information, updating the medical history, supporting the role of the physician.
** Romanos, GE; Javed, F; Romanos, EB; Williams, RC (October 2012). "Oro-facial manifestations in patients with eating disorders". Appetite. 59 (2): 499–504. doi:10.1016/j.appet.2012.06.016. PMID 22750232.

## S

* Anorexia nervosa (AN) is a severe and often chronic disorder with uncertain aetiology and poor prognosis. New approaches to the understanding of the disorder are needed in order to aid the development of more effective treatments. Several authors have suggested that AN has a considerable overlap with obsessive-compulsive disorder (OCD) and that this may reflect common neurobiological, genetic, or psychological elements. However, more recent studies have suggested that AN may have a closer relationship with obsessive-compulsive personality traits such as those found in obsessive-compulsive personality disorder (OCPD). In this paper, evidence for links between the three conditions is reviewed, suggestions for further research are outlined and possible implications for the treatment of AN are presented.
** Serpell, L; Livingstone, A; Neiderman, M; Lask, B (2002). "Anorexia nervosa: obsessive-compulsive disorder, obsessive-compulsive personality disorder, or neither?". Clinical Psychology Review, 22 (5): 647–69. doi:10.1016/S0272-7358(01)00112-X. PMID 12113200.
* The cognitive model of eating disorders (EDs) states that the processing of external and internal stimuli might be biased in mental disorders. These biases, or cognitive errors, systematically distort the individual's experiences and, in that way, maintains the eating disorder. This chapter presents an updated literature review of experimental studies investigating these cognitive biases. Results indicate that ED patients show biases in attention, interpretation, and memory when it comes to the processing of food-, weight-, and body shape-related cues. Some recent studies show that they also demonstrate errors in general cognitive abilities such as set shifting, central coherence, and decision making. A future challenge is whether cognitive biases and processes can be manipulated. Few preliminary studies suggest that an attention retraining and training in the cognitive modulation of food reward processing might be effective strategies to change body satisfaction, food cravings, and eating behavior.
** Siep N, Jansen A, Havermans R, Roefs A, “Cognitions and emotions in eating disorders.”, Curr Top Behav Neurosci. 2011;6:17-33. doi: 10.1007/7854_2010_82.
* An individual who is a first degree relative of someone who has had or currently has an eating disorder is seven to twelve times more likely to have an eating disorder themselves. Twin studies also show that at least a portion of the vulnerability to develop eating disorders can be inherited, and there is evidence to show that there is a genetic locus that shows susceptibility for developing anorexia nervosa.
** Siep N, Jansen A, Havermans R, Roefs A, “Cognitions and emotions in eating disorders.”, Curr Top Behav Neurosci. 2011;6:17-33. doi: 10.1007/7854_2010_82.
* Anorexia nervosa is currently considered a disorder confined to Western culture. Its recent identification in non-Western societies and different subcultures within the Western world has provoked a theory that Western cultural ideals of slimness and beauty have infiltrated these societies. The biomedical definition of anorexia nervosa emphasizes fat-phobia in the presentation of anorexia nervosa. However, evidence exists that suggests anorexia nevosa can exist without the Western fear of fatness and that this culturally biased view of anorexia nervosa may obscure health care professionals' understanding of a patient's own cultural reasons for self-starvation, and even hinder their recovery.
** Simpson, KJ (2002). "Anorexia nervosa and culture". Journal of Psychiatric and Mental Health Nursing. 9 (1): 65–71. doi:10.1046/j.1351-0126.2001.00443.x. PMID 11896858.
* Anorexia nervosa is currently considered a disorder confined to Western culture. Its recent identification in non-Western societies and different subcultures within the Western world has provoked a theory that Western cultural ideals of slimness and beauty have infiltrated these societies. The biomedical definition of anorexia nervosa emphasizes fat-phobia in the presentation of anorexia nervosa. However, evidence exists that suggests anorexia nevosa can exist without the Western fear of fatness and that this culturally biased view of anorexia nervosa may obscure health care professionals' understanding of a patient's own cultural reasons for self-starvation, and even hinder their recovery.
** Soh, NL; Touyz, SW; Surgenor, LJ (2006). "Eating and body image disturbances across cultures: A review". European Eating Disorders Review. 14 (1): 54–65. doi:10.1002/erv.678.
* Patients with eating disorders (ED) frequently exhibit additional psychiatric disorders. This study aimed to examine whether psychiatric comorbidity in ED patients is associated with increased severity of ED symptoms in a sample of 277 women with a current ED (84 anorexia nervosa, 152 bulimia nervosa, 41 eating disorders not otherwise specified). Psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview (SCID) for DSM-IV. Severity of ED-related symptoms was assessed using interviewer-rated scales from the Structured Interview for Anorexia and Bulimia Nervosa (SIAB). Affective and anxiety-related disorders of both axes were linked with increased intensity of weight- and appearance-related fears and concerns. Frequency of binge-eating and frequency of purging both were associated with Axis I anxiety disorders, substance-related disorders, and Cluster B personality disorders. Frequency of dieting was related to anxiety disorders on both axes. Multivariate analyses revealed that Axis I anxiety disorders were more closely linked with severity of ED symptoms than affective or substance-related disorders. The results showed that psychiatric comorbidity of both axes is linked with increased severity of ED symptoms and that there are associations between specific ED symptoms and specific forms of comorbidity.
** Spindler, A; Milos, G (2007). "Links between eating disorder symptom severity and psychiatric comorbidity". Eating Behaviors. 8 (3): 364–73. doi:10.1016/j.eatbeh.2006.11.012. PMID 17606234.
* Eating disorders, such as anorexia, bulimia, and binge eating disorder, commonly involve a dysregulation of behavior (e.g., a lack or excess of inhibition and impulsive eating patterns) that is suggestive of prefrontal dysfunction. Functional neuro-imaging studies show that prefrontal-subcortical systems play a role in eating behavior and appetite in healthy individuals, and that people with eating disorders have altered activity in these systems. Eating behavior is often disturbed by illnesses and injuries that impinge upon prefrontal-subcortical systems. This study examined relationships between executive functioning and eating behavior in healthy individuals using validated behavioral rating scales (Frontal Systems Behavior Scale and Eating Inventory). Correlations demonstrated that increased dysexecutive traits were associated with disinhibited eating and greater food cravings. There was also a positive association with cognitive restraint of eating, suggesting that increased compensatory behaviors follow disinhibited eating. These psychometric findings reinforce those of other methodologies, supporting a role for prefrontal systems in eating.
** Spinella, M; Lyke, J (2004). "Executive personality traits and eating behavior". The International Journal of Neuroscience. 114 (1): 83–93. doi:10.1080/00207450490249356. PMID 14660070.
* Recent research has modified both the conceptualization and treatment of eating disorders. New diagnostic criteria reducing the "not otherwise specified" category should facilitate the early recognition and treatment of anorexia nervosa (AN) and bulimia nervosa (BN). Technology-based studies identify AN and BN as "brain circuit" disorders; epidemiologic studies reveal that the narrow racial, ethnic and income profile of individuals no longer holds true for AN. The major organs affected long term-the brain and skeletal system-both respond to improved nutrition, with maintenance of body weight the best predictor of recovery. Twin studies have revealed gene x environment interactions, including both the external (social) and internal (pubertal) environments of boys and of girls. Family-based treatment has the best evidence base for effectiveness for younger patients. Medication plays a limited role in AN, but a major role in BN. Across diagnoses, the most important medicine is food.
** Starr TB, Kreipe RE, “Anorexia nervosa and bulimia nervosa: brains, bones and breeding”, Curr Psychiatry Rep. 2014 May;16(5):441. doi: 10.1007/s11920-014-0441-4.
* There were large variations in the outcome parameters across studies. Mortality estimated on the basis of both crude and standardized rates was significantly high. Among the surviving patients, less than one-half recovered on average, whereas one-third improved, and 20% remained chronically ill. The normalization of the core symptoms, involving weight, menstruation, and eating behaviors, was slightly better when each symptom was analyzed in isolation. The presence of other psychiatric disorders at follow-up was very common. Longer duration of follow-up and, less strongly, younger age at onset of illness were associated with better outcome. There was no convincing evidence that the outcome of anorexia nervosa improved over the second half of the last century. Several prognostic features were isolated, but there is conflicting evidence. Most clearly, vomiting, bulimia, and purgative abuse, chronicity of illness, and obsessive-compulsive personality symptoms are unfavorable prognostic features.
** Steinhausen HC, “The outcome of anorexia nervosa in the 20th century”, Am J Psychiatry. 2002 Aug;159(8):1284-93.
* Anorexia nervosa did not lose its relatively poor prognosis in the 20th century. Advances in etiology and treatment may improve the course of patients with anorexia nervosa in the future.
** Steinhausen HC, “The outcome of anorexia nervosa in the 20th century”, Am J Psychiatry. 2002 Aug;159(8):1284-93.
* Anorexia nervosa (AN) has the highest mortality rate between psychiatric disorders, and evidence for managing it is still very limited. So far, pharmacological treatment has focused on a narrow range of drugs and only a few controlled studies have been performed. Furthermore, the studies have been of short duration and included a limited number of subjects, often heterogenic with regard to stage and acute nutritive status. Thus, novel approaches are urgently needed. Body weight homeostasis is tightly regulated throughout life. With the discovery of orexigenic and anorectic signals, an array of new molecular targets to control eating behavior has emerged. This review focuses on recent advances in three important signal systems: leptin, ghrelin, and endocannabinoids toward the identification of potential therapeutical breakthroughs in AN. Our review of the current literature shows that leptin may have therapeutic potentials in promoting restoration of menstrual cycles in weight restored patients, reducing motor restlessness in severely hyperactive patients, and preventing osteoporosis in chronic patients. Ghrelin and endocannabinoids exert orexigenic effects which may facilitate nutritional restoration. Leptin and endocannabinoids may exert antidepressive and anxiolytic effects. Finally, monitoring serum concentration of leptin may be useful in order to prevent refeeding syndrome. Circulating concentrations of leptin are exceedingly low during the acute stage of anorexia nervosa. Which symptoms result from these diminished concentrations must be clarified. Furthermore, research is required to evaluate whether or not a too rapid weight gain might induce a physiological counter-regulation which would predispose to renewed loss of weight.
** Støving RK1, Andries A, Brixen K, Flyvbjerg A, Hørder K, Frystyk J, “Leptin, ghrelin, and endocannabinoids: potential therapeutic targets in anorexia nervosa”, J Psychiatr Res. 2009 Apr;43(7):671-9. doi: 10.1016/j.jpsychires.2008.09.007. Epub 2008 Oct 15.
* Eating disorders are significant causes of morbidity and mortality in adolescent females and young women. They are associated with severe medical and psychological consequences, including death, osteoporosis, growth delay and developmental delay. Dermatologic symptoms are almost always detectable in patients with severe anorexia nervosa (AN) and bulimia nervosa (BN), and awareness of these may help in the early diagnosis of hidden AN or BN.
** Strumia, R (2005). "Dermatologic signs in patients with eating disorders". American Journal of Clinical Dermatology. 6 (3): 165–73. doi:10.2165/00128071-200506030-00003. PMID 15943493.

## T

* Anorexia nervosa (AN) is a severe mental illness. Drug treatments are not effective and there is no established first choice psychological treatment for adults with AN. Neuropsychological studies have shown that patients with AN have difficulties in cognitive flexibility: these laboratory based findings have been used to develop a clinical intervention based on Cognitive Remediation Therapy (CRT) which aims to use cognitive exercises to strengthen thinking skills.
** Tchanturia, K; Davies, H; Campbell, IC (2007). "Cognitive remediation therapy for patients with anorexia nervosa: preliminary findings". Annals of General Psychiatry. 6 (1): 14. doi:10.1186/1744-859X-6-14. PMC 1892017. PMID 17550611.
* This preliminary study suggests that CRT changed performance on flexibility tasks and may be beneficial for acute, treatment resistant patients with AN. Feedback gathered from this small case series has enabled modification of the intervention for a future larger study, for example, by linking exercises with real life behavioural tasks and including exercises that encourage global thinking.
** Tchanturia, K; Davies, H; Campbell, IC (2007). "Cognitive remediation therapy for patients with anorexia nervosa: preliminary findings". Annals of General Psychiatry. 6 (1): 14. doi:10.1186/1744-859X-6-14. PMC 1892017. PMID 17550611.
* This exploratory study has produced encouraging data supporting the use of CRT in patients with AN: it has also provided insight into how the module should be tailored to maximise its effectiveness for people with acute AN.
** Tchanturia, K; Davies, H; Campbell, IC (2007). "Cognitive remediation therapy for patients with anorexia nervosa: preliminary findings". Annals of General Psychiatry. 6 (1): 14. doi:10.1186/1744-859X-6-14. PMC 1892017. PMID 17550611.
* This review summarises the results of psychopharmacological treatment studies on anorexia and, bulimia nervosa. Although several drugs have tested in patients with anorexia nervosa, the outcome of controlled studies has been disappointing. Trials of pharmacotherapy for bulimia nervosa have demonstrated that tricyclic antidepressants, monoamine oxidase inhibitors and selective serotonin reuptake inhibitors significantly reduce the frequency of binge eating and purging. In some cases, psychotherapists should accept the necessity of psychopharmacological intervention, although this does not imply a known biological cause of the eating disorder. However, the significance of antidepressant medication in the overall treatment of anorexia and bulimia nervosa remains unclear.
** Thiel A. “Are psychotropic drugs necessary for the treatment of anorexia and bulimia nervosa?”, Psychother Psychosom Med Psychol. 1997 Sep-Oct;47(9-10):332-45.
* Studies using the Cloninger's personality theory suggested that high Harm Avoidance might be relevant to the pathology of anorexia nervosa and high Novelty Seeking and Harm Avoidance to bulimia nervosa.
** Tomotake M, Ohmori T, "Personality profiles in patients with eating disorders", J Med Invest. 2002 Aug;49(3-4):87-96.
* The Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) is a psychometrically sound self-report instrument for assessing women's attitudes towards their own bodies. The BAQ responses of a large sample of patients with eating disorders (ED) diagnosed in accordance with DSM-III-R criteria were compared with those from a normative population and from diverse groups of psychiatrically and physically ill patients. The ED group was distinct, and showed extreme responses in the area of weight and shape concerns. But a better discrimination between the ED and other populations was achieved using subscales that related to 'body disparagement' (an intense loathing of the body) and 'attractiveness', rather than to weight and shape concerns. ED patients may have a more pervasive disturbance in body-related attitudes than is currently widely accepted. Patients with anorexia and bulimia nervosa showed very similar attitudes despite the symptomatic differences between the groups.
** Ben-Tovim, DI; Walker, MK (1992). "A quantitative study of body-related attitudes in patients with anorexia and bulimia nervosa". Psychological Medicine. 22 (4): 961–9. doi:10.1017/S0033291700038538. PMID 1488491.
* There are a number of differences in the aetiology of subtypes of eating disorder. The present results suggest that cognitive styles pertaining to the social arena in adolescence, and prior to the onset of any eating disorders, may play a causal role in the development of anorexia nervosa of the binge/purge subtype, but not anorexia nervosa of the restricting subtype.
** Troop, NA; Bifulco, A (2002). "Childhood social arena and cognitive sets in eating disorders". The British Journal of Clinical Psychology. 41 (Pt 2): 205–11. doi:10.1348/014466502163976. PMID 12034006.
* Aetiology and pathogenesis of eating disorders is a matter of controversy. In some cases they can occur in association with tumours involving the temporal cortex, in temporal lobe epilepsy or in the advanced state of degenerative diseases involving temporal structures. We report about three patients with right frontal intracerebral lesions, one oligo-astrocytoma and two vascular malformations, associated with partial seizures and anorexia nervosa.
** Trummer, M; Eustacchio, S; Unger, F; Tillich, M; Flaschka, G (2002). "Right hemispheric frontal lesions as a cause for anorexia nervosa report of three cases". Acta Neurochirurgica. 144 (8): 797–801. doi:10.1007/s00701-002-0934-5. PMID 12181689.
* Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders. We therefore recommend performing a cranial MRI in all patients with suspected eating disorders, especially if they occur in combination with focal seizures.
** Trummer, M; Eustacchio, S; Unger, F; Tillich, M; Flaschka, G (2002). "Right hemispheric frontal lesions as a cause for anorexia nervosa report of three cases". Acta Neurochirurgica. 144 (8): 797–801. doi:10.1007/s00701-002-0934-5. PMID 12181689.

## U

* Eating disorders, including anorexia and bulimia nervosa, are characterised by abnormal eating behaviour and typical psychopathological features, including fear of fatness, drive for thinness, and body image disturbance. In most patients, there is no detectable focal brain abnormality. Nonetheless, associations of anorexia and bulimia nervosa with history of perinatal complications and head injuries suggest a role of cerebral pathology in some cases. A number of case studies describe eating disorders with intracranial tumours, injuries, or epileptogenic foci. However, many clinical descriptions are limited to changes in appetite and lack psychopathological features characteristic of eating disorders. A previous review of 21 anorexia cases associated with brain tumours found that only three of them fulfilled formal diagnostic criteria. In the present paper, we provide a systematic review of published case reports and highlight those relatively rare cases where typical eating disorders appear to be causally associated with localised brain damage.
** Uher R, Treasure J, "Brain lesions and eating disorders", J Neurol Neurosurg Psychiatry. 2005 Jun; 76(6):852-7.

## V

* Eighteen female inpatients were included in a double-blind placebo-controlled cross-over study aimed at testing the hypothesis that dopamine blockade may enhance the effectiveness of behavior therapy in the short-term weight restoration of anorexia nervosa patients. The patients were given a uniform contingency management program and, after a baseline period, they alternatingly (3-week periods) received pimozide (4 to 6 mg) or a placebo. During the first two periods pimozide almost significantly enhanced the weight gain induced by the behavior therapy program and beneficially influenced the patients' attitude towards treatment.
* Vandereycken, W; Pierloot, R (1982). "Pimozide combined with behavior therapy in the short-term treatment of anorexia nervosa. A double-blind placebo-controlled cross-over study". Acta Psychiatrica Scandinavica. 66 (6): 445–50. doi:10.1111/j.1600-0447.1982.tb04501.x. PMID 6758492.
* All dominant models of the eating disorders implicate personality variables in the emergence of weight concerns and the development of specific symptoms such as bingeing and purging. Standardized measures of personality traits and disorders generally confirm clinical descriptions of restricting anorexics as constricted, conforming, and obsessional individuals. A less consistent picture suggesting affective instability and impulsivity has emerged from the assessment of subjects with bulimia nervosa. Considerable heterogeneity exists within eating disorder subtypes, however, and a number of special problems complicate the interpretation of personality data in this population. These include young age at onset, the influence of state variables such as depression and starvation sequelae, denial and distortion in self-report, the instability of subtype diagnoses, and the persistence of residual problems following symptom control.
** Vitousek, K; Manke, F (1994). "Personality variables and disorders in anorexia nervosa and bulimia nervosa". Journal of Abnormal Psychology. 103(1): 137–47. doi:10.1037/0021-843X.103.1.137. PMID 8040475.

## W

* The Eating Disorder Service at the Children's Hospital at Westmead (CHW) in Sydney, provides comprehensive inpatient and outpatient treatment for children and adolescents with eating disorders. In 2003 the Maudsley Model of family based treatment for anorexia nervosa was introduced to support outpatient care. This has resulted in positive changes in the dynamics of the eating disorder team, a change in the philosophies that underpin the program and the experience of families that consult the service. There has also been a significant decrease in readmission rates. Our experience with the model has resulted in requests to provide training to other clinicians around Australia and a number of ongoing consultative relationships have followed. Implementation of the Maudsley model at CHW is described, followed by an overview of the theory and a summary of the key changes and challenges since moving in this new direction in 2003.
** Wallis, A; Rhodes, P; Kohn, M; Madden, S (2007). "Five-years of family based treatment for anorexia nervosa: the Maudsley Model at the Children's Hospital at Westmead". International Journal of Adolescent Medicine and Health. 19 (3): 277–83. doi:10.1515/IJAMH.2007.19.3.277. PMID 17937144.
* Would anorexia have so quickly become part of Hong Kong’s symptom repertoire without the importation of the Western template for the disease? It seems unlikely. Beginning with scattered European cases in the early 19th century, it took more than 50 years for Western mental-health professionals to name, codify and popularize anorexia as a manifestation of hysteria. By contrast, after Charlene fell onto the sidewalk on Wan Chai Road on that late November day in 1994, it was just a matter of hours before the Hong Kong population learned the name of the disease, who was at risk and what it meant.
** Ethan Watters, “The Americanization of Mental Illness”, New York Times, (JAN. 8, 2010).
* Clinical observation has long suggested a link between personality and eating disorders. Research has consistently linked anorexia (particularly when the patient does not also have bulimic symptoms) to personality traits such as introversion, conformity, perfectionism, rigidity, and obsessive-compulsive features. The picture for bulimia is more mixed. Traits such as perfectionism, shyness, and compliance have consistently emerged in studies of individuals with bulimia or with anorexia, although research has often found bulimic patients to be extroverted, histrionic, and affectively unstable.
** Westen, D; Harnden-Fischer, J (2001). "Personality profiles in eating disorders: rethinking the distinction between axis I and axis II". The American Journal of Psychiatry. 158 (4): 547–62. doi:10.1176/appi.ajp.158.4.547. PMID 11282688.
* Circulating concentrations of leptin are exceedingly low during the acute stage of anorexia nervosa. Which symptoms result from these diminished concentrations must be clarified. Furthermore, research is required to evaluate whether or not a too rapid weight gain might induce a physiological counter-regulation which would predispose to renewed loss of weight.
** Wewetzer C, Mauer-Mucke K, Ballauff A, Remschmidt H, Hebebrand J., “Possible pathophysiologic, diagnostic and therapeutic implications of new findings on leptin secretion within the scope of anorexia nervosa” Z Kinder Jugendpsychiatr Psychother. 1998 Dec;26(4):244-52.
* Anorexia nervosa and bulimia nervosa are serious psychiatric illnesses related to disordered eating and distorted body images. They both have significant medical complications associated with the weight loss and malnutrition of anorexia nervosa, as well as from the purging behaviors that characterize bulimia nervosa. No body system is spared from the adverse sequelae of these illnesses, especially as anorexia nervosa and bulimia nervosa become more severe and chronic.
** Westmoreland P, Krantz MJ, Mehler PS, “Medical Complications of Anorexia Nervosa and Bulimia”, Am J Med. 2016 Jan;129(1):30-7. doi: 10.1016/j.amjmed.2015.06.031. Epub 2015 Jul 10.
* Published photographs of models that have been modified “in order to narrow or widen the silhouette” should be labelled as “photograph touched up”. Those who failed to comply could face a fine of up to €37,500, or 30% of the value of the advert featuring the model. An earlier version of the bill also made it an offence punishable by up to a year’s imprisonment to encourage excessive thinness, a measure aimed at “pro-ana” websites that extol or promote anorexia or bulimia. Catherine Lemorton, president of the government’s social affairs committee, said many of those who ran such sites “suffered themselves with eating problems” and might be damaged further by the threat of prison. When the law was first introduced to the house in April this year, Marie-Rose Moro, a psychoanalyst and psychiatrist, said the law would solve nothing. “It would be better to provide more resources to care for anorexic patients,” she said, adding that there should be “more awareness to eating disorders in society”. Modelling agencies also attacked the law. “It’s very serious to conflate anorexia with the thinness of models and it ignores the fact that anorexia is a psychogenic illness,” Isabelle Saint-Felix, secretary general of Synam, which represents around 40 modelling agencies in France, told AFP. In France, an estimated 30,000 to 40,000 people – almost all of them adolescents – suffer from anorexia nervosa, an eating disorder with a high mortality rate.
** Kim Willsher, "Models in France must provide doctor's note to work”, The Guardian, (18 December, 2015).
* Tumors of the hypothalamic-pineal region may present with a wide variety of symptoms, including disturbed eating. We present a case where such a tumor was misdiagnosed as anorexia nervosa.
** Winston, AP; Barnard, D; D'souza, G; Shad, A; Sherlala, K (2006). "Pineal germinoma presenting as anorexia nervosa: Case report and review of the literature". The International Journal of Eating Disorders. 39 (7): 606–8. doi:10.1002/eat.20322. PMID 17041920.
* Organic disorder should always be considered before making a diagnosis of anorexia nervosa, particularly if the presentation is atypical.
** Winston, AP; Barnard, D; D'souza, G; Shad, A; Sherlala, K (2006). "Pineal germinoma presenting as anorexia nervosa: Case report and review of the literature". The International Journal of Eating Disorders. 39 (7): 606–8. doi:10.1002/eat.20322. PMID 17041920.
* Social media have become a significant means for peer-related communication, self-presentation, and identity management. So-called eating disorder websites that propagate a drastic thin ideal and unhealthy eating behaviors have triggered a debate about the harmful facets of social Internet activity. Little research has addressed the language that is used by the authors of these websites. The present study focuses on personal weblogs, a popular form of mostly text-based, diary-like, online journals. We compared 31 pro–eating disorder blogs, 29 recovery blogs, and 27 control blogs by the means of computerized quantitative text analyses. The language of pro–eating disorder blogs featured lower cognitive processing, a more closed-minded writing style, was less emotionally expressive, contained fewer social references, and focused more on eating-related contents than recovery blogs. A subset of 12 language indicators correctly classified the blogs in 84% of the cases. The distinct language patterns appear to reflect the psychological conditions of the blog authors and provide insight into their various stages of coping.
** Wolf, M; Theis, F; Kordy, H (2013). "Language Use in Eating Disorder Blogs: Psychological Implications of Social Online Activity". Journal of Language and Social Psychology. 32 (2): 212–226.

### "Unbearable Weight” (2003)

Susan Bordo, “Unbearable Weight: Feminism, Western Culture and the Body”, Berkeley and Los Angeles, CA: University of California Press, 2003
* In their world, there is a size zero, and it’s a status symbol. The chronic dieters have been as it since they were eight and nine years old. “Epidemic of eating disorders” is old stuff; being preached to about it turns them right off. Their world is one in which the anorexics swap starvation diet tips on the Internet, participate in group fasts, offer advice on how to hide your “ana” from family members, and share inspirational photos of emaciated models. But full-blown anorexia has never been the norm among teenage girls; the real epidemic is among the girls with seemingly healthy eating habits, seemingly health bodies, who commit or work their butts off as a result form of anti-fat maintenance.
** pp.xxvi-xxviii
* [A]norexia nervosa, which often manifests itself after an episode of sexual abuse or humiliation, can be seen as at least in part a defense against the “femaleness” of the body and a punishment of its desires. Those desires (as I argue in “Hunger as Ideology”) have frequently been culturally represented trough the metaphor of female appetite. The extremes to which the anoretic takes the denial of appetite (that is, to the point of starvation) suggests the dualistic nature of the construction of reality: either she transcends body totally, becoming pure “male” will, “or” she capitulates utterly to the degraded female body and its disgusting hungers. She sees no other possibilities, no middle ground.
** pp.7-8
* The feminist perspective has never questioned the reality of the anoretic’s disorder or the severity of her suffering.
** p.60
* At one end of this continuum we find anorexia and bulimia, extremes which set into play physiological and psychological dynamics that lead the sufferer into addictive patterns and medical and emotional problems outside the “norms” of behavior and experience. But is is not only anoretics and bulimics whose lives are led into “disorder.” This is a culture in which rigorous dieting and exercise are being engaged in by more and younger girls all the time-girls as young as seven or eight, according to some studies.(32) These little girls live in constant fear- a fear reinforced by the attitudes of the boys in their classes-of gaining a pound and thus ceasing to be “attractive.” They jog daily, count their calories obsessively, and risk serious vitamin deficiencies and delayed reproductive maturation. We may be producing a generation of young, privileged women with severely impaired menstrual, nutritional, and intellectual functioning.
** pp.60-61
* The search for distinctive patterns, profiles, and abnormalities underlying anorexia nervosa and bulimia is thus not, as man researchers claim, “conceptually” demanded; a myriad of heterogeneous factors, “family resemblances” rather than essential features, unpredictable combinations of elements, may be at work in determining who turns out to be most susceptible. It may be, too, that patterns and profiles could one be assembled but are now breaking apart under the pressure of an increasingly coercive mass culture with its compelling, fabricated images of beauty and success.
** pp.61-62
* [F]rom it’s nineteenth-century emergence as a cultural phenomenon, anorexia has been a class-biased disorder, appearing predominantly among the daughters of families of relative affluence. The reasons for this are several. Slenderness and rejection of good have, of course, very different meanings in conditions of deprivation and scarcity than in those of plenty. Demonstrating an ability to “rise above the need to eat imparts moral or aesthetic superiority only where others are prone to overindulgence. Where people are barely managing to put nutritious food on the table, the fleshless, “dematerialized” body suggests death, not superior detachment, self control , or resistance to parental expectations. Moreover, the possibility of success in attaining dominant ideals (for example, that of the glamorous superwoman so many anoretics emulate) depends on certain material preconditions which economically struggling women lack; hence, they may be “protected” (so to speak) against eating disorders by their despair of ever embodying the images of feminine success that surround them.
** p.62
* The decoding of slenderness to reveal deep associations with autonomy, will, discipline, conquest of desire, enhanced spirituality, purity, and transcendence of the female body suggests that the continuities proposed by Rudolph Bell between contemporary anorexia and the self-starvation of medieval saints are not so farfetched as such critics as Brumberg have claimed. Brumberg argues that attempts to find common psychological or political features in the anorexia of medieval saints and that of contemporary women founder on the fact that anorexia mirabilia was centered on a quest for spiritual perfection, “while the modern anoretic strives for perfection in terms of society’s ideal of physical rather than spiritual beauty.” But Brumberg here operates on the assumption-an assumption challenged by the essays in this volume-that there is such a thing as purely “physical” beauty. Granted, the medieval saint was utterly uninterested in attaining a slender appearance. But it does not follow that the contemporary obsession with slenderness is without deep “spiritual” dimensions, and that these cannot share important-that is, illuminating-affinities with the ascetic ambitions of medieval saints. Here, one anoretic explicitly makes the connection: “I felt like one of those early Christian saints who starved themselves in the desert sun.” This is not to say that meaning of self-starvation for the fasting nuns of the Middle Ages can be simply equated with its meaning for adolescent anoretics of today. But in the context of enduring historical traditions that have dominantly coded appetite, lack of will, temptation, and, indeed, the body itself as female, surely we would expect that women’s projects to transcend hunger and desire would reveal some continuous elements.
** pp.68 -69
* The shallow and unanalyzed conception of slenderness as merely “an external body configuration “rather than” an internal spiritual state,” an ideal without psychological or moral depth, still predominates in the literature on anorexia and bulimia. Why? One explanation is that so long as eating disorders remain situated within a medical model, those who are entrusted with the conceptualization of anorexia and bulimia will be medical professionals who have little experience in or inclination toward cultural interpretation and criticism. But more important is the fact that to begin to incorporate such interpretation and criticism within the medical model would be to transform that model itself.
** p.69

### "Nursing assistants' experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa" (2020)

Kodua, Michael; Mackenzie, Jay-Marie; Smyth, Nina (2020). "Nursing assistants' experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa". International Journal of Mental Health Nursing. 29 (6): 1181–1191. doi:10.1111/inm.12758. ISSN 1447-0349. PMID 32578949. S2CID 220046454.
* Presently, little research has been conducted on the use of manual restraint within child and adolescent settings. However, even less research has been conducted on the use of manual restraint for CNF of patients with AN within inpatient eating disorder settings.
** pp.3-4
* AN is an eating disorder characterised by an extremely low body weight, a severe restriction of food, a strong desire to be thin, and an intense fear of gaining weight (National Institute of Mental Health, 2018). Under relevant mental health legislation, patients with AN can be administered CNF in extreme cases when they are presenting with very low body weight, and refusing to eat and/or drink (Fuller et al., 2019; Royal College of Psychiatrists, 2014). In the rare case when a patient is resistant to nasogastric feeding, staff members may administer manual restraint to ensure the safety of themselves and the patient during feeding (Fuller et al., 2019, 2020; Neiderman et al., 2001). Within the UK, manual restraint in this context may be used in the absence of other restrictive practices (e.g., seclusion), and may involve holding the patient’s arms, legs and head in a safe position, in order to allow for the safe passing of a nasogastric tube and subsequent feeding (Fuller et al., 2019; Neiderman et al., 2001). Feeding in the context of active resistance is a rare event and raises ethical, legal and clinical issues for all those involved (National Collaborating Centre for Mental Health, 2004). Despite the wealth of research that exists on the treatment of AN, we could only locate one published qualitative study that explored the experience of CNF in the context of AN, including the experience of CNF under manual restraint (Neiderman et al., 2001). In this qualitative survey study exploring children and adolescent patients’, and their parents’ experiences of nasogastric feeding, the authors summarised patients’ nasogastric feeding experiences into two main categories: “I regretted it at the time but think that it was necessary” and “I hated it then and hate it now”.
** p.4
* An Unpleasant Practice Administering manual restraint for CNF of young persons with AN was an unpleasant practice for all nursing assistants, and this was evidenced by the numerous reported adverse physical, psychological and interpersonal outcomes. Some felt that they did not receive enough support from the eating disorder organisation in managing these outcomes. Six subthemes are reported. Emotional distress. Despite recognising the necessity of CNF under manual restraint for young persons with AN who were refusing all foods and/or fluids, seven of the eight nursing assistants described the emotional distress they experienced as a result of administering manual restraint.
** pp.8-9
* Becoming desensitised and sensitized Despite the physical and emotional challenges that encapsulated participants’ experiences of administering manual restraint for CNF of young persons with AN, and unlike the “Importance of coping” theme which described participants’ conscious attempts to cope with the procedure, five of the eight nursing assistants reported becoming emotionally desensitised to the practice over time.
** pp.12-13
* The purpose of this phenomenological study was to explore nursing assistants’ experiences of administering manual restraint for CNF of young persons with AN. The findings paint a physically and emotionally distressing picture of the participants’ experiences and provide valuable insight into the experience of applying manual restraint for CNF of patients with AN. It is clear from the analysis that administering manual restraint for CNF of young persons with AN was a distressing practice for nursing assistants.
** pp.13-14
* By far the most prevalent finding in this study concerned the adverse physical outcomes that pervaded nursing assistants’ experiences of administering manual restraint for CNF of young persons with AN.
** pp.14-15
* It is critical that relevant eating disorder services prioritise the use of psychological interventions, and alternatives to CNF interventions under manual restraint where practically possible, given the highly distressing impact this practice may have on both nursing staff and patients. This can include offering a range of psychological interventions (e.g., art, family, individual and group therapy, etc) and dietary choices to patients (e.g., diverse food types, liquid supplements, etc), with such options frequently being re-communicated to patients who refuse them. The provision of staff training in communication and trauma-informed approaches may help nursing staff develop improved therapeutic relationships with patients (Maguire & Taylor, 2019), which in turn may have an impact on patients’ receptiveness towards staff support, their willingness to accept dietary intake, and in turn, their recovery from AN (Sly et al., 2013). CNF interventions under manual restraint should only be used as a last resort after exhaustive unsuccessful attempts have been made to offer oral dietary intake to patients, and there is a clinical need for feeding. This is particularly important for patients who present with ongoing refusal of significant dietary intake, where there may be a risk of the habitual use of manual restraint for CNF as a first resort intervention rather than a last resort. The findings of this study can be used as a useful source of information for relevant eating disorder services, to illustrate the potential adverse physical, psychological and interpersonal challenges that administering manual restraint for CNF of patients with AN, could pose to their nursing staff.
** p.16
* To our knowledge, this study is the first to explore nursing assistants’ experiences of administering manual restraint for CNF of patients with AN,and makes a substantial contribution to the limited literature on this practice. The findings highlight that the use of manual restraint for CNF of young persons with AN is a highly physically and emotionally distressing practice for nursing assistants. It is therefore important that sufficient supervision, support and training is made available to staff working in these settings.
** p.17

## See also

* Bulimia nervosa
* Binge eating
* Diet
* Eating
* Eating disorder
* Food
* Force-feeding
* Hunger
* Gluttony
* Starvation