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."