This study investigated the relationship between the perception of family functioning and depressive symptomatology in individuals with eating disorders (EDs). Subjects were evaluated by diagnostic clinical interview using DSM-III-R criteria for EDs, the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L), and two self-report measures, the Beck Depression Inventory (BDI) and the Family Assessment Device (FAD). A significant association was found between self-reported depressive symptomatology and perceived poor family functioning. Subjects with bulimia nervosa (BN) reported a significantly more dysfunctional family background than subjects with anorexia nervosa (AN). In our sample, the presence of self-reported depressive symptomatology was a more powerful predictive variable for perceived family dysfunction than the diagnosis of affective disorder. Also, the diagnosis of BN was a more consistent predictor of dysfunctional family interaction than the diagnosis of affective disorder. Depressive symptoms and EDs seem to play different roles in the way in which they contribute to dysfunctional family patterns.

Objective: Interoceptive awareness is known to be impaired in eating disorders. To date, it has remained unclear whether this variable is related to the construct of interoceptive sensitivity. Interoceptive sensitivity is considered to be an essential variable in emotional processes. The objective of the study was to elucidate this potential relationship and to clarify whether general interoceptive sensitivity is reduced in anorexia nervosa. Methods: Using a heartbeat perception task, interoceptive sensitivity was assessed in 28 female patients with anorexia nervosa and 28 matched healthy controls. Questionnaires assessing interoceptive awareness (EDI) and several other variables were also administered. Results: Patients with anorexia nervosa displayed significantly decreased interoceptive sensitivity. They also had more difficulties in interoceptive awareness. Conclusions: In addition to a decreased ability to recognize certain visceral sensations related to hunger, there is a generally reduced capacity to accurately perceive bodily signals in anorexia nervosa. This highlights the potential importance of interoceptive sensitivity in the pathogenesis of eating disorders.

Eating disorders in males are understudied, underrecognised and misunderstood. Despite evidence that males constitute 25-33% of diagnoses of anorexia and bulimia nervosa, and up to 50% of diagnoses of binge eating disorder, limited research has focused on the “male experience” of eating and body image concerns. In addition, researchers and clinicians have only recently begun to focus on the role that muscularity plays in males with eating and body image psychopathology. We present evidence that disordered eating behaviours are increasing more rapidly in men than in women, particularly with regard to binge eating. We further present a clinical comparison of men with anorexia nervosa and muscle dysmorphia (“reverse anorexia”) and review community-held attitudes and beliefs about people with these conditions. We conclude with a discussion of clinical treatment guidelines for males with eating disorders. This workshop will (1) present an overview of the evidence base pertinent to males with eating disorders, (2) evaluate evidence for the prevalence of disordered eating amongst males, compare the phenomenology of muscle dysmorphia and anorexia nervosa, and review the stigmatization of males with anorexia nervosa and muscle dysmorphia. Finally, this workshop 3) details treatment guidelines for clinicians working with males.

This systematic review analysed published data on the effectiveness of enhanced cognitive behaviour therapy (CBT-E) for adolescents with eating disorders. Of the 28 papers retrieved, eight (6 case series, 1 prospective cohort study, and 1 non-randomized effectiveness trial) met the inclusion criteria and revealed the following five findings. First, outpatient CBT-E is well accepted by adolescent patients with anorexia nervosa; it is completed by about two-thirds of participants, and produces improvements in eating-disorder and general psychopathology. Remission from anorexia nervosa is achieved by about 50% of patients at 12-month follow-up. Second, outpatient CBT-E seems more effective for adolescents than adults. Third, inpatient CBT-E for adolescents with anorexia nervosa seems particularly effective-about 80% of patients achieve normal weight by 12-month follow-up. Fourth, CBT-E also seems promising for adolescents who are not underweight. Fifth, CBT-E appears to yield similar outcomes to FBT in terms of weight regain and eating-disorder and general psychopathology improvements at 6-and 12-month follow-up. The fourth and fifth findings derive from a single study and require confirmation. In conclusion, CBT-E is a viable and promising treatment for adolescents with eating disorders.

Anorexia nervosa (AN) is a common condition affecting young people. The medical management of AN on a general paediatric ward is challenging. It is important to identify young people who are at risk of medical complications, so early intervention can be instigated. This article aims to review the clinical practice and evidence supporting the current medical management of young people with AN. It provides a system-based approach to potential complications of the disease, guidance on feeding and the management of re-feeding syndrome. Approaches to legal and ethical challenges are also considered. While the importance of psychiatric treatment is recognised, the same is not discussed within this article.

Changes in body morphology of anorectic girls during illness as well as during the treatment period were studied using data on 23 anthropometric traits. The sample consisted of 20 adolescent girls, aged 16.05 +/- 2.21 years. Girls with shorter duration of anorexia nervosa have larger amounts of fat and muscle tissue on the upper arm, as well as thicker subcutaneous fat tissue of the trunk, than the girls with longer duration of illness. These differences remain even after the treatment period. Growth rate of girls with longer duration of illness has been decreased. Slight changes in the latent structure of body morphology in anorectic girls at the end of hospitalisation in comparison with those at the beginning of hospitalisation were observed. The above-mentioned changes could have resulted from greater relative increase of fat than muscular tissue mass during hospitalisation and possible difference in the sequence of fat gain between the trunk and the extremities. Further studies ...

Background: Evidence of a role of brain-derived neurotrophic factor (BDNF) in the pathophysiology of eating disorders (ED) has been provided by association studies and by murine models. BDNF plasma levels have been found altered in ED and in psychiatric disorders that show comorbidity with ED. Aims: Since the role of BDNF levels in ED-related psychopathological symptoms has not been tested, we investigated the correlation of BDNF plasma levels with the Symptom Checklist 90 Revised (SCL-90R) questionnaire in a total of 78 ED patients. Methods: BDNF levels, measured by the enzyme-linked immunoassay system, and SCL-90R questionnaire, were assessed in a total of 78 ED patients. The relationship between BDNF levels and SCL-90R scales was calculated using a general linear model. Results: BDNF plasma levels correlated with the Global Severity Index and the Positive Symptom Distress Index global scales and five of the nine subscales in the anorexia nervosa patients. BDNF plasma levels were able to explain, in the case of the Psychoticism subscale, up to 17% of the variability (p = 0.006). Conclusion: Our data suggest that BDNF levels could be involved in the severity of the disease through the modulation of psychopathological traits that are associated with the ED phenotype.

Introduction: Studies show that patients' perception of their illness has a direct influence both on their utilization of health services and their adherence to treatment plans. This may be particularly relevant to the treatment of Anorexia Nervosa (AN). Previous studies on AN have typically explored single psycho-social factors that patients with AN relate to the emergence of their illness. There is a need for more coherent systematic descriptions of the complexity of the patients' narratives about how their illness emerged. In this study we sought to identify common components in the participants' narratives. By identifying different combinations of these components in the narratives, we sought to describe differences in patients' perceived pathways to AN. Methods: Participants were 36 women aged 18-51 years who had been treated for AN within the past two years at five clinical institutions in Norway. Semi-open qualitative interviews were conducted, tape-recorded, transcribed and analysed using grounded theory techniques. Results: We identified the following four distinct perceived pathways into AN: "The Avoidant", "The Achiever", "The Transformer", and "The Punisher". The pathways could be regarded as four different projects for mastering life's challenges. Discussion: Our results suggest that there seem to be at least four pathways into AN. This indicates that a common array of symptoms might cover very different psychological dynamics. These might need to be treated therapeutically in different ways and should probably be taken into account during the refinement of diagnostic tools. Key Practitioner Message:  Although patients with AN might present similar symptoms, patients' perspectives on the emergence of their problems indicate that a common array of symptoms cover a variety of subjective psychological dynamics.

hypothesis -now fully accepted throughout the cognitive neuroscience community -that the cerebellum is centrally involved in linguistic acquisition. Since Professor Bishop's research area is specific language impairment, she must have repressed this knowledge.

for many years, if not for life, and the damage done to their minds and bodies may be irreversible. Anorexia nervosa is characterized by a deliberate loss of weight and refusal to eat. Overactivity is common. Approximately 50% of patients also use unhealthy purging and vomiting behaviours to lose weight. There are two main areas of physical interest: the undernutrition and malnutrition of the illness and the various detrimental weight-losing behaviours themselves. Basic psychopathology ranges from an over-valued idea of high salience concerning body shape through to total preoccupation and eventually to firmly held ideas that resemble delusions. Comorbid features are frequent, especially depression and obsessionality. It is inadvisable in clinical practice to apply too strict a definition of AN because to do so excludes patients in the early stage of the illness in whom prompt intervention is most likely to be effective.

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.

Background: Body image distortions are a core feature of anorexia nervosa (AN). Increasing evidence suggests that the fat distribution immediately after weight restoration in patients with AN differs from the distribution typical of healthy adult women. Objective: The purpose of this study was to assess body fat distribution before and shortly after normalization of weight in women with AN. Design: Body composition and fat distribution were assessed by anthropometry, dual-energy X-ray absorptiometry, and whole-body magnetic resonance imaging in 29 women with AN before and after weight normalization and at a single time point in 15 female control subjects. Hormone concentrations were also evaluated in patients and control subjects. Results: During Ȃ10.1 Ȁ 2.9 wk (range: 4-17.3 wk) of treatment, patients with AN gained 12.2 Ȁ 3.6 kg, and refed weight (54.1 Ȁ 4.2 kg) did not differ significantly from that of control subjects (54.7 Ȁ 4.4 kg). Waist-to-hip circumference ratio (P 0.006), total trunk fat (P 0.003), visceral adipose tissue (P 0.006), and intramuscular adipose tissue (P 0.003) were significantly greater in the weightrecovered patients than in the control subjects. In contrast, after refeeding, total subcutaneous adipose tissue and skeletal muscle mass did not differ significantly between the patients and control subjects. In patients with AN, serum cortisol decreased and serum estradiol increased significantly with refeeding but not to control concentrations. Conclusions: In women with AN, normalization of weight in the short term is associated with an abnormal distribution of body fat. The implications of these findings for the long-term psychological and physical health of women with AN are unknown.

This study evaluated the relative distribution and inter-rater reliability of revised DSM-5 criteria for eating disorders in a residential treatment program. Consecutive adolescent and young adult females (N=150) admitted to a residential eating disorder treatment facility were assigned both DSM-IV and DSM-5 diagnoses by a clinician (n=14) via routine clinical interview and a research assessor (n=4) via structured interview. We compared the frequency of diagnostic assignments under each taxonomy and by type of assessor. We evaluated concordance between clinician and researcher assignment through inter-rater reliability kappa and percent agreement. Significantly fewer patients received either clinician or researcher diagnoses of a residual eating disorder under DSM-5 (clinician-12.0%; researcher-31.3%) versus DSM-IV (clinician-28.7%; researcher-59.3%), with the majority of reassigned DSM-IV residual cases reclassified as DSM-5 anorexia nervosa. Researcher and clinician diagnoses show...

Objective: To provide a summary of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guideline for the Management of Anorexia Nervosa (AN). Conclusions: Anorexia nervosa affects only a small proportion of the Australian and New Zealand population but it is important because it is a serious and potentially life-threatening illness. Sufferers often struggle with AN for many years, if not for life, and the damage done to their minds and bodies may be irreversible. Anorexia nervosa is characterized by a deliberate loss of weight and refusal to eat. Overactivity is common. Approximately 50% of patients also use unhealthy purging and vomiting behaviours to lose weight. There are two main areas of physical interest: the undernutrition and mal-nutrition of the illness and the various detrimental weight-losing behaviours themselves. Basic psychopathology ranges from an over-valued idea of high salience concerning body shape through to total preoccupatio...

Objective. To identify risk factors for eating disorders. Methods. A community cohort study was conducted in Navarra, Spain. A region-wide representative sample of 2862 girls who were 12 to 21 years of age completed the Eating Attitudes Test (40-item version) and other questionnaires in 1997. Girls who scored high in the Eating Attitudes Test-40 were interviewed by a psychiatrist who applied Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria to diagnose prevalent cases of eating disorders. Girls who were free of any eating disorder in 1997 were reassessed after 18 months of follow-up using the same methods. Results. Ninety new cases of eating disorders according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria were identified during the follow-up. In the multivariate logistic analysis, a higher risk of incident eating disorder was found for several exposures assessed at the beginning of follow-up, such as younger age, usually eating alone (odds ratio [OR]: 2.9; 95% confidence interval: 1.9-4.6), and frequently reading girls' magazines or listening to radio programs (OR: 2.1; 1.2-3.8 for those most frequently using both media). No independent association was found for television viewing or socioeconomic status. A marital status of parents different from "being married" was associated with a significantly higher risk in the multivariate analysis (OR: 2.0; 1.1-3.5). Conclusions. Our results support the role of mass media influences and parental marital status in the onset of eating disorders. The habit of eating alone should be considered as a warning sign of eating disorders.

This study used a community sample of 954 participants (475 girls and 479 boys; aged between 10.9 and 17.3 years and from the city of Barcelona) and a risk group of 78 participants (35 men and 43 women; derived from the community sample) that have exceeded ≥95 percentile ...

Objective: Anorexia nervosa (AN) has been associated with impulse regulation problems. This study investigated subjective and behavioural impulsivity in women with anorexia nervosa (n=15) and a control group (n=16). Method: A self-report measure (the impulsiveness, venturesomeness, and empathy questionnaire; I 7 ) and two behavioural measures (a continuous performance task [CPT]; and a novel risk taking measure [Bets 16]) of impulsivity were used along with the Beck Depression Inventory (BDI). Results: The AN group had elevated BDI scores and lower self-reported impulsiveness and venturesomeness scores, but they also displayed impulsive behaviour on the CPT (more errors of commission with faster reaction times). Discussion: The coexistence, in AN, of self-reported self-control and behavioural impulsivity indicates that the relationship between impulsivity and disordered eating in AN is more complex than previously recognised and supports the view that self-awareness in AN is low. D

Anorexia nervosa (AN) is characterized by self-induced starvation leading to severe weight and fat loss. In the present study, we measured fasting plasma levels of adiponectin, leptin, resistin, insulin and glucose in 10 women with a restrictive type of AN and in 12 healthy women (C). Insulin sensitivity was determined according to homeostasis model assessment of insulin resistance (HOMA-R). Plasma resistin, leptin and insulin levels were significantly decreased, whereas plasma adiponectin levels were significantly increased in patients with AN compared to the C. HOMA-R was significantly decreased in patients with AN compared to the C group. Plasma adiponectin and leptin concentrations negatively and positively correlated with the body mass index and percentage body fat in both groups. Plasma adiponectin levels were negatively related to plasma insulin levels in the AN group only. In conclusion, we demonstrated that AN is associated with significantly decreased plasma leptin and res...

contract and presence of a comorbid disorder. Conclusions The identification of factors influencing duration of stay, both at the outset and during the hospitalization, could help clinicians to optimize and individualize treatments, as well as increase patient and family compliance.

Outcome of teenage-onset anorexia nervosa in a Swedish community-based sample s Abstract In a prospective longterm outcome study of a representative sample of teenage-onset anorexia nervosa (AN), 51 individuals with AN, recruited after community screening, were contrasted with 51 matched comparison cases at a mean age of 24 years (10 years

Objective: The objectives were (1) to examine whether 3 eating disorder subgroups, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classification system, exhibit a specific profile in terms of early maladaptive schema (EMS) factors, and (2) to investigate the relationship between body mass index (BMI) and EMS factors in each of the individual eating disorder subgroups. Methods: The presence of EMS was measured by the Young Schema Questionnaire Long Form among patients affected by restrictive anorexia nervosa, binge/purging-type anorexia nervosa, and bulimia nervosa. Principal component factor analysis was used to investigate the factor structure of the EMS across eating disorder subgroups. General linear model analysis was applied to examine the differences of the subgroups in terms of their EMS factors. Differential association between BMI and schema factors was tested by analysis of covariance. Results: Four EMS factors were extracted, which accounted for approximately 72% of the variance. The 3 eating disorder subgroups differed in terms of their EMS factor profiles. The analysis of covariance resulted in a significant negative relationship between BMI and EMS factor 2 in the bulimia nervosa group ( P b .0099), indicating that higher severity on defectiveness, failure, dependence, enmeshments, subjugation, approval-seeking (EMS factor 2) was associated with lower values on BMI. Conclusion: The findings of this study indicate that EMSs based on Young's conceptualization of EMS, as measured by the Young Schema Questionnaire, differ significantly among eating disorder subgroups defined by the phenomenological approach used by the DSM-IV diagnoses. These results are consistent with the notion that dysfunctional cognitions may play an important role in the development and maintenance of the symptoms that underlie the DSM-IV classification of the eating disorder subtypes. D

Brain CT studies of 35 patients with anorexia nervosa confirmed the observations of other authors: cerebral dystrophic changes correlate with weight loss and the reversibility of these changes also correlates with the normalization of body weight. Other corroborated facts are: the most numerous and most pronounced enlargements are of the cortical sulci and the interhemispheric fissure, moderate widening affects the ventricles and the rarest and most insignificant changes are those of the cerebellum. The reversibility of the changes showed a parallel to the extent of the changes themselves and to the duration of improvement of the body weight. The reversibility of the enlargement of the cortical sulci and of the distances between the frontal horns of the lateral ventricles was more often significant than that of the abnormal measurements of the celia media. This difference is based on minimal early acquired brain damage which occurs in 60% of our patients. This high incidence of early acquired minimal brain disease in patients with anorexia nervosa is here discussed as a nonspecific predisposing factor. Although there is no exact explanation of the etiology of the reversible enlargement of cerebrospinal fluid (CSF) spaces in anorexia nervosa, the changes resemble those in alcoholics. The mechanisms of brain changes in alcoholism, as shown experimentally, seem to us to throw light on the probable mechanism of reversible dystrophic brain changes in anorexia nervosa.

Additional psychiatric disorders in eating disorders patients may contribute to the risk of suicide and suicide attempts. The aim of this study was to examine associations between Axes I and II comorbidity and suicidality in a large sample of women currently suffering from an eating disorder (ED). In a sample of 288 women (87 anorexia nervosa, 158 bulimia nervosa, 43 eating disorders not otherwise specified) psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview for DSM-IV. Histories of attempted suicide were explored in a structured interview. Suicidal ideation was determined by means of the SCL-90. Past suicide attempts were reported by 26%. Subjects with a purging type ED more frequently had a history of attempted suicide than subjects with a nonpurging type ED. A history of suicide attempts was associated with higher levels of Axes I and II comorbidity, in particular with affective disorders and Cluster B personality disorders. Current suicidal ideation was generally linked with higher levels of all types of Axes I and II comorbidity. Eating disorders are serious psychiatric disorders associated with high levels of comorbidity and suicidality. Incorporating a comprehensive psychiatric evaluation into the clinical assessment of ED patients is important for the assessment of suicidality and for the provision of adequate treatments.

This study examined the relationship of selflessness, the tendency to ignore one's own needs and interests and serve others, to the severity of anorexia nervosa (AN) symptomatology. Measures of selflessness, perfectionism, obsessiveness, self-esteem, disordered eating, body dissatisfaction, drive for thinness and general symptomatology were completed by 205 women with a history of AN (ANh) in various stages of illness and recovery (42 ill, 90 partially recovered and 78 recovered) and 238 female controls. The ANh women's scores on the Selflessness Scale declined significantly as the severity of current pathology decreased. Recovered anorexics scored similarly to female controls. Assertion of one's own needs and interests may be an integral component of recovery from AN, and should be emphasized in therapy. Copyright © 2006 John Wiley & Sons, Ltd and Eating Disorders Association.

This paper critically analyses from a feminist, poststructuralist perspective the ways in which the concepts of gender and amenorrhea are used in current discussions of the revision of the definition of the eating disorder anorexia nervosa. The data consists of the DSM IV and journal articles revising the definition of anorexia nervosa for the DSM V written by the team of psychiatrists and psychologist in charge of this revision. The main findings of the study are that in the DSM IV amenorrhea is used to gender the phenomenon of anorexia nervosa and to associate negative historical discourses about women to the description of anorexia. In the proposed changes for the DSM V, amenorrhea has been removed and thus fulfills the role of de-gendering anorexia nervosa. In both cases psychiatric discourse has revealed its difficulty in addressing and understanding female gender. The options it proposes are the negative perception of femininity (DSM IV) or complete avoidance of any discussion of gender (DSM V).

Recent studies have reported a genetic association between the 21438 G/A polymorphism within the promoter region of the 5-HT 2A receptor gene and eating disorders (ED), with conflicting results. To clarify the role of the 21438 G/A polymorphism in different ED categories we have analyzed the genotype and allele frequency distribution in 54 Italian patients with Binge ED (BED) compared to 132 obese non-BED subjects. No significant differences were found between obese BED and obese non-BED individuals, suggesting that this polymorphism does not genetically distinguish these two phenotypes. Moreover, the evaluation of 148 patients with anorexia nervosa and 86 patients with bulimia nervosa revealed an association of the A allele with both these disorders.

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The current study evaluated whether difficulties regulating emotions explained unique variance in binge eating and examined which types of emotion regulation difficulties are most strongly associated with binge eating. The Eating Disorders Diagnostic Scale and the Difficulties in Emotion Regulation Scale were completed by 695 undergraduates. Hierarchical regression results indicated that difficulties regulating emotions accounted for a significant amount of the variance in binge eating over and above sex, food restriction, and over-evaluation of weight and shape. Results also indicated that greater difficulty identifying and making sense of emotional states, and limited access to emotion regulation strategies were primarily responsible for the link between emotion regulation difficulties and binge eating. This supports a model of binge eating that includes emotional vulnerability and a deficit of skills to functionally modulate negative moods.

Objective To compare the prevalence of eating disorders (ED), socio-cultural risk factors, and body image characteristics in two populations of female adolescents, one Mexican and one Spanish, from similar socio-economic backgrounds. Method A total of 467 Spanish and 329 Mexican girls aged from 11–12 to 17–18 years were assessed using the Eating Attitude Test-26 (EAT-26), the CETCA (Eating Disorders Assessment Questionnaire), the CIMEC (Questionnaire on Influences on Body Shape Model), and a survey of socio-demographic and risk factors produced for this study. Results One out of four subjects showed a significant risk of an eating disorder and 6–7% probably already had one. No significant differences were found between the two samples. Significant differences were found in risk behaviors: more Spanish girls reported body dissatisfaction and binging; more Mexican girls had a history of psychiatric and psychological treatment, pressure from parents and friends to lose weight, dieting, physical activity and vomiting to lose weight, and a history of greater weight loss. In both the groups around 50% of subjects wanted to increase the size of their breasts. However, significantly more Mexican girls desired thinner arms and narrower shoulders and back, and more Spanish girls wanted thinner hips, buttocks, and legs, parts of the body that many Mexicans wanted to increase. Conclusions Risk behaviors and the ideal body models of these Spanish and Mexican adolescent girls varied significantly, indicating major socio-cultural differences. However, the prevalence of ED was similar. Further research should aim to clarify whether the similarities found between this Spanish sample and a Mexican sample taken from an upper-middle class urban environment, a minority that is unrepresentative of the general population, are also observed in samples from other sectors of Mexican society.

Background: Suicide is a leading cause of death among individuals with anorexia nervosa (AN). In this paper, we examined competing explanations of the high rate of death by suicide among individuals with anorexia nervosa (AN). Methods: Nine case reports of individuals with AN who died by suicide were evaluated to determine whether death by suicide occurred a) because physical health was so compromised that what would be a non-lethal suicide attempt in a healthy adult became a fatal suicide attempt, or b) because highly lethal suicide attempts that would have killed any adult, healthy or medically compromised, were made. Results: The findings converged with the latter hypothesis, as predicted by Joiner's [Joiner, T., 2006. Why People Die By Suicide. Harvard University Press, Cambridge, MA] theory of suicide, which suggests individuals with AN may habituate to the experience of pain during the course of their illness and accordingly die by suicide using methods that are highly lethal. Limitations: This study utilized case reports instead of an experimental design, which impedes its ability to comment on whether there is a causal relationship between Joiner's theory and death by suicide among individuals with AN. Conclusions: Clinicians are encouraged to carefully assess suicidality in AN patients, paying particular attention to issues related to lethality.

Anorexia nervosa (AN) and bulimia nervosa (BN) are complex disorders characterized by disordered eating behavior where the patient's attitude towards weight and shape, as well as their perception of body shape, are disturbed. Formal genetic studies on twins and families suggested a substantial genetic influence for AN and BN. Candidate gene studies have initially focused on the serotonergic and other central neurotransmitter systems and on genes involved in body weight regulation. Hardly any of the positive findings achieved in these studies were unequivocally confirmed or substantiated in meta-analyses. This might be due to too small sample sizes and thus low power and/or the genes underlying eating disorders have not yet been analyzed. However, some studies that also used subphenotypes (e.g., restricting type of AN) led to more specific results; however, confirmation is as yet mostly lacking. Systematic genome-wide linkage scans based on families with at least two individuals with an eating disorder (AN or BN) revealed initial linkage regions on chromosomes 1, 3 and 4 (AN) and 10p (BN). Analyses on candidate genes in the chromosome 1 linkage region led to the (as yet unconfirmed) identification of certain variants associated with AN. Genome-wide association studies are under way and will presumably help to identify genes and pathways involved in these eating disorders. The elucidation of the molecular mechanisms underlying eating disorders might improve therapeutic approaches.

A major problem that has dogged research into body image disturbance in anorexia nervosa concerns the diversity of measurement procedures employed in studies of body size estimation. Many researchers believe that results obtained with different procedures cannot meaningfully be compared with each other, because the methods used measure different aspects of the body image. A meta-analysis of 33 body size estimation studies was conducted to investigate whether methodological differences do indeed influence outcome. Thls analysis revealed a general overestimation of body size among anorexia patients. Although a difference in mean effect size was found between studies using Body Part and Whole Body methods, this difference was absent when only the most commonly used Body Part method, the visual size estimation procedure, was considered. Among Whole Body methods, sdhouette methods could not be distinguished from the rest in terms of effect size. It was concluded that Whole Body methods and the visual size estimation procedure assess correlated aspects of the body image.

Brain alterations are known to be associated with anorexia nervosa (AN) and tend to be distributed across brain structures, with only a few reports describing focal damage. Magnetic resonance images of 21 anorexic patients with different disease duration and 27 control subjects were acquired and compared using voxelbased morphometry (VBM). Patients had a significant reduction of total white matter (WM) volume and focal gray matter (GM) atrophy in cerebellum, hypothalamus, caudate nucleus and frontal, parietal and temporal areas. The cerebellum was more affected in patients with longer disease duration, whereas the hypothalamic alterations were more pronounced in patients with shorter food restriction. A correlation with body mass index (BMI) and GM was found in the hypothalamus. Our data demonstrate a diffuse reduction of WM together with focal areas of GM atrophy in AN. The finding of a hypothalamic focal atrophy points to hormonal dysfunction and opens the possibility for a central dysregulation of homeostasis. The involvement of temporoparietal areas could account for body image distortion. Finally, the cerebellar GM atrophy confirms previous findings and seems to be a late consequence of AN that could play a role in the chronic phase of the disease.