Anorexia Nervosa and other eating disorders are arguably the most complex mental health problems that a child or adolescent may experience. Numbers seeking help are on the increase, and the complexity of these disorders challenges even the most experienced clinician. In this 2006 book, the experience of numerous practitioners with international reputations in the field is brought to bear on the broad range of issues a good clinician needs to know about, from the history of the disorder through to treatment, psychopharmacology, the psychotherapies, epidemiology, comorbidities, eating disorders in boys, and neuroimaging. The book is divided into parts detailing the scientific underpinnings, abnormal states, the evidence base for treatments, and finally public health issues, including service delivery models and perspectives on prognosis and outcomes. Clinicians encountering eating disorders will find this latest addition to the Cambridge Child and Adolescent Psychiatry series invaluable.
'The book is pleasingly presented and … The introduction consists of a truly fascinating historical and developmental review, … The section on evidence-based care has useful reviews of acute and chronic medical complications, individual and family psychotherapies, … there is much of interest and value for those who wish to gain an overview of current knowledge of the many problems in this population, without having to delve into a voluminous text.'
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This chapter reviews how conceptualizations of eating disorders have evolved and highlights the power of social context in the development and maintenance of these 'diseases'. It reviews current research into eating disorders, which spans numerous disciplines, including psychology, psychiatry, sociology, and more recently genetics and molecular biology. The 1940s and 1950s saw the rise of psychoanalysis in psychiatry, and so followed a dominance of psychoanalytic perspectives on anorexia nervosa and obesity. Biopsychosocial approaches in multidisciplinary conceptualizations recognize component contributions of biological vulnerabilities, psychological vulnerabilities and environmental triggers. The developmental approach is the next logical step in the evolution of the diagnosis of eating disorders, which call for a careful consideration of multiple pathogenetic factors in an effort to deliver effective treatments. History demonstrates that eating behaviours are sensitive to stress and environmental demands, particularly in children and adolescents, and particularly in women.
The increasing global prevalence of obesity, and the medically and economically important diseases and illnesses that are associated with obesity, have propelled research on the regulation of food intake and body weight into the public spotlight. Most mammals consume food as individual meals, and energy intake must be regulated through the frequency with which meals are taken, and the size of the meals. A number of brain regions are involved in the regulation of food intake, energy balance and body weight. One of these regions is the hindbrain, which is a target for signalling from the gastrointestinal tract, processing information in anatomically distinct structures. A substantial and growing body of evidence supports the existence of hypothalamic homeostatic mechanisms for regulating the food consumption. The potential to manipulate energy balance systems to therapeutic advantage in obesity, metabolic syndrome and eating disorders is fuelling the current frenetic activity within the pharmaceutical industry.
Body shape, weight and eating concerns are at the heart of the psychopathology of eating disorders. This chapter aims to consider what we currently know about the development of children's shape and weight concerns and associated body dissatisfaction. One of the most commonly used methods for describing body dissatisfaction in children is a scale of outline body shapes. Peers are hugely influential in the context of children's self-perception, taking over from parents at an increasingly early age. There are several ways that talking about weight and dieting ('fat talk') could be functional in adolescent peer group interactions. Peer behaviour in relation to children's weight concerns and control deserves far more attention than it has so far received. The chapter considers the early presentation of both shape and weight concerns and their main determinants. More obvious is children's distaste for overweight, a reflection of a salient cultural view.
Eric Stice, University of Texas at Austin, Austin, TX, USA,
Emily Burton, University of Texas at Austin, Austin, TX, USA,
Michael Lowe, Drexel University, Philadelphia, PA, USA,
Meghan Butryn, Drexel University, Philadelphia, PA, USA
One of the most widely studied risk factors for eating disorders is dieting. Theorists have proposed several mechanisms by which dieting might increase the risk for eating disorder symptoms. Dieting has become an increasingly common practice among adolescent and preadolescent females. Randomized trials that have examined the effects of long-term low-calorie diets on changes in binge eating and DSM-IV bulimic symptoms have generated findings that seem completely at odds with the dieting theory of eating pathology. This chapter consistently indicates that adolescents with elevated scores on dieting scales are at elevated risk for future onset of eating pathology. Elevated scores on dieting scales have emerged as the most consistent and robust risk factor for subsequent development of eating disorders. It would be highly desirable to develop objective and unobtrusive measures of dieting for use in prospective risk factor studies.
This chapter discusses the physical and cognitive changes characteristic of pubertal maturation. Just prior to puberty, the sensitivity of the gonadostat to the negative feedback of gonadal sex steroids decreases, releasing the hypothalamic-pituitary axis (HPA) from inhibition. Puberty is heralded by the myriad of physical changes that occur in the body with the advent of the hormonally mediated effects and the cognitive shift associated with them. With both the psychological and biological maturity of adolescence come issues of separation and individuation, consolidation of a sense of self, development of a sexual identity and progress toward academic and vocational plans for adult life. The most useful framework for the discussion is the biopsychosocial model, which has also been used successfully in so many other domains. Throughout adolescence, the work of development that was made possible by the physical, cognitive and psychological changes induced by puberty continues unabated.
Shani Leor, Schneider Children's Medical Center, Petach Tikva, Israel,
Orit Krispin, Schneider Children's Medical Center, Petach Tikva, Israel,
Alan Apter, Schneider Children's Medical Center, Petach Tikva, Israel
This chapter focuses on the genetic factors influencing the development of eating disorders (EDs). One strategy for identifying the genetic influence on EDs has been to determine whether particular psychiatric disorders or traits are expressions of a shared genetic diathesis. Two genetic strategies have predominantly been used to identify susceptibility loci for EDs on the human genome: linkage-type analyses and association studies. Linkage studies test the hypothesis of co-segregation between a marker locus and a trait within families. Association studies test whether an allele and a phenotypic trait show correlated occurrence within a population. The available data strongly suggest that the genetic influences reside in multiple genes and reflect interaction between multiple genes and the environment. The identification and analysis of endophenotypes related to EDs can therefore be of great importance for determining the genetic mechanism underlying EDs.
Eating disorders in children and adolescents might be the only psychiatric condition with some positive connotations in the Westernized 'cult of thinness'. This chapter provides details about Haute-Marne study, Buskerud study, Navarra study and Ontario study conducted across France, Norway, Spain and Canada. Across reported epidemiological studies of eating disorders in child and adolescent samples the following picture emerges: incidence of anorexia nervosa (AN) seems to have levelled off since 1970. Prevalence and incidence are strongly dependent on source population, i.e. the figures are much higher in 'community' samples than in 'treated' samples. Variations in availability of services and in treatment seeking behaviour have a significant influence on reported figures in register studies. Incidence of bulimia nervosa (BN) is not yet stable. Incidence and prevalence of binge eating disorder (BED) in children and adolescents is not well elucidated.
Neuroimaging studies have provided new insights in neural brain circuits and neuroreceptor functions of eating disorders and as a consequence have contributed to a change of the conceptual framework of the pathophysiology and aetiology of eating disorders. Changes in brain structure and metabolism during resting conditions showed several brain alterations in eating-disordered patients. Brain imaging studies using neurotransmitter ligands have offered new opportunities to study neurotransmitter functions and pathways, as well as their relation to pathological behaviour. Neuromediators such as dopamine (DA) and serotonin (5-HT) are believed to be involved in eating disorder pathology. This chapter has summarised findings of neuroimaging research in eating disorders across a wide range of different methods and tools. A promising challenge in the future will be to consider how genetic, developmental and environmental influences shape brain circuit structure and function.
This chapter focuses on diagnostic, classification and presentation issues in relation to children and adolescents with anorexia nervosa (AN). The two diagnostic systems most commonly used throughout the world are those drawn up by the American Psychiatric Association and the World Health Organization's ICD-10. AN is seen in clinical settings in children from around the age of 8 years upwards, and occurs in boys and girls. Although the clinical features, and even the physical appearance of such young people when they are in an emaciated state, bear strong similarities, each young person's illness will be related to a unique pattern of traits, circumstances and triggers. AN remains a serious illness that can develop in children before puberty, and can have devastating effects. We need to continue to improve our means of identifying and describing this disorder so that we can conduct the research needed to inform and improve available treatment.
This chapter discusses eating disorder psychopathology and the prevalence of eating disorders diagnoses in boys. The key determinants in childhood eating disorders considered include psychological constructs such as body dissatisfaction and its influence on dieting and other weight loss strategies, biological factors such as height, weight, body mass index (BMI) and pubertal status. Recently boys have been included in epidemiological studies of eating disorders. Eating disorder psychopathology has most usually been reported as the dependent variable in risk factor research. Conclusions from the current literature highlight that boys do exhibit some of the psychological and biological factors that have been identified as eating disorders risk factors for girls. It is unlikely that an evidence-based treatment approach for boys and young men will be developed without multicentred trials that ensure adequate treatment sample sizes.
The identification of children and adolescents with bulimia nervosa (BN) or syndromes including binge-eating has been an area of development in recent years. This chapter reviews this increasingly important area, providing an overview of the nature of these phenomena, risk factors for their development and the medical complications of these disorders. Few clinical research studies have specifically focused on the medical complications of binge eating disorder (BED) and BN in children and adolescents. Abnormalities of fluids and electrolytes, most commonly hypokalaemia, are found in children and adolescents with BN. Cardiovascular abnormalities occur in adolescents with BN and cause significant morbidity and mortality. Gastrointestinal complications occur frequently and are a major source of morbidity for patients with BN. Binge eating can result in gastric dilatation, necrosis and perforation. The chapter has attempted to provide a comprehensive review of the nature of BN and binge-eating symptoms in children and adolescents.
This chapter describes the range of eating problems seen in middle childhood (latency) and early adolescence (prepubertal or early puberty) that do not fit within 'eating disorders' as a diagnostic category. One of many developmental tasks of childhood and early adolescence is managing the transition from feeding to eating. Over a period of years children with selective eating develop an avoidance reinforced anxiety associated with new foods. There may be anticipatory nausea (with sight or smell triggers), fear of vomiting (textures) or a fear of choking. The term food avoidance emotional disorder (FAED) has mainly been used to describe cases presenting in middle childhood and early adolescence in which age group it may be more common than anorexia nervosa or bulimia nervosa. In some children, food phobias may be a feature of more pervasive anxiety disorder or obsessive-compulsive disorder (OCD).
Separation anxiety disorder (SAD) is probably the most common anxiety disorder presenting during childhood and may increase the risk of subsequent anxiety and mood disorders. Recent reviews conclude that childhood sexual abuse (CSA) is a significant, albeit nonspecific, risk factor for the development of eating disorders (EDs), particularly those with bulimic features that present in association with psychiatric comorbidity. Since traumatic experiences and subsequent post-traumatic stress disorder (PTSD) are associated with an array of psychiatric disorders similar to those found in association with bulimic EDs, and bulimic EDs are linked with trauma and PTSD, then it is reasonable that trauma and PTSD may mediate the association between psychiatric comorbidity and bulimic EDs. This chapter examines our present knowledge regarding the most common comorbid psychiatric conditions seen in association with eating disorders in children and adolescents.
This chapter describes the interrelationship between eating and disease in children with reference to some common conditions. Enteral feeding via gastrostomy tube is increasingly being used in disabled children with oral-motor dysfunction and feeding problems to provide nutrition. It is important to recognize that chronic disease in any organ system in a child can be associated with poor feeding. Difficulties with feeding are common in children with congenital heart disease (CHD). Both decreased energy intake and increased energy requirements contribute to malnutrition. Good nutritional care is an essential part of the management of the child with cystic fibrosis (CF) and is one of the major factors contributing to the improved longevity of such children. Much of the interaction between an infant and its parents surrounds feeding and thus early feeding experience is important to the psychological development of the child.
Childhood obesity is associated with health complications, including elevated blood pressure, hyperinsulinaemia and glucose intolerance, and respiratory abnormalities. The effects of childhood obesity on morbidity and mortality suggest that effective prevention and intervention for childhood obesity is essential. In most obesity treatments, reduction of caloric intake is the most significant contribution to negative energy balance. Increased physical activity, however, also contributes, and may accelerate weight loss and improve maintenance of lost weight. Children have a right to treatment for their obesity no matter how difficult it is to engage them or their parents in treatment. Parents and obese children should be clear that the child has a lifelong predisposition to obesity. More research is planned to investigate whether weight regain can be prevented if the treatment programme is followed by individualized booster sessions in which the children learn maintenance strategies or relapse prevention techniques.
This chapter explains the refeeding syndrome, how to prevent it and how to treat it should it occur. To reduce the risk of refeeding, it is advisable to begin correcting deficiencies before feeding, to commence feeding slowly and to increase the rate gradually. Serious complications of refeeding are more likely to occur in those patients who have low serum levels of vitamins or minerals before refeeding, those who binge and purge compared with those who restrict, those with more severe malnutrition and those who are treated with rapid refeeding. Finally, it is the author's observation and personal opinion that mental health professionals should consult paediatricians more often than they do when caring for children and adolescents with eating disorders. The need for a paediatric consultation depends on many factors, including the state of health of the child and concurrent treatment outside the eating disorders programme.
Patients with chronic medical complications associated with an eating disorder (ED) often elicit negative counter-transference from medical care providers. From a clinical standpoint, the primary area of the brain affected by EDs, especially with weight loss, is the hypothalamus, with important influence on the endocrine regulatory function. Amenorrhea related to decreased hypothalamic function is one of the most clinically relevant chronic medical complications of EDs. It is a diagnostic feature of anorexia nervosa (AN) and is associated with both infertility and low levels of sex steroids. The primary focus of treatment for adolescent patients with EDs who experience menstrual irregularities and amenorrhoea should be weight recovery and normalization of eating habits. Although chronic dysfunctional weight control habits practised by children and adolescents with EDs have recognized effects on all tissues, the primary foci with respect to chronic medical complications are the heart, brain, gonads and bones.
Individual psychotherapy in most instances, particularly with children, should occur following a thorough assessment of the patient's family and social context. This chapter describes individual therapies that have been applied in eating disorders, summarizes their evidence base, and concludes with a commentary on their appropriateness for children and adolescents. Psychodynamic therapies have the longest history in therapies for eating disorders. Cognitive-analytic therapy (CAT) is a treatment that combines elements of cognitive therapy (CT) and psychodynamic therapy. CAT integrates active symptom management, and has been recommended as a viable alternative to cognitive-behavior therapy (CBT). Self-help therapy is a modified form of CBT, in which a treatment manual is provided for people to proceed with treatment on their own, or with support from a non-professional. CBT and interpersonal psychotherapy (IPT) have been found to be effective in reviews that have included trials of eating disorder not otherwise specified (EDNOS) or binge-eating disorder.
This chapter first reviews different models of family therapy for eating disorders, then reviews and synthesizes the evidence from uncontrolled trials and randomized controlled trials. The goal of structural family therapy is to alter the overall structural organization of the family through limiting pathological patterns of family interaction, by challenging alliances between parents and children that limit parental effectiveness, by encouraging development of stronger sibling subsystems and by encouraging more open communication. As involvement of family members appears to be important when treating adolescents with bulimia nervosa (BN), cognitive-behavioural therapy (CBT) for BN has recently been modified for this age group. Intervention for eating disorders involving several families at the same time is a relatively new approach that has most commonly been seen in the psychiatric literature in the area of schizophrenia. The importance of families in treatments for adolescent eating disorders must be underscored.
This chapter reviews models of service delivery, the evidence to support them and the associated recommendations in clinical guidelines. Family therapy approaches are often the treatment of choice for clinicians working with eating disorder patients in child and adolescent psychiatry, owing to their familiarity with systemic approaches and also a growing evidence base. Inpatient treatment programmes generally consist of a mixture of elements, usually involving a combination of nutritional and medical rehabilitation, psychotherapeutic treatment, psychosocial rehabilitation and often family interventions. For those patients not requiring the intensity of inpatient treatment but requiring more than an outpatient programme, day hospital treatment may be considered. In choosing between different models of service, availability is a major consideration, with patients as well as referrers sometimes having to weigh up the advantages of a locally accessible service with those of a more comprehensive service at some geographical distance.
This chapter reviews the pharmacological options for the treatment of anorexia nervosa (AN) and bulimia nervosa (BN). AN is associated with the highest mortality rate of any psychiatric disorder. Enduring negative mood, obsessionality, perfectionism and core eating disorder symptoms are frequently observed in recovered AN patients. BN is a more prevalent condition than AN, affecting between 1% and 3% of adolescent and young adult females. The results of a recent controlled trial of adults with BN suggest that the androgen antagonist flutamide may be efficacious. While there is currently no pharmacological algorithm to guide the treatment of AN, anticipated atypical antipsychotic studies may yield new insight into the treatment of this disorder. In BN, pharmacotherapy is more advanced, although trials involving adolescent populations are scarce. Additional long-term antidepressant trials and further study into non-antidepressant compounds is indicated to enrich the pharmacotherapy of BN.
This chapter provides a review of the various studies on the outcome and prognosis of eating disorders separately anorexia nervosa (AN) and bulimia nervosa (BN). A considerable number of outcome studies also provided some information on prognosis. Irrespective of the outcome criterion, the most consistent finding was the unfavourable role that rejection or premature termination of treatment played for the long-term course of the eating disorders. The variability in findings on various prognostic factors preclude any delineation of rules as to the individual prognosis in a patient suffering from AN. Due to the smaller body of scientific studies, the overall prognostic picture in BN is even less clear than in AN. There is clear evidence that treatment of BN is efficient in the short-term, whereas the longer-term outcome shows a similar though only slightly better result as compared to AN.