Advertisement

Sex Differences in Adolescent Anorexia and Bulimia Nervosa: Beyond the Signs and Symptoms

  • C. Alix TimkoEmail author
  • Levi DeFilipp
  • Antonios Dakanalis
Sex and Gender Issues in Behavioral Health (CN Epperson and L Hantsoo, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Sex and Gender Issues in Behavioral Health

Abstract

Purpose of Review

We review research related to sex differences in eating disorders (EDs) in adolescents. Prior work has explored clinical differences; thus, we examine literature in areas identified as playing an etiological or maintenance role in EDs including: genetics, hormones, neurocognitive inefficiencies, and reward circuitry.

Recent Findings

Sex steroids appear to a play role in the unmasking of genetic risk for development of EDs and puberty may be a heightened period of risk for females. While neurocognitive differences have been well studied in adults with ED, research with adolescents has been less conclusive. Recent work suggests that neural circuitry involved in reward and punishment may play role in development and maintenance of EDs in females. Males are underrepresented in these areas of research.

Summary

Given known sex differences in healthy adolescents, it is likely there are sex differences in the putative biological etiology/maintenance of EDs. Males should be included in future research.

Keywords

Eating disorders Anorexia nervosa Bulimia nervosa Sex differences Adolescents Neurobiology Reward circuitry Gonadal hormones 

Notes

Compliance with Ethical Standards

Conflict of Interest

Levi DeFilipp and Antonios Dakanalis declare no conflict of interest. C. Alix Timko is supported by 5K12HD085848 (PI: N. Epperson).

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Association AP. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.CrossRefGoogle Scholar
  2. 2.
    Smink FR, et al. Prevalence and severity of DSM-5 eating disorders in a community cohort of adolescents. Int J Eat Disord. 2014;47(6):610–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Dakanalis A, et al. Predicting onset and maintenance of men’s eating disorders. Int J Clin Health Psychol. 2016;16(3):247–55.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Klump KL, et al. Academy of Eating Disorders position paper: eating disorders are serious mental illnesses. Int J Eat Disord. 2009;42(2):97–103.PubMedCrossRefGoogle Scholar
  5. 5.
    Dakanalis A, Riva G. Current considerations for eating and body-related disorders among men. In: Sams LB, Keels JA, editors. Body image: gender differences, sociocultural influences and health implications. New York: Nova Science Publishers; 2013. p. 195–215.Google Scholar
  6. 6.
    • Bale TL, Epperson CN. Sex as a biological variable: who, what, when, why, and how. Neuropsychopharmacology. 2016;42(2):386–96 Review of the necessity for inclusion of sex as a variable in clinical research. Provides multiple examples for reference. PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Blakemore S-J, Choudhury S. Development of the adolescent brain: implications for executive function and social cognition. J Child Psychol Psychiatry. 2006;47:296–312.PubMedCrossRefGoogle Scholar
  8. 8.
    Lenroot RK, Giedd JN. Brain development in children and adolescents: insights from anatomical magnetic resonance imaging. Neurosci Biobehav Rev. 2006;30:718–29.PubMedCrossRefGoogle Scholar
  9. 9.
    Ingalhalikar M, et al. Sex differences in the structural connectome of the human brain. Proc Natl Acad Sci. 2014;111(2):823–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Satterthwaite TD, et al. Sex differences in the effect of puberty on hippocampal morphology. J Am Acad Child Adolesc Psychiatry. 2014;53(3):341–350. e1.PubMedCrossRefGoogle Scholar
  11. 11.
    Herting MM, Sowell ER. Puberty and structural brain development in humans. Front Neuroendocrinol. 2017;44:122–37.PubMedCrossRefGoogle Scholar
  12. 12.
    •• Klump KL. Puberty as a critical risk period for eating disorders: a review of human and animal studies. Horm Behav. 2013;64(2):399–410 Reviews human and animal research to support the role of puberty and pubertal timing in the development of eating disoders. Data for males and females is examined, and the role of gonadal hormones is highlighted. PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Swanson SA, et al. Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011;68(7):714–23.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Madden S, et al. Burden of eating disorders in 5–13-year-old children in Australia. Med J Aust. 2009;190(8):410–4.PubMedGoogle Scholar
  15. 15.
    Nicholls DE, Lynn R, Viner RM. Childhood eating disorders: British national surveillance study. Br J Psychiatry. 2011;198:295–301.PubMedCrossRefGoogle Scholar
  16. 16.
    • Kinasz K, et al. Does sex matter in the clinical presentation of eating disorders in youth? J Adolesc Health. 2016;58(4):410–6 Summarizes the psychosoical and medical correlates of adolescent males and females presenting for treatment of eating disorders. Comparisons between the sexes were conducted and similarities/differences highlighted. One of the larger samples of adolecent males that was able to compare males and females. PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Le Grange D, et al. Eating disorder not otherwise specified presentation in the US population. Int J Eat Disord. 2012;45:711–8.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Mancuso SG, et al. Classification of eating disorders: comparison of relative prevalence rates using DSM-IV and DSM-5 criteria. Br J Psychiatry. 2015;206(6):519–20.PubMedCrossRefGoogle Scholar
  19. 19.
    Fisher MM, et al. Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. J Adolesc Health. 2014;55(1):49–52.PubMedCrossRefGoogle Scholar
  20. 20.
    Hudson JI, et al. “The prevalence and correlates of eating disorders in the national comorbidity survey replication”: Erratum. Biol Psychiatry. 2012;72(2):164.Google Scholar
  21. 21.
    Nicely TA, et al. Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. J Eat Disord. 2014;2(1):21.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Gueguen J, et al. Severe anorexia nervosa in men: comparison with severe AN in women and analysis of mortality. Int J Eat Disord. 2012;45(4):537–45.PubMedCrossRefGoogle Scholar
  23. 23.
    Crisp A. 1.5. Anorexia nervosa in males: similarities and differences to anorexia nervosa in females. Eur Eat Disord Rev. 2006;14(3):163–7.CrossRefGoogle Scholar
  24. 24.
    Chatterton JM, Petrie TA. Prevalence of disordered eating and pathogenic weight control behaviors among male collegiate athletes. Eat Disord. 2013;21(4):328–41.PubMedCrossRefGoogle Scholar
  25. 25.
    Lewinsohn PM, et al. Gender differences in eating disorder symptoms in young adults. Int J Eat Disord. 2002;32(4):426–40.PubMedCrossRefGoogle Scholar
  26. 26.
    Norris ML, et al. An examination of medical and psychological morbidity in adolescent males with eating disorders. Eat Disord. 2012;20(5):405–15.PubMedCrossRefGoogle Scholar
  27. 27.
    Welch E, Ghaderi A, Swenne I. A comparison of clinical characteristics between adolescent males and females with eating disorders. BMC psychiatry. 2015;15(1):45.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Woodside DB, et al. Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. Am J Psychiatr. 2001;158(4):570–4.PubMedCrossRefGoogle Scholar
  29. 29.
    Raevuori A, et al. Epidemiology of anorexia nervosa in men: a nationwide study of Finnish twins. PLoS One. 2009;4(2):E4402.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Joiner TE, Katz J, Heatherton TF. Personality features differentiate late adolescent females and males with chronic bulimic symptoms. Int J Eat Disord. 2000;27(2):191–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Kjelsås E, Augestad L, Flanders D. Screening of males with eating disorders. Eating and Weight Disorders-Studies on Anorexia Bulimia and Obesity. 2003;8(4):304–10.CrossRefGoogle Scholar
  32. 32.
    Darcy AM, Lin IH-J. Are we asking the right questions? A review of assessment of males with eating disorders. Eat Disord. 2012;20(5):416–26.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Murray SB, et al. The transition from thinness-oriented to muscularity-oriented disordered eating in adolescent males: a clinical observation. J Adolesc Health. 2017;60(3):353–5.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Núñez-Navarro A, et al. Do men with eating disorders differ from women in clinics, psychopathology and personality? Eur Eat Disord Rev. 2012;20(1):23–31.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    MacCaughelty C, Wagner R, Rufino K. Does being overweight or male increase a patient’s risk of not being referred for an eating disorder consult? Int J Eat Disord. 2016;49(10):963–6.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Bentley C, et al. Sex differences in psychosocial impairment associated with eating disorder features in adolescents: a school-based study. Int J Eat Disord. 2015;48(6):633–40.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Murray SB, et al. A comparison of eating, exercise, shape, and weight related symptomatology in males with muscle dysmorphia and anorexia nervosa. Body Image. 2012;9:193–200.PubMedCrossRefGoogle Scholar
  38. 38.
    • Kask J, et al. Anorexia nervosa in males: excess mortality and psychiatric co-morbidity in 609 Swedish in-patients. Psychol Med. 2017;47(8):1489–99 Review of the mortality rate and co-morbidity in males. Though focused on adults, highlights the severity of anorexia in males. PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Brown CS, Kola-Palmer S, Dhingra K. Gender differences and correlates of extreme dieting behaviours in US adolescents. J Health Psychol. 2015;20(5):569–79.PubMedCrossRefGoogle Scholar
  40. 40.
    Raevuori A, Keski-Rahkonen A, Hoek HW. A review of eating disorders in males. Curr Opinion Opin Psychiatry. 2014;27(6):426–30.CrossRefGoogle Scholar
  41. 41.
    •• Murray SB, et al. The enigma of male eating disorders: a critical review and synthesis. Clin Psychol Rev. 2017;57:1–11 A broad review of salient issues relevant to the diagnosis, treatment, and research on males with eating disorders. The review is slanted more toward adults; however, the issues discussed are relevant for adolescents. Highlights areas for furture research. PubMedCrossRefGoogle Scholar
  42. 42.
    Klump KL, et al. Genetic and environmental influences on anorexia nervosa syndromes in a population-based twin sample. Psychol Med. 2001;31(4):737–40.PubMedCrossRefGoogle Scholar
  43. 43.
    Bulik CM, et al. Understanding the relation between anorexia nervosa and bulimia nervosa in a Swedish national twin sample. Biol Psychiatry. 2010;67(1):71–7.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Helder SG and Collier DA, The genetics of eating disorders, in Behavioral neurobiology of eating disorders. 2010, Springer. 157–175.Google Scholar
  45. 45.
    Slof-Opt’Landt MC, et al. Eating disorders: from twin studies to candidate genes and beyond. Twin Res Hum Genet. 2005;8(5):467–82.CrossRefGoogle Scholar
  46. 46.
    Scherag S, Hebebrand J, Hinney A. Eating disorders: the current status of molecular genetic research. Eur Child Adolesc Psychiatry. 2010;19(3):211–26.PubMedCrossRefGoogle Scholar
  47. 47.
    Boraska V, et al. A genome-wide association study of anorexia nervosa. Mol Psychiatry. 2014;19(10):1085.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Yilmaz Z, Hardaway JA, Bulik CM. Genetics and epigenetics of eating disorders. Adv Genom Gen. 2015;5:131.Google Scholar
  49. 49.
    Klump KL, et al. The effects of puberty on genetic risk for disordered eating: evidence for a sex difference. Psychol Med. 2012;42(03):627–37.PubMedCrossRefGoogle Scholar
  50. 50.
    Klump KL, et al. Preliminary evidence that estradiol moderates genetic influences on disordered eating attitudes and behaviors during puberty. Psychol Med. 2010;40(10):1745–53.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Baker JH, et al. Shared genetic effects between age at menarche and disordered eating. J Adolesc Health. 2012;51(5):491–6.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Hinney A, et al. Evidence for three genetic loci involved in both anorexia nervosa risk and variation of body mass index. Mol Psychiatry. 2017;22(2):192.PubMedCrossRefGoogle Scholar
  53. 53.
    Klump KL, Culbert KM. Molecular genetic studies of eating disorders: current status and future directions. Curr Dir Psychol Sci. 2007;16(1):37–41.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Ostlund H, Keller E, Hurd YL. Estrogen receptor gene expression in relation to neuropsychiatric disorders. Ann N Y Acad Sci. 2003;2007:54–63.CrossRefGoogle Scholar
  55. 55.
    Culbert KM, et al. The emergence of sex differences in risk for disordered eating attitudes during puberty: a role for prenatal testosterone exposure. J Abnorm Psychol. 2013;122(2):420.PubMedPubMedCentralCrossRefGoogle Scholar
  56. 56.
    Klump KL, et al. Preliminary evidence that gonadal hormones organize and activate disordered eating. Psychol Med. 2006;36(4):539–46.PubMedCrossRefGoogle Scholar
  57. 57.
    • Culbert KM, et al. Age differences in prenatal testosterone’s protective effects on disordered eating symptoms: developmental windows of expression? Behav Neurosci. 2015;129(1):18 Investigation into age differences in prenatal testosterone’s protective effects on disordered eating. Suggestive of developmental window of expression for prenatal testosterone’s effect. PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Klump KL, Culbert KM, Sisk CL. Sex differences in binge eating: gonadal hormone effects across development. Annu Rev Clin Psychol. 2017;13:183–207.PubMedCrossRefGoogle Scholar
  59. 59.
    Procopio M, Marriott P. Intrauterine hormonal environment and risk of developing anorexia nervosa. Arch Gen Psychiatry. 2007;64(12):1402–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Booij L, et al. DNA methylation in individuals with anorexia nervosa and in matched normal-eater controls: a genome-wide study. Int J Eat Disord. 2015;48(7):874–82.PubMedCrossRefGoogle Scholar
  61. 61.
    Swinbourne JM, et al. The comorbidity between eating disorders and anxiety disorders: prevalence in an eating disorder sample and anxiety disorder sample. Aust N Z J Psychiatry. 2012;46(2):118–31.PubMedCrossRefGoogle Scholar
  62. 62.
    McAdams CJ, Krawczyk DC. Impaired neural processing of social attribution in anorexia nervosa. Psychiatry Res Neuroimaging. 2011;194(1):54–63.CrossRefGoogle Scholar
  63. 63.
    Bergen AW, et al. Candidate genes for anorexia nervosa in the 1p33-36 linkage region: serotonin 1D and delta opioid receptor loci exhibit significant association to anorexia nervosa. Mol Psychiatry. 2003;8(4):397–406.PubMedCrossRefGoogle Scholar
  64. 64.
    Baker JH, Girdler SS, Bulik CM. The role of reproductive hormones in the development and maintenance of eating disorders. Expert review Obstet Gynecol. 2012;7(6):573–83.CrossRefGoogle Scholar
  65. 65.
    Holliday J, et al. Is impaired set-shifting an endophenotype of anorexia nervosa? Am J Psychiatr. 2005;162:2269–75.PubMedCrossRefGoogle Scholar
  66. 66.
    Lang K, et al. Central coherence in eating disorders: an updated systematic review and meta-analysis. World J Biol Psychiatry. 2014;15(8):586–98.PubMedCrossRefGoogle Scholar
  67. 67.
    van Noort BM, et al. Cognitive performance in children with acute early-onset anorexia nervosa. Eur Child Adolesc Psychiatry. 2016;25(11):1233–44.PubMedCrossRefGoogle Scholar
  68. 68.
    Dakanalis A, et al. Body-image distortion in anorexia nervosa. Nat Rev Dis Primers. 2016;2:16026.CrossRefGoogle Scholar
  69. 69.
    Roberts ME, et al. A systematic review and meta-analysis of set-shifting ability in eating disorders. Psychol Med. 2007;37(8):1075–84.PubMedCrossRefGoogle Scholar
  70. 70.
    Lopez C, et al. Central coherence in eating disorders: a systematic review. Psychol Med. 2008;38(10):1393–404.PubMedCrossRefGoogle Scholar
  71. 71.
    Tchanturia K, Lounes N, Holttum S. Cognitive remediation in anorexia nervosa and related conditions: a systematic review. Eur Eat Disord Rev. 2014;22(6):454–62.PubMedCrossRefGoogle Scholar
  72. 72.
    Teconi E, et al. Set-shifting abilities, central coherence, and handedness in anorexia nervosa patients, their unaffected siblings and healthy controls: exploring putative endophenotypes. World J Biol Psychiatry. 2010;11(6):813–23.CrossRefGoogle Scholar
  73. 73.
    Roberts ME, Tchanturia K, Treasure JL. Is attention to detail a similarly strong candidate endophenotype for anorexia nervosa and bulimia nervosa? World J Biol Psychiatry. 2012;0:1–12.Google Scholar
  74. 74.
    • Lang K, et al. Set shifting in children and adolescents with anorexia nervosa: an exploratory systematic review and meta-analysis. Int J Eat Disord. 2014;47(4):394–9 Summary of research on neurocognitive inefficiencies in adolescents with AN. Sex differences are not discussed, but this is an important summary of the literature at time of publication. PubMedCrossRefGoogle Scholar
  75. 75.
    Allen KL, et al. Neurocognitive functioning in adolescents with eating disorders: a population-based study. Cogn Neuropsychiatry. 2013;18(5):355–75.PubMedCrossRefPubMedCentralGoogle Scholar
  76. 76.
    Andrés-Perpiña S, et al. Clinical and biological correlates of adolescent anorexia nervosa with impaired cognitive profile. Eur Child Adolesc Psychiatry. 2011;20(11–12):541–9.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Kjaersdam Telléus G, et al. Cognitive profile of children and adolescents with anorexia nervosa. Eur Eat Disord Rev. 2015;23(1):34–42.PubMedCrossRefPubMedCentralGoogle Scholar
  78. 78.
    Stedal K, et al. The neuropsychological profile of children, adolescents, and young adults with anorexia nervosa. Arch Clin Neuropsychol. 2012;27(3):329–37.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    Kalkut EL, et al. Development of set-shifting ability from late childhood through early adulthood. Arch Clin Neuropsychol. 2009;24(6):565–74.PubMedCrossRefGoogle Scholar
  80. 80.
    Hara Y, et al. Estrogen effects on cognitive and synaptic health over the lifecourse. Physiol Rev. 2015;95(3):785–807.PubMedPubMedCentralCrossRefGoogle Scholar
  81. 81.
    Wahjoepramono EJ, et al. The effects of testosterone supplementation on cognitive functioning in older men. CNS Neurol Disorders-Drug Targets (Formerly Current Drug Targets-CNS & Neurological Disorders). 2016;15(3):337–43.Google Scholar
  82. 82.
    Chui HT, et al. Cognitive function and brain structure in females with a history of adolescent-onset anorexia nervosa. Pediatrics. 2008;122(2):e426–37.PubMedCrossRefGoogle Scholar
  83. 83.
    Berridge KC. Liking’and ‘wanting’ food rewards: brain substrates and roles in eating disorders. Physiol Behav. 2009;97(5):537–50.PubMedPubMedCentralCrossRefGoogle Scholar
  84. 84.
    O’Hara CB, Campbell IC, Schmidt U. A reward-centred model of anorexia nervosa: a focussed narrative review of the neurological and psychophysiological literature. Neurosci Biobehav Rev. 2015;52:131–52.PubMedCrossRefGoogle Scholar
  85. 85.
    Cowdrey FA, et al. Increased neural processing of rewarding and aversive food stimuli in recovered anorexia nervosa. Biol Psychiatry. 2011;70(8):736–43.PubMedCrossRefGoogle Scholar
  86. 86.
    Titova OE, et al. Anorexia nervosa is linked to reduced brain structure in reward and somatosensory regions: a meta-analysis of VBM studies. BMC psychiatry. 2013;13(1):110.PubMedPubMedCentralCrossRefGoogle Scholar
  87. 87.
    Harrison A, et al. Sensitivity to reward and punishment in eating disorders. Psychiatry Res. 2010;177(1):1–11.PubMedCrossRefGoogle Scholar
  88. 88.
    Frank GK, Kaye WH. Current status of functional imaging in eating disorders. Int J Eat Disord. 2012;45(6):723–36.PubMedCrossRefGoogle Scholar
  89. 89.
    DeGuzman M, et al. Association of elevated reward prediction error response with weight gain in adolescent anorexia nervosa. Am J Psychiatr. 2017;174(6):557–65.PubMedCrossRefGoogle Scholar
  90. 90.
    Frank GK. The perfect storm-a bio-psycho-social risk model for developing and maintaining eating disorders. Front Behav Neurosci. 2016;10:44.PubMedPubMedCentralCrossRefGoogle Scholar
  91. 91.
    Mussap AJ. Motivational processes associated with unhealthy body change attitudes and behaviours. Eat Behav. 2007;8(3):423–8.PubMedCrossRefGoogle Scholar
  92. 92.
    Galvan A. Adolescent development of the reward system. Front Hum Neurosci. 2010;4:6.PubMedPubMedCentralGoogle Scholar
  93. 93.
    • Richards JM, Plate RC, Ernst M. A systematic review of fMRI reward paradigms used in studies of adolescents vs. adults: the impact of task design and implications for understanding neurodevelopment. Neurosci Biobehav Rev. 2013;37(5):976–91 This review is not specific to EDs but does highlight how adolescents and adults differ on the same reward paradigms. Useful for thinking about how we might expect adolescents to differ on the same tasks used in adults and support the idea that findings in adults cannot be generalized to adolescents. PubMedCrossRefGoogle Scholar
  94. 94.
    • Chao AM, et al. Sex/gender differences in neural correlates of food stimuli: a systematic review of functional neuroimaging studies. Obes Rev. 2017;18(6):687–99 Systematic reivew of studies in an adult, non-ED samples. Highlights sex differences in response to food stimuli. PubMedPubMedCentralCrossRefGoogle Scholar
  95. 95.
    Spreckelmeyer KN, et al. Anticipation of monetary and social reward differently activates mesolimbic brain structures in men and women. Soc Cogn Affect Neurosci. 2009;4(2):158–65 nsn051.PubMedPubMedCentralCrossRefGoogle Scholar
  96. 96.
    • Harden KP, et al. Developmental differences in reward sensitivity and sensation seeking in adolescence: testing sex-specific associations with gonadal hormones and pubertal development. J Pers Soc Psychol. 2017;115(1):161–78 This study does not inlcude a sample of adolescents with EDs. However, it suggests that reward sensitivity may be related to pubertal development. Sex differences in relation to reward seeking and pubertal devleopment are discussed. The moderating/mediating role of gonadal hormones is included. Important for understanding the impact of EDs on normal devleopment and how this can be disrupted in adolescents with EDs. PubMedCrossRefGoogle Scholar
  97. 97.
    Op de Macks ZA, et al. Testosterone levels correspond with increased ventral striatum activation in response to monetary rewards in adolescents. Dev Cogn Neurosci. 2011;1(4):506–16.CrossRefGoogle Scholar
  98. 98.
    Hammerslag LR, Gulley JM. Sex differences in behavior and neural development and their role in adolescent vulnerability to substance use. Behav Brain Res. 2016;298:15–26.PubMedCrossRefGoogle Scholar
  99. 99.
    Steinhausen H-C, Seidel R. Outcome in adolescent eating disorders. Int J Eat Disord. 1993;14(4):487–96.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • C. Alix Timko
    • 1
    • 2
    Email author
  • Levi DeFilipp
    • 2
  • Antonios Dakanalis
    • 3
  1. 1.Department of Psychiatry, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of Child and Adolescent Psychiatry and Behavioral ScienceRobert’s Center for Pediatric ResearchPhiladelphiaUSA
  3. 3.Department of Medicine and SurgeryUniversity of Milano BicoccaMonzaItaly

Personalised recommendations