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Psychiatry Res. Apr 16;62(1) The psychobiology of eating behavior in anorexia nervosa. Halmi KA(1). Author information: (1)Cornell University.
Table of contents

Self-starvation: A problem of overriding the satiety signal? Robin Bennett Kanarek , George H. Recidivism and self-cure of smoking and obesity.

Psychiatry: Complexities of cause and effect in anorexia nervosa | Nature

Stanley Schachter. Refeeding after fasting in the rat: effects on body composition and food efficiency. Tolerance to anorectic drugs: Pharmacological or artifactual David A. Levitsky , Barbara J.

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Strupp , Janet Lupoli. Animal anorexias. Nicholas Mrosovsky , David F. Likewise, perfectionism may be expressed through high grades and excellent performance, and it may be perceived as never good enough and experienced with little reward sensation. Alterations in reward and punishment reactivity also account for the tendency for anorexia nervosa individuals to see their own errors over their successes.

Individuals with anorexia nervosa often demonstrate a natural preference towards highly structured and predictable environments due to difficulties with tolerating uncertainty and set-shifting. These same traits also influence response to food for individuals with anorexia nervosa. Individuals with anorexia nervosa tend to report that they do not experience a sense of reward in response to food intake, but instead experience anxiety.

Catalog Record: The Psychobiology of anorexia nervosa | HathiTrust Digital Library

As such, restriction of food intake appears to provide an anxiolytic effect [ 57 ]. Recent research, including our own, has implicated neural substrates in the ventral lower or bottom area limbic circuitry, dorsal top cognitive circuitry and insula, underlying altered reward processing [ 37 , 58 , 59 ], cognitive or self-regulatory control [ 32 , 60 — 62 ] and interoception [ 41 , 63 — 65 ] in the pathophysiology of anorexia nervosa Fig.


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The ventral area of the limbic neural circuit includes the nucleus accumbens, putamen and caudate, as well as the orbitofrontal cortex and amygdala. These regions code for the rewarding and motivating value of eating and contribute to approach or avoidance behaviors. The dorsal cognitive network makes and executes decisions, such as to control food consumption, based on considerations of both short- and long-term outcomes e. It includes the dorsal caudate and dorsal anterior cingulate, lateral prefrontal cortex and parietal cortex. Specifically, the insula is a hub for the evaluation of interoceptive cues, such as internal pain, tastes or feelings of fullness, and plays a pivotal role in anticipation and processing of interoceptive states by conveying information about the internal milieu of the person or organism [ 66 , 67 ] and perceived importance or salience of a food stimulus.

These systems interactively weigh the reward value of food and consequences of consuming it, and integrate this information with homeostatic and motivational drives to guide eating behavior. The model describes brain response changes for those with anorexia nervosa from mounting evidence that indicates that an altered balance of reward and inhibition may contribute to disordered eating [ 1 ]. Imaging data further suggest that anticipatory anxiety contributes to restricted eating.

For example, individuals with anorexia nervosa report exaggerated anxious and avoidance responses to food cues [ 41 , 44 ].

The Psychobiology of Anorexia Nervosa

This is reflected in ventral striatal limbic responses up emotion arrow [ 41 ] and implicates elevated HA and anxiety in anorexia nervosa. This also entails altered dopamine DA and serotonin 5-HT function. This disconnect between anticipating and experiencing food stimuli likely contributes to restricted eating in AN. Lowered dopamine and increased serotonin response may also contribute to the ability of persons with anorexia nervosa to delay rewards since reward may be experienced as less pleasurable [ 41 ].

Evidence also suggests parietal disturbance [ 68 ], which codes for perception of body image and shape disturbance increases up body disturbance arrow ; and the motor cortex area implements the overactive anxiety and body shape disturbance through excessive exercise up movement arrow. Together, these findings have implications for motivation to eat and ability to evaluate reward and make decisions. It is plausible that elevated harm avoidance, perfectionism, anxiety and inhibition, present during childhood, may increase the inclination of compliance with rules for adults with anorexia nervosa.

The hypothalamic-pituitary gonadal axis initiates biological changes during puberty, contributing to a shift from nurture to nature taking the dominate role in trait expression through mid-twenties [ 69 ]. This may trigger changes in neurochemical circuity and contribute to how thought patterns, emotions and motor expression alter [ 70 , 71 ]. In our view, to acknowledge that anorexia nervosa tends to develop around puberty and may rise in incidence again around 18, when faced with a multitude of new life and daily decisions, is not enough to understand the illness.

In addition, the arrow on the right, social and traumatic experiences, influence and may even alter genetic expression during adolescent and adult life, contributing to the development of anorexia nervosa shown as the arrow on the right in the Figure. Neurobiological findings indicate and direct us to possible truths. However, research holds little value if clinicians and clients do not understand it or know how to interpret it. Neurobiologically based research is new to the treatment field and needs to be presented to anorexia nervosa adults and their supports in a way that they can understand the findings, so the client can identify and determine how the findings relate to their own experience.

Interpreting research accurately and creatively in a manner that enhances understanding can lead to increased motivation, instead of resistance, to change. Biological underpinnings of the cognitions and behaviors are given less to no focus. It is a neurobiologically informed, interactive, family-based treatment that draws upon the specific etiological traits characterizing anorexia nervosa [ 72 ]. Persons with a current diagnosis of bulimia nervosa BN or binge eating disorder BED and have a history of anorexia nervosa may be in the treatment program if their temperament is comprised of anorexia nervosa traits.

The client and supports come together to learn about anorexia nervosa together with a biological perspective and to explore why and how the supports are needed. It is an experiential treatment where all neurobiological information is applied and integrated through activities that provide a clear reliable structure that set a foundation for safety while learning and practicing new approaches to manage the traits and symptoms. Information is presented in the manner that anorexia nervosa clients tend to think: in detail, not in generalized points.

This appears to transform resistance into client motivation. Phase II is the follow-up. It is being developed currently by gathering input monthly from the clients and supports who have completed Phase I. They identify what is additionally needed for this phase and report how they are eating and using the tools learned while functioning in their home or other treatment settings. How to best integrate Phase I into ongoing treatment, or offer it as a free-standing program, is currently being studied to determine best impact.

The development of Phase I has been over the last four years and has been in preliminary testing over the last two years. The suggestions for changes have evolved from many recommendations for alterations to consistently requesting that the schedule, activities, tools and manual remain the same.


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  • The clinical reliability has been established over the past two years via open treatment trials, allowing the treatment team to refine the schedule and neurobiological content, approach to meals, movement and Behavioral Agreement until they have been consistently reported by clients and supports as above average to excellent as presented. The Behavioral Agreement is a 16 page treatment plan written for and with the clients, supports and therapists to establish a clear structured plan in response to primary anorexia nervosa traits and symptoms Sample is found as Additional file 1. It provides clients and supports with structure while addressing individual concerns.

    It is a central tool that identifies how each client chooses to manage their traits, tools and decisions when at home. An intent of Phase I is to provide detailed nutritional information, neurobiologically based information and tools that structure while drawing upon the ideas and feedback from the supports and experts clients. It is the client and support who apply and practice the practical treatment methods to better manage anorexia nervosa traits and symptoms at home or in ongoing treatment.

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    The supports hear the same information and learn the same tools in tandem with the adult clients. Their presence allows them to learn and practice the tools at the same time as the clients.


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    In these cases, supports can be significant agents of change. They often assume a greater role in ongoing assistance to help shift the anorexia nervosa traits toward constructive expressions over time.

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    They also realize the importance of increasing structure, planning, rules and rituals into daily patterns. Follow-up data will help determine the impact of Phase I in these multiple roles. The supports are appearing to be a central source in helping the anorexia nervosa client transition with continuity into the home setting, even if the supports live in different locations. Clinicians who assume the client for treatment at their home sites are asked to adopt the Behavioral Agreement established during NEW FED TR and integrate the details that are clearly laid out by the client and supports.

    This has had varying responses from different clinicians ranging from openly welcoming the treatment tools and Behavioral Agreement and including family and supports in ongoing treatment to rejecting and ignoring the Behavioral Agreement and supports in their practice. It has also been stated repeatedly by anorexia nervosa clients leaving NEW FED TR that the clinicians at their home sites know little to no anorexia nervosa neurobiological information to help them better manage the illness.

    It is used throughout each day of Phase I and taken home at the end of the five-day treatment. NEW FED TR consists of five daily modules aimed at targeting anorexia nervosa trait constructs, delivered with clients, supports and treatment providers. See Fig.

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    The details to the modules and how they are structured in treatment are described in the therapist manual, which is in the final stages of being written. Every hour of each of the five days the clients, supports and therapy team work together to learn, experience, practice and establish a practical, livable structure for food and daily life activities at home.

    The only exception is Module 3, where the clients and supports enter separate groups to learn and practice new tools among peers.