Anorexia Research: 2002-2006
   
Int J Psychiatr Nurs Res. 2006 Sep;12(1):1364-77.
The efficacy of family intervention in adolescent mental health.
Goodman D, Happell B.
Barwon Health, Geelong, Victoria, Australia. derekg@barwonhealth.org.au

The term 'family therapy' is used to encompass a range of approaches that share a common view about the importance of family involvement in psychiatric disorders. This paper reviews the effectiveness of family interventions in adolescent mental health with a special emphasis on single session therapy. Research evidence shows that the family intervention in psychiatric disorders such as schizophrenia, depression, attention deficit hyperactive disorder, anxiety and anorexia not only provides better outcomes, but also increases client satisfaction with services. Among the family therapy approaches, single session therapy (SST) seems to be a flexible and very effective model for adolescent mental disorders, which seem to offer an efficient means of providing rapid access to services whilst removing some of the difficulties associated with other forms of family therapy approaches. A new service development model is also discussed by drawing together a number of ideas encountered in practice settings.

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Ther Umsch. 2006 Aug;63(8):551-4.
[Family therapy within the treatment of eating disorders]
[Article in German]
Schrauth M, Nikendei C, Kochling A, Martens U, Herzog W, Zipfel S.
Abteilung fur Psychosomatische Medizin und Psychotherapie, Universitatsklinikum Tubingen. markus.schrauth@med.uni-tuebingen.de

The families of patients suffering from eating disorders such as Anorexia nervosa (AN) und Bulimia nervosa (BN) are, owing to the illness, subject to considerable emotional strain and are furthermore often characterised by significant structures and patterns of interaction within the family. Consequently the inclusion of patients' family members, whose status can be seen as increasingly gaining in scientific approval, plays an important role within both diagnosis and therapy. Of particular importance is the medical informative discussion with both patients and their parents which takes place in a primarily medical context and aims to develop and increase therapy motivation. For this purpose the doctor should possess basic knowledge concerning dialogue management with families, as will be presented in the current article. Within further stages of the therapeutic process the spectrum of interventions at the level of the family ranges from educational and supportive measures to family therapy in a more narrow sense, which is carried out by specialist psychotherapists either as outpatient-treatment or within the framework of therapy with inpatients of a clinic.

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Ther Umsch. 2006 Aug;63(8):545-9.
[Eating disorders--an increasing problem in children and adolescents?]
[Article in German]
Brunner R, Resch F.
Klinik fur Kinder- und Jugendpsychiatrie, Zentrum fur Psychosoziale Medizin, Universitatsklinikum Heidelberg. romuald.brunner@med.uni-heidelberg.de

Recent evidence from epidemiological studies suggests that the prevalence of eating disorders is rising in adolescents and the age of onset has fallen. An average prevalence rate for anorexia nervosa of 0.5% and for bulimia nervosa of 0.5% was found for teenaged girls. For both disorders the highest incidence was found in females aged 10-19 years. Disordered eating attitudes and behaviors are common in a substantial proportion of adolescents and are associated with an increased risk of the manifestation of a full disorder or other forms of emotional or behavior problems (depression, anxiety, substance abuse, suicidal behavior). For both disorders a complex multifactorial aetiology has been postulated, involving the interaction of genetic predisposition and certain specific environmental risk factors, particularly social factors. Next to other comorbid psychiatric conditions medical complications resulting from semistarvation and purging often require an inpatient treatment. The multimodal therapeutic approach focus on controlled weight restoration in combination of specific psychoeducational and psychotherapeutic methods involving the patients and their families.

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Ther Umsch. 2006 Aug;63(8):539-43.
[Anorexia nervosa]
[Article in German]
Herzog W, Friederich HC, Wild B, Lowe B, Zipfel S.
Klinik fur Psychosomatische und Allgemeine Klinische Medizin, Zentrum fur Psychosoziale Medizin, Universitatsklinikum Heidelberg. wolfgang.herzog@med.uni-heidelberg.de

Anorexia nervosa differs distinctly from other psychogenic eating disorders. Well known for the past 300 years, anorexia occurs consistently and is one of the most serious illnesses to be found for a certain age group. Three-quarters of the patients are healed or improve their condition long-term; one-quarter has a chronic course frequently including somatic complications and death. Because of the long healing process as well as the extensive chronification and complication rate, an individual treatment plan should be set up at the beginning of therapy to allow for a long-term structure of the course of therapy. Depending on the severity, phase and co-morbidity, inpatient and ambulant therapies are indicated. Depending on the duration of therapy, adequate weight (BMI > 15 kg/m2), good motivation, and lack of complications, an ambulant therapy is justified. Inpatient treatment is multimodal corresponding to the multifactorial etiology of anorexia nervosa. Weight gain is an important primary goal of therapy and a prerequisite for a conflict oriented, ambulant psychotherapy to be carried on after inpatient treatment. Ambivalent psychotherapy motivation and the necessity of symptom orientation demand technical modification both for inpatient as well as ambulant psychotherapy.

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Int J Eat Disord. 2006 Aug 25; [Epub ahead of print]
Role of therapeutic alliance in family therapy for adolescent anorexia nervosa.
Pereira T, Lock J, Oggins J.
Department of Psychiatry, Stanford University, Stanford, California.

OBJECTIVE:: The purpose of this study is to examine the role of therapeutic alliance in predicting treatment dropout, response and outcome in a cohort of adolescents with anorexia nervosa (AN) and their families who were treated using a manualized form of family-based therapy (FBT). METHOD:: Independent assessors scored early and late therapeutic alliances for patients and parents using the Working Alliance Inventory-Observer (WAIo). Outcomes were weights and scores on the subscales of the Eating Disorder Examination at the end of 12 months of FBT. RESULTS:: Therapeutic alliance throughout treatment was strong both for adolescents and for their parents. A strong early alliance with adolescents was associated with early treatment response in terms of weight gain. A strong early alliance with parents prevented dropout, whereas a strong late parental alliance predicted their child's total weight gain at the end of treatment. CONCLUSION:: Therapeutic alliance in both patients and parents treated with FBT is generally strong and likely contributes to treatment retention and treatment outcome. (c) 2006 by Wiley Periodicals, Inc. Int J Eat Disord 2006.

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Z Kinder Jugendpsychiatr Psychother. 2006 Jul;34(4):267-74.
[Family-oriented group therapy in the treatment of female patients with anorexia and bulimia nervosa--a pilot study]
[Article in German]
Salbach H, Bohnekamp I, Lehmkuhl U, Pfeiffer E, Korte A.
Klinik fur Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Charite, Universitatsmedizin Berlin. harriet.salbach@charite.de

OBJECTIVES: Family therapy has proven effective in the treatment of anorexia nervosa (AN) and bulimia nervosa (BN) in adolescence. While cognitive-behavioural treatment has been shown to be effective in adult patients suffering from BN, there have been few studies on the effectiveness of psychotherapy in the treatment of adolescents. Since in the majority of AN patients their illness starts in mid-adolescence, and in late adolescence in BN patients, it is crucial to develop and evaluate treatment programmes for these disorders and age groups. In view of these arguments, a programme of group psychotherapy was set up for eating-disordered patients and their parents, combining disorder-specific psychoeducational components with a family group psychotherapy approach that is more open with regard to individual treatment goals. Patients participated together with their parents in the same group. METHODS: The treatment programme was evaluated within the framework of a naturalistic single-group study design. Pre-post changes were assessed. RESULTS: 32 female patients (29 with AN, 3 with BN) and their parents took part in the treatment programme. All of the families completed the programme, which was interpreted as a high rate of acceptance. Pre-post analysis revealed a decrease in the degree of eating-disorder symptoms. CONCLUSIONS: The advantages and disadvantages of this treatment programme, as well as the limitations of the pilot study are critically discussed.

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Pediatr Res. 2006 Apr;59(4 Pt 1):598-603.
Role of cortisol in menstrual recovery in adolescent girls with anorexia nervosa.
Misra M, Prabhakaran R, Miller KK, Tsai P, Lin A, Lee N, Herzog DB, Klibanski A.
Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA. mmisra@partners.org

Neuroendocrine abnormalities in anorexia nervosa (AN) include hypercortisolemia, hypogonadism, and hypoleptinemia, and neuroendocrine predictors of menstrual recovery are unclear. Preliminary data suggest that increases in fat mass may better predict menstrual recovery than leptin. High doses of cortisol decrease luteinizing hormone (LH) pulse frequency, and cortisol predicts regional fat distribution. We hypothesized that an increase in fat mass and decrease in cortisol would predict menstrual recovery in adolescents with AN. Thirty-three AN girls 12-18 y old and 33 controls were studied prospectively for 1 y. Body composition [dual energy x-ray absorptiometry (DXA)], leptin, and urinary cortisol (UFC) were measured at 0, 6, and 12 mo. Serum cortisol was measured overnight (every 30 min) in 18 AN subjects and 17 controls. AN subjects had higher UFC/cr x m2 and cortisol area under curve (AUC), and lower leptin levels than controls. Leptin increased significantly with recovery. When menses-recovered AN subjects were compared with AN subjects not recovering menses and controls, menses-recovered AN subjects had higher baseline cortisol levels and greater increases in leptin than controls and greater increases in fat mass than AN subjects not recovering menses and controls (adjusted for multiple comparisons). In a logistic regression model, increasing fat mass, but not leptin, predicted menstrual recovery. Baseline cortisol level strongly predicted increases in the percentage of body fat. We demonstrate that 1) high baseline cortisol level predicts increases in body fat and 2) increases in body fat predict menses recovery in AN.

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Int J Eat Disord. 2006 Mar 9; [Epub ahead of print]
Residential treatment for eating disorders.
Frisch MJ, Herzog DB, Franko DL.
University of Minnesota, Minneapolis, Minnesota.

OBJECTIVE:: The current study describes residential treatment for eating disorders in the United States. METHOD:: A national study involving 22 residential eating disorder treatment programs was conducted using a survey to determine treatment program descriptions and trends. Data from 19 respondents, representing 86% of all residential treatment programs in the United States, were examined. RESULTS:: Residential treatment options for individuals with anorexia nervosa and bulimia nervosa are becoming increasingly more common. A wide variety of techniques and methods are employed in the treatment of individuals with eating disorders in residential treatment programs. The average length of stay in treatment was 83 days, with an average cost per day of $956 U.S. dollars. CONCLUSION:: The residential treatment of individuals with eating disorders is a growing, variable, and largely unregulated enterprise. Future research is needed to focus on quantifying treatment program effectiveness in the residential treatment of individuals with eating disorders. (c) 2006 by Wiley Periodicals, Inc. Int J Eat Disord 2006.

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Vertex. 2006 Jan-Feb;17(65):7-15.
[Lunch session, weight gain and their interaction with the psychopathology of anorexia nervosa in adolescents]
[Article in Spanish]
Rausch Herscovici C.
Facultad de Psicologia y Psicopedagogia, Universidad del Salvador, Buenos Aires, Argentina. cecilerh@fibertel.com.ar

OBJECTIVE: Evaluate the effectiveness of the family meal intervention (FMI) on weight gain. METHOD: Upon admission 12 adolescents diagnosed with anorexia nervosa were randomly assigned to two groups of outpatient family - based therapy, treated during 6 months, and followed-up at 12 months. Measures were administered at each of these instances. Groups differed only with regard to the FMI. RESULTS: Both treatments produced considerable and comparable improvement in biological parameters, in depression, and in eating and general psychological symptoms. DISCUSSION: Although the FMI did not appear to have a significant effect on weight gain, results suggest it might have a differential benefit for the intractable self-starving patient with greater psychopathology. The finding that weight recovery was not associated to general psychological outcome in those patients with more psychiatric co - morbidity, suggests caution when prioritizing clinical goals.

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Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004365.
Antidepressants for anorexia nervosa.
Claudino AM, Hay P, Lima MS, Bacaltchuk J, Schmidt U, Treasure J.
Federal University of Sao Paulo - UNIFESP / Escola Paulista de Me, Department of Psychiatry, Rua dos Otonis 887, Sao Paulo, SP Brazil, CEP 04025 002. angelica@psiquiatria.epm.br

BACKGROUND: Anorexia Nervosa (AN) is an illness characterised by extreme concern about body weight and shape, severe self-imposed weight loss, and endocrine dysfunction. In spite of its high mortality, morbidity and chronicity, there are few intervention studies on the subject. OBJECTIVES: The aim of this review was to evaluate the efficacy and acceptability of antidepressant drugs in the treatment of acute AN. SEARCH STRATEGY: The strategy comprised of database searches of the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register, MEDLINE (1966 to April 28th, 2005), EMBASE (1980 to week 36, 2004), PsycINFO (1969 to August week 5, 2004), handsearching the International Journal of Eating Disorders and searching the reference lists of all papers selected. Personal letters were sent to researchers in the field requesting information on unpublished or in-progress trials. SELECTION CRITERIA: All randomised controlled trials of antidepressant treatment for AN patients, as defined by the Diagnostic and Statistical Manual, fourth edition (DSM-IV) or similar international criteria, were selected. DATA COLLECTION AND ANALYSIS: Quality ratings were made giving consideration to the strong relationship between allocation concealment and potential for bias in the results; studies meeting criteria A and B were included. Trials were excluded if non-completion rates were above 50%. The standardised mean difference and relative risk were used for continuous data and dichotomous data comparisons, respectively. Whenever possible, analyses were performed according to intention-to-treat principles. Heterogeneity was tested with the I-squared statistic. Weight change was the primary outcome. Secondary outcomes were severity of eating disorder, depression and anxiety symptoms, and global clinical state. Acceptability of treatment was evaluated by considering non-completion rates. MAIN RESULTS: Only seven studies were included. Major methodological limitations such as small trial size and large confidence intervals decreased the power of the studies to detect differences between treatments, and meta-analysis of data was not possible for the majority of outcomes. Four placebo-controlled trials did not find evidence that antidepressants improved weight gain, eating disorder or associated psychopathology. Isolated findings, favouring amineptine and nortriptyline, emerged from the antidepressant versus antidepressant comparisons, but cannot be conceived as evidence of efficacy of a specific drug or class of antidepressant in light of the findings from the placebo comparisons. Non-completion rates were similar between the compared groups. AUTHORS' CONCLUSIONS: A lack of quality information precludes us from drawing definite conclusions or recommendations on the use of antidepressants in acute AN. Future studies testing safer and more tolerable antidepressants in larger, well designed trials are needed to provide guidance for clinical practice.

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J Sch Nurs. 2005 Dec;21(6):329-32.
Boys with eating disorders.
Hatmaker G.
Clovis Unified School District, Clovis, CA, USA.

Although commonly associated with girls and women, eating disorders do not discriminate. School nurses need to be aware that male students also can suffer from the serious health effects of anorexia nervosa, bulimia, anorexia athletica, and eating disorders not otherwise specified. Sports that focus on leanness and weight limits can add to a growing boy's risk of developing an eating disorder. Issues of body image and sexual development can complicate and can distort previously normal eating habits. Students may use powerful and dangerous drugs readily available via the Internet, including growth hormone, creatine, testosterone, and aminophylline, to build muscle and to eliminate fat, potentially causing serious health consequences. School nurses can partner with health and physical education teachers, coaches, school staff, parents, and students to identify and to support boys with eating disorders

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Schweiz Monatsschr Zahnmed. 2005;115(12):1163-71.
[Eating disorders (II)—dental aspects]
[Article in German]
Imfeld C, Imfeld T.
Klinik fur Praventivzahnmedizin, Parodontologie und Kariologie, Zentrum fur Zahn-, Mund- und Kieferheilkunde der Universitat Zurich. carola.imfeld@zzmk.unizh.ch

Patients suffering from eating disorders exhibit oral symptoms indicative to the otherwise concealed illness. The most striking features are the intrinsic erosions due to the regular surreptitious vomiting. They occur in very typical locations within the dental arches and have been termed "perimolysis". Dental professionals are often the first to discover and diagnose eating disorders by detecting perimolysis and consequently face the difficult task to motivate the patients--who often deny their illness--to seek psychiatric help and dental care. Such motivation must be done while respecting the patients' integrity and sense of self-worth. The primary goal of dental care is to preserve the remaining teeth and to prevent further erosive loss of dental hard tissue. The key elements of a dental preventive programme based on pathophysiologic grounds are to enhance local defence mechanisms, to offer chemical and mechanical protection and to diminish abrasive and erosive challenges. Dental restorative therapy must be part of a combined medical and dental treatment plan and should not be started before the eating disorder has been treated and the patients are considered to have stable prognosis. In view of the young age of the patients, the large extension of the erosive lesions and in order to avoid endodontological treatment of mostly sound pulps, non-invasive restorative concepts using adhesive technology should be preferably used. Prophylactic measures and restorative treatment are covered by health insurance (KGV; KLV 18c, 7) if the patients undergo psychiatric or similar adequate treatment.

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Schweiz Monatsschr Zahnmed. 2005;115(12):1157-62.
[Eating disorders (I)—medical and psychiatric aspects]
[Article in German]
Imfeld C, Imfeld T.
Klinik fur Praventivzahnmedizin, Parodontologie und Kariologie, Zentrum fur Zahn-, Mund- und Kieferheilkunde der Universitat Zurich. carola.imfeld@zzmk.unizh.ch

Adolescent, predominantly female patients suffering from eating disorders usually reveal characteristic personality traits which should be taken into account during the treatment of such cases. Some patients deny their illness, others again feel ashamed of it. At any rate, we ought to respect the patients' integrity and their sense of self-worth. Such disorders tend to result from the stress of being unable to cope with the multiple demands made by the biological and social changes of the patients' development into full maturity. Additional predisposing factors should be noted. Eating disorders are often accompanied by specific psychic and somatic symptoms in terms of comorbidity. These symptoms have to be anamnestically accounted for since they may later result in oral symptoms. A considerable number of these patients suffering from eating disorders either do not completely recover or else tend to relapse.

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Isr J Psychiatry Relat Sci. 2005;42(3):154-62.
Case illustration of the self-psychological treatment of eating disorders.
Bachar E.
Dept of Psychiatry, The Hebrew University of Jerusalem, Israel. eytanb@hadassah.org.il

The theoretical conceptualization of self-psychology and the implications for the therapist's stance open up new opportunities for the treatment of anorexia and bulimia. The major contributions of self-psychology to the treatment of anorexia and bulimia are centered upon the following principles: 1) the conceptualization of food, its consumption and avoidance as fulfilling selfobject needs, 2) the unique therapeutic stance of the therapist as selfobject who tries to empathize with the patient from an experience-near position, and 3) the respect that the theory attributes to the significance of the symptoms for the patient. This paper presents a case which can exemplify some of the principles which underlie the self-psychological understanding of eating disorders and their cure.

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Joint Bone Spine. 2005 Dec;72(6):489-95.
Bone loss associated with anorexia nervosa.
Legroux-Gerot I, Vignau J, Collier F, Cortet B.
Service de Rhumatologie, CHRU Lille, Hopital Roger Salengro, 59037 Lille cedex, France.

The objective of this study was to evaluate the epidemiology, diagnosis, pathophysiology, and treatment of bone loss related to anorexia nervosa. Earlier onset and longer duration of anorexia nervosa are associated with more severe bone loss. Osteoporosis develops in 38-50% of cases. Bone mineral density measurement by dual-energy X-ray absorptiometry is useful for assessing bone mass, and bone marker assays provide information on bone turnover. Bone loss in anorexia nervosa is probably multifactorial. Estrogen deficiency was long felt to be the major factor. However, in contrast to postmenopausal osteoporosis, bone loss associated with anorexia nervosa is related mainly to inadequate bone formation, with only a slight increase in bone resorption. This suggests a role for nutritional factors, such as disturbances in the growth hormone-somatomedin C axis (GH/IGF-I) related to malnutrition. The best treatment strategy for correcting bone mass in patients with anorexia nervosa is not agreed on. Resumption of menstrual cycles and weight gain seem necessary but not always sufficient. Studies found no benefits with estrogen therapy, but this was usually given as estrogen-progestin contraceptives. No vast studies evaluating hormone replacement therapy have been reported. Bone formation enhancers such as IGF-I seem to provide the best results, most notably when used in combination with estrogens. This suggests that complex treatment strategies combining bone formation enhancers and bone resorption inhibitors may deserve evaluation.

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Psychiatry Res. 2005 Dec 30;140(3):251-8. Epub 2005 Nov 8.
Comparison of regional cerebral blood flow in patients with anorexia nervosa before and after weight gain.
Kojima S, Nagai N, Nakabeppu Y, Muranaga T, Deguchi D, Nakajo M, Masuda A, Nozoe S, Naruo T.
Department of Behavioral Medicine, Kagoshima University Graduate School of Medical and Dental Science, 8-35-1 Sakuragaoka, Kagoshima-City 890-8520, Japan.

We investigated changes in regional cerebral blood flow (rCBF) before and after weight gain in patients with restrictive anorexia nervosa (AN-R) in comparison with findings in normal subjects. We assessed resting rCBF using single photon emission computed tomography with technetium-99m hexamethylpropylene amine oxime in 12 AN-R patients and 11 controls. Each patient was examined at two time points, at the beginning of treatment and after weight gain (average examination interval=88+/-26 days). Control subjects were examined only once. Before treatment, the AN-R group had lower rCBF in the bilateral anterior lobes, including the anterior cingulate cortex (ACC), and in the right parietal lobe, the insula, and the occipital lobes. After weight gain, the patients showed significant increases in the right parietal lobe and decreases in the basal ganglia and cerebellum in accordance with significant improvement in body weight and eating attitudes. However, they showed persistent decreases in the ACC area even after weight gain compared with findings in the controls. A significant positive correlation was observed between body mass index and rCBF in the occipital lobes in the patients. These results suggest that weight gain is associated with a normalization of rCBF in a number of brain areas, but that the low level of rCBF in the ACC at baseline is unaffected by treatment in AN-R.

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Int J Eat Disord. 2005 Nov;38(3):200-7.
How do eating disorders and alcohol use disorder influence each other?
Franko DL, Dorer DJ, Keel PK, Jackson S, Manzo MP, Herzog DB.
Harvard Eating Disorders Center, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. d.franko@neu.edu

OBJECTIVE: Although eating disorders and alcohol use disorder (AUD) are known to co-occur, the influence of one on the other has not been studied. METHOD: In a prospective study, women diagnosed with either anorexia nervosa (AN; n = 136) or bulimia nervosa (BN; n = 110) were interviewed and assessed for Research Diagnostic Criteria (RDC) AUD every 6-12 months over 8.6 years. RESULTS: Over one fourth of the sample (n = 66 [27%]) reported a lifetime history of AUD. Ten percent of the study subjects (n = 24) developed AUD over the course of the study. AUD did not influence recovery from either eating disorder. Poor psychosocial functioning and history of substance use predicted prospective onset of an episode of AUD for both diagnostic groups. Unique predictors for AUD for women with AN were depression, overconcern with body image, and vomiting. Recovery from AUD was predicted by group therapy and hospitalization (women with AN) and individual therapy and exercise (women with BN). CONCLUSION: The influence of eating disorders on AUD appears to be greater than the reverse. A substantial number of patients who initially present with an eating disorder develop alcohol problems over the course of time, suggesting that the risk is an ongoing one that should be monitored by clinicians.

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Presse Med. 2005 Nov 19;34(20 Pt 1):1505-10.
[Retrospective study of anorexia nervosa: reduced mortality and stable recovery rates]
[Article in French]
Viricel J, Bossu C, Galusca B, Kadem M, Germain N, Nicolau A, Millot L, Vergely N, Lassandre S, Carrot G, Lang F, Estour B.
Service d'endocrinologie, CHU de Saint-Etienne.

OBJECTIVES: Anorexia nervosa is an eating disorder that combines malnutrition, amenorrhea, and distorted body image. To learn more about the course of this disease we undertook a retrospective study of girls diagnosed with anorexia nervosa in the Saint Etienne Endocrinology Department between 1979 and 2004. METHODS: Patients were diagnosed according to DSMIV criteria. Data collected to complete the Morgan-Russell outcome assessment schedule included chronology of illness, patients' morphological features, anorexia type, treatment choice, patient's gynecological history, and social status. RESULTS: The study included 206 cases. The average follow-up period was 8.3 +/- 5.3 years. Defining recovery as stable BMI>17.5 kg/m2 for at least one year and recovery of normal menstruation, full recovery was observed in 55.8% and partial recovery in 25.7%, while 18.5% remained chronically ill. Early onset (i.e., during adolescence) was associated with good prognosis, and advanced emaciation and delayed or insufficient medical care with poor prognosis. CONCLUSIONS: The seriousness of this disease is due more to the incidence of cases that become chronic than to the mortality rate. Prediction of severity would be improved by taking into account underlying personality traits, such as addictive tendencies and depression.

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Eur Child Adolesc Psychiatry. 2005 Oct;14(7):376-85.
Why do adolescents with bulimia nervosa choose not to involve their parents in treatment?
Perkins S, Schmidt U, Eisler I, Treasure J, Yi I, Winn S, Robinson P, Murphy R, Keville S, Johnson-Sabine E, Jenkins M, Frost S, Dodge L, Berelowitz M.
Eating Disorders Unit, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London, UK.

BACKGROUND: Although the use of family therapy for adolescents with anorexia nervosa is well established, there has been limited research into the efficacy of family therapy in adolescents with bulimia nervosa (BN). No previous research has investigated why individuals with BN do or do not involve their parents in treatment. This is an exploratory study aimed at determining whether there are any differences between these individuals in terms of eating disorder symptomatology, psychopathology, familial risk factors, patients' perception of parental expressed emotion (EE) and family functioning. METHODS: Participants were 85 adolescents with BN or Eating Disorder Not Otherwise Specified, recruited to a randomised controlled evaluation of the cost-effectiveness of cognitive-behavioural guided self-care vs. family therapy. Participants were interviewed regarding the history of their eating disorder and completed self-report measures. RESULTS: Patients who did not involve their parents in treatment were significantly older, had more chronic eating disorder symptoms, exhibited more co-morbid and impulsive behaviours and rated their mothers higher in EE. However, they did not have more severe eating disorder symptomatology. CONCLUSIONS: These preliminary findings, although in need of replication with a larger sample and limited by the attrition rate in some of the self-report measures, indicate that patients who did not involve their parents in treatment may perceive their mothers as having a more blaming and negative attitude towards the patient's illness. Public awareness about BN needs to be raised, focusing on reducing the stigma and negative views attached to this illness.

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J Clin Exp Neuropsychol. 2005 Nov;27(8):931-42.
Fast psychomotor functioning in anorexia nervosa: effect of weight restoration.
Pieters G, Hulstijn W, Vandereycken W, Maas Y, Probst M, Peuskens J, Sabbe B.
University Centre St-Jozef, Kortenberg, Belgium.

In a previous study young seriously underweight anorexia nervosa (AN) patients in the early phase of treatment were found to react faster in psychomotor tasks. To further understand this finding we studied the impact of weight restoration on the performance of AN patients in drawing and copying tasks. A group of 17 female AN patients, aged 14 to 25, was compared with 17 healthy controls, matched for sex, age and educational level. Patients were tested when severely underweight and after weight restoration. Control subjects were also tested twice. Using computerized recording and analysis of writing and drawing behavior, reaction times and drawing times were derived, while cognitive and motor demands were manipulated. Overall, AN patients showed shorter reaction times in copying tasks and shorter drawing time in the drawing task than normal controls, and this pattern persisted after weight restoration. No significant group (AN vs. controls) by session (test vs. retest) effect emerged. The finding of a consistent pattern of shorter reaction and drawing times in AN patients before and after weight restoration is compatible with a personality characteristic of perfectionism and overachievement in AN patients.

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Physiol Behav. 2005 Sep 15;86(1-2):15-7.
Brain imaging of serotonin after recovery from anorexia and bulimia nervosa.
Kaye WH, Bailer UF, Frank GK, Wagner A, Henry SE.
University of Pittsburgh, School of Medicine, Department of Psychiatry, Western Psychiatric Institute and Clinic, Iroquois Building, Suite 600, 3811 O'Hara Street, Pittsburgh, PA 15213, USA.

Anorexia nervosa (AN) and bulimia nervosa (BN) are related disorders with relatively homogenous presentations such as age of onset and gender distribution. In addition, they share symptoms, such as extremes of food consumption, body image distortion, anxiety and obsessions, and ego-syntonic neglect. Taken together, these observations raise the possibility that these symptoms reflect disturbed brain function, which contributes to the pathophysiology of these illnesses. Several lines of evidence suggest that disturbances of serotonin (5-HT) pathways play a role. First, 5-HT pathways contribute to the modulation of feeding, mood, and impulse control. Second, medications that act on 5-HT pathways have some degree of efficacy in individuals with AN and BN. Third, such disturbances are present when subjects are ill and persist after recovery, suggesting that 5-HT alterations may be traits that are independent of the state of the illness. Positron emission tomography (PET) with radioligands offers an opportunity to directly characterize brain 5-HT pathways and their relationship with behavior. For example, reduced 5-HT(2A) receptor function occurs in AN whereas increased 5-HT(1A) receptor function occurs in BN. Moreover, imaging studies correlate altered 5-HT(1A) and 5-HT(2A) receptor function with traits often found in individuals with AN and BN, such as harm avoidance. Finally, alteration of these receptors tends to implicate pathways involving frontal, cingulate, temporal, and parietal regions. Alterations of these circuits may affect mood and impulse control as well as the motivating and hedonic aspects of feeding behavior. Such imaging studies may offer insights into new pharmacology and psychotherapy approaches.

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Am J Clin Nutr. 2005 Aug;82(2):296-301.
Eating behavior among women with anorexia nervosa.
Sysko R, Walsh BT, Schebendach J, Wilson GT.
Department of Psychology, Rutgers University, Piscataway, NJ, USA. rsysko@eden.rutgers.edu

BACKGROUND: Disturbed eating and severe caloric restriction are characteristic features of patients with anorexia nervosa (AN). Despite the importance of eating behavior in the presentation of AN, there have been relatively few objective laboratory studies of eating behavior among persons with eating disorders. OBJECTIVE: The purpose of the study was to obtain objective measures of eating behavior among patients with AN before and immediately after weight restoration and to compare those measures with measures among control subjects. DESIGN: Twelve patients hospitalized for AN and 12 control subjects participated in the study. Eleven of the 12 patients were retested at 90% of ideal body weight. RESULTS: The average meal consumption was 103.97 +/- 102.08 g for patients at low weight and 178.03 +/- 202.97 g after weight restoration (NS). Control subjects consumed significantly more than did AN patients at both time points, and the average meal size was 489.58 +/- 187.64 g. Patients showed significant decreases in psychological and eating-disordered symptoms after weight restoration. CONCLUSION: These data suggest that patients with AN show a persistent disturbance in eating behavior, despite the restoration of body weight and significant improvements in eating-disordered and psychological symptoms.

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Z Kinder Jugendpsychiatr Psychother. 2005 Jul;33(3):159-68.
[Aatypical antipsychotics in child and adolescent psychiatry--indications apart from schizophrenia]
[Article in German]
Mehler-Wex C, Rothenhofer S, Warnke A.
Klinik und Poliklinik fur Kinder- und Jugendpsychiatrie und Psychotherapie der Universitat Wurzburg. mehler@kjp.uni-wuerzburg.de

OBJECTIVES: Given their special receptor profile, atypical antipsychotics are effective in the treatment of both positive and negative symptoms. Especially the serotonergic affinity suggests their potential utility for the treatment of depressive, anxious, and obsessive-compulsive symptoms as well. Reviewed here are the clinical experience with, studies of, and published reports on the use of atypical antipsychotics in the treatment of different psychiatric disorders other than schizophrenia in children and adolescents. METHODS: The literature from 1998-2004 was reviewed by means of PubMed and CurrentContents. RESULTS: In addition to schizophrenic symptoms, the therapeutic indications for atypical antipsychotics include tic disorders, bipolar affective disorders and mania, impulsiveness and disruptive behaviour, (auto-)aggression, and severe anorexia nervosa. Empirical data such as those from placebo-controlled double-blind or open-label studies in larger child and adolescent populations are rare. Substances are used mostly off-label. CONCLUSIONS: Atypical antipsychotics today comprise part of the standard psychopharmacotherapy in child and adolescent psychiatry. They have proved to be effective in the treatment of schizophrenia, tic disorders, impulsiveness, (auto-)aggression, and eating disorders.

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Med Hypotheses. 2005 Jul 6; [Epub ahead of print]
Repetitive transcranial magnetic stimulation: A possible novel therapeutic approach to eating disorders.
Tsai SJ.
Department of Psychiatry, Taipei Veterans General Hospital, Taiwan Division of Psychiatry, School of Medicine, National Yang-Ming University, No. 201 Shih-Pai Road, Sec. 2, 11217 Taipei, Taiwan.

The two most common eating disorders, anorexia nervosa and bulimia nervosa, are characterized by aberrant eating patterns and disturbances in body image. Treatment involves combining individual, behavioural, group, and family therapies, possibly with medications. Studies have found that medication, chiefly antidepressants, could be of help in bulimia nervosa but the evidence is weaker for use in anorexia nervosa. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive technique that briefly stimulates or depresses cortical areas within the brain. It has been used in the treatment of various psychiatric disorders, especially major depression, which is a condition that patients with eating disorders often experience as a significant comorbidity. Given that both disorders may share a common pathogenesis, this report proposes that rTMS may represent an alternative strategy for the treatment of eating disorders. Other evidence that supports this notion comes from animal studies that show that rTMS can change feeding behaviours and central neurotransmitters related to the regulation of eating behaviours. Further investigation into the dose, duration and type of rTMS stimulus is needed to verify the efficacy of this intervention in eating disorders.

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Osteoporos Int. 2005 Jul 19; [Epub ahead of print]
A prospective study of changes in bone turnover and bone density associated with regaining weight in women with anorexia nervosa.
Bolton JG, Patel S, Lacey JH, White S.
Liaison Psychiatry Service, St Helier Hospital, Wrythe Lane, Carshalton Surrey, SM5 1AA, UK, jgbolton@sghms.ac.uk.

Anorexia nervosa (AN) is a condition of self-induced weight loss, associated with an intense fear of gaining weight. Previous studies have shown that bone density may increase with regaining and maintaining normal weight; however, relatively little is known about the changes in bone metabolism that occur during weight restoration. We describe the effect of weight restoration and maintenance of weight over 1 year on bone mineral density (BMD) and bone turnover. We recruited women from the eating disorders services at the South West London and St George's Mental Health NHS Trust, and the Priory and Charter Nightingale Hospitals in London, UK. Details of their AN, fracture history, menstrual history and exercise were obtained by interview and case note review. Morning samples of blood and second void urine were taken for biochemical analysis. BMD was measured by DXA at the lumbar spine (LS), femoral neck (FN), distal radius (RD) and total body bone mineral content (BMC). Patients then entered the treatment program, which includes re-feeding, dietary education and psychotherapy. Over a period of 42 months, we recruited 55 women who agreed to participate in this study and underwent baseline investigations. Of these, 15 (27%) subjects achieved and then maintained their target weight for the duration of the study. At baseline for all subjects ( n =55) estradiol levels were lower than the normal reference ranges (both follicular and luteal phases) in 91% of the women. Bone specific alkaline phosphatase (BSAP) concentrations were lower than the premenopausal reference range in 55% of women, and urinary deoxypyridinoline (DPD) was above the premenopausal reference range in 78% of women. Baseline lumbar spine BMD was positively related to BMI (Pearson's r =0.29, P =0.04) and inversely related to bone turnover markers: urinary DPD (Pearson's r =-0.39, P =0.01 and serum BSAP (Pearson's r =-0.3, P =0.06). The 15 patients who regained and maintained weight were followed-up for a mean duration of 69 weeks (SD 7.3, range 54 to 84 weeks). Mean BMI increased from 14.2 (1.7) to 20.2 (0.77) kg/m(2) and remained stable throughout follow-up. Menstruation resumed in 8 of the 15 women. Total body BMC and LS BMD increased significantly over the duration of follow-up (by 4.3% each), but FN BMD and distal radius remained stable. Lumbar spine bone area also increased significantly, whereas FN and distal radius did not. These changes were associated with a significant increase in BSAP ( P =0.01), and a non-significant trend for a decrease in DPD ( P =0.10). Our findings suggest that when women are at low body weight they are in a hypo-estrogenic state, which is associated with imbalance of bone turnover (high bone resorption and low bone formation). This is reversed with weight gain and persists as target weight is maintained and is associated with increases in BMC and BMD.

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J Am Acad Child Adolesc Psychiatry. 2005 Jul;44(7):632-9.
A comparison of short- and long-term family therapy for adolescent anorexia nervosa.
Lock J, Agras WS, Bryson S, Kraemer HC.
>From the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA.

OBJECTIVE:: Research suggests that family treatment for adolescents with anorexia nervosa may be effective. This study was designed to determine the optimal length of such family therapy. METHOD:: Eighty-six adolescents (12-18 years of age) diagnosed with anorexia nervosa were allocated at random to either a short-term (10 sessions over 6 months) or long-term treatment (20 sessions over 12 months) and evaluated at the end of 1 year using the Eating Disorder Examination (EDE) between 1999 and 2002. RESULTS:: Although adequately powered to detect differences between treatment groups, an intent-to-treat analysis found no significant differences between the short-term and long-term treatment groups. Although a nonsignificant finding does not prove the null hypothesis, in no instance does the confidence interval on the effect size on the difference between the groups approach a moderate .5 level. However, post hoc analyses suggest that subjects with severe eating-related obsessive-compulsive features or who come from nonintact families respond better to long-term treatment. CONCLUSIONS:: A short-term course of family therapy appears to be as effective as a long-term course for adolescents with short-duration anorexia nervosa. However, there is a suggestion that those with more severe eating-related obsessive-compulsive thinking and nonintact families benefit from longer treatment.

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J Clin Endocrinol Metab. 2005 Jun 7; [Epub ahead of print]
Depression in Anorexia Nervosa - A Risk Factor for Osteoporosis.
Konstantynowicz J, Kadziela-Olech H, Kaczmarski M, Zebaze RM, Iuliano-Burns S, Piotrowska-Jastrzebska J, Seeman E.
Department of Pediatrics and Auxology, Medical University of Bialystok, 3rd Department of Pediatrics, Medical University of Bialystok, University Children's Hospital 'Dr. Ludwik Zamenhof', Bialystok, Poland; Department of Endocrinology & Medicine, University of Melbourne, Austin Campus, Heidelberg, VIC, Australia.

Context: Both Anorexia nervosa (AN) and depression are associated with osteoporosis. We hypothesized that adolescent girls with AN and depression will have lower BMD than anorexic girls without depression. Objective: To investigate whether depression is an independent risk factor for osteoporosis in anorexic adolescent girls. Design: Cross-sectional study. Setting: University Children's Hospital in Bialystok (Poland), from October 2002 - September 2003. Participants: 45 Caucasian anorexic girls aged 13 - 23 yr; fourteen with comorbid depression (based on Hamilton Depression Rating Scale (HAM-D) and Montgomery-Asberg Depression Rating Scale (MADRS)) and 31 anorexic girls without depression, matched by age, Tanner stage, weight, height, calcium intake and duration of AN. Main Outcome Measures: Total body and lumbar spine bone mineral density (TB BMD, LS BMD), fat mass (FM) and lean mass (LM) assessed using dual energy x-ray absorptiometry (DXA) were compared between AN girls with and without depression. Results: BMD was reduced in both groups, relative to reference data, but girls with AN and depression had lower BMD than those with AN alone (lumbar spine Z-scores -2.6 +/- 0.3 vs. -1.7 +/- 0.3 SD; P = 0.02) (mean +/- SEM). Quantitative assessment of depression correlated independently with TB BMD (r = -0.4; P < 0.05) and LS BMD (r = -0.6; P < 0.001). Conclusion: Anorexic girls with depression are at higher risk of osteoporosis than those without depression. The mechanisms responsible for decreased BMD in depression are not known. Independent treatment of the depressive disorder in AN may partly alleviate the bone fragility.

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Prax Kinderpsychol Kinderpsychiatr. 2005 Apr;54(4):286-302.
[Cognitive-behavioral psychotherapy for adolescents with eating disorders]
[Article in German]
Ruhl U, Jacobi C.
TU Dresden, Institut fur Klinische Psychologie und Psychotherapie-Institutsambulanz und Tagesklinik, Dresden, Germany. ruhl@psychologie.tu-dresden.de

Anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) are grouped together under the term eating disorders. Due to its typical onset in adolescence, AN in particular represents a frequent disorder with often an unfavourable course in this age range (Steinhausen 2002). The mental, social and physical consequences are serious. Research has shown that cognitive-behavioral treatment (CBT) has good effectiveness in adult patients with AN, BN and BED and that it is superior to other treatments. However, there have been few studies on children and adolescents. The effectiveness in adolescence can thus be judged only when the results in adulthood are taken into account. At present, there is limited evidence for the effectiveness of CBT in adolescence.

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Psychol Med. 2005 Mar;35(3):377-86.
Female adolescents with anorexia nervosa and their parents: a case-control study of exercise attitudes and behaviours.
Davis C, Blackmore E, Katzman DK, Fox J.
Department of Kinesiology & Health Sciences, York University, Toronto, ON, Canada. cdavis@yorku.ca

BACKGROUND: Few studies of physical activity in patients with anorexia nervosa (AN) have included a suitable control group. Nor has such research considered the influence of parents' activity on that of their children. Our first prediction was that adolescents with AN would be significantly more active than healthy controls both prior to, and during, the progression of their disorder. We also expected that the activity levels of parents and their daughters would be correlated, and that this relationship would be stronger in patient than control families. Finally, we expected that the AN parents would be more active and report a greater commitment to exercise than the control parents. METHOD: In a case-control design, we employed multiple indicators of physical activity from adolescent females and their parents, using longitudinal, retrospective, self-report measurements. RESULTS: AN patients were significantly more active than controls both during the course of their disorder and prior to its onset. Parents' activity related to their daughter's activity, but this relationship was not stronger in the parents of the patients. CONCLUSIONS: Future research is needed to determine whether the relationship between parents' and children's activity levels reflects environmental or genetic influences, or a combination of both factors. The important observation of a significant increase in patients' activity levels at least a year prior to diagnosis of the disorder suggests that enhanced physical activity may play a role in the development of the disorder. This may also serve as an early warning sign of a subclinical eating disorder in adolescent girls.

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Am J Clin Dermatol. 2005;6(3):165-73.
Dermatologic signs in patients with eating disorders.
Strumia R.
Unit of Dermatology, University Hospital S. Anna, Ferrara, Italy. restrumi@tin.it

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. Cutaneous manifestations are the expression of the medical consequences of starvation, vomiting, abuse of drugs (such as laxatives and diuretics), and of psychiatric morbidity. These manifestations include xerosis, lanugo-like body hair, telogen effluvium, carotenoderma, acne, hyperpigmentation, seborrheic dermatitis, acrocyanosis, perniosis, petechiae, livedo reticularis, interdigital intertrigo, paronychia, generalized pruritus, acquired striae distensae, slower wound healing, prurigo pigmentosa, edema, linear erythema craquele, acral coldness, pellagra, scurvy, and acrodermatitis enteropathica. The most characteristic cutaneous sign of vomiting is Russell's sign (knuckle calluses). Symptoms arising from laxative or diuretic abuse include adverse reactions to drugs. Symptoms arising from psychiatric morbidity (artefacta) include the consequences of self-induced trauma.The role of the dermatologist in the management of eating disorders is to make an early diagnosis of the 'hidden' signs of these disorders in patients who tend to minimize or deny their disorder, and to avoid over-treatment of conditions which are overemphasized by patients' distorted perception of skin appearance. Even though skin signs of eating disorders improve with weight gain, the dermatologist will be asked to treat the dermatological conditions mentioned above. Xerosis improves with moisturizing ointments and humidification of the environment. Acne may be treated with topical benzoyl peroxide, antibacterials or azaleic acid; these agents may be administered as monotherapy or in combinations. Combination antibacterials, such as erythromycin with zinc, are also recommended because of the possibility of zinc deficiency in patients with eating disorders. The antiandrogen cyproterone acetate combined with 35 microg ethinyl estradiol may improve acne in women with AN and should be given for 2-4 months. Cheilitis, angular stomatitis, and nail fragility appear to respond to topical tocopherol (vitamin E). Russell's sign may decrease in size following applications of ointments that contain urea. Regular dental treatment is required to avoid tooth loss.

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Psychoneuroendocrinology. 2005 Jul;30(6):534-40.
Hormonal and metabolic responses to acute ghrelin administration in patients with bulimia nervosa.
Fassino S, Abbate Daga G, Mondelli V, Piero A, Broglio F, Picu A, Giordano R, Baldi M, Arvat E, Ghigo E, Gianotti L.
Division of Psychiatry, Department of Neuroscience, University of Turin, Via Cherasco 11, 10126 Turin, Italy.

Ghrelin is generally influenced by energy balance status and is inversely associated with body mass index (BMI), being reduced in simple obesity, notable exception being Prader Willi syndrome, and elevated in several conditions of undernutrition, including anorexia nervosa (AN). Interestingly, ghrelin levels have also been found elevated in patients with bulimia nervosa (BN) in spite of normal BMI. In humans, intravenous (iv) ghrelin administration induces endocrine (increase in GH, PRL, ACTH and cortisol) and metabolic (increase in glucose and decrease in insulin) effects as well as an increase in appetite and food intake. In AN, ghrelin administration surprisingly leads to a decreased GH response and absence of glycemic variations but normal PRL, ACTH and insulin response. This pattern would reflect a decrease in sensitivity to ghrelin or, alternatively, the metabolic status of AN. To further clarify the function of ghrelin in eating disorders, the endocrine and metabolic response to acute iv ghrelin (1.0mug/kg) was studied in seven young women with purging BN (BW, BMI, mean+/-SEM: 20.3+/-0.5kg/m(2)). Circulating total ghrelin levels were also measured. The results in BW were compared to those recorded in a group of nine healthy women (HW; BMI 22.3+/-2.5kg/m(2)). The GH response to ghrelin in BW overlapped with that in HW. Ghrelin administration also led to a similar increase in PRL, ACTH, cortisol and glucose levels in the two groups. Insulin levels were not significantly modified by ghrelin administration in either group. The overlapping endocrine and metabolic response to ghrelin in the two groups occurred with regard to circulating total ghrelin levels which were higher in BW than in HW. In conclusion, BN, a condition of ghrelin hypersecretion, is connoted by a normal endocrine and metabolic response to exogenous ghrelin administration.

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J Psychiatr Res. 2005 May;39(3):303-10.
A retrospective study of SSRI treatment in adolescent anorexia nervosa: insufficient evidence for efficacy.
Holtkamp K, Konrad K, Kaiser N, Ploenes Y, Heussen N, Grzella I, Herpertz-Dahlmann B.
Department of Child and Adolescent Psychiatry and Psychotherapy, University Clinic of Aachen, Germany.

Although selective-serotonin-reuptake-inhibitors (SSRI) have been of limited efficacy in the treatment of eating disorder psychopathology and comorbid symptoms of malnourished patients with anorexia nervosa (AN), there is recent data suggesting that SSRI may play a role in preventing relapse among weight-restored patients. Though some previous studies included patients in late adolescence, the vast majority of investigated subjects have been adults. The aim of our retrospective study was to assess the effects of SSRI treatment in partially weight-restored children and adolescents with AN. Thirty two females with AN (mean 14.5+/-1.4 years) were investigated three times during inpatient treatment and at 3- and 6-month follow-up for BMI, eating disorder psychopathology, depressive symptomology, and obsessive-compulsive symptomology. Medication history during inpatient and outpatient treatment was reconstructed at the 6-month follow-up. Nineteen patients received SSRI treatment, while 13 subjects were non-medicated. In comparison to the non-SSRI group, the SSRI group had similar BMI and obsessive-compulsive scores, but higher levels of core eating disorder psychopathology and depressive symptoms at the start of medication. Rates of re-admissions were similar in both groups (SSRI group: 36%, non-SSRI group: 31%, Phi: p=0.72). Repeated measures ANOVA revealed no significant group with time interactions for BMI-SDS (p=0.84), core eating disorder symptoms (ANIS, p=0.79), depression (DIKJ, p=0.75), and obsessive-compulsive (CY-BOCS, p=0.40) scores indicating minimal or no effects of SSRI medication on the course of these variables. In conclusion, our results challenge the efficacy of SSRI medication in the treatment of eating disorder psychopathology as well as depressive and obsessive-compulsive comorbidity in adolescent AN. Clinicians should be chary in prescribing SSRI in adolescent AN unless randomized controlled trials have proofed the benefit of these drugs.

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Am J Psychiatry. 2005 Apr;162(4):741-7.
Three psychotherapies for anorexia nervosa: a randomized, controlled trial.
McIntosh VV, Jordan J, Carter FA, Luty SE, McKenzie JM, Bulik CM, Frampton CM, Joyce PR.
Department of Psychological Medicine, Christchurch School of Medicine & Health Sciences, P.O. Box 4345, 4 Oxford Terrace, Christchurch, New Zealand. virginia.mcintosh@chmeds.ac.nz.

OBJECTIVE: Few randomized, controlled trials have examined the efficacy of treatments for anorexia nervosa. Cognitive behavior therapy and interpersonal psychotherapy are effective in a related disorder, bulimia nervosa. There are theoretical and treatment indications for these therapies in anorexia nervosa. METHOD: Fifty-six women with anorexia nervosa diagnosed by using strict and lenient weight criteria were randomly assigned to three treatments. Two were specialized psychotherapies (cognitive behavior therapy and interpersonal psychotherapy), and one was a control treatment combining clinical management and supportive psychotherapy (nonspecific supportive clinical management). Therapy consisted of 20 sessions over a minimum of 20 weeks. RESULTS: For the total study group (intent-to-treat group), there were significant differences among therapies in the primary global outcome measure. Nonspecific supportive clinical management was superior to interpersonal psychotherapy, while cognitive behavior therapy was intermediate, neither worse than nonspecific supportive clinical management nor better than interpersonal psychotherapy. For the women completing therapy, nonspecific supportive clinical management was superior to the two specialized therapies. CONCLUSIONS: The finding that nonspecific supportive clinical management was superior to more specialized psychotherapies was opposite to the primary hypothesis and challenges assumptions about the effective ingredients of successful treatments for anorexia nervosa.

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J Clin Endocrinol Metab. 2005 Mar 22; [Epub ahead of print]
Alendronate for the treatment of osteopenia in anorexia nervosa: a randomized double-blind placebo-controlled trial.
Golden NH, Iglesias E, Jacobson MS, Carey D, Meyer W, Schebendach J, Hertz S, Shenker IR.
Division of Adolescent Medicine (Drs. Golden, Iglesias, Jacobson, Shenker, Janet Schebendach and Wendy Meyer); Division of Pediatric Endocrinology (Dr. Carey) and Division of Child Psychiatry (Dr. Hertz), Schneider Children's Hospital, New Hyde Park, New York. North Shore-Long Island Jewish Health System, Albert Einstein College of Medicine.

Osteopenia is a serious medical complication of anorexia nervosa with no known effective treatment. We conducted a double-blinded randomized trial comparing alendronate 10 mg daily with placebo in 32 adolescents with anorexia nervosa, mean age 16.9 +/- 1.9 yr. All subjects received 1200 mg of elemental calcium and 400 IU Vitamin D a day and received the same multidisciplinary treatment for their eating disorder. Bone mineral density (BMD) of the lumbar spine and femoral neck were measured by dual energy x-ray absorptiometry at baseline and after 1 yr of treatment. 29 subjects completed the study. Femoral neck and lumbar spine BMD increased 4.4 +/- 6.4% and 3.5 +/- 4.6%, in the alendronate group compared with increases of 2.3 +/- 6.9% and 2.2 + 6.1% in the control group (P = 0.41 femoral neck; P = 0.53 lumbar spine). From baseline to follow-up, BMD increased significantly at the femoral neck (P = 0.02) and lumbar spine (P = 0.02) in those receiving alendronate but did not do so in those assigned placebo (P = 0.22 femoral neck, P = 0.18 lumbar spine). At follow-up, body weight was the most important determinant of BMD. BMD was significantly higher in those who were weight restored compared with those who remained at low weight (P = 0.002 femoral neck, P = 0.04 lumbar spine). After controlling for body weight, treatment group assignment still had an independent effect at the femoral neck. We conclude that in adolescents with anorexia nervosa, weight restoration is the most important determinant of BMD but treatment with alendronate did increase BMD of the lumbar spine and femoral neck within the group receiving alendronate but not compared with placebo in the primary analysis. Until further studies have demonstrated efficacy and long-term safety, the use of alendronate in this population should be confined to controlled clinical trials.

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Australas Psychiatry. 2005 Mar;13(1):72-5.
Randomized controlled trial of olanzapine in the treatment of cognitions in anorexia nervosa.
Mondraty N, Birmingham CL, Touyz S, Sundakov V, Chapman L, Beumont P.
Psychiatrist, Peter Beumont Eating Disorder Service, Ashfield, NSW, Australia.

Objective: Recovery from anorexia nervosa is confounded by intrusive anorectic cognitions and rituals. It has been observed that olanzapine, an atypical antipsychotic, can reduce this anorexic rumination. A pilot study was designed to test the effectiveness of olanzapine in this role. Methods: A randomized trial of olanzapine versus chlorpromazine, with anorexic rumination as the primary outcome, was conducted. Of the 26 patients who presented, 15 were randomized in a balanced block design, eight to olanzapine and seven to chlorpromazine. Results: Only the olanzapine group had a significant reduction in the degree of rumination. Conclusion: Olanzapine may be of benefit in anorexia nervosa by causing a reduction in anorexic rumination.

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J Endocrinol Invest. 2004 Nov;27(10):975-81.
The psychopharmacotherapy of anorexia nervosa: clinical, neuroendocrine and metabolic aspects.
Abbate Daga G, Gianotti L, Mondelli V, Quartesan R, Fassino S.
Division of Psychiatry, Department of Neurosciences, University of Turin, Turin, Italy.

Anorexia nervosa (AN) is a complex mental disorder presenting psychiatric and physical symptoms. Literature recognizes the role of several factors in the pathogenesis of this disorder, according to the biopsychosocial model. Many mechanisms are still partly unclear. Endocrine and metabolic alterations usually occur in AN, probably having a role in its pathogenesis and in the disorder perseverance. In consideration of the multifactorial pathogenesis, a multidisciplinary approach is needed in the treatment of anorexic patients. Up-to-date psychotherapy, psychopharmacological, endocrine and nutritional treatments are considered effective in improving AN. Literature does not however provide evidence of a single validated psychopharmacotherapy for anorexic patients. It is known that psychopharmacotherapy can influence hormonal and metabolic states in some conditions, but for the moment few data are present about these effects in AN. This article aims to review the data about the psychopharmacotherapy role in AN, focusing on the endocrine and metabolic effects of anti-depressants (AD) and novel antipsychotic drugs which seem to be the most effective in AN. Scant data are however available and further research should provide more evidence about these effects and also assess whether the severity of the neuroendocrine, hormonal and metabolic impairments can predict the lack of response to the psychopharmacological treatment with AD and neuroleptics.

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J Am Acad Child Adolesc Psychiatry. 2005 Jan;44(1):41-6.
Manualized family-based treatment for anorexia nervosa: a case series.
Le Grange D, Binford R, Loeb KL.
Department of Psychiatry, Section of Child and Adolescent Psychiatry, The University of Chicago, Chicago, IL 60637, USA. dlegrang@uchicago.edu

OBJECTIVE: The purpose of this study was to describe a case series of children and adolescents (mean age = 14.5 years, SD = 2.3; range 9-18) with anorexia nervosa who received manualized family-based treatment for their eating disorder. METHOD: Forty-five patients with anorexia nervosa were compared pre- and post-treatment on weight and menstrual status. RESULTS: After an average of 17 treatment sessions, patients were significantly improved on primary measures of outcome (body mass index and percentage of ideal body weight). Defining outcome categorically (Morgan-Russell outcome criteria), 56% (n = 25) had a good outcome (>85% ideal body weight and menses), 33% (n = 15) an intermediate outcome (>85% IBW and menses intermittent), and 11% (n = 5) responded poorly (<85% ideal body weight and no menses). CONCLUSIONS: Findings provide preliminary support for the feasibility of an outpatient approach with active parental involvement in the treatment of children and adolescents with anorexia nervosa. However, randomized, controlled studies are needed to establish the relative efficacy of this family-based treatment approach.

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Psychiatry Res. 2004 Dec 30;132(3):197-207.
Testosterone administration attenuates regional brain hypometabolism in women with anorexia nervosa.
Miller KK, Deckersbach T, Rauch SL, Fischman AJ, Grieco KA, Herzog DB, Klibanski A.
Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, BUL 457B, Boston, MA 02114, USA.

Abnormalities in brain metabolism have not been consistently well localized in anorexia nervosa (AN), and effects of specific therapies on these functional abnormalities have not been studied. Androgen replacement therapy improves mood, well-being and cognitive function in men with androgen deficiency. We therefore hypothesized that women with AN and relative androgen deficiency would exhibit regional brain hypometabolism compared with healthy controls, and that low-dose physiologic androgen replacement would attenuate the hypometabolism in some of these brain loci. We used FDG PET and statistical parametric mapping methods to investigate regional brain glucose metabolism in (1) 14 women with AN and 20 healthy control subjects of similar mean age and (2) women with AN after randomization to low-dose replacement testosterone therapy or placebo. Cerebral metabolism was decreased in the posterior cingulate, pregenual anterior cingulate, left middle temporal, right superior temporal, and left dorsolateral prefrontal cortex in the AN group compared with controls. In AN patients receiving testosterone, cerebral metabolism increased in the posterior cingulate, subgenual anterior cingulate, premotor cortex, right caudate and right parietal lobes. In conclusion, our data demonstrate distinct loci of regional brain hypometabolism in women with AN compared with controls. Moreover, abnormalities in one of these regions-the posterior cingulate cortex-were attenuated towards normal with low-dose testosterone replacement therapy. Further study is warranted to replicate these findings, as well as to determine their physiological and clinical significance.

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J Clin Endocrinol Metab. 2004 Dec 21; [Epub ahead of print]
Testosterone Administration in Women with Anorexia Nervosa.
Miller K, Grieco K, Klibanski A.
*Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114.

Anorexia nervosa (AN) is complicated by severe bone loss, cognitive function deficits, and a high prevalence of major depression. We hypothesized that bone formation would increase, and depressive symptoms and spatial cognition would improve with short-term physiologic testosterone administration. We randomized 33 women with AN and relative testosterone deficiency to transdermal testosterone (Intrinsa, Procter and Gamble Pharmaceuticals, Cincinnati, OH), 150 mcg, 300 mcg or placebo, for three weeks. At baseline, free testosterone correlated with L4 bone density (r=0.51, P < 0.001), BMI (r=0.39, P = 0.02), depressive symptoms (r0.44, P = 0.02), and spatial cognition (r=0.45, P = 0.04). C-terminal propeptide of type 1 collagen (PICP) levels were higher during testosterone administration than placebo (P = 0.03). The change in PICP correlated with change in free testosterone over three weeks (r=0.50, P = 0.02). Osteocalcin and bone specific alkaline phosphatase did not change. Depressed patients receiving testosterone improved from severely depressed to moderately depressed; the placebo group was unchanged (P = 0.02). Spatial cognition improved in the testosterone group compared with placebo (P = 0.0015). Therefore, short-term low-dose testosterone may improve depressive symptoms and spatial cognition in women with AN. Low-dose testosterone may also prevent decreased bone formation in AN, but as testosterone did not affect all markers of bone formation studied, further data are needed.

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Best Pract Res Clin Gastroenterol. 2004 Dec;18(6):1073-88.
Psychological aspects of eating disorders.
Williamson DA, Martin CK, Stewart T.
Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA 70808, USA. williada@pbrc.edu

Eating disorders (anorexia nervosa, bulimia nervosa, and binge eating disorder) are regarded as psychiatric syndromes that have some relationship to obesity. This review describes current clinical and scientific knowledge concerning the clinical descriptions of these disorders, etiology of each disorder, diagnostic signs, and treatment approaches that have been found to be efficacious. Anorexia nervosa is a very serious eating disorder that is associated with severe medical complications. Anorexia nervosa is very difficult to successfully treat, even when intensive inpatient methods are used. Bulimia nervosa and binge eating disorder are typically less severe eating disorders and are more easily treated using outpatient therapy. Pharmacotherapy has not been found to be an effective treatment for anorexia nervosa, but it has been used successfully with bulimia nervosa and binge eating disorder. Psychotherapy approaches have been successfully employed for all three eating disorders. The review concludes with an integrative perspective that illustrates the similarities and differences of the eating disorders and obesity.

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Z Kinder Jugendpsychiatr Psychother. 2004 Nov;32(4):279-89.
[Paroxetine versus clomipramine in female adolescents suffering from anorexia nervosa and depressive episode--a retrospective study on tolerability, reasons for discontinuing the antidepressive treatment and different outcome measurements]
[Article in German]
Strobel M, Warnke A, Roth M, Schulze U.
Klinik und Poliklinik fur Kinder- und Jugendpsychiatrie und Psychotherapie der Julius-Maximilian-Universitat Wurzburg.

OBJECTIVES: So far, there have only been few studies concerning the question of indication and efficacy of antidepressive medication in children and adolescents with anorexia nervosa and depressive episode in the course of an inpatient treatment. In addition, there is a lack of studies comparing the tolerability and efficacy of different antidepressants given to anorectic patients of this particular age group. This study compares paroxetine, a specific SRI, with clomipramine, a TCA with SRI activity, concerning the frequency and quality of adverse side effects, the frequency and the reasons for discontinuating the antidepressive treatment and different outcome measurements. METHODS: 83 female patients, aged 10.9 to 18.1 years, who underwent an inpatient treatment at the Departement of Child and Adolescent Psychiatry and Psychotherapy at the University of Wuerzburg, Germany, were enrolled in this retrospective study. All of them met the ICD-10 criteria for anorexia nervosa and depressive episode and received an antidepressant medication with clomipramine or paroxetine. We collected data from basic documentation, treatment reports, and the multiaxial classification (MAS). Outcome measurements were the duration of treatment (days) and the increase of body weight (kg/m2). RESULTS: The discontinuation of the antidepressive treatment due to adverse side effects or a lack of efficacy was significantly more frequent with clomipramine than paroxetine (33.3 vs. 15.4%). The increase of body weight (2.8 vs. 2.6 kg/m2) was similar in both groups, but the duration of treatment was significantly shorter under paroxetine (71.9 vs. 96.5 days). CONCLUSIONS: A shorter duration of treatment, faster increase of body weight, lower percentage of dicontinuating the antidepressive medication and last but not least economic reasons lead to the conclusion, that paroxetine should be preferred in female adolescents with anorexia nervosa and depressive episode. However, prospective studies are needed to confirm our findings.

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J Clin Psychiatry. 2004 Nov;65(11):1480-2.
An open trial of olanzapine in anorexia nervosa.
Barbarich NC, McConaha CW, Gaskill J, La Via M, Frank GK, Achenbach S, Plotnicov KH, Kaye WH.
Department of Psychiatry, University of Pittsburgh Medical School, Anorexia and Bulimia Nervosa Research Module, Western Psychiatric Institute and Clinic, Pittsburgh, PA 15213, USA.

BACKGROUND: Recent reports raise the possibility that olanzapine can assist weight gain and improve behavioral symptoms during refeeding in anorexia nervosa. METHOD: Seventeen DSM-IV anorexia nervosa subjects hospitalized between May 1999 and October 2000 were enrolled in open-label treatment with olanzapine for up to 6 weeks. Baseline weight and symptoms were compared to patients' status at the end of treatment. RESULTS: Olanzapine administration was associated with a significant reduction in depression, anxiety, and core eating disorder symptoms, and a significant increase in weight. A comparison with our historical data suggests that subjects in this study had a significantly greater decrease in depression. CONCLUSION: These data lend support to the possibility that olanzapine may be useful in treating anorexia nervosa. However, a controlled trial is necessary to demonstrate that olanzapine is efficacious.

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J Nutr. 2004 Nov;134(11):3026-30.
Improvement of nutritional status as assessed by multifrequency BIA during 15 weeks of refeeding in adolescent girls with anorexia nervosa.
Mika C, Herpertz-Dahlmann B, Heer M, Holtkamp K.
Department of Child and Adolescent Psychiatry and Psychotherapy, Technical University of Aachen, Aachen, Germany. cmika@ukaachen.de

In patients with anorexia nervosa (AN), an assessment of changes in body composition and nutritional status is crucial for adequate nutritional management during refeeding therapies. Phase-sensitive multifrequency bioelectrical impedance analysis (BIA) is an inexpensive and noninvasive technique with which to determine nutritional status and body composition. We investigated 21 female adolescents with AN (initial BMI 15.5 +/- 1.1 kg/m(2)) 4 times between wk 3 and 15 of inpatient refeeding and 19 normal-weight, age-matched female controls. From wk 3 to 15, BMI, fat mass, body cell mass (BCM), total body water (TBW), intracellular water (ICW) but not extracellular mass (ECM), and extracellular water (ECW) increased significantly. Reactance (Xc), phase angle (PhA), and the ECM/BCM index as parameters of nutritional status improved significantly in patients and no longer differed from controls in wk 15, although the BMI of patients was significantly lower than those of controls. Changes in the ECM/BCM index were due to accretion of BCM, which was associated with an increase of ICW. Multifrequency phase-sensitive BIA seems to be a promising tool for the assessment of changes in nutritional status and body composition in patients with AN. An individually determined and controlled hyperenergetic diet as part of a multidimensional, interdisciplinary treatment program for eating disorders seems to quickly improve the nutritional status of AN patients.

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Expert Opin Pharmacother. 2004 Nov;5(11):2287-92.
Available pharmacological treatments for anorexia nervosa.
Powers PS, Santana C.
University of South Florida, Department of Psychiatry and Behavioral Medicine, College of Medicine, Health Sciences Center, Tampa, FL 33559, USA.

Currently, no medications are approved by the FDA for the treatment of anorexia nervosa (AN). However, there are several promising pharmacological targets. Treatment includes a weight restoration and a weight maintenance phase and different pharmacological treatments may be useful in one phase, but not the other. Although cyproheptadine has some modest benefit during the weight restoration phase, it is not widely used. Fluoxetine administered during the weight maintenance phase decreases relapse rate. The medications currently being most widely studied are the atypical antipsychotics, particularly olanzapine. Emerging evidence suggests that some AN patients have psychotic symptoms that may respond to antipsychotic agents. There are promising case reports and open-label studies of the atypical antipsychotics, but as yet, no randomised, placebo-controlled, double-blind studies have been reported. Additional novel treatment approaches are urgently needed for this group of severely ill patients who have a high premature mortality rate.

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Panminerva Med. 2004 Sep;46(3):189-98.
Psychological treatment of eating disorders. A review of the literature.
Fassino S, Piero A, Levi M, Gramaglia C, Amianto F, Leombruni P, Abbate Daga G.
Psychiatry Unit, Department of Neurosciences, University of Turin, Center for Food Behaviour Disorders, Amedeo di Savoia Hospital, Turin, Italy.

The aim of this study is to review the existing literature (PubMed database) on the psychological treatments for eating disorders (EDs), subdivided in individual, group and family therapies. Moreover new approaches and directions in this field are addressed. An extensive literature review is performed to identify the psychological treatment trials in anorexia nervosa (AN) and bulimia nervosa (BN) published over the past 2 decades. Eighty-two studies focused on psychotherapeutic treatment of EDs are reviewed. Only a minor part of these studies are randomised and controlled. While there is evidence of the efficacy of cognitive behavioral therapy (CBT), this is still missing for other psychotherapeutic approaches. However, there is general agreement about the importance of psychotherapy in multimodal treatments. There is still a need for a shared concept of outcome in EDs, since the efficacy of psychological treatment is greatly influenced by the definition of outcome adopted (concerning symptoms, psychosocial functioning, personality).

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Adv Perit Dial. 2004;20:209-12.
Treatment of anorexia and malnutrition in peritoneal dialysis patients with megestrol acetate.
Costero O, Bajo MA, del Peso G, Gil F, Aguilera A, Ros S, Hevia C, Selgas R.
Department of Nephrology, University Hospital La Paz, Madrid, Spain. olgacostero@hotmail.com

Anorexia and malnutrition are common complications and powerful predictors of morbidity and mortality in peritoneal dialysis (PD) patients. Megestrol acetate (MA) is a progestogen that has been demonstrated to increase appetite and weight in patients with cancer or acquired immunodeficiency syndrome. To determine whether MA might benefit PD patients, we treated 32 patients with 160 mg MA daily. Treatment lasted a mean of 5.93 +/- 5.12 months (range: 1 - 23 months). In 68.8% of the patients, appetite improved. Weight gain was statistically significant starting in the third month (initial weight: 66.5 +/- 11.4 kg; weight at third month: 68 +/- 10.4 kg; p < 0.05). We observed a nonsignificant increase in serum albumin at the third treatment month (initial serum albumin: 3.44 +/- 0.27 g/L; serum albumin at third month: 3.54 +/- 0.27 g/L; p = 0.45). No side effects were observed. Our experience suggests that treatment with 160 mg MA daily in PD patients leads to an increase in appetite, serum albumin, and weight gain in most patients, with no negative side effects.

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Tidsskr Nor Laegeforen. 2004 Sep 9;124(17):2254-7.
[Eating disorders—how to work with the family?]
[Article in Norwegian]
Thune-Larsen KB, Vrabel K.
Ulleval universitetssykehus, Psykiatrisk divisjon, Regional avdeling for spiseforstyrrelser, 0407 Oslo. thka@uus.no

Working with families with a child or an adult with an eating disorder is to work with the resources and limitations in the families, how they could cope with this challenge. Family interventions in eating disorders are counselling, working with the family and family-oriented therapy. Studies show documented effects, especially for patients below 18 with anorexia nervosa who have had this disorder for less than three years. Indications for going from working with the family to family therapy are conflicts between parents or between the child and parents, delayed or disturbed psychological development of the child, or when siblings or other family members are believed to have an effect on the healing. Family therapy is to work with the family as a system. The professional responsibilities, the practical tasks and the goals are about interaction in the family, about relations and communication patterns. Interventions in the family are mainly rooted in systemic family therapy. Motivational methods are important, as are cognitive methods and psychoeducational methods, information and learning how to cope with eating disorders.

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Rev Enferm. 2004 Jul-Aug;27(7-8):49-53, 55-6.
[Cachexia]
[Article in Spanish]
Olalla Gallo MA, Delgado Porres I, Miguel Vazquez MP, Ruiz Moreno A.
Equipo de Soporte de Atencion Domicillaria, Atencion Primaria, Burgos.

Cachexia is a frequent syndrome in patients suffering from advanced cancer; it is characterized by anorexia, weight loss, and malnutrition, which combined with other psychic and social consequences lead to a deterioration in a patient's quality of life. Various factors play a role in the development of cachexia; these depend on the patient, the type of tumor, and the treatments received. Its complexity warrant the intervention of an interdisciplinary team, in which nursing plays an essential role. Up to present time, the results of pharmaceutical treatment have been rather unfavorable; therefore, nutritional treatments based on advise for concrete problems and dietary supplements gain importance; enteral or parenteral nutrition are reserved for selected cases. Other important aspects are psychological support, control of associated symptoms and the prevention and treatment of any complication which may appear.

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J Clin Endocrinol Metab. 2004 Aug;89(8):3903-6.
Effects of risedronate on bone density in anorexia nervosa.
Miller KK, Grieco KA, Mulder J, Grinspoon S, Mickley D, Yehezkel R, Herzog DB, Klibanski A.
Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts 02114. kkmiller@partners.org.

Anorexia nervosa (AN), a psychiatric disease characterized by chronic starvation, is complicated by severe bone loss (1), for which there is no effective, available therapy. Although bone resorption is markedly increased in these patients, estrogen is an ineffective anti-resorptive therapy in the setting of undernutrition. We hypothesized bisphosphonate administration would result in a decrease in bone resorption and an increase in bone density in women with AN and bone loss, despite undernutrition. We therefore administered risedronate 5 mg daily for nine months to 10 women with AN, all of whom had osteopenia (mean AP spine T score: -2.7 +/- 2) and compared NTX and bone density with baseline values and with those from available control data prospectively followed for the same time period. Bone density increased significantly in patients who received risedronate compared with controls and compared with baseline, despite lack of significant weight gain, for an increase of AP spine bone density of 4.1 +/- 1.6% at six months and 4.9 +/- 1.0% at nine months. Bone resorption, as measured by NTX, decreased 23.8% at one month and 29.6% at three months, from the high-normal to mid-normal range of young women. Our data suggest that risedronate 5 mg daily administered to women with AN and osteopenia may increase in bone density at the AP spine despite low weight. This is the first study to demonstrate marked increases in bone density in women with AN. Because of the lack of data regarding the safety of such medications in women of reproductive age, bisphosphonates are not approved in the U.S. for premenopausal women other than those receiving glucocorticoids. Further studies are needed to establish the efficacy and safety of bisphosphonate therapy in this population.

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Expert Opin Investig Drugs. 2004 Jul;13(7):879-81.
Academy of eating disorders international conference.
Brewerton TD.
Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Charleston, SC 29425. tbrewerton1@comcast.net

New information is being acquired and disseminated about eating disorders, particularly in terms of integrating the roles of genes and environment, and new treatment approaches. Although evidence indicates that genes are not more important in the aetiology of anorexia nervosa (AN) than bulimia nervosa, Western culture does appear to be more important in the aetiology of bulimia nervosa than AN. Pathological fear conditioning offers a very useful and experimentally testable theory of the aetiology of AN. New evidence suggests that an enhanced, 'transdiagnostic' form of cognitive behavioural therapy is highly effective in eating disorder patients suitable for out-patient treatment. Patients who are homozygotic for the short (s) allele of the 5-hydroxytryptamine transporter gene promoter region appear to be more resistant to multimodal treatment.

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Int J Adolesc Med Health. 2004 Apr-Jun;16(2):131-44.
Nutritional rehabilitation of anorexia nervosa. Goals and dangers.
Golden NH, Meyer W.
Schneider Children's Hospital, Division of Adolescent Medicine, Long Island Jewish Medical Center, New Hyde Park, New York 11040, United States of America. golden@lij.edu

Nutritional rehabilitation of adolescents with anorexia nervosa is both a science and an art. The goals are to promote metabolic recovery; restore a healthy body weight; reverse the medical complications of the disorder and to improve eating behaviors and psychological functioning. Most, but not all of the medical complications are reversible with nutritional rehabilitation. Refeeding patients with anorexia nervosa results in deposition of lean body mass initially, followed by restoration of adipose tissue as treatment goal weight is approached. The major danger of nutritional rehabilitation is the refeeding syndrome, characterized by fluid and electrolyte, cardiac, hematological and neurological complications, the most serious of which is sudden unexpected death. The refeeding syndrome is most likely to occur in those who are severely malnourished. In such patients, this complication can be avoided by slow refeeding with careful monitoring of body weight, heart rate and rhythm and serum electrolytes, especially serum phosphorus. This paper reviews our clinical experience.

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MMW Fortschr Med. 2004 Apr 22;146(17):31-3.
[Eating disorders--how to recognize and treat them]
[Article in German]
Backmund M.
Klinik 3, Bereich Suchtmedizin, Krankenhaus Munchen-Schwabing. Markus.Backmund@kms.mhn.de

Eating disorders are common among adolescent girls and young women and are associated with potentially serious medical complications. Anorexia nervosa, bulimia nervosa, binge-eating disorder are characterized by a serious disturbance in eating, such as restriction of intake or bingeing, as well as distress or excessive concern about body shape or body weight. The mortality rate associated with anorexia nervosa alone, at 0.56 percent per year, is more than 12 times as high as the mortality rate among young women in the general population. All patients with eating disorders should be evaluated and treated for medical complications of the disease at the same time that psychotherapy and nutritional counselling are undertaken.

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Eat Weight Disord. 2004 Mar;9(1):62-8.
Short-term follow-up of adults with long standing anorexia nervosa or non-specified eating disorder after inpatient treatment.
Ro O, Martinsen EW, Hoffart A, Rosenvinge JH.
Modum Bad, Research Institute, Vikersund, Norway. oyvind.roe@modum-bad.no

OBJECTIVE: There are few follow-up studies on outcome for patients with long standing anorexia nervosa (AN) or non-specified eating disorder with several comorbid psychiatric disorders. Inpatient treatment is one option for these patients. The aim of this prospective study was to report one-year follow-up for a consecutive sample of these patients after an inpatient treatment program. METHOD: All 24 patients with a mean age of 28 years and mean duration of an eating disorder of 11 years were treated in a 23-week inpatient group treatment program for AN. Patients were assessed using Eating Disorder Examination interview (EDE), Eating Disorder Inventory (EDI) and Symptom Check List (SCL-90-R) at pre-treatment, post-treatment and at one year after start of treatment. At the follow-up 24 patients were personally interviewed. On admission 12 (50%) had AN, 8 (33%) non-specified eating disorder (EDNOS) and 4 (17%) bulimia nervosa (BN). All had previously suffered from AN and were clinically evaluated to have mostly anorectic psychopathology. RESULTS: Ten (42%) patients had improved at follow-up and 14 (58%) had a poor outcome. There was a moderate but significant improvement on the EDE, EDI and GSI from pre-treatment to follow-up. The improvement occurred during inpatient treatment, and no significant differences from post-treatment to follow-up were found. Patients with low weight on admission showed a significant mean weight increase of about 4 kg at the follow-up. CONCLUSIONS: At one-year follow-up there was a moderate reduction of eating disorder symptoms and general psychiatric symptoms for patients with long standing anorexic symptoms. The improvement occurred during inpatient treatment. Inpatient treatment may be a treatment option in long-time rehabilitation for some of these patients.

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Acta Diabetol. 2004 Mar;41(1):18-24.
Time course of total and distrectual weight gain after refeeding in anorexia nervosa.
Bertoli S, Corradi E, Vangeli V, Tarlarini P, Salvatori GC, Gentile MG, Testolin G, Battezzati A.
International Center for the Assessment of Body Composition (DiSTAM), University of Milan, Via Botticelli 21, I-20133, Milan, Italy. simona.bertoli@unimi.it

Anorectic patients who achieve complete recovery from the eating disorder can obtain a favorable psychosocial outcome but the long-term nutritional outcome is ill-defined. We investigated the time course of total and distrectual body composition during and after refeeding in 32 female patients with anorexia nervosa. Patients were enrolled at their lowest weight (T0) and re-examinated after a 15% weight gain (at a mean of 3 months, T1; n=17) and after 3 years of stable weight recovery (T2; n=8). At T2 patients were compared to a control group of 8 healthy females matched for age and body mass index. All subjects underwent dual X-ray absorptiometry and anthropometry at each visit. At T0, the 32 subjects were at 61%+/-8% of ideal body weight (IBW) with severe reductions in fat mass (FM; 7.1%+/-4.5%), fat free mass (FFM) and bone mineral content (BMC). At T2, the 8 subjects had gained 40% of initial weight, but remained at 85.1%+/-7.7% of IBW ( p<0.01 vs. controls), with a percent FM comparable to that of controls and an absolute FFM still deficient. BMC did not improve at T2 and remained 79% of that in controls. FM depletion was more severe in the limbs than in the trunk and at T2 the trunk/limb FM ratio remained greater than that in controls. These data strongly suggest that continued nutritional surveillance and support is necessary throughout these patients' lives, even after correction of the psychiatric illness and of severe underweight.

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Int J Eat Disord. 2004 Mar;35(2):234-8.
Randomized controlled trial of warming in anorexia nervosa.
Birmingham CL, Gutierrez E, Jonat L, Beumont P.
Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada. clbirm@interchange.ubc.ca

OBJECTIVE: To determine if warming therapy increases the rate of weight gain in patients with anorexia nervosa (AN) who are hospitalized for refeeding. METHOD: Patients admitted to an eating disorders unit of a university teaching hospital were randomized to treatment and control arms. All patients wore a heating vest for 3 hr a day for 21 days. In the experimental arm, the vest was set to medium heat and in the control arm it was set in the off position. RESULTS: Twenty-one females were recruited. They had an average age of 28.4 +/- 6.6 years, a body mass index (BMI) of 17.7 +/- 2.8, and the duration of AN lasted 13.6 +/- 6.7 years. Ten subjects were randomized to the treatment arm and 11 to the control arm. Of the 18 completers, there was no difference in the change in BMI. DISCUSSION: Our study did not demonstrate an increase in the rate of weight gain with warming. Copyright 2004 by Wiley Periodicals, Inc. Int J Eat Disord 35: 234-238, 2004.

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Int J Eat Disord. 2004 Mar;35(2):169-78.
Persistence of nutritional deficiencies after short-term weight recovery in adolescents with
anorexia nervosa.
Castro J, Deulofeu R, Gila A, Puig J, Toro J.
Eating Disorders Unit, Department of Child and Adolescent Psychiatry and Psychology, Institute of Psychiatry and Psychology, Hospital Clinic Universitari Barcelona, IDIBAPS, Spain. jcastro@clinic.ub.es

OBJECTIVES: To study nutritional abnormalities in adolescent anorexia nervosa and to establish whether certain abnormalities persist after short-term refeeding. METHOD: Sixty-one patients (10-19 years old) admitted to a reference unit for eating disorders between 1999 and 2000 with a diagnosis of anorexia nervosa were evaluated at admission and at discharge. A range of biochemical, nutritional, and hormonal parameters were determined. RESULTS: At admission, no protein or lipid deficiencies were found, although many patients presented with hormonal abnormalities and red blood cell folate and zinc deficiencies. Hormonal abnormalities reverted significantly (p <.000) after renutrition. There were decreases in erythrocytes and in levels of hemoglobin (p <.000) and folic acid (p <.05). Red blood cell folate and zinc increased but did not reach normal levels. CONCLUSIONS: In a large proportion of adolescent anorexic patients, supplementation of folic acid and zinc is recommended although protein or hormonal replacement does not seem to be necessary. Copyright 2004 by Wiley Periodicals, Inc. Int J Eat Disord 35: 169-178, 2004.

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JPEN J Parenter Enteral Nutr. 2003 Jul-Aug;27(4):268-76.
Efficacy of voluntary nasogastric tube feeding in female inpatients with anorexia nervosa.
Zuercher JN, Cumella EJ, Woods BK, Eberly M, Carr JK.
Nutrition Services Department, Remuda Ranch Center for Anorexia and Bulimia Inc., Wickenburg, Arizona 85390, USA.

BACKGROUND: This investigation assesses the efficacy of a voluntary nasogastric tube feeding protocol on the weight gain of patients with anorexia nervosa, tube feeding's effect on recovery from the psychologic aspects of anorexia, patient satisfaction with treatment, and medical complications. METHODS: The study included a nonrandomized retrospective review of 381 female inpatients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of anorexia nervosa, both subtypes. A total of 155 patients received tube feeding and oral refeeding; 226 received oral refeeding alone. Recovery from the psychologic aspects of anorexia was measured by the change in Eating Disorder Inventory-2 scores between admission and discharge. Patient satisfaction with treatment was measured with a patient satisfaction questionnaire completed at discharge. Repeated measures and multivariate analyses were performed. RESULTS: When severity-of-illness and caloric intake differences between patients with and without tube feeding were controlled, patients who received tube feeding gained significantly more weight per treatment week than those who received oral kilocalories alone. Patients who received tube feeding for at least one-half their length of stay gained 1 kg/week versus 0.77 kg/week for patients receiving oral refeeding alone. Tube-fed patients evidenced no differences in recovery from anorexia's psychologic aspects, satisfaction with treatment, or medical complication frequency. CONCLUSIONS: In residential psychiatric treatment settings in which intensive therapeutic interventions and appropriate medical monitoring can manage potential psychologic and medical risks, tube feeding's weight gain benefits may be a viable and safe option in treating anorexia.

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Arch Pediatr. 2003 Sep;10(9):836-40.
[Anorexia nervosa: impact on growth and bone mineral density]
[Article in French]
Brihaye Abadie I, de Tournemire R, Alvin P.
Service de medecine pour adolescents, federation de pediatrie, CHU de Bicetre, 94275 cedex, Le Kremlin-Bicetre, France

Anorexia nervosa (AN) concerns 1% of adolescent girls and happens at a time of intense bone growth. Adolescents who develop AN before or during puberty have growth retardation and may not achieve their genetic height potential. Osteopenia, as evidenced by dual-energy X-ray absorptiometry, is also frequent. The degree of osteopenia depends on the age of onset and the duration of AN. The role of estrogen deficiency is no more considered paramount with regards to other factors like the fall of growth factor IGF1. The prevention of osteopenia in AN relies mostly on early nutritional intervention. Hormone replacement therapy or calcium/vit D supplements are not sufficient to improve bone density in undernourished patients. New therapeutic strategies combining anabolic and antiresorptive agents are being developed.

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Zhejiang Da Xue Xue Bao Yi Xue Ban. 2003 Jun;32(3):249-52.
[Gastrointestinal pacemaking for gastric dynamic disorders]
[Article in Chinese]
Hu CY, Li YM, Liu YS, Wang HY.
The First Affiliated Hospital, College of Medical Sciences, Zhejiang University, Hangzhou 310003, China.

OBJECTIVE: To investigate the efficacy and safety of gastrointestinal pacemaker in treatment of gastric dynamic disorders. METHODS: Sixty patients with more than two symptoms as postprandial fullness, epigastric pain,epigastric fullness, belch, nausea, hypercoria,anorexia,vomiting and at least for twelve weeks were divided into three groups randomly. Thirty patients were treated with gastrointestinal pacemaker for ten days(pace maker group); fifteen patients were treated with gastrointestinal placebo machine for ten days (control group); fifteen patients received treatment with cisapride 5 mg three times daily, thirty minutes before meal (cisapride group) for ten days. Electrogastrogram(EGG) was performed on before and after treatments, the mean frequency and mean amplitude of EGG, the clinical symptoms and adverse reactions were observed. RESULTS: Total efficacy of pace maker group, control group and cisapride group was 90.0%, 46.6% and 86.7%, respectively. The score of symptoms was significantly decreased after treatment with gastrointestinal pacemaker and cisapride (P<0.05). Before and after meal EGG exam showed that average frequency was reversed to normal level after treatment with gastrointestinal pacemaker. CONCLUSION: Gastrointestinal pacemaking can relieve symptoms and improve the average frequency of EGG in patients with gastric dynamic disorders.

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Eat Weight Disord. 2003 Jun;8(2):168-72.
Outcome predictors in the short-term treatment of anorexia nervosa: an integrated medical-psychiatric approach.
Signorini A, Bellini O, Pasanisi F, Contaldo F, De Filippo E.
CISRO, Clinical Nutrition, Department of Clinical and Experimental Medicine, Federico II University Hospital, Naples, Italy.

OBJECTIVES: Factors predicting clinical outcome in the short-term treatment of anorexia nervosa. DESIGN: Longitudinal follow-up study. SETTING: Department of Clinical and Experimental Medicine, "Federico II" University of Naples. PARTICIPANTS: Fifty-eight young anorectic women consecutively attending the outpatient Unit between January 1997 and December 2000. MAIN OUTCOME MEASURES: Body weight changes over six months' follow-up. RESULTS: Body weight changes in the short term was exclusively predicted by the prevalent underlying psychiatric disorder, being increased in the patients with prevalently depressive traits, decreased in those with psychotic features and unchanged in those with a prevalently narcissistic personality. CONCLUSIONS: The prevalent psychiatric disorder seems to predict clinical outcome in the short term. Body weight gain per se cannot always be the main target of medical intervention, at least in the early phase of the treatment of malnutrition secondary to major eating disorders.

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Neoplasma. 2003;50(3):227-33.
Palliative treatment of cancer anorexia with oral suspension of megestrol acetate.
Tomiska M, Tomiskova M, Salajka F, Adam Z, Vorlicek J.
Department of Internal Medicine-Hematooncology, Masaryk University Hospital, 62500 Brno, Czech Republic. mtomiska@fnbrno.cz

Megestrol acetate (MA) is a progestational agent, currently known as one of the most effective appetite stimulants in patients suffering from cancer anorexia/cachexia syndrome. Oral suspension of this drug may be particularly useful in patients with far advanced disease, where taking larger amount of pills may lead to the decrease of patient compliance. The influence of oral MA suspension on quality of life and nutritional status was evaluated in 22 patients with far advanced cancer suffering from anorexia and more than 5 per cent weight loss, all beyond the scope of anticancer treatment. Most patients had lung or gastrointestinal cancer. QLQ-C30 questionnaire, visual analogue scale (VAS) for appetite, anthropometry, maximal handgrip strength and laboratory data were obtained before treatment and then after 2, 4, and 8 weeks of therapy. Despite of a known high mortality in this prognostically unfavorable group of patients (36% within two months in this study), overall quality of life after the daily dose of 480-840 mg of MA was improved in 63, 56, and 55% of patients remaining on therapy after 2, 4, and 8 weeks, respectively. Appetite was the most successfully influenced parameter with an improvement in VAS in 95% of cases after 2 weeks of therapy (p=0.0001). The drug was well tolerated by the great majority of patients. Oral suspension of megestrol acetate maybean effective palliative treatment for many patients with far advanced cancer suffering from anorexia/cachexia syndrome.

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J Chemother. 2003 Jun;15(3):220-5.
Treatment of the cancer anorexia-cachexia syndrome: a critical reappraisal.
Lelli G, Montanari M, Gilli G, Scapoli D, Antonietti C, Scapoli D.
Clinical Oncology Unit, Department of Oncology-Pathology, Azienda Ospedaliera Universitaria, Ferrara, Italy. g.lelli@ospfe.it

Cancer anorexia-cachexia syndrome (CACS) is a combination of anorexia, tissue wasting, weight loss and poor performance status. Some CACS symptoms are due to a macrophage production of TNF and IL-1, while the metabolic effects are mainly explained by the release of IL-6 from tumor cells. Clinical treatment of CACS involves progestational agents (medroxyprogesterone acetate, MPA, megestrol acetate, MA) for long term treatment. The use of prokinetic agents (like metoclopramide) is recommended, especially if patients need concomitant opioid treatment for pain; if otherwise indicated, corticosteroids are useful for short periods. The administration of artificial nutrition should be individualized following the clinical condition of the patient and possibly taking into account the wishes of the patient. The practical evaluation criteria of the drugs employed for CACS are based on weight increase and appetite stimulation. Hence, a new approach to the mechanism of action of MPA, MA and of other agents is urgently needed.

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Int Psychogeriatr. 2003 Mar;15(1):73-87.
Eating habits and appetite control in the elderly: the anorexia of aging.
Donini LM, Savina C, Cannella C.
Istituto di Scienza dell'Alimentazione, Universita di Roma La Sapienza, Rome, Italy. lorenzomaria.donini@uniroma1.it

Although a high prevalence of overweight is present in elderly people, the main concern in the elderly is the reported decline in food intake and the loss of the motivation to eat. This suggests the presence of problems associated with the regulation of energy balance and the control of food intake. A reduced energy intake causing body weight loss may be caused by social or physiological factors, or a combination of both. Poverty, loneliness, and social isolation are the predominant social factors that contribute to decreased food intake in the elderly. Depression, often associated with loss or deterioration of social networks, is a common psychological problem in the elderly and a significant cause of loss of appetite. The reduction in food intake may be due to the reduced drive to eat (hunger) resulting from a lower need state, or it arises because of more rapidly acting or more potent inhibitory (satiety) signals. The early satiation appears to be predominantly due to a decrease in adaptive relaxation of the stomach fundus resulting in early antral filling, while increased levels and effectiveness of cholecystokinin play a role in the anorexia of aging. The central feeding drive (both the opioid and the neuropeptide Y effects) appears to decline with age. Physical factors such as poor dentition and ill-fitting dentures or age-associated changes in taste and smell may influence food choice and limit the type and quantity of food eaten in older people. Common medical conditions in the elderly such as gastrointestinal disease, malabsorption syndromes, acute and chronic infections, and hypermetabolism often cause anorexia, micronutrient deficiencies, and increased energy and protein requirements. Furthermore, the elderly are major users of prescription medications, a number of which can cause malabsorption of nutrients, gastrointestinal symptoms, and loss of appetite. There is now good evidence that, although age-related reduction in energy intake is largely a physiologic effect of healthy aging, it may predispose to the harmful anorectic effects of psychological, social, and physical problems that become increasingly frequent with aging. Poor nutritional status has been implicated in the development and progression of chronic diseases commonly affecting the elderly. Protein-energy malnutrition is associated with impaired muscle function, decreased bone mass, immune dysfunction, anemia, reduced cognitive function, poor wound healing, delayed recovery from surgery, and ultimately increased morbidity and mortality. An increasing understanding of the factors that contribute to poor nutrition in the elderly should enable the development of appropriate preventive and treatment strategies and improve the health of older people.

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Prog Neuropsychopharmacol Biol Psychiatry. 2003 May;27(3):425-30.
Nutritional management of anorexic patients with and without fluoxetine: 1-year follow-up.
Ruggiero GM, Mauri MC, Omboni AC, Volonteri LS, Dipasquale S, Malvini L, Redaelli G, Pasqualinotto L, Cavagnini F.
Studi Cognitivi Research Center and Psychotherapy School, Milan, Italy.

This study evaluated the efficacy of nutritional management with and without fluoxetine (FLX) in anorexia nervosa diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Twenty-one patients, with a mean body mass index (BMI) of 15.21+/-2.33 kg/m(2), were treated with nutritional management and FLX at a mean dosage of 30.00+/-9.35 mg (pharmacological group); seventy-four patients, with a mean BMI of 14.24+/-2.16 kg/m(2), were treated only with nutritional management (nutritional group). Clinical evaluation was carried out under single-blind conditions at basal time and after 3, 6, and 12 months by a structured clinical interview, the Eating Disorder Interview based on Longitudinal Interval Follow-Up Evaluation (EDI-LIFE) and using a self-reported questionnaire, the Eating Disorder Inventory (EDI). BMI significantly increased in both the two treatment groups. In addition, the increase shown by the pharmacological group appeared near the beginning of treatment (i.e., at T1) and it was significantly higher than the increase shown by the nutritional group. Physical exercise showed a significant decrease in the pharmacological treatment group. On the other hand, fear of fatness and the scores of the subscales of the EDI significantly decreased in the nutritional treatment group. In terms of weight, the pharmacological group presented the higher amount of therapeutic success.

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Rev Prat. 2003 Feb 1;53(3):259-62.
[Anorexia and malnutrition]
[Article in French]
Bertrand PC, Roulet M.
Unite de nutrition clinique Centre hospitalier universitaire vaudois CH-1011 Lausanne, Suisse.

Anorexia is a frequent and complex symptom occurring physiologically in older persons and during acute or chronic pathology. It's an adaptable physiological response to stress. It must be respected as such, as long as it's quickly reversible. The study of anorexia requires evaluation of oral intakes, causal aetiology and nutritional repercussion on body composition, different systems function and quality of life. Early artificial nutrition is recommended for adult patient who severely diminished oral intakes for 7 to 10 days after the beginning of acute pathology. Artificial nutrition is also indicated with chronic pathology associated with a significant weight loss. Faced to the impossibility of treating anorexia and its all causes, we have to treat at least anorexia repercussions and prevent undernutrition with an adequate artificial nutrition.

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Lakartidningen. 2002 Dec 5;99(49):4982-9.
[Peptides are opening the door for novel treatments of obesity and loss of appetite]
[Article in Swedish]
Broberger C, Hokfelt T.
Yale University, School of Medicine, Department of Neurobiology, New Haven, USA. Christian.Broberger@yale.edu

A wide spectrum of diseases, as well as states of attenuated ability to heal and recover, can be traced to over- or underweight. Patients at the extremes of the energy balance spectrum are becoming more and more common. In order to provide adequate care for such patients an understanding of the mechanisms governing feeding behaviour is required. In the last decade, important advances have been made in this direction, as several factors mediating signals of hunger and satiety to and within the brain have been identified. These factors include hormonal signals (such as leptin and insulin) from the energy stores as well as neuronal influences (via the vagus nerve) from the digestive tract. The information encoded therein is routed to specific nuclei of the hypothalamus and brain stem, respectively, leading to activation of complex neuronal networks spanning the most rostral regions of the brain all the way to the effector neurones of the autonomic nervous system located in the spinal cord. Several recently characterized neuropeptides showing potent stimulation of appetite (neuropeptide Y, agouti gene-related peptide, orexin, melanin-concentrating hormone) and satiety (melanocortins, cholecystokinin, cocaine- and amphetamine-regulated transcript) have been localized to these pathways. These peptides, and the mechanisms through which they operate, offer promise for new therapeutic strategies in the treatment of obesity and anorexia.

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Psychopharmacol Bull 2002 Spring;36(2):88-104
How useful are pharmacological treatments in eating disorders?
Casper RC.
Department of Psychiatry, Stanford University Medical School, 401 Quarry Road, Stanford, CA 94305, USA. rcasper@stanford.edu

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.

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Behav Res Ther 2002 Oct;40(10):1169-77
Thought-shape fusion in anorexia nervosa: an experimental investigation.
Radomsky AS, de Silva P, Todd G, Treasure J, Murphy T.
Department of Psychology, University of British Columbia, Vancouver, Canada. radomsky@vax2.concordia.ca

Cognitive biases and cognitive distortions have been implicated as important factors in the development and maintenance of many disorders. The concept of thought-shape fusion (TSF) in eating disorders was developed by Shafran, Teachman, Kerry, and Rachman (British Journal of Clinical Psychology 38 (1999) 167) as a variant of thought-action fusion, described by Shafran, Thordarson and Rachman (Journal of Anxiety Disorders 10 (1996) 379). TSF occurs when thinking about eating certain types of food increases a person's estimate of their shape and/or weight, elicits a perception of moral wrongdoing, and/or makes the person feel fat. Shafran et al. (1999) examined both the psychometric and experimental properties of TSF in an undergraduate sample. This paper reports an extension of this work to a clinical group (N=20) of patients with anorexia nervosa. After completing a set of relevant questionnaires, participants were asked to think about a food which they considered extremely fattening. They were then asked to write out the sentence, "I am eating--.", inserting the name of the fattening food in the blank. After being asked to rate their anxiety, guilt, feelings about their weight, morality, etc., participants were given the opportunity to neutralize their statement in any way they chose. The majority of the participants neutralized in ways consistent with the findings of Shafran et al. (1999). The results are discussed in terms of cognitive-behavioural formulations of eating disorders, and of the influence of cognitive biases and cognitive distortions on the processing of information relevant to food, weight and shape in anorexia nervosa.

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Int J Eat Disord 2002 Sep;32(2):146-54
Olanzapine in the treatment of anorexia nervosa: an open label trial.
Powers PS, Santana CA, Bannon YS.
Department of Psychiatry and Behavioral Medicine, College of Medicine, University of South Florida, Tampa, Florida 33613, USA. ppowers@hsc.usf.edu

OBJECTIVE: The primary goal of the study was to determine if olanzapine is effective in producing weight gain in patients with anorexia nervosa. METHOD: Twenty patients with anorexia nervosa (restricting or binge/purge subtype) without schizophrenia, schizoaffective disorder, or bipolar disorder enrolled in an open label study of olanzapine 10 mg. Patients attended weekly drug monitoring sessions and weekly group medication adherence sessions that provided psychoeducation. RESULTS: Eighteen patients received the drug and 14 patients completed the 10-week study. The four drop-outs had gained a mean of 3.25 lb at their last visit. Of the 14 patients who completed the study, 10 gained an average of 8.75 lb and 3 of these patients attained their ideal body weight. The remaining four patients who completed the study lost a mean of 2.25 lb. DISCUSSION: These findings are promising with clinically significant weight gain in an outpatient setting during a brief 10-week period. Copyright 2002 by Wiley Periodicals, Inc.

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Int J Eat Disord 2002 Sep;32(2):135-45
High-caloric supplements in anorexia treatment.
Imbierowicz K, Braks K, Jacoby GE, Geiser F, Conrad R, Schilling G, Liedtke R.
Clinic for Psychosomatic Medicine and Psychotherapy, Friedrich-Wilhelms University of Bonn on the Rhine, Bonn, Germany. K.Imbierowicz@uni-bonn.de

OBJECTIVE: This study compares weight gain and therapy duration in two groups of patients with anorexia nervosa, the first receiving a normal diet aimed at promoting weight gain, the second receiving high-caloric supplements in addition to this normal diet. The study includes patients from two clinics with comparable psychotherapeutic treatment settings except for the substitution. METHODS: Eighty-four patients were examined. Of these, 29 patients with substitution were compared with 29 patients without substitution. In addition, 13 patients without substitution from the first clinic were compared with 13 patients without substitution from the second clinic to exclude potential differences between the two institutions independent of the substitution. RESULTS: Substitution leads to more rapid weight gain, to greater weight on discharge, and to shorter therapy duration. Differences could be observed between patients severely or less severely underweight on admission and between patients with restrictive or bulimic anorexia. CONCLUSION: Within the framework of inpatient psychosomatic treatment involving a psychotherapeutic treatment setting, substitution facilitates weight gain. Copyright 2002 by Wiley Periodicals, Inc.

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Eur Neuropsychopharmacol 2002 Oct;12(5):453-9
Efficacy of citalopram in anorexia nervosa: a pilot study.
Fassino S, Leombruni P, Daga G, Brustolin A, Migliaretti G, Cavallo F, Rovera G.
Department of Neuroscience, Sezione di Psichiatria, University of Turin, Via Cherasco 11, 10100, Turin, Italy. secondo.fassino@unito.it

INTRODUCTION: Anorexia nervosa (AN) still lacks a defined treatment. Since fluoxetine proved effective in weight-restored anorexics, this pilot study evaluates the efficacy of another SSRI, citalopram, in restricting-type AN. EXPERIMENTAL PROCEDURES: Fifty-two female anorectic outpatients were randomized in the citalopram (n=26) and waiting list (n=26) as a control group. Efficacy was assessed using Eating Disorder Inventory-2, Eating Disorder Inventory-Symptom Checklist, State-Trait Anger Expression Inventory, Beck Depression Inventory, Symptom Checklist-90 and Structured Clinical Interview for DSM-IV Axis II Disorders. RESULTS: Thirteen patients dropped-out, thus 19 patients received citalopram and 20 remained in the control group. After 3 months of treatment, the citalopram group showed a decrease on BDI and SCL-90 Depression subscale and an improvement of baseline obsessive compulsive features on SCL-90, EDI-2 impulsiveness and Trait-anger on STAXI. Weight gain was similar in the two groups. DISCUSSION: These preliminary results support the efficacy of citalopram in anorectics. Citalopram seems to improve depression, obsessive-compulsive symptoms, impulsiveness and Trait-anger.

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Int J Psychoanal 2002 Aug;83(Pt 4):837-50
Body, mother, mind: anorexia, femininity and the intrusive object.
Lawrence M.
61 Godolphin Road, London W12 8JN, UK.

This paper takes as its starting point the preponderance of female to male patients who suffer from anorexia. The author suggests that there may be something specific about certain experiences of femaleness which predispose towards anxieties of intrusion. Two contemporary theories of the aetiology of anorexia are outlined. Both of these suggest that the problem has its origins in intrusion or invasion of different sorts. The author suggests that many women who suffer from anorexia have an intrusive object instated in their minds, which may not necessarily be the result of actual intrusions in external reality. In the final part of the paper, the author examines the intrusiveness of anorexic patients in the transference and suggests that such patients very often harbour profound phantasies of intruding between the parents, with a wish to regain their special place with mother, untroubled by the presence of father. It is further suggested that the psychopathology underlying certain cases of anorexia leads to a failure in symbolisation. This failure in turn complicates the clinical picture, making such patients particularly difficult to think with about their difficulties.

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Psychiatry Clin Neurosci 2002 Oct;56(5):515-20
A behavior therapy program combined with liquid nutrition designed for anorexia nervosa.
Okamoto A, Yamashita T, Nagoshi Y, Masui Y, Wada Y, Kashima A, Arii I, Nakamura M, Fukui K.
Department of Psychiatry, Kyoto Prefectural University of Medicine, Japan. oakiko@koto.kpu-m.ac.jp

We have introduced behavior therapy as standard in-patient treatment for anorexia nervosa and have modified the treatment program. At first, we used Fukamachi's activity restriction therapy (FT), followed by Token economy therapy (TET), which combined token economy with FT. Finally, we have developed Kyoto Prefectural University of Medicine Behavior Therapy (KPT). According to KPT, only liquid formula is given in the early stages of hospitalization and a target weight is not set at admission. We examined the effect of these three programs with respect to bodyweight gain. Thirty-five anorexic patients participated in these three programs in our hospital: seven completed FT, seven completed TET and 21 completed KPT. We compared the effects of these three programs on body mass index (BMI). Furthermore, the effects of these three programs on BMI were compared at admission, 1 month after admission and at discharge, 6 months after discharge. In addition, the rate of increase of BMI for the following three periods was investigated: 1 month after admission, total hospitalization (from admission to discharge) and from admission to 6 months after discharge. The result is that KPT was the most effective of the three programs with regard to both the amount and the rate of increase of BMI at all points and there is a significant difference between KPT and FT. This effectiveness may be attributable to the use of an oral liquid formula, the setting of target weight at a later stage of hospitalization and the release of activity restriction based on weight gain.

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J Contemp Dent Pract 2001 May 15;2(2):98
Eating disorders: identification and intervention.
Mueller JA.

Society's preoccupation with outward appearance and thinness has increased the incidence of both anorexia nervosa and bulimia nervosa, two potentially threatening diseases. Unfortunately, it is difficult to obtain accurate statistics on these eating disorders. Those with an eating disorder are often unwilling to admit they have this disorder and are reluctant to seek help. Subsequently, eating disorders have become a serious concern for medical and dental professionals. Since dental professionals see patients on a regular basis, he/she may be the person to whom the eating disorder patient confides.1 For the same reason, the oral care provider may be the first to notice oral manifestations of disease in the anoretic or bulimic person.2,3 The dental professional can serve as an important link between the person with an eating disorder and professional therapy. Knowledge of the signs and symptoms for these diseases is important because early diagnosis and treatment can result in more successful therapy.

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Int J Emerg Ment Health 2002 Spring;4(2):113-8
Eating disorders and posttraumatic stress: phenomenological and treatment considerations using the two-factor model.
Lating JM, O'Reilly MA, Anderson KP.
Loyola College Department of Psychology, 4501 North Charles Street, Baltimore, MD 21210-2699, USA.

The incidence and impact of eating disorders and posttraumatic stress disorder (PTSD) are both profound. Recent data have suggested, however, that a possible concomitance may at times exist between the two diagnoses. The purpose of this paper is to increase awareness of the possibility that a presentation of an eating disorder may not be an isolated phenomenon, and it may be diagnostically prudent for clinicians to assess for a history of trauma and/or current trauma symptoms. For a clinician treating both diagnoses concurrently, we suggest utilizing the two-factor model of PTSD, and its natural corollary of neuropersonologic therapy, as a reasonable conceptual and treatment model.

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Am J Psychiatry 2002 Aug;159(8):1347-53
Supplemental nocturnal nasogastric refeeding for better short-term outcome in hospitalized adolescent girls with anorexia nervosa.
Robb AS, Silber TJ, Orrell-Valente JK, Valadez-Meltzer A, Ellis N, Dadson MJ, Chatoor I.
Department of Psychiatry and Behavioral Sciences, Children's National Medical Center, Washington, DC 20010, USA. arobb@cnmc.org

OBJECTIVE: Although controversy exists regarding nasogastric refeeding for patients with anorexia nervosa, current methods of inpatient care often result in low discharge weight, a critical risk factor in relapse. This study compared the short-term outcomes of standard oral refeeding and supplemental nocturnal nasogastric refeeding. METHOD: Subjects were 100 hospitalized Caucasian adolescent girls who met DSM-IV criteria for anorexia nervosa. Subjects were partitioned into two groups: oral refeeding (N=48, mean age=15.0 years, SD=1.8) and nocturnal nasogastric refeeding (N=52, mean age=14.8 years, SD=1.9). Unpaired t tests, with Bonferroni correction, were used to compare groups at hospital admission and at discharge. Multivariate linear regression was used to establish the independent effects of nocturnal nasogastric refeeding after adjustment for potential confounding variables. RESULTS: On admission, the groups were comparable in terms of age, weight, and other factors but differed significantly in number of prior hospitalizations (the nocturnal nasogastric refeeding group had more than the oral refeeding group). A series of separate multivariate linear regression models revealed that nocturnal nasogastric refeeding was a significant predictor of weight at discharge and absolute weight gain. CONCLUSIONS: Over a comparable period of time, patients treated with nocturnal nasogastric refeeding had a greater and more rapid weight gain than patients treated with traditional oral refeeding. Supplemental nocturnal nasogastric refeeding was more effective than oral refeeding alone in weight restoration during hospitalization. However, further study is needed on its short-term and long-term effectiveness.

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Am J Psychiatry 2002 Aug;159(8):1284-93
The outcome of anorexia nervosa in the 20th century.
Steinhausen HC.
Department of Child and Adolescent Psychiatry, University of Zurich, Postfach, Switzerland. steinh@kjpd.unizh.ch

OBJECTIVE: The present review addresses the outcome of anorexia nervosa and whether it changed over the second half of the 20th century. METHOD: A total of 119 study series covering 5,590 patients suffering from anorexia nervosa that were published in the English and German literature were analyzed with regard to mortality, global outcome, and other psychiatric disorders at follow-up. RESULTS: 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. CONCLUSIONS: 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.

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Arch Psychiatr Nurs 2002 Aug;16(4):176-86
Anorexia nervosa: analysis of long-term outcomes and clinical implications.
Finfgeld DL.
Sinclair School of Nursing, University of Missouri, Columbia, MO 65211, USA. finfgeldD@health.missouri.edu

Recovery from anorexia nervosa is a lengthy process and involves overcoming physical as well as psychosocial problems. Factors such as weight at referral, laboratory values, and psychosocial variables tend to predict long-term outcomes and help guide clinical interventions. Non-weight restored as well as some weight restored individuals experience chronic problems. Long-term consequences of anorexia nervosa indicate a need for continued oversight and individual treatment planning. Copyright 2002, Elsevier Science (USA). All rights reserved.

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Curr Opin Pediatr 2002 Aug;14(4):379-83
Evidence-based treatment of eating disorders.
Rosenblum J, Forman S.
Division of Adolescent and Young Adult Medicine, Children's Hospital, Boston, Massachusetts 02115, USA. Jennifer.Rosenblum@tch.harvard.edu

Anorexia nervosa and bulimia nervosa are common problems facing adolescents and young adults. Treatment of these disorders poses a challenge to health care providers given the general paucity of clinical trials to guide management. There is evidence to support the use of CBT as well as psychopharmacotherapy to decrease binge and purge behaviors in bulimia nervosa. Significantly fewer trials have examined the efficacy of such therapies for anorexia nervosa. Short-term trials appear promising regarding potential treatments for bone loss in anorexia nervosa. The role of exercise in the management of anorexia nervosa remains controversial and begs future investigative efforts.

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Altern Med Rev 2002 Jun;7(3):184-202
Eating disorders: a review of the literature with emphasis on medical complications and clinical nutrition.
Patrick L.

Eating disorders, including anorexia nervosa, bulimia nervosa, binge-eating disorder, and atypical eating disorder (eating disorder not otherwise specified or NOS), are estimated to occur in 5-10 million young and adult women and one million males in the United States. The etiology of eating disorders is complex and appears to include predisposing genetic factors and serotonin dysregulation, as well as psychological factors that include a history of trauma and childhood sexual abuse. Both anorexia nervosa and bulimia nervosa are medical conditions complicated by multiple neuroendocrine dysfunctions, nutritional deficiencies, and psychiatric diagnoses. Medical complications, specific nutritional deficiencies, and research involving the therapeutic use of inositol and zinc are reviewed.

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J Pediatr Adolesc Gynecol 2002 Jun;15(3):135-43
The effect of estrogen-progestin treatment on bone mineral density in anorexia nervosa.
Golden NH, Lanzkowsky L, Schebendach J, Palestro CJ, Jacobson MS, Shenker IR.
Department of Pediatrics, Division of Adolescent Medicine, Schneider Children's Hospital of Long Island Jewish Medical Center, New Hyde Park, New York 11040, USA. golden@lij.edu

INTRODUCTION: Osteopenia is a serious complication of anorexia nervosa (AN). Although in other states of estrogen deficiency, estrogen replacement therapy increases bone mass, its role in AN remains unresolved. STUDY OBJECTIVE: To study the effect of estrogen-progestin administration on bone mass in AN. DESIGN, SETTING, AND PARTICIPANTS: A prospective observational study of 50 adolescents with AN (mean age 16.8 +/- 2.3 yrs) was conducted in a tertiary referral center. MAIN OUTCOME MEASURES: Bone mineral density (BMD) of the lumbar spine and left hip were prospectively measured using dual-energy x-ray absorptiometry at baseline and annually. INTERVENTIONS: Twenty-two subjects received estrogen-progestin and 28 standard treatment (Rx) alone. Estrogen-progestin was administered daily as an oral contraceptive containing 20-35 mcg ethinyl estradiol. All subjects received calcium supplementation and the same medical, psychological, and nutritional intervention (standard Rx). Mean length of follow-up was 23.1 +/- 11.4 months. RESULTS: At presentation, patients were malnourished (79.5% +/- 7.6% IBW), hypoestrogenemic (estradiol 24.7 +/- 10.7 pg/mL), and had reduced bone mass (lumbar spine BMD -2.01 +/- 0.69 SD below the young adult reference mean). Ninety-two percent of subjects were osteopenic and 26% met WHO criteria for osteoporosis. Body weight, and no treatment group, was the major determinant of BMD. At one-year follow-up, there were no significant differences in absolute values or in net change of lumbar spine or femoral neck BMD between those who received estrogen-progestin and those who received standard Rx (80% power of finding a 3% difference in BMD at 1 yr). In those followed for 2-3 yrs, osteopenia was persistent and in some cases progressive. CONCLUSION: In our study population, estrogen-progestin did not significantly increase BMD compared with standard Rx. These results question the common practice of prescribing hormone replacement therapy to increase bone mass in AN.

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Psychother Psychosom 2002 Jul-Aug;71(4):200-6
Dropout from brief psychotherapy in anorexia nervosa.
Fassino S, Daga GA, Piero A, Rovera GG.
Department of Neurosciences, Psychiatry Section, Service for Eating Disorders, Turin University, Turin, Italy. secondo.fassino@unito.it

BACKGROUND: Dropout from psychotherapy is an important issue that has received little systematic attention. This study investigated the phenomenon of dropout from brief psychotherapy for anorexia nervosa (AN). METHODS: 99 outpatients suffering from AN of the restrictor type (n = 53) or binge/purging type (n = 46) were evaluated. Their clinical and personal characteristics were recorded, and body mass index was calculated for participants. They were administered the Eating Disorder Inventory-II (EDI-II), the State-Trait Anger Expression Inventory (STAXI) and the Temperament and Character Inventory (TCI). RESULTS: Significant differences in some baseline psychopathologic (EDI-II, STAXI) and personality (TCI) variables emerged from the comparison between dropouts and completers. Patients who dropped out of the treatment showed higher levels of anger temperament, anger expression-in and expression-out and lower scores for the dimensions of character (low self-directedness and low cooperativeness). No differences were found between the two groups regarding sociodemographic and clinical variables. CONCLUSIONS: Dropout from brief psychotherapy seems to be related to either psychopathologic or personality aspects, such as the tendency to repress anger, which is encountered also in psychosomatic disorders, and the presence of more compromised dimensions of character, typical of subjects with personality disorders. This study of dropout from brief psychotherapy in AN provided interesting results that will need further confirmation. Possible implications for treatment are addressed. Copyright 2002 S. Karger AG, Basel

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J Perinat Neonatal Nurs 2001 Sep;15(2):36-48
Eating disorders, fertility, and pregnancy: relationships and complications.
James DC.
Saint Louis University School of Nursing, MO, USA.

Women are becoming heavier with each generation although the ideal female image emphasizes slimness. This focus results in the development of eating disorders in a significant number of women. The most common eating disorders are anorexia nervosa and bulimia nervosa. Eating disorder behaviors during pregnancy are associated with complications such as preterm delivery, low birthweight, intrauterine growth restriction, Caesarean birth, and low Apgar scores. Increasing the understanding of eating disorders assists health care professionals to accurately assess and intervene to improve a woman's nutritional status, monitor eating behaviors that may negatively affect a woman's health and fertility, and promote positive outcomes during pregnancy.

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Int J Group Psychother 2002 Jul;52(3):409-17
Comparison of group climate in an eating disorders partial hospital group and a psychiatric partial hospital group.
Tasca GA, Flynn C, Bissada H.
Eating Disorders Program, Department of Psychology, Ottawa Hospital, University of Ottawa, Canada. gtasca@ottawahospital.on.ca

Women in an eating disorders partial hospital program and a psychiatric partial hospital program were compared on a self-report measure of group climate following a psychodynamic-interpersonal therapy group. Those with eating disorders experienced their groups as more engaged and as more avoiding than those in the psychiatric partial hospital group. Therapists may be able to use initial heightened engagement in eating disorder groups to counteract the tendency to avoid content.

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Proc Natl Acad Sci U S A 2002 Jul 9;99(14):9486-91
Randomized controlled trial of a treatment for anorexia and bulimia nervosa.
Bergh C, Brodin U, Lindberg G, Sodersten P.
Section of Applied Neuroendocrinology and Center for Eating Disorders, Karolinska Institutet, Novum, S-141 57 Huddinge, Sweden. cecelia.bergh@neurotec.ki.se

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.

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J Clin Endocrinol Metab 2002 Jun;87(6):2883-91
Effects of recombinant human IGF-I and oral contraceptive administration on bone density in anorexia nervosa.
Grinspoon S, Thomas L, Miller K, Herzog D, Klibanski A.
Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA. sgrinspoon@partners.org

Over 90% of women with anorexia nervosa demonstrate osteopenia, and almost 40% demonstrate osteoporosis at one or more skeletal sites. In addition to estrogen deficiency causing an increase in bone resorption, nutritional effects on the GH-IGI-I axis may contribute to the severe bone loss in this population by decreasing bone formation. We tested the hypothesis that recombinant human IGF-I (rhIGF-I) would increase bone density in women with anorexia nervosa and furthermore assessed the effects of combined rhIGF-I and oral contraceptive administration (OCP) in this population. Sixty osteopenic women with Diagnosis and Statistical Manual of Mental Disorders IV Revised confirmed anorexia nervosa [age (25.2 +/- 0.7 yr, range 18-38 yr), body mass index (17.8 +/- 0.3 kg/m(2) ), spinal bone mineral density T score (-2.1 +/- 0.1 SD) were randomized to one of four treatment groups [rhIGF-I (30 microg/kg sc twice daily) and a daily oral contraceptive (Ovcon 35, 35 microg ethinyl estradiol and 0.4 mg norethindrone], rhIGF-I alone (30 microg/kg sc twice daily), oral contraceptive alone, or neither treatment for 9 months. All subjects received calcium 1500 mg/d and a standard multivitamin containing 400 IU of vitamin D. Administration of rhIGF-I was placebo controlled and blinded to subjects. The rhIGF-I was titrated to maintain IGF-I levels within the age-adjusted normal range for each patient and was well tolerated. The effects of rhIGF-I and OCP were analyzed simultaneously among all subjects in a factorial analysis and in an analysis of the four individual treatment groups. Anteroposterior spinal bone density increased significantly in response to rhIGF-I (1.1% +/- 0.5% vs. -0.6% +/- 0.8%, P = 0.05, all rhIGF-I vs. all placebo treated, respectively, by analysis of covariance). In contrast, OCP did not result in increased bone density (0.8% +/- 0.6% vs. -0.4% +/- 0.8%, P = 0.21, all OCP vs. all non-OCP treated, respectively, by analysis of covariance). However, bone density increased to the greatest extent in the combined treatment group (rhIGF-I and OCP), compared with control patients receiving no active therapy (1.8% +/- 0.8% vs. 0.3% +/- 0.6% vs. -0.2% +/- 0.8% vs. -1.0% +/- 1.3%, rhIGF-I and OCP vs. rhIGF-I alone vs. OCP alone vs. no active therapy, P < 0.05 for rhIGF-I and OCP vs. no active therapy). These data demonstrate that osteopenic women with anorexia nervosa treated with rhIGF-I showed more beneficial changes in bone density, compared with patients not treated with rhIGF-I. Antiresorptive therapy with OCP is not sufficient to improve bone density in undernourished patients, but such therapy may augment the effects of rhIGF-I in a combined treatment strategy. Further long-term studies are needed to investigate the effects of rhIGF-I and combined anabolic/antiresorptive strategies on bone in women with anorexia nervosa.

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Can J Psychiatry 2002 Apr;47(3):267-70
Treatment resistance in anorexia nervosa and the pervasiveness of ethics in clinical decision making.
MacDonald C.
Dept of Philosophy, Dalhousie University, Halifax, NS B3H 4H7. Chris.MacDonald@dal.ca

Clinical efforts to treat anorexia nervosa (AN) are constantly resisted by patients. Although the primacy of patient autonomy is a cornerstone of modern medical ethics, clinicians will nonetheless often be justified in pursuing particular interventions despite such resistance, give the reduced competency of patients suffering from this multifactorial psychiatric illness. While a literature exists on the ethical justification for imposing treatment, that literature has focused exclusively on situations in which patients refuse treatment outright. When patients resist rather than refuse treatment, clinicians are faced with the ethical challenge of deciding whether particular interventions constitute justified infringements upon patient autonomy. Given the fact that treatment resistance is endemic to AN, we see that ethical decision making must also be a continual part of the disorder's treatment. This paper argues that the treatment of AN merely constitutes a particularly clear example of what is in fact a general phenomenon: ethical decision making pervades all clinical practice.

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Can J Psychiatry 2002 Apr;47(3):235-42
Psychological treatments for anorexia nervosa: a review of published studies and promising new directions.
Kaplan AS.
Toronto General Hospital/University Health Network, 200 Elizabeth Street, EN 8-231, Toronto, ON M5G 2C4.

OBJECTIVE: To review the existing literature on the psychological treatments for anorexia nervosa (AN), especially randomized clinical trials that have been published. In addition, new psychological approaches will be described. METHODS: An extensive literature review was conducted to identify the psychological treatment trials on AN that have been published over the past 3 decades. RESULTS: Fewer than 20 controlled clinical trials were identified, evaluating the effectiveness of various types of psychotherapy in AN treatment. Evidence for the effectiveness of these interventions, with the exception of family therapy for younger patients with shorter duration of illness, remains questionable. Promising new approaches include motivational enhancement therapy and psychotherapies aimed at relapse prevention. CONCLUSION: Currently, there is little empirical evidence on which to base treatment decisions regarding the psychological treatments for AN. There is a desperate need for further research in this area, especially examining relapse prevention and motivational enhancement strategies for AN.

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Can J Psychiatry 2002 Apr;47(3):227-34
Pharmacologic treatment of eating disorders.
Zhu AJ, Walsh BT.
Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 98, New York, NY 10032, USA.

OBJECTIVE: Eating disorders are a serious group of conditions that affect 3% of women in industrialized nations over their lifetimes. Recent years have seen considerable progress in the treatment of these disorders. This article reviews the current body of evidence for the pharmacologic treatment of eating disorders. METHODS: We undertook a literature review. RESULTS: For patients with anorexia nervosa (AN), drug trials have been disappointing. In contrast, numerous studies have demonstrated a clear role for antidepressants in the treatment of bulimia nervosa (BN). Pharmacologic investigations of binge eating disorder (BED), a more recently defined entity, have identified several promising drugs. There is also support for the utility of combined medication and psychotherapy. CONCLUSION: Continued research efforts are necessary, particularly regarding the long-term effects of therapy and the development of new pharmacologic strategies.

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Eat Weight Disord 2002 Mar;7(1):20-2
Zinc supplementation in the treatment of anorexia nervosa.
Su JC, Birmingham CL.
University of British Columbia, Vancouver, Canada.

The clinical manifestations of zinc deficiency and anorexia nervosa are remarkably similar, and a number of studies have demonstrated that there may be a positive correlation between zinc therapy and the rate of recovery of anorexia nervosa patients. However, because of the different interpretations of the results of these studies, the use of zinc supplementation varies. This article examines the evidence supporting zinc supplementation in the treatment of anorexia nervosa. Randomised, double-blind, controlled clinical trials indicate that zinc therapy enhances the rate of recovery in anorexia nervosa patients by increasing weight gain and improving their levels of anxiety and depression. On the basis of these findings and the low toxicity of zinc, zinc supplementation should be included in the treatment protocol for anorexia nervosa.

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Int J Eat Disord 2002 Apr;31(3):251-60
Estimating readiness for change in anorexia nervosa: comparing clients, clinicians, and research assessors.
Geller J.
St. Paul's Hospital Eating Disorders Program, University of British Columbia, Vancouver, British Columbia, Canada. jgeller@providencehealth.bc.ca

OBJECTIVE: This research compared the relative ability of clients, clinicians, and research assessors in estimating readiness for change in individuals with anorexia nervosa. METHOD: Fifty-six individuals with a current or past diagnosis of anorexia nervosa made ratings of the extent to which they perceived themselves to be ready for treatment and recovery. Clinicians and research assessors made the same ratings based on their impressions following clinical and research assessments, respectively. The outcome variables included questionnaire measures of change activities, assigned behavioral tasks, and clients' decision to accept intensive treatment. RESULTS: While research assessor and client ratings predicted questionnaire recovery activities, only research assessor ratings predicted completion of behavioral tasks and clients' decision to accept intensive treatment. Clinician ratings were not related to any of the questionnaire or behavioral recovery activity measures. DISCUSSION: Conditions favoring the accurate prediction of readiness for treatment and recovery are discussed, and implications for clinical practice are addressed. Copyright 2002 by Wiley Periodicals, Inc.

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Int J Eat Disord 2002 Mar;31(2):185-90
Body image treatment within an inpatient program for anorexia nervosa: the role of mirror exposure in the desensitization process.
Key A, George CL, Beattie D, Stammers K, Lacey H, Waller G.
Department of General Psychiatry, St. George's Hospital Medical School, University of London, London, United Kingdom. akey@sghms.ac.uk

OBJECTIVE: This pilot study examined the role of mirror confrontation in the desensitization process of a body image treatment within an inpatient program for anorexia nervosa. METHOD: A within-subjects design was used. It compared the impact of two modes of group body image treatment on body dissatisfaction, anxiety, and avoidance behaviors. Both treatments followed a set format of exposure exercises and homework, but the modified treatment also included mirror confrontation as an exposure exercise. RESULTS: Standard treatment did not produce any significant changes. Modified treatment produced a significant and sustained improvement in body dissatisfaction and a significant reduction in body anxiety and avoidance behaviors. DISCUSSION: Mirror confrontation is a more effective form of exposure because of the strong emotional response it elicits. Patients' pronounced emotional response to this exercise allowed easier identification of the affective and behavioral components of body dissatisfaction and more cogent links into a developmental body image timeline. Copyright 2002 by Wiley Periodicals, Inc.

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Tidsskr Nor Laegeforen 2002 Jan 30;122(3):285-8
[Eating disorders--how should treatment be organized?]
[Article in Norwegian]
Rosenvinge JH, Gotestam KG.
Institutt for psykologi Universitetet i Tromso 9037 Tromso. janr@psyk.uit.no

BACKGROUND: Well controlled normal population studies show no sharp increase in the incidence and prevalence of eating disorders. However, more individuals seem to seek treatment, and there is a need for more precise estimates of the expected patient load at various levels of care. MATERIALS AND METHODS: The total number of potential patients was estimated on the basis of data on the number of women aged 15-44 years, the number of hospitals and outpatient clinics per county in Norway, working hours per year for general practitioners, and the prevalence of eating disorders. RESULTS: In total, about 50,000 Norwegian women may suffer from eating disorders; about 600 may need highly specialized services. At the most, each outpatient clinic may expect about 80 annual referrals for bulimia nervosa and binge eating disorder, and each hospital may expect 10-20 patients with bulimia nervosa. On average, each outpatient clinic and hospital may expect 8-9 referrals of patients with anorexia nervosa. INTERPRETATION: There is a need for increased treatment capacity, better clinical skills and better organization of treatment services for patients with eating disorders.

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Prim Care 2002 Mar;29(1):81-98, vii
Eating disorders: a guide for the primary care physician.
Powers PS, Santana CA.
Department of Psychiatry and Behavioral Medicine, University of South Florida, Tampa, Florida 33613, USA.

The diagnostic criteria for eating disorders are described, including assessment of complications related to semi-starvation, binge eating, and purging. The key components of treatment are presented, including normalization of eating, individual and family therapy, and cognitive behavioral therapy. The role of the primary care physician in diagnosis and treatment is outlined.
   

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