Download Anorexia Nervosa

Anorexia Nervosa
Tran Huynh, Kristina Nguyen, Jake McGrane,
Taylor Minckley
Video
Importance
95% of those who have eating disorders are
between the ages of 12 and 25.8
What is Anorexia Nervosa
•  DSM-IV Criteria
o  Intense fear of gaining weight
o  Distorted view of body
o  Loss of menstrual cycle
o  Body weight 85% or below normal for age/
height
•  2 Types:
o  Restricting
o  Binge/Purge
Statistics
•  Average American woman:
o  5’4” and 140 lbs
•  Average American model:
o  5’11” and 117 lbs
•  80% American women dissatisfied with
• 
their appearance
Highest mortality rate of psychiatric
disorder
Behaviors and Symptoms
•  Behaviors
o  Unusual eating habits, rituals
o  Compulsive, punishing exercise
• 
o  Cycles of hyperactivity and fatigue
Symptoms
o  Isolation from friends/family
o  Dry skin, shallow complexion
o  Brittle hair, nails, purple nail beds
o  Sensitivity to/intolerance of cold
Anorexic personalities
•  Exhibit high levels of:
o  low self-esteem
o  obsessionality
o  perfectionism
o  anxiety
o  harm avoidance
o  drive for thinness
o  dietary preoccupation
Clicker question
Based on the behaviors, symptoms, and
personalities of patients with anorexia
nervosa, what do you think would be a
comorbid psychiatric disorder of
anorexia?
A) Schizophrenia
B) Insomnia
C) Obsessive-compulsive disorder
D) Munchausen Syndrome
Comorbidity
•  Depression
•  Phobias
•  Anxiety disorder
•  Obsessive-compulsive disorder
•  Panic attacks
•  Post-traumatic stress disorder
•  Substance abuse
•  Body dysmorphic disorder
Models of Anorexia Through Time
1300's - Anorexia was motivated by religious
conviction or illness, often confabulated with consumption
St. Catherine of Siena (1347-80)
1689 - Dr. Richard Morton gives first case studies. He described AN as "a
nervous consumption"
1874 - Sir William Gull publishes "Anorexia Nervosa",
coining the term. He prescribed bicholoride of
mercury, syrup of iodide of iron, and citrate of quinine
Catherine of Siena died at the age of 33.
Catherine herself described her inability to
eat as an infermita (illness).
Eating Disorders in the 20th
Century
1940's1973 -
Freudian psychoanalytic interpretations. Origins of AN were sexual
Hilde Bruch's working Eating Disorders considered the seminal work
on AN.
- Identified three pathognomonic psychological
factors in AN
1. Disturbance of Body Image
2. Disturbance of Perception
3. Sense of Ineffectiveness
- Also associates AN with schizophrenia
- Created the idea of the "anorexigenic family"
- On the surface, family life is perfect, BUT underneath
the family was riddled with secrecy, and followed a similar
pattern in case studies
The Role of the Media
1980s - The rise of feminism brought attention to body image
1940
Ideals of body image in the media changed greatly between
and 1970.
1960's
1940's
Laurette Luez
1950's
Bunny Yeager
Twiggy
The Role of the Media
Whilst women models were getting thinner,the incidence
of anorexia was increasing
This supported the theory that AN was a sociocultural
phenomenon. The fact that dancers and models have
the highest prevalence of AN would appear to support
this assertion.
Clicker question
What do you think is a possible
predisposition to anorexia nervosa?
A) Environmental factors
B) Personality traits
C) Neurotransmitters
D) All of the above
Predisposition
•  Genetic factors
o  ~50-80% heritability rate
o  not linked to single gene
o  possible linkage at chromosome 1, 2, 13
•  Personality traits
o  obsession
o  perfectionism
o  finding little rewards in life
•  Neurotransmitter system
o  dopamine and serotonin
Dopamine and ABA
•  Involved in major symptoms of AN
o  repulsion to food
o  weight loss
o  hyperactivity
o  menstrual abnormalities (amenorrhea)
o  distortion of body image
o  OCD behavior
•  Non Selective DA antagonist = reduces
ABA behavior
o  cis-flupenthixol
Reward Pathway: Dopamine
•  Disruption = sensitization/desensitization
o  reinforces behavior/addiction
•  Food restriction = heightened dopamine
response
o  Sensitive to dopamine
•  AN: Significantly increase brain reward
response in orbitofrontal cortex
o  Limbic system: Decision making
Dopamine: Brain Region
•  Ventral Striatum
•  Midbrain
•  Insula
•  Anterior Cingulate Cortex
•  Orbitofrontal*
o  Impulse Control
o  High food-intake control
•  Increase in brain regions = high ability to
discriminate rewards
Dopamine: Animal Studies
•  Does not affect preference, but desire
o  "wanting" not "liking"
•  Damage to dopamine innervation of
forebrain = no hedonic effect, only
motivational signals
Recovered AN Studies
•  Reduced D2/D3 receptor binding
o  Linking to Ventral Striatum
•  Dopaminergic Drugs promote weight loss
o  methylphenidate
o  antidepressants bupropion
Serotonin: 5-HT pathway
•  5-HT pathway
o  modulates appetite, body weight regulation
o  motor activity
o  mood
o  obsessive compulsive behavior (OCD)
•  5-HT2A - restricting
o  link between OCD and AN
•  5-HT1A - bulimic
o  harm avoidance
AN and the Brain
-A cross-sectional and follow-up voxel-based
morphometric MRI study in adolescent anorexia nervosa
(2009)
+Josefina Castro-Fornieles, et. al.
-12 children & adolescents
-9 control subjects
-Follow up test 7 months later (after AN weight recovery)
-Weight recovery procedure
-MRI procedure
+MRI volume calculation
+VBM analysis
2009 Results (VBM MRI)
2009 Results (VBM MRI) cont'd
The Comprehensive Model!
The Neurobiological Substrate
Noradrenergic Dysregulation
- Noradrenaline is a neurotransmitter that has multiple
functions, including:
1. Regulating sympathetic arousal
2. The regulation of cerebral blood flow
3. The mediation of cortical neuroplasticity
- Premorbidly, there is increased noradrenergic activity
due to genetic predisposition
- This leads to an increased resting sympathetic tone,
which increases the likelihood of high-arousal and highsensitivity states
- The result
ANXIETY
However, Once Dieting Starts...
Early Stages (days to weeks):
There is a depletion of noradrenaline
and its precursors. This reduces noradrenergic activity, which reduces
stress and reinforces dieting.
Medium Term (weeks to months): The noradrenergic system
adjusts to lack of neurotransmitter, and anxiety re-emerges.
After Refeeding:
When the patient begins eating, there is a repletion of
noradrenaline, and the activity of the noradrenergic system increases,
leading back to anxiety and re-starting the cycle.
Chronic AN:
Eventually, if AN persits and refeeding is resisted, over time
the noradrenergic system becomes so severely compromised that the
capacity for anxiety is lost, and the patient often will become depressed
and apathetic.
Impaired Neuroplasticity
- Dysregulation of any neurotransmitter system can impair
cortical neuroplasticity.
- Specifically, impairment of neuroplasticity in the insula
has been implicated in AN.
- Reduced capacity to respond to demands for
neuroplasticity during puberty, the cortical pruning of
adolescence, and the effects of dieting on
neuromodulatory system leads to AN
Insula Dysfunction
-The insular cortex is involved with several functions
1. Interoceptive Awareness
- Pain, temperature, itch, tickle, sensual touch
- Provides link between perceptive and cognitive brain regions
2. Bridge between left and right hemispheres
3. Social emotion and the sense of self.
-Sensory homunculi
- Every person has somatotopic representation of a body map in their mind.
This is called a sensory homunculi. Sensory homunculi have three overlapping
components.
1. Primary (anterior parietal lobe), Sensory and Perceptual
2. Secondary (anterior parietal lobe), Interpretive
3. Tertiary (insula), Integration and meaning
- Each homunculus provides "representational space" for each body part
- These homuncular representations change throughout life due to
Neuroplasticity!
Bringing it all together
- Puberty is the most crucial time for neuroplascity.
- The growth spurt experiences creates competition
-In normal children, neuroplasticity will allow the insula to create a
homunculi that represents their new bodies post-puberty. In AN, the
insula is dysfunction due to impaired neuroplasticity created through
noradrenergic dysregulation. Thus, a major discrepancy between actual
body size and the homunculi occurs, creating a distorted body image (DBI)
-The parts of the body most commonly misrepresented in AN are those parts
that grow fastest in puberty and have the least volume in the
somatotopic map
-Given that puberty has an earlier onset and shorter duration in girls vs boys,
this could explain why prevalence of AN is higher in girls vs boys.
Works Cited:
Bruch, Hilde. "Anorexia Nervosa: Therapy and Theory." The American Journal of Psychiatry 139.12 (1982): 1531-538.
PsychiatryOnline. Web. 21 Nov. 2012. <http://www.neuro.psychiatryonline.org/data/Journals/AJP/3299/1531.pdf>.
Bruch, Hilde. "Family Transactions in Eating Disorders." Comprehensive Psychiatry12.3 (1971): 238-48. SciVerse. Web. 22 Nov.
2012. <http://www.sciencedirect.com/science/article/pii/0010440X71900216#>.
Castro-Fornieles, J., N. Bargallo, L. Lazaro, S. Andres, C. Falcon, M. Plana, and C. Junque. "A Cross-sectional and Follow-up
Voxel-based Morphometric MRI Study in Adolescent Anorexia Nervosa." Journal of Psychiatric Research 43.3 (2009):
331-40. Print.
Castro-Fornieles, Josefina, Xavier Caldú, Susana Andrés-Perpiñá, Luisa Lázaro, Nuria Bargalló, Carles Falcón, Maria Teresa
Plana, and Carme Junqué. "A Cross-sectional and Follow-up Functional MRI Study with a Working Memory Task in
Adolescent Anorexia Nervosa." Neuropsychologia 48.14 (2010): 4111-116. Print.
Lask, Bryan; Frampton, Ian. Eating Disorders and the Brain. Wiley, 2011. 6 December 2012 <
http://lib.myilibrary.com?ID=317799>
Lucas, Alexander R., C. M. Beard, Michael O'Fallon, and Leonard T. Kurland. "50-Year Trends in the Incidence of Anorexia
Nervosa in Rochester, Minn.: A Population-Based Study." American Journal of Psychiatry 148.7 (1991): 917-22. Web. 26
Nov. 2012. <http://www.focus.psychiatryonline.org/data/Journals/AJP/3558/917.pdf>.
Schmidt, Ulrike. "Aetiology of Eating Disorders in the 21st Century. New Answers to Old Questions." European Child and
Adolescent Psychiatry 12.Suppl 1 (2003): 30-37. Web. 21 Nov. 2012. <http://link.springer.com/article/
10.1007%2Fs00787-003-1105-9?LI=true>.
The Anorexigenic Family
The Idea
1. Feeding in the human infant ALWAYS demands the cooperation of another
person.
2. The interaction between infant and food giver is accompanied by
emotional and affectional experience with surround eating and food
intake forever
3. Non-normal interaction could lead to later inability to characterize hunger
correctly, leading to disturbances in perception.