Sunday, October 26, 2008

Hostility during refeeding

Admittedly, this isn't research. It's an observation by author and anthropologist Sharman Apt Russell in her book Hunger: An Unnatural History. Although only a chapter is spent looking at anorexia nervosa in particular, the book is haunting and well worth a read.

Russell spends much time on events that took place during World War II: the Minnesota Starvation study, the Dutch Hunger Winter, and the tragedies in the Warsaw Ghetto. This excerpt is from Russell's summaries of the refeeding portion of the Starvation Study- the most important part. After all, the purpose of the study was not just to learn what exactly happened when people starved (that was generally well known). It was also to learn how to most effectively refeed a group of starving people on the lowest amounts of calories, funded by the war effort to help keep Europe out of Communist hands after the Nazis surrendered.*

But the men were not initially allowed free access to food. Their calories were only increased slowly, much to the chagrin of the men who thought that their ordeal would finally be over. They got irritable, cranky, desperate.

From Russell:

By the end of the sixth week of refeeding, almost all the subjects were in active rebellion. Many "grew argumentative and negativistic." Some questioned the value of the project, as well as the motives and competence of the researchers. A few admitted that their desire to help the relief effort had completely disappeared. At the same time, unnoticed by the subjects themselves, their energy was returning. They became more responsive, albeit in a negativistic way. They were annoyed at the restrictions still imposed on them. They rejected the buddy system, which was removed "in the face of imminent wholesale violation." They resisted going back to a regular work schedule. At times, the experimenters felt they were watching "an overheated boiler, the capacity of the safety values an unknown variable."

Later, the researchers compared this with what they learned about refeeding camps after the war, where aid workers also noted a growing aggressiveness and surprising "lack of gratitude" in men and women who had previously been dull and apathetic with hunger.

So it seems from these anecdotal cases that some of the resistance seen by eating disordered children during refeeding seems almost purely organic and NOT related to the eating disorder. Perhaps the brain is reawakening and is not happy. Perhaps the person is unable to process what the hell just happened. The anxiety around food that is, of course, related to the eating disorder, seems only to make this worse.

But the negativity and hostility may also be the intrinsic response of a starving brain.

*I thought this was fascinating- obviously, because I included it.

Sunday, October 12, 2008

FBT for bulimia in single-parent families

Despite its efficacy in studies, family-based treatment isn't for every family. For single-parent families, FBT can be "ruled out" as a treatment approach because of the time-intensive nature of treatment. Every meal, every snack, every day.

Of course, single-parent families can make it work. The other parent may be nearby and willing to help. Other caring adults can pitch in, or other family members. The parent may be able to take time off of work to care for their sick child until s/he is able to manage better on their own.

But the efficacy of FBT in single- vs. double-parent families hadn't been studied. In the International Journal of Eating Disorders, Daniel LeGrange and the team at the University of Chicago found that single-parent families were able to help their teens with bulimia nervosa as effectively as double-parent families.

Writes LeGrange in the introduction of the paper:

Given the emphasis in FBT on the involvement of the entire family in helping to reduce binge eating and purging behaviors, it could be that single-parent families demonstrate poorer outcomes than two-parent families receiving FBT. Although there is no research indicating that individuals from single-parent families have poorer outcomes in FBT for BN, there are several lines of indirect evidence to suggest that family status may relate to treatment outcomes.

First, single parent families may have less time, fewer social supports, or fewer financial resources than two-parent families. This could predispose single parents toward premature autonomy-granting or decrease their ability to provide adequate parental monitoring.

He also cites unconscious therapist bias against single parents being able to make FBT work, as well as evidence from AN treatment. Single-parent families battling AN benefit from 12 month FBT as opposed to the shorter-course 6 month treatment.

However, LeGrange et al. found:

There were no statistically significant differences between two-parent and single-parent groups on any of the treatment variables at post-treatment or 6-month follow-up...Patients in both groups showed significant reductions in eating disorder behavior and depressive symptoms as well as increases in self-esteem.

Part of the reason that FBT is just as effective in single-parent families is that in dual-parent families, responsibility isn't always shared equally between parents.

The study concluded:

Despite the reliance on parental intervention to reduce bulimic symptoms and normalize eating patterns, the results of this study suggest that FBT is an appropriate and efficacious treatment for single-parent families as well as two-parent families.

Wednesday, September 17, 2008

Predicting Anxiety Disorders

Anxiety disorders are some of the most common brain diseases amongst adults and teens. Walter Kaye found that an anxiety disorder is the strongest risk factor for an eating disorder. That researchers have found a better way to predict anxiety in teens is important in and of itself, but it might also be able to identify people at a much higher risk for eating disorders.

Says a summary of the research on Science Daily:

Craske and her colleagues are finding that neuroticism — the tendency to experience negative emotions such as fear, anxiety, guilt, shame, sadness or anger — is a powerful predictor of both anxiety and depression. Newly published research from the long-term study highlights a potential mechanism by which neuroticism confers risk. The researchers report that teenagers who are high in neuroticism appear to become unnecessarily anxious in ways that are out of proportion with actual circumstances.

Neuroticism is also a common trait of people with eating disorders, especially those with anorexia nervosa.


"This is interpreted as neuroticism leading to enhanced anxiety under conditions associated with aversive events but in which negative events themselves are very unlikely," Craske said. "It may represent a failure to distinguish conditions that are safe from conditions in which threatening events are very likely to occur. By translation, these findings suggest that persons with high neuroticism would respond with appropriate fear to actual threatening events, but with additional unnecessary anxiety to surrounding conditions. This type of responding may explain why neuroticism contributes to the development of pervasive anxiety."

Craske and her colleagues report their findings this month in the journal Biological Psychiatry. She hopes the study will reveal the risk factors that predict anxiety, versus depression, and which risk factors are common to both anxiety and depression.

"Anxiety and depression often go hand in hand; we're trying to learn what factors place adolescents at risk for the development of anxiety and depression, what is common between anxiety and depression, and what is unique to each," Craske said.

It would be interesting to see whether this leads to any better predictions of what traits in what people predispose them to eating disorders.

Because many eating disorder prevention efforts are targeted more generally at improving self-esteem and media literacy, and important population at higher risk may be overlooked. Perhaps these teens would benefit from lessons in decreasing perfectionism and increasing resilience. No doubt it would help with anxiety. Might it also help with eating disorders?

Saturday, August 23, 2008

Eating Disorders and Athletic Participation

With the passage of Title IX, more and more women have been participating in athletics. Although participation in sports has many benefits--including teamwork, fitness, and fun--it also brings a risk of eating disorders, especially at an elite level. A recent study from the International Journal of Eating Disorders, led by Jill Holm-Denoma (now of the University of Denver), looked at eating disordered attitudes and behaviors in relation to level of athletic participation and sports anxiety.

Women who participate in intercollegiate varsity athletics have much higher rates of eating disorder symptomatology when compared to women in club sports, independent exercisers and non-exercisers. Furthermore, higher levels of sports anxiety (that is, anxiety about physical activity and/or sports) were predictive of increased levels of bulimic symptoms and a drive for thinness.

Varsity athletes have devoted much of their recent lives to their sport, increasing both their identity with athletics and the pressure to perform well. As well, it could be that eating disordered attitudes and behaviors are normalized, tolerated, or even encouraged. Traits of obsessionality and perfectionism are risk factors for eating disorders, that may also cause a woman to excel at the varsity level.

Yet the results show an interesting variation. Writes Holm-Denoma:

Despite the trend for women who participated in higher levels of athletic competition to have higher levels of eating disorders, our data do not suggest a clear dimension ranging from nonexercisers to varsity athletes. In some cases, for instance, independent exercisers appear to have similar traits to varsity athletes (e.g., see Fig. 1). Thus, some independent exercisers may engage in exercise as frequently and/or intensely as women who participate in competitive athletics.

It appears that some women with eating disorders (or their accompanying attitudes) exercise alone, independently, and perhaps obsessively. This could perhaps come from a desire to hide their disorder.

The researchers conclude that:

Coaches and clinicians should be aware that athletes experience higher rates of eating disorder symptoms than nonathletes. Moreover, sports anxiety should be considered as a possible target of therapy among athletes.

(cross-posted at ED Bites)

Thursday, August 21, 2008

Sobering Statistics

A recent story from the News Observer had these startling statistics to remind everyone why early treatment of eating disorders is essential:
  • 20 percent of adults overcome their eating disorder, compared with an 80 percent recovery rate among adolescents.
Given that most eating disorders start in adolescence (most estimates range from 13-18 as the peak years of onset, with bulimia generally beginning at a later age than anorexia), most adults have been suffering for years, if not decades. The disease at this point has become entrenched, a part of the sufferer's life.

There are also no researched, effective treatments for adults, in part due to the chronicity, as well as the difficulties in compelling a loved one into treatment for long enough to reach a stable, healthy weight.

In the book "Hunger: An Unnatural History," a famine relief worker said that malnutrition in children is always easier to treat than in adults. Part of it is, he says, the greater resilience of young bodies. But the other part is the simple power of a mother urging her child to eat.

Other statistics from the story:
  • 80 percent of eating disorders start out as diets.
  • Ten million women in the U.S. have an eating disorder, according to the National Eating Disorders Association.
  • 79 percent of deaths from anorexia occur in people who are over the age of 45.

Sunday, August 17, 2008

Administrative Update

Sorry for the lack of posts lately- I'm trying to find a place to live and apply for jobs, so I have been both busy and stressed.

At any rate, I just posted a huge list of links of free full-text research articles on the right-hand side of the page. Please email me any other articles you might have that you think will be of use to parents at carrie [at] edbites [dot] com and I will post them as soon as I am able.

Lastly, I found that the parent book that accompanies "Next to Nothing" is now available for free download online:

If your adolescent has an eating disorder

You will need Adobe Acrobat to read the book (and no, I didn't write a single word of it!).

I'm hoping to have one or two things up this week, depending on how quickly I can pack up my apartment.

Thursday, July 31, 2008

Starving in the Midst of Plenty

One of the characteristics of anorexia, says researcher and clinician Daniel LeGrange, is not just starvation; rather, he says, it is starvation in the midst of plenty. While one theory is that anorexia may have evolved as an adaptation to allow humans to better withstand famine, most modern cases of anorexia occur where food is abundant. In that sense, perhaps anorexia can be understood as self-administered starvation.

Which is where a recent study on cocaine addiction comes in.

A recent study from the University of California, San Francisco found that self-administered cocaine had different effects on dopamine receptors than a passive infusion of the drug.

Says a press release:

...cocaine-associated changes were due to an associative process and not just to the pharmacological effects of the drug. "We suggest that neuroadaptations induced specifically by drug self-administration may form a powerful 'memory' that can be activated by drug-associated cues," explains coauthor Dr. Billy T. Chen.

How self-administration of a drug but not a natural reward can elicit enduring changes within the brain remains a mystery. "Future studies are required to identify the exact mechanisms through which drugs of abuse alter neural circuitry that is normally accessed by naturally reinforcing events but is usurped by cocaine to persistently cement these synaptic adaptations, perhaps ultimately leading to pathological drug-seeking behavior," concludes Dr. Bonci.

While anorexia is not cocaine addiction, the illness does involve differences in dopamine levels and receptors in the brain. Perhaps part of what cements anorexia (besides the starvation itself) is the self-seeking behavior. The "benefits" of starvation to the sufferer are reinforced each time he or she skips a meal, binges, purges, and overexercises.

From an evolutionary standpoint, the survival of the human species means that people will need to begin eating after a famine has passed. The ability to withstand starvation may have descended from this. But anorexia nervosa may cement itself into a life-threatening illness when a person begins to starve while food is abundant.

Sunday, July 27, 2008

FBT: Two case studies

I found two case studies of success with Family-Based Treatment (Maudsley) that was published in the Mayo Clinic research journal.

You can read the pdf here: Family Based Therapy for Adolescents with Anorexia Nervosa

On a personal note, what I found especially illustrative were the charts of the weights of the teens (one girl, one boy) on pages 3 and 4.

I intend to compile some of these links and post them in the right-hand column. I'll be working on this, and a longer article on dopamine, over the next week.

Self-reported eating disorder symptoms differ between adolescents and parents

Part of the difficulties in diagnosing an eating disorder is finding out precisely what's going on, both behaviorally and psychologically. Traditionally, professionals have relied on patients to self-report thoughts and behaviors. Given the secretive nature of eating disorders, this certainly makes sense. There may be other things going on that the sufferer is hiding from friends and family. And a sufferer may not always vocalize their thoughts and feelings to loved ones, perhaps feeling threatened or vulnerable, or not wanting people to worry.

Yet eating disorders--especially anorexia--are anosognostic. That is, the very illness the person has prevents him or her from seeing that they are ill. It's subtly different than denial. When a person is said to be "in denial," which is common with substance abuse and other addictions, he or she inherently knows that something is wrong, but it unwilling or unable to admit it. With anosognisia, the person literally doesn't understand that there is a problem. I wanted to lose weight, and I did, thinks a sufferer. What's the problem?

Which makes the self-reporting of symptoms, behaviors, and thoughts inherently problematic. Researchers in Germany recently compared surveys and forms comparing reports of physical and psychological issues confronted by ED patients. It turns out that parents consistently rated their children as having more severe thoughts and behaviors than their adolescent.

The researchers conclude:

Agreement between parents and adolescents regarding the presence and severity of psychiatric symptoms in adolescents with ED is low. In contrast to previous studies in non-ED samples, adolescents with ED reported lower levels of internalizing problems than their parents. Denial and minimization may be underlying reasons for our findings and represent obstacles in the psychological assessment of adolescents with ED.

Therefore, it is crucial to make sure parents are included not only in treatment, but also in the diagnosis of their child's eating disorder.

Wednesday, July 9, 2008

Unearthing anorexia's genetic roots

While eating disorders remain complex, multifaceted brain diseases, research is uncovering the importance of genetics in causing these diseases. Some families have long known that eating disorders, like other illnesses such as depression, bipolar disorder, and anxiety disorders, run in families.

The question that has remained is how: how are risks for these illnesses inherited? And what are these risks, anyway? Despite all of the talk, there will almost certainly be no "anorexia gene" or "bulimia gene" uncovered. Issues likely involve differences in appetite regulation (especially the hormones leptin and ghrelin), and altered levels of the neurotransmitters serotonin and dopamine, which regulate mood.

Abnormal levels of serotonin have also been found in those with obsessive-compulsive disorder, an anxiety disorder that is several times more common in those with anorexia nervosa.* The close links between OCD and AN have prompted some researchers and clinicians to question whether anorexia should be classified as an obsessive-compulsive spectrum disorder. This spectrum includes Tourette's syndrome, tic disorders, compulsive skin picking, trichotillomania (compulsive hair pulling), and body dysmorphic disorder. All of which are, not surprisingly, more common in people with anorexia than in the general population.** This confirms and strengthens the contribution of serotonin to anorexia.

Now, researchers have made links between anorexia and what appears to be the illness' mirror image: 'bigorexia,' or muscle dysmorphia. Those who suffer from muscle dysmorphia, almost exclusively men, believe themselves to be small and unfit. Their response (again, the eerie mirror image of anorexia) is to bulk up through weight lifting, special diets, and occasionally injectible steroids.

The initial commonality between anorexia and bigorexia are the obvious body image distortions. But the similarities may go deeper than that. Finnish researchers studied five pairs of twins, which included at least one male with anorexia nervosa in each twin pair. A story on Reuter's Health revealed that the researchers found "a 'striking familial liability' for traits related to the eating disorder, including major depression, muscle dysmorphic disorder (which is sometimes called 'bigorexia), and obsessive compulsive disorder. The findings suggest that all of the symptoms have similar genetic roots, the researchers point out."

Just as telling, eight out of the ten twins had suffered from a mood disorder during their lifetime. And body dysmorphic disorder (especially muscle dysmophia) was common in the twins without AN.

The abstract of the study says this: In males, overweight commonly predated AN, and symptoms of body dysmorphic disorder, particularly of muscle dysmorphia, were common among the anorexia-discordant co-twins. Affective and anxiety disorders were present in both the probands and their co-twins. CONCLUSION: We found a strong familial clustering of AN, affective and anxiety disorders, and symptoms of muscle dysmorphia among men in the general population. In men, muscle dysmorphia may represent an alternative phenotype of AN.

While a study involving five pairs of twins is by no means conclusive, the link to muscle dysmorphia and mood disorders implicates a serotonin dysfunction as a contributing factor to anorexia and the body image disturbances that so often accompany it.

*And the reverse is also true: those with OCD are more likely to have AN or BN. Although this study out of Spain provides evidence that eating disorders and OCD might not be related.
**Sadly, research on bulimia, EDNOS, and binge eating disorder is limited at best.

(Cross-posted on ED Bites)

Tuesday, July 1, 2008

Family Based Treatment is Cost-Effective for Adolescent AN

There's no way around it: anorexia (and other eating disorders) are difficult, expensive illnesses to treat. The good news is that effective treatments are available. Recovery can be a long, winding road (as I and other families know), but new research is showing the most effective ways to treat anorexia.

James Lock and his group out of Stanford University published an article in the latest issue of Eating Disorders: The Journal of Treatment and Prevention, titled "Costs of Remission and Recovery Using Family Therapy for Adolescent Anorexia Nervosa: A Descriptive Report." He looked at the costs to treat adolescents with AN and their families with a standard Family-Based Treatment approach.

The majority of the costs (72%), Lock found, were due to medical hospitalization, before or during outpatient treatment. Another 20% were due to outpatient psychiatric treatment, a much smaller percentage than is traditionally given. Noted Lock: "This result may be due to the specific outpatient management strategy used in this study which employed parents as the main agents for change. In cases where this approach is effective, this results in decreasing both the intensity of treatment as well as the need for other types of treatment such as individual, group, nutritional counselling, or other forms of treatment that would add expense."

Due to differences in insurance, the final costs listed in the paper did not factor in health coverage, or any deductibles and co-pays. The costs listed, then are the market cost of treatment and NOT what most people with insurance coverage would pay. Costs, however, would still be extensive. The study also failed to factor in food costs (which can be significant) and extraneous costs such as time off work for parents. Obviously, this would vary greatly from family to family, but again, these costs are significant.

Lock found that costs to recovery can vary widely, ranging from USD$33,000 for "partial remission," defined as weight >85% IBW, to USD$84,000 for full recovery (weight >95% IBW and Eating Disorder Examination scores in the normal range). This treatment is more expensive than that of even schizophrenia. But, considering that the average residential treatment stay lasts for 90 days, costs approximately USD$84,000 (often not covered by insurance), and lacks the scientific research and integrity of evidence based methods.

The Stanford group concluded that when "compared to costs described for adults with AN, adolescent treatment costs appear to be lower when families are used effectively to aid in treatment."

Friday, June 27, 2008


Hello everyone!

I am delighted and honored to be asked by Laura Collins to blog about eating disorders research for FEAST. I am not the parent of someone with an eating disorder- rather, I am the sufferer herself. One who is on her way to recovery with the help of her parents and a modified Maudsley approach.

I am also a science writer by profession. I have written two books on eating disorders: a memoir, Running on Empty, and a self-help book for teens and their parents called Next to Nothing. I have a Master's of Public Health in epidemiology from the University of Michigan, and I recently graduated from Johns Hopkins University with an MA in science writing (master's degrees- collect them all!).

I have written a variety of freelance pieces for such magazines as the Johns Hopkins Public Health Magazine, ScienceNOW, Eating Disorders Today, and the Etsy Storque. I currently work at Chemical and Engineering News as an editorial intern. After that, who knows.

Besides that, I also have a blog on eating disorders called ED Bites. Though I do blog about research there, it's not always my focus, and nor is my audience parents. There will likely be some cross-posting between the two blogs, especially if I think an article is generally useful.

If you have any questions, suggestions for articles, or comments, please email me at carrie [AT] edbites [.] com or post them in the "comments" section.

I'm very excited to work with FEAST and I hope to meet some of you at the NEDA conference in Austin this September.