Anorexia Nervosa and Bulimia Nervosa: Brains, Bones and Breeding

Child and Adolescent Disorders (T Benton, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Child and Adolescent Disorders


Recent research has modified both the conceptualization and treatment of eating disorders. New diagnostic criteria reducing the “not otherwise specified” category should facilitate the early recognition and treatment of anorexia nervosa (AN) and bulimia nervosa (BN). Technology-based studies identify AN and BN as “brain circuit” disorders; epidemiologic studies reveal that the narrow racial, ethnic and income profile of individuals no longer holds true for AN. The major organs affected long term—the brain and skeletal system—both respond to improved nutrition, with maintenance of body weight the best predictor of recovery. Twin studies have revealed gene x environment interactions, including both the external (social) and internal (pubertal) environments of boys and of girls. Family-based treatment has the best evidence base for effectiveness for younger patients. Medication plays a limited role in AN, but a major role in BN. Across diagnoses, the most important medicine is food.


Anorexia nervosa Bulimia nervosa Eating disorders Brain circuitry Limbic system Cingulate gyrus fMRI Bone mineral density Osteopenia Osteoporosis Genetics Gene-environment interaction Epigenetics Family-based treatment Cognitive behavioral therapy SSRIs Atypical antipsychotics Mood stabilizers 


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

  1. 1.
    Gull WW. Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica). R Clin Soc Lond Trans. 1873;vii:22.Google Scholar
  2. 2.••
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5: DSM-5th ed. Arlington: American Psychiatric Publishing; 2013. Less restrictive criteria, supported by clinical evidence, should facilitate earlier recognition.Google Scholar
  3. 3.
    Ornstein RM, Rosen DS, Mammel KA, et al. Distribution of eating disorders in children and adolescents using the proposed DSM-5 criteria for feeding and eating disorders. J Adolesc Health. 2013;53:303–5.PubMedCrossRefGoogle Scholar
  4. 4.
    Rosen DS, American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126:1240–53.PubMedCrossRefGoogle Scholar
  5. 5.•
    Wooldridge T, Lytle P. An overview of anorexia nervosa in males. Eat Disord J Treat Prev. 2012;20:68–78. Males are increasingly identified as underdiagnosed.CrossRefGoogle Scholar
  6. 6.
    Xanthopoulos MS, Borradaile KE, Hayes S, et al. The impact of weight, sex, and race/ethnicity on body dissatisfaction among urban children. Body Image. 2011;8:385–9.PubMedCrossRefGoogle Scholar
  7. 7.•
    Gordon KH, Sitnikov L, Castro Y, et al. Cultural body shape ideals and eating disorder symptoms among White, Latina, and Black college women. Cult Divers Ethn Minor Psychol. 2010;16:135–43. Cultural and ethnic norms affect eating disorders.CrossRefGoogle Scholar
  8. 8.
    Marques L, Alegria M, Becker AE, et al. Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: implications for reducing ethnic disparities in health care access for eating disorders. Int J Eat Disord. 2011;44:412–20.PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Rogers-Wood NA, Petrie TA. Body dissatisfaction, ethnic identity, and disordered eating among African American women. J Couns Psychol. 2010;57:141–53.PubMedCrossRefGoogle Scholar
  10. 10.
    Becker AE, Arrindell AH, Perloe A, et al. A qualitative study of perceived social barriers to care for eating disorders: perspectives from ethnically diverse health care consumers. Int J Eat Disord. 2010;43:633–47.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.••
    Becker AE, Fay K, Agnew-Blais J, et al. Social network media exposure and adolescent eating pathology in Fiji. Br J Psychiatr. 2011;198:43–50. Landmark anthropological study of eating disorders developing in remote Pacific islands.CrossRefGoogle Scholar
  12. 12.
    Peebles R, Wilson JL, Litt IF, et al. Disordered eating in a digital age: eating behaviors, health, and quality of life in users of websites with pro-eating disorder content. J Med Internet Res. 2012;14(5):e148.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Datlof S, Coleman W, Forbes GB, et al. Ventricular dilation on CAT scans of patients with anorexia nervosa. Am J Psychiatr. 1986;143:96–8.PubMedGoogle Scholar
  14. 14.••
    Lask B, Frampton I, editors. Eating disorders and the brain. Oxford: Wiley-Blackwell; 2011. Comprehensive, integrated book defining eating disorders as brain disorders.Google Scholar
  15. 15.•
    Frank GKW, Kaye WH. Current status of functional imaging in eating disorders. Int J Eat Disord. 2012;45:723–36. Leading neuroscientists review brain-imaging studies.PubMedCrossRefGoogle Scholar
  16. 16.
    Miller KM, Lee EE, Lawson EA, et al. Determinants of skeletal loss and recovery in A.N. J Clin Endocrinol Metab. 2006;91(8):2931–7.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.•
    Misra M, Klibanski A. Bone health in anorexia nervosa. Curr Opin Endocrinol Diabetes Obes. 2011;18(6):376–82. Review by leading researchers studying bone health.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Grinspoon S, Thomas L, Miller K, et al. Effects of recombinant human IGF-I and oral contraceptive administration on bone density in anorexia nervosa. J Clin Endocrinol Metab. 2002;87(6):2883–91.PubMedCrossRefGoogle Scholar
  19. 19.••
    Misra M, Katzman D, Miller KK, et al. Physiologic estrogen replacement increases bone density in adolescent girls with anorexia nervosa. J Bone Miner Res. 2011;26(10):2430–8. Multicenter controlled clinical trial to increase BMD with treatment mirroring puberty.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Javed A, Tebben PJ, Fischer PR, Lteif AN. Female athlete triad and its components: toward improved screening and management. Mayo Clin Proc. 2013;88(9):996–1009.PubMedCrossRefGoogle Scholar
  21. 21.
    Klump KL, Miller KB, Keel PK, et al. Genetic and environmental influences on anorexia nervosa syndromes in a population-based twin sample. Psychol Med. 2001;31:737–40.PubMedCrossRefGoogle Scholar
  22. 22.
    Bulik CM, Sullivan PF, Wade TD, et al. Twin studies of eating disorders: a review. Int J Eat Disord. 2000;27:1–20.PubMedCrossRefGoogle Scholar
  23. 23.
    Slane JD, Burt SA, Klump KL. Genetic and environmental influences on disordered eating and depressive symptoms. Int J Eat Disord. 2011;44(7):605–11.PubMedCrossRefGoogle Scholar
  24. 24.
    Favro A. Brain development and neurocircuit modeling are the interface between genetic/environmental risk factors and eating disorders. Int J Eat Disord. 2013;46:443–6.CrossRefGoogle Scholar
  25. 25.••
    Klump KL, Culbert KM, Slane JD, et al. The effects of puberty on genetic risk for disordered eating: evidence for a sex difference. Psychol Med. 2012;42(3):627–37. Leading researchers in twin studies continue elegant work in gene x environment and epigenetic effects.PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Klump KL, Keel PK, Sisk C, et al. Preliminary evidence that estradiol moderates genetic influences on disordered eating attitudes and behaviors during puberty. Psychol Med. 2010;40(10):1745–53.PubMedCentralPubMedCrossRefGoogle Scholar
  27. 27.
    Klump KL, Burt AS, Spanos A, et al. Age differences in genetic and environmental influences on weight and shape concerns. Int J Eat Disord. 2010;43:679–88.Google Scholar
  28. 28.••
    Trace SE, Baker JH, Pefias-Lledó E, et al. The genetics of eating disorders. Ann Rev Clin Psychol. 2013;9:589–620. Comprehensive review of genetics in eating disorders.CrossRefGoogle Scholar
  29. 29.
    Katzman DK, Peebles R, Sawyer SM, et al. The role of the pediatrician in family-based treatment for adolescent eating disorders: Opportunities and challenges. J Adolesc Health. 2013;53:433–40.PubMedCrossRefGoogle Scholar
  30. 30.
    Lock J, leGrange D. Help your teenager beat an eating disorder. New York: Guilford Press; 2005.Google Scholar
  31. 31••.
    leGrange D, Lock J. Eating disorders in children and adolescents: a clinical handbook. New York: Guilford Press; 2011. Comprehensive evidence-based clinical guide edited by leading researchers in family-based treatment.Google Scholar
  32. 32.
    Couturier J, Kimber M, Szatmari P. Efficacy of family-based treatment for adolescents with eating disorders: a systematic review and meta-analysis. Int J Eat Disord. 2013;46:3–11.PubMedCrossRefGoogle Scholar
  33. 33.
    Tantillo MD, Kreipe RE. Improving connections for adolescents across high-intensity settings for the treatment of eating disorders, Chapter in, eating disorders in children and adolescents: a clinical handbook. New York: Guilford Press; 2011. p. 199–222.Google Scholar
  34. 34.•
    Milano W, De Rosa M, Milano L, et al. The pharmacological options in the treatment of eating disorders. ISRN Pharmacol. 2013;Jul 15: 352865. eCollection. Comprehensive review of all medications with potential therapeutic effects in eating disorders. Google Scholar
  35. 35.
    Hay PJ, Claudino AM. Clinical psychopharmacology of eating disorder: a research update. Int J Neuropsychopharmacol. 2011;6:1–14.Google Scholar
  36. 36.
    Lebow J, Sim LA, Erwin PJ, Murad MH. The effect of atypical antipsychotic medications in individuals with anorexia nervosa: A systematic review and meta-analysis. Internat J Eat Disord 2013;46:332-39.Google Scholar
  37. 37.
    Powers PS, Santana C. Available pharmacological treatments for anorexia nervosa. Expert Opin Pharmacother. 2004;5:2287–92.PubMedCrossRefGoogle Scholar
  38. 38.
    Hedges DW, Reimherr FW, Hoopes SP, et al. Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-controlled trial—part 2: improvement in psychiatric measures. J Clin Psychiatry. 2003;64:1449–54.PubMedCrossRefGoogle Scholar
  39. 39.
    Hoopes SP, Reimherr FW, Hedges DW, et al. Treatment of bulimia nervosa with topriamate in a randomized, double-blind, placebo controlled trial—part 1: improvement in psychiatric measures. J Clin Psychiatry. 2003;64:1335–41.PubMedCrossRefGoogle Scholar
  40. 40.
    Ricca V, Castellini G, LoSauro C, et al. Zonisamide combined with cognitive behavioral therapy in binge eating disorder: a one-year follow-up study. Psychiatry. 2009;6:23–8.PubMedCentralPubMedGoogle Scholar
  41. 41.
    Halmi KA, Eckert E, LaDu TJ, et al. Anorexia nervosa: treatment efficacy of cyproheptadine and Amitriptyline. Arch Gen Psychiatry. 1986;43:177–81.PubMedCrossRefGoogle Scholar
  42. 42.
    Hotta M, Ohwada R, Akamizu T, et al. Therapeutic potential of ghrelin in restricting-type anorexia nervosa. Methods Enzymol. 2012;514:381–98.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of Pediatrics, Division of Adolescent Medicine, Western New York Comprehensive Care Center for Eating DisordersUniversity of Rochester, Golisano Children’s HospitalRochesterUSA

Personalised recommendations