What do you think is the major determinant of whether our children excel in school? IQ? Good teachers? Good schools? Good standards and curricula? No, I say it is the students' motivation, or just plain grit. Other teachers think so too.

Education reporter, Libby Nelson, calls attention to the issue of grit in student learning achievement. Teachers and parents sometimes put too much emphasis on intelligence, when the more typical problem in education is that students don't try hard enough and are not sufficiently persistent in trying to achieve excellence.

Indeed, excellence is not even a goal for most students. Many students just want to do the minimum required to pass tests. A few students don't care at all. They just drop out. One student told a teacher friend of mine, "I don't need to learn this stuff. Somebody will always take care of me."

Nelson points to evidence of grit's importance with these examples:

·         West Point cadets who scored highest on a scale of grit were more likely to complete the grueling first summer of training.

·         National spelling bee contestants with more grit ranked higher than other contestants of the same age who had less grit.

·         College admissions officers know how important grit is (more important than SAT tests) but they don't know how to measure it other than grades, which of course may be inflated and inaccurate indicators of grit.

Clearly motivation is essential. I regard motivation as the cornerstone of what I call the "learning skills cycle." Learning begins with being motivated to learn, and successful completion of every step in the cycle strengthens motivation. However, every step in this cycle (organization, attentiveness, understanding/synthesis, memory, and problem solving/creativity) requires a degree of grit—the more, the better.

As applied to specific learning tasks, grit is central to all the ideas in the learning skills cycle. In the case of memory, for example, the well-known strategy of deliberate practice requires disciplined grit. Students diligently need to use established memory principles in a systematic way. This includes constructing a systematic learning strategy that includes organizing the learning materials in an effective way, intense study focus in short periods, elimination of interferences, use of mnemonic devices, and frequent rehearsals repeated in spaced intervals. Learning success depends on mental discipline and persistence.

Students differ enormously in their level of grit. It would be nice if we knew how to teach grit. Surely, parental influence is central. Parents lacking in grit are unlikely to model or teach it to their children. Some schools, especially private schools, teach grit by having high expectations and programs that help students discover the positive benefits that come from having more grit. One of those benefits is confidence, because grit promotes achievement and achievement develops confidence.

Confidence in the ability to learn is necessary for a student to try hard to learn. Here is the area where teaching skills count most: showing students they can learn difficult material and thereby building the confidence to take on greater learning challenges.

Students who have passionate goals are much more likely to invest effort and persistence in doing what is needed to achieve those goals. It is unrealistic to expect grade-school children to have well-formulated career goals. But certainly by early high-school, students should be forming specific lifetime goals. What a career goal is probably does matter as much as having one in the first place. Achieving a goal, regardless of whether it is later abandoned or not, teaches a youngster that grit is necessary for the achievement. The student learns that grit has a payoff.

Grit may not always lead to excellence in students with innate limited abilities. But grit allows such students to "become all they can be," as the Army recruitment slogan claims. Moreover, the benefits of grit perpetuate beyond success at any one learning challenge. Learning anything requires physical and chemical changes in the brain needed to store the positive attitudes that come from learning success and the learning content itself. In other words, the more you know, the more you can know.

Source:

http://www.vox.com/2014/10/9/6835197/grit-kipp-noncognitive-skills-duckworth-teaching

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As 2014 year comes to an end, I will continue the Brain Posts tradition of highlighting the Top Ten most viewed posts for the year.

It is always informative to find the posts that generate the most site visits. I am surprised at some of the posts that make the list and at some of the posts that do not.

Here are the posts making the list for 2014 beginning with number 10. Clicking on the post title will link you to the full post.

Naptime Stories Boost Word Learning in Children

This post summarized an interesting study of reading and word memory retention in children. It highlights the importance of sleep for memory consolidation and retention. The time immediately proceeding naps is an important time to use for teaching.

The Genetics of Religious Belief

In April, I reviewed some recent brain research related to religion and religious belief. The number 9 most viewed post examined a twin study of religious belief. This study found important genetic contributions to adult religious belief and attendance. Apparently, genetic brain wiring contributes to our later religious affiliation.

The Social Brain: Weeking Reading Links 

In 2014 I started posting links to a list of abstracts I felt were important. These came from my PubMed searches on specific topics. Some abstracts were later give a full post but many did not. The Weekend Reading links on the Social Brain was popular and ended up number 8 on the Top Ten list.

Is Insomnia Relief Just a Mouse Click Away?

The number 7 ranked post for 2014 was a review of an internet-based cognitive behavioral treatment for insomnia. This study supported the value of this approach and holds the potential to make CBT treatments more accessible and potential more affordable. Look for more studies of using internet and mobile health approaches for the treatment of common medical conditions.

Acute Brain Response to Exercise in Healthy Adults

There are both acute and chronic effects of exercise on the brain. The number 6 most viewed post this year highlighted a study of acute effects of exercise on healthy adults. The study used advanced brain imaging techniques and demonstrated changes in the pattern of blood flow distribution with exercise. These changes may contribute to the known beneficial effects of exercise on brain plasticity.

Merry Christmas and Happy Holidays! I will post the top five viewed posts next week.

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My research training is in psychiatric epidemiology. 

Alcohol and drug dependence have been two of my topic areas of research.

So I found a recent novel study of the epidemiology of illicit drug use in Europe intriguing.

Typical methods of looking for the prevalence of drug use in populations are direct diagnostic interviews and studies of emergency room attendees or autopsy cases with medical complications of drug use.

However, Christopher Ort from Switzerland along with a host of European colleagues took an interesting approach to studying illicit drug use in European populations.

They conducted population wastewater illicit drug concentration analyses using liquid chromatography. They examined changes in illicit drug concentrations over time and across a number of cities and regions in Europe.

This approach is slightly messy (pun intended) but logically follows a reasonable argument: high illicit drug concentrations in waste water reflects high drug use in the population producing the waste.

Their full text manuscript can be accessed by clicking on the PMID link below. But for the few lazy readers of my blog here are the five highest ranked European cities by the five illicit drug classes. This list is produced by me through the precise method known as "eyeballing" from charts in the manuscript. Countries are listed after municipalities where waste water was sampled when city first makes a list.

Cannabis

1. Amsterdam, Netherlands
2. Paris, France
3. Novisad, Serbia
4. Antwerp, Belgium
5. Utrecht, Netherlands

Amphetamines

1. Eindhoven, Netherlands
2. Antwerp
3. Gothenburg, Sweden
4. Ninove, Belgium
5. Helsinki, Finland

Methamphetamine

1. Prague, Czech Republic
2. Budweis, Czech Republic
3. Oslo, Norway
4. Bratislava, Slovakia
5. Dresden, Germany

Cocaine

1. Antwerp
2. London, England
3. Zurich, Switzerland
4. Amsterdam
5. Barcelona, Spain

MDMA (Ecstasy)

1. Eindhoven
2. Utrecht
3. Amsterdam
4. Antwerp
5. Zurich/Barcelona (Eyeball tie)

The authors note their findings for the prevalence of illicit drugs in wastewater generally match regional prevalence estimates for drug use using other methods.

They note wastewater samples can be done by day of the week to follow chronological patterns of drug use (no surprise levels of drugs in wastewater samples are higher on the weekend). Additionally, this approach may be a valuable secondary source of trends in regional drug use over longer periods such as years.  

I found the differences in metabolite rankings for amphetamine versus methamphetamine interesting. The methamphetamine rank list is made up of more cities with lower per capita incomes. 

This suggests possible local production of methamphetamine while amphetamine is more likely diverted from pharmaceutical grade manufacture.

This study did not include samples from the U.S., South America, Japan, China or Russia so it only reflects the cities listed in the methods section of the paper. 

Again, click on the citation PMID link below if you are interested in getting into more detail of this study. I would be interested in any comments from readers in Europe on whether these results seem valid.

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Ort C, van Nuijs AL, Berset JD, Bijlsma L, Castiglioni S, Covaci A, de Voogt P, Emke E, Fatta-Kassinos D, Griffiths P, Hernández F, González-Mariño I, Grabic R, Kasprzyk-Hordern B, Mastroianni N, Meierjohann A, Nefau T, Ostman M, Pico Y, Racamonde I, Reid M, Slobodnik J, Terzic S, Thomaidis N, & Thomas KV (2014). Spatial differences and temporal changes in illicit drug use in Europe quantified by wastewater analysis. Addiction (Abingdon, England), 109 (8), 1338-52 PMID: 24861844

All children, if given the chance, will play, preferably with other children. The games they play

are often creative, rough and tumble, and of course―fun. Some consequences are obvious:

·         Fun is a positively reinforcing emotion. It makes kids happy.

·         Play encourages exploration with fewer constraining boundaries than the drone of regular life.

·         Play is an effective way to socialize and make friends.

·         Play stimulates initiative and engagement, rather than passively observing what others do.

But there is another less obvious reason, one that is biological. In a review in the American Journal of Play (yes, there really is a scholarly journal on play), evidence is provided from controlled studies in rats and some primates. These studies show that when young animals are encouraged to play they develop improved social competence, cognition, and emotional regulation later in life. Play experience also makes them more adaptable to unexpected situations.

It is true that play is not a developmental feature in all species. The capacity (and need) for play is most evident in higher mammals with developed neocortex and that live in complex social environments. Play fighting is adaptive in predator species, like bears and lions that depend on aggression for survival as adults. In all species that exhibit juvenile play, play is a developmental tool that promotes the neocortical executive control regions to control other neural systems.

Play fighting is especially interesting because the juveniles must construct and obey certain rules. They intuitively recognize that they must not bite too hard, for example, and must give the opponent at chance to win sometimes or at least hold their own in the contest. The juveniles are clearly learning self-control, which will serve them well as adult. This reminds me of the touch football games that kids play.

Species that most obviously exhibit juvenile play are humans, dogs, cats, and ravens. In species where adults play, play can have immediate functions such as defusing social tensions and dominance relationships. Rats are an interesting case. They engage in juvenile play much more than other rodent species. Adult rats seem to exhibit novel mental capabilities, especially those involving social interactions that are not so prominent in other rodents.

When members of a play-oriented species are denied access to juvenile play, they can become dysfunctional adults. For example, rats raised in social isolation show physical and chemical deficiencies in their brains and they have behavioral abnormalities linked to impaired executive control function. They show excessive anxiety to stressful or fear-inducing situations. They over-react to benign social interactions. They are less able to coordinate movements with a partner, both in sexual and non-sexual contexts. They are less able to solve mental tasks. Similar problem are seen in monkeys deprived of juvenile play. Being raised by a surrogate mother is emotionally and intellectually devastating, but less so if the surrogate is robot-like and can interact in play-like behavior with the infant.

Juvenile play sculpts the brain to be more adaptable later in life. In modern human society, juvenile play is often obstructed by such externals as over-scheduling, too much adult supervision, and too many restrictions. The restrictions are often for reasons of safety, which is understandable in today's world. When I was a child, we had a lot more freedom to play, and in safety. It was not unusual in the summer time for a kid to leave home after breakfast and not return until supper, going alone to a park or neighbor kid's house to play unsupervised as we wished. Sadly, that is too much freedom these days. In this respect, the "good old days" really were the "good old days."

Source:

Pellis, S. M., Pellis, V. C., and Himmler, B. T. (2014). How play makes for a more adaptable brain. Ame. J. Play. 7 (1) 73-98

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Prescription opiate abuse is a significant problem in the United States.

I have previously written about this issue in several previous posts.

One important factor for clinicians and patients is the need to identify high-risk populations that may be more vulnerable to opiate abuse and dependence.

One obvious group would be those with alcohol or another non-opiate abuse diagnosis. Additionally, some psychiatric disorders are associated with increased risk for substance abuse including opiate abuse.

Given these high-risk markers, it would be encouraging if there would be evidence prescription opiate use is limited in those with substance abuse or a primary psychiatric disorder.

Unfortunately, there is not much evidence for restriction of opiate prescribing in high-risk populations.

Daniel Hackman and colleagues found the opposite finding in a study of patients with a substance abuse or primary psychiatric diagnosis in a dual diagnosis clinic.

Patients (N=201) in this clinic had prescription drug use reviewed for a period of 12 months and found the following key findings:

• Subjects received an average of 4.0 prescriptions for an opiate by medical personnel not associated with the dual diagnosis clinic
• These prescriptions resulted in the dispensing of an average of 213 opioid pills
• Concurrent benzodiazepine prescriptions were also common in this population
• Medicare or Medicaid coverage was associated with higher rates of opiate prescription compared to patients without insurance coverage

There are several take-home messages from this study.

First, some high-risk populations for opiate abuse seem to be more likely to get prescription opiates from a medical provider. From the current study, it does not appear clinicians are restricting prescription opiates to those most likely to misuse or abuse these drugs.

Second, concurrent benzodiazepine and opiate prescription use is common in this dual diagnosis group. This is important because accidental overdose deaths commonly find the combination of opiates and benzodiazepines in toxicology analysis.

I am not suggesting that no legitimate reasons exist for careful opiate prescription use for the treatment of pain in those with a dual diagnosis. However, this population needs to be carefully assessed and monitored when prescribing opiates in the clinical setting.

Readers with more interest in this topic can access the free full-text manuscript by clicking on the PMID link in the citation below.

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Hackman DT, Greene MS, Fernandes TJ, Brown AM, Wright ER, & Chambers RA (2014). Prescription drug monitoring program inquiry in psychiatric assessment: detection of high rates of opioid prescribing to a dual diagnosis population. The Journal of clinical psychiatry, 75 (7), 750-6 PMID: 25093472

Relapse rates are high in treatment samples of adults with cocaine dependence.

Cognitive behavioral therapy (CBT) is a common standard of care for cocaine dependence.

A recent clinical trial from Switzerland examined the use of financial prize incentives to augment standard CBT in the treatment of cocaine dependence.

Sixty subjects participated in this trial with the following inclusion criteria: least 18 years of age, had a DSM-IV diagnosis of cocaine dependence with at least one positive cocaine urine drug screen at baseline.

Exclusion criteria included: current psychotic disorder, current severe alcohol or benzodiazepine dependence, serious medical illness, pathological gambling, language impairment, methylphenidate use and active homelessness.

All subjects received 18 manual-based CBT sessions over 24 weeks targeted towards a goal of cocaine abstinence.

Half of the subjects received an additional treatment intervention labelled prize-based contingency management: 

• Subjects with cocaine negative urine samples (taken twice weekly in weeks 1-12 and weekly during weeks 13-24) were eligible to earn prizes
• Prizes were determined from a patient drawing from 500 chips in a bowl
• 250 chips were non-winners
• 219 had a value of $2 traded for food or hygiene rewards
• 30 had a value of $20 with a voucher for prizes in this price range
• One jumbo prize valued at $500 was present and could be traded for a television or vacation prize

Interestingly, the number of chips that was drawn started at one with the first cocaine free drug sample and increased by one with each consecutive negative sample up to a maximum of 15 chips.

Subjects relapsing after a period of abstinence returned to a one chip reward restart with the next clean urine sample.

The study failed to find a large statistically significant effect for the addition of prize-based contingency management.

However, those in the prize-based contingency management group had higher rates of clean urine samples beginning at weeks 8, 9 and 10 as well as several other later time points.

Additionally, the prize group had higher cocaine clean urine rates at 6 months follow up (66% vs 45%) although this did not reach statistical significance.

One issue with this study is the small sample size with limited power to detect clinically significant differences between treatment. The trend for improvement with adding the prize intervention suggests the potential merit of conducting a similar study using larger samples, possibly in several settings and nations.

The authors note the cost for the incentives in their design averaged $576 over the 24 week study. This additional cost is non-trivial and will need to be examined in larger samples.

Readers with more interest in this clinical trial can access the free full-text manuscript by clicking on the free full-text link in the PMID link below.

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Petitjean SA, Dürsteler-MacFarland KM, Krokar MC, Strasser J, Mueller SE, Degen B, Trombini MV, Vogel M, Walter M, Wiesbeck GA, & Farronato NS (2014). A randomized, controlled trial of combined cognitive-behavioral therapy plus prize-based contingency management for cocaine dependence. Drug and alcohol dependence, 145C, 94-100 PMID: 25456571

Finding a specific genes linked to specific neuropsychiatric disorders has been a key research strategy.

However, this strategy has not been entirely successful.

One problem with this unitary approach is the diagnostic overlap and comorbidity common to neuropsychiatric disorders such as mood disorders and autism.

A promising alternative strategy is to focus on genes that share risk with more than one neuropsychiatric condition.

Amit Lotan from Israel along with colleagues from the Netherlands, Germany and the U.S. recently published a study of common and distinct genetic components in six major neuropsychiatric disorders.

Their study used large genome wide association databases mined from the National Human Genome Research Institute linked to the following six neuropsychiatric disorders:

• Anxiety disorders
• Attention deficit/hyperactivity disorder
• Autism/autism spectrum disorders
• Bipolar disorder
• Major depression 
• Schizophrenia

Using a variety of genetic and molecular biology strategies, the research team examined human and mouse genes common to more than one neuropsychiatric disorder as well as genes unique to only one of the six disorders.

The key findings of the study including identification of 15 genes common to five of the six disorders. 

The genes identified in this analysis shared known activity in neuronal function known as postsynaptic density. Additionally, these shared genes are known to influence immune as well as brain function.

Additionally, the research identified two genetic components shared by all six of the disorders. These two components were involved in neuronal projection, synaptic activity, CNS development and cellular process. In total, these two genetic components contributed to 20-30% of the genetic load.

Obviously, 20-30% is a significant shared genetic contribution but it leaves important genetic contributions specific to each of the six conditions. 

The authors conclude in their discussion:

".. it could be hypothesized that a common (pathologic) molecular infrastructure located to neural projections, cytoplasm (or possibly both) may be necessary to induce a primary vulnerability to develop a neuropsychiatric disorder. Further distinct molecular processes which build-up on top of this common infrastructure ultimately lead, in certain patients, to the development of one or another specific neuropsychiatric disorder."

This type of study provides significant insight into the complexity of genetic influences in neuropsychiatric disorders.

Examining shared genetic influences in different conditions can aid in understanding common pathophysiology mechanisms for distinct neuropsychiatric disorders. Additionally, these types of studies show the limitations of current diagnostic classification systems and may aid in future refinement of diagnostic systems.

Readers with more interest in this research can access the free full-text manuscript by clicking on the PMID link in the citation below. 

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Lotan A, Fenckova M, Bralten J, Alttoa A, Dixson L, Williams RW, & van der Voet M (2014). Neuroinformatic analyses of common and distinct genetic components associated with major neuropsychiatric disorders. Frontiers in neuroscience, 8 PMID: 25414627

Clinicians treating patients with eating disorders find the challenge great with many treatment-resistant cases.

To some extent, this is true of any clinical disorder. Outpatient treatment rolls and inpatient samples are over-represented by those failing to respond to initial interventions.

A medical example is helpful here. Endocrinologists specializing in diabetes see more complicated cases where glucose control is difficult and diabetic complications are common.

Diabetics with easy glucose control and no complications do not need to see an endocrinologists. To an endocrinologist, clinical practice seems to point to the disease as a treatment-resistant and clinically challenging disorder.

Nevertheless, treatment resistance in eating disorders is a significant issue that has been recently summarized in a nice review by Dr. Katherine Halmi.

Here are my notes from review of the Halmi manuscript using her key headings:

Core eating disorder psychopathology

• Adolescent eating disorder subjects lack insight into the seriousness of illness
• Many do not acknowledge need for treatment
• Body weight, exercise and dieting provide a distraction from other life problems
• Malnutrition in eating disorders contributes to cognitive impairment, treatment engagement problems
• Bulimia treatment resistance has been linked to greater depression, lower BMI and social adjustment problems

Psychiatric and psychological comorbidity

• U.S. National Survey found high rates of psychiatric comorbidity in eating disorders (56% in anorexia nervosa, 95% in bulimia nervosa and 79% in binge eating disorder)
• Anxiety disorders rates are elevated in eating disorders with obsessive compulsive disorder and social anxiety disorder two common conditions
• Anxiety disorders can contribute to resistance of treatment of eating disorder symptoms
• Cluster B personality disorders are elevated in bulimia nervosa and appear related to higher rates of substance dependence in this disorder
• Perfectionism is common in anorexia nervosa. Early onset and high perfectionism traits contribute to higher treatment resistance

Biological features

• Serotonin receptor and transporter function appear to influence course of illness in eating disoders
• GABA receptor genotype appears to be related to level of trait anxiety in both bulimia nervosa and anorexia nervosa
• GABA receptor abnormalities are also possibly related to treatment resistance

Treating refractory patients

• Quetiapine, olanzapine, haloperidol and duloxetine are drugs with some promise in treatment resistant anorexia nervosa
• Novel psychotherapies including CBT and the Maudsley Model  target key features of resistance in anorexia nervosa
• Treatment resistant bulimia nervosa may respond to sequential treatment strategies that include partial hospitalization, selective serotonin reuptake inhibitor (SSRI) drugs and cue exposure
• Binge eating disorder may respond to high dose SSRI therapy or topiramate in a graduated dosing schedule

This review points to the key elements for treatment of the difficult eating disorder patient.

This population needs access to specialized hospitalization units, psychopharmacology expertise and specialized psychotherapy services.

Dr. Halmi notes advances in the treatment of this population may require advances in understanding the neurobiology and neurocircuitry for the disorder.

Readers with more interest in this summary can find the free full-text manuscript by clicking on the DOI link in the citation below.

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Halmi, K. (2013). Perplexities of treatment resistence in eating disorders BMC Psychiatry, 13 (1) DOI: 10.1186/1471-244X-13-292

The recent revision of the American Psychiatric Associations Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) altered several eating disorder diagnostic criteria.

Some have expressed concern that these revisions are overly broad and may result in over diagnosis in some clinical populations. One clinical population where this is a concern is obesity.

A research study has been recently published addressing this issue.

Jennifer Thomas and colleagues at Harvard University and Massachusetts General Hospital recruited a series of subjects from an obesity program for eating disorder diagnostic assessment.

All subjects completed an assessment for presence of an eating disorder 
diagnosis using both DSM-IV and DSM-5 criteria.

For DSM-IV eating disorder diagnoses, the research team used a validated module from a validated measure known as SCID-IV. For DSM-5 eating disorder diagnosis an early structured interview developed by the DSM-5 Eating Disorders Task Group was used.

The key findings from the study included:

• Prevalence rates for eating disorders using DSM-5 criteria did not increase compared to DSM-IV criteria
• Bulimia nervosa prevalence rates were 2% in both interviews
• Binge eating disorder prevalence rates were 9% in both interviews
• An additional 20% of the obese sample met residual eating disorder criteria in both interviews

Obese individuals with a formal eating disorder diagnosis endorsed higher rates of psychological impairment, depression and anxiety validating the impact of eating disorder comorbidity.

Assessment for the presence of eating disorders is an important part of treatment planning. Eating disorders are more prevalent in obese populations are relatively easy to diagnose.

Some studies have found poor outcomes in obese populations with severe binge eating behaviors.

Treatment of a comorbid eating disorder in obese populations may improve weight and psychological outcomes.

Readers with more interest in this research can access the free full-text manuscript by clicking on the PMID link below.

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Thomas JJ, Koh KA, Eddy KT, Hartmann AS, Murray HB, Gorman MJ, Sogg S, & Becker AE (2014). Do DSM-5 eating disorder criteria overpathologize normative eating patterns among individuals with obesity? Journal of obesity, 2014 PMID: 25057413

Binge eating is defined as the recurrent rapid consumption of high calorie meals accompanied by a feeling that eating is out of control.

Bulimia nervosa is an eating disorder characterized by binge eating paired with a purging behavior such as self-induced vomiting.

Binge eating without purging is receiving increased clinical and research attention.

Binge eating is a relative common component in elevated body mass index and obesity. Successful behavior and drug treatment for obesity often includes a significant reduction in the frequency of binge eating.

Binge eating is frequently accompanied by symptoms of gastrointestinal disorders such as gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS). However, these GI symptoms and disorders are also increased in obesity. 

These relationships have made it difficult to determine the specific effects of binge eating on GI symptoms as it is possible these effects may occur through an obesity mechanism.

Christine Peat along with colleagues from the University of North Carolina and Sweden recently published a study teasing out relationships between binge eating, BMI and GI symptoms.

This study used data from the Swedish Twin Study of Adults: Genes and Environment (STAGE). For the current study, over 23,000 twin pairs were interviewed for presence of lifetime history of binge eating, weight history and presence of gastrointestinal symptoms.

The key findings from this study included the following:

• Gastrointestinal reflux symptoms were present in 15.7% of men and 28.9% of women
• Irritable bowel syndrome (broad definition) was present in 3.7% of men and 8.1% of women
• Binge eating was linked to to higher rates of GERD and IBS
• However, when BMI was controlled binge eating was independently related to IBS but not related to GERD

The authors propose three potential mechanisms for this link between binge eating and IBS.

1. Stress may be a common factor as it is known that stress can precipitate bingeing episodes and increase IBS symptoms
2. IBS may cause dietary restriction including periods of fasting. Fasting is known to increase later risk for binge eating as the body attempts to compensate via a strong hunger mechanism
3. Binge eating of large quantities of high fat foods may directly produce IBS symptoms as the GI system responds to a feeding load

The take home message for clinicians treating IBS is that it is important to assess for the presence of binge eating. Successful reduction in the frequency of binge eating may contribute to a successful reduction in IBS symptoms. 

Readers with more interest in this study can access the free full-text manuscript by clicking on the PMID link in the citation below.

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Peat CM, Huang L, Thornton LM, Von Holle AF, Trace SE, Lichtenstein P, Pedersen NL, Overby DW, & Bulik CM (2013). Binge eating, body mass index, and gastrointestinal symptoms. Journal of psychosomatic research, 75 (5), 456-61 PMID: 24182635

Functional magnetic resonance imaging is providing a new tool for understanding brain circuitry in normal brain development and in brain disorders. 

Anorexia nervosa is an restrictive calorie eating disorder often resistant to treatment.

No effective drug treatment for anorexia nervosa currently exists and psychotherapy is often only partially effective. A better understanding of the brain pathophysiology in anorexia nervosa is needed to aid in treatment development.

Stephanie Kullman along with colleagues at the University of Tubingen recently published a study of brain connectivity in twelve women with anorexia nervosa.

This study used a resting state functional connectivity approach with magnetic resonance imaging. In functional connectivity studies, the brain is studied during rest and levels of coherent activity between brain regions measured. 

The authors of this study noted anorexia nervosa commonly includes motor hyperactivity and so they used both a non-athlete and athlete female control group for comparision.

The primary findings from this study included the following:

• The brain inferior frontal gyrus (IFG) in both the left and right sides demonstrated reduced effective connectivity 
• Decreased effective connectivity was noted between the right IFG and the cingulate
• Increased effective connectivity was noted between the right IFG and the bilateral orbitofrontal gyrus region
• Increased effective connectivity was noted between the left IFG and the bilateral insular cortex

The authors note the inferior frontal cortex is a key region for executive functions, or control of complex cognitive functions. Disturbance of executive function in anorexia nervosa may contribute to food consumption and activity decision making.

The authors note their study found a link between level of physical hyperactivity in individual patients with anorexia nervosa and reduced IFG connectivity. Women with the highest level of physical activity had the lowest levels of IFG connectivity.

The areas of increased connectivity in this sample of patients with anorexia contribute to processing of the salience of stimuli. The authors note the insular cortex is a "multisensory neural node" involved in integration of "perception, emotion, interoceptive awareness, cognition and gustation". 

Disturbance of connectivity balance between the IFG and insular cortex may contribute to anxiety and fear related to somatic sensations.

The findings in this imaging study occurred in the context of active illness in anorexia nervosa. It would be interesting to follow these findings with recovery and weight restoration.

Additionally, modification of functional connectivity disturbances in anorexia may hold promise for new drug development and more effective psychological interventions.

Readers with more interest in this study can access the free full-text manuscript by clicking on the citation link below.

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Kullmann S, Giel KE, Teufel M, Thiel A, Zipfel S, & Preissl H (2014). Aberrant network integrity of the inferior frontal cortex in women with anorexia nervosa. NeuroImage. Clinical, 4, 615-22 PMID: 24936412

There is increasing evidence for inflammation contributing to risk for a variety of psychiatric disorders.

I previously summarized research supporting use of anti-inflammatory drugs in the treatment of depression.

A recent study from Finland supports an inflammation link to the eating disorder categories.

The key elements of the design of this study included:

• Subjects: 2342 subjects admitted for treatment in the Eating Disorders Unit at the central hospital in Finland. Four controls were identified for each case matched by age, gender and place of residence
• Identification of presence for autoimmune diseases: Cases and controls were examined for the presence of one of 30 autoimmune diagnoses in their Hospital Discharge Register
• Statistical analysis: Period and lifetime rates for autoimmune disorders were compared between eating disorder cases and control using logistic regression modeling with calculation of odds ratios and 95% confidence intervals.

Here are the important findings from the study:

• Eating disorders subjects had a 5.6% rate for presence of any autoimmune disease compared to only 2.8% of controls (Odds ratio 2.13, 95% confidence interval 1.71-2.65)
• Rates for autoimmune disorders were increased across all eating disorder diagnostic categories including anorexia nervosa, bulimia nervosa and binge eating disorder
• Within autoimmune disease subtypes, endocrinological and gastroenterological diseases were statistically increased in eating disorders
• Type I diabetes and Crohn's disease were individual autoimmune disorders found at higher rates in eating disorders

The authors note there are several methods that could explain the association between autoimmunity and eating disorder risk. Higher rates of autoantibodies against peptides that control appetite and stress response could contribute to eating disorder risk.

Additionally, the authors note disturbed eating may contribute to disturbance of the microbiome of the gut. Gut microbiome is a known regulator of autoimmunity and a contributor to allergies and type I diabetes risk.

The authors noted additional specific autoimmune disorders may be increased in eating disorders but due to small sample size their study may have not found a statistical association.

Systemic lupus erythematosis rates were increased in the eating disorder group but this was one of the individual disorders that failed to reach statistical significance.

The take home message for clinicians treating eating disorder patients is to be vigilant for the presence of autoimmune medical disorders in this population. Accurate and early detection of autoimmune disorders in those with eating disorders may contribute to improved medical outcomes.

Readers with more interest can access the free full text manuscript by clicking on the PMID link below.

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Raevuori A, Haukka J, Vaarala O, Suvisaari JM, Gissler M, Grainger M, Linna MS, & Suokas JT (2014). The increased risk for autoimmune diseases in patients with eating disorders. PloS one, 9 (8) PMID: 25147950

I am focusing on recent research in eating disorders this month on Brain Posts.

Here are some of the research abstracts I will be reviewing for upcoming posts.

Clicking on the title will take you to the PubMed abstract and also to a link for the free full-text manuscript.

Higher parental education as a risk factor for eating disorders
This study of the Swedish population examined the effect education and social class on risk for eating disorders. Individuals diagnosed with an eating disorder were more likely to have higher educational levels in their parents. This is an interesting finding as educational typically reduces rates for many psychiatric disorders. 

Increased rates of autoimmune diseases in patients with eating disorders
A study of a large cohort from Finland found higher rates of a variety of autoimmune disorders in a sample of patients treated for eating disorders. Type I diabetes and Crohn's disease were two of the disorders that were more likely to be seen in eating disorder patients compared to controls.

Epidemiology of eating disorders
This literature examined 149 studies on the epidemiology of eating disorders. The review found evidence for genetic and environmental factors as risk factors for eating disorders. Additionally, the review found support for esthetic or weight-oriented sport participation also as risk factors for eating disorders.

Evidence for effective treatment options of eating disorders in young people
This review examined evidence for effective prevention and treatment of eating disorders in adolescents and young adults. The authors note the paucity of large well-designed clinical trials for the treatment of most eating disorders and make recommendations about directions for future research. 

Inferior frontal cortex network abnormalities in anorexia nervosa
This study examined resting functional connectivity in 12 subjects with anorexia nervosa compared to controls. The study found impairment in connectivity in the inferior frontal cortex in those with anorexia nervosa.

Binge eating and risk for gastrointestinal disorders
The Swedish Twin Study of Adults: Genes and Environment (STAGE) cohort was used to look for associations between binge eating and gastrointestinal disorders. Binge eating was found to be increased in irritable bowel syndrome and may be important in effectively managing this disorder. 

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A key feature in anorexia nervosa is the disturbance in perception of the body.

This perceptual disturbance is encapsulated in criteria 3 from DSM-5:

 "Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape evaluation, or denial of the seriousness of the current low weight"

 Santino Guadio from Italy and colleagues recently published a nice summary of the support for body image disturbance in anorexia nervosa. This study focused on research in the neuropsychology of anorexia nervosa.

This review is informative in outlining the components involved in sensory perception.

Here are the key findings from their review following their perception components outline.

Tactile perception
What it is: identifying touch stimuli and discriminating differences in stimuli
How it is tested: finger identification test, tactile estimation task (estimating distance between two tactile stimuli in different body sites
Findings in anorexia nervosa: Patients with anorexia nervosa perform poorly on identifying finger perception when blindfolded and two fingers are stimulated. Anorexia nervosa is also associated with overestimation of distance between stimulation sites over multiple body parts

Haptic perception
What it is: ability to identify shapes by touch when no visual input is available
How it is tested: Identifying figures and shapes with eyes closed using hands for sensory input
Findings in anorexia nervosa: Patients with anorexia nervosa perform more poorly than controls on correctly identify shape and form when unable to see an object. This deficit appears to be present during both active illness with weight loss and persists following weight restoration.

Propioception
What it is: identification of body and limb position in space
How it is tested: identification of right-left orientation, ability to place a rod in a vertical postion as body position is modified and no visual sensation is provided
Findings in anorexia nervosa: Patients with anorexia nervosa show impaired spatial orientation perception as well as deficits in correctly identifying right-left orientation.

Haptic-visual-proprioception integration:
What it is: Ability to estimate correct physical properties using both haptic and visual stimuli
How it is tested: Two objects of identical weight but difference size are presented for touch and sight input. Subjects estimate weight of two objects relative to each other
Findings in anorexia nervosa: Subjects with anorexia nervosa show reduction in size-weight performance and reduction integration of visual and haptic information.

Visual-tactile-proprioception integration:
What it is: use and integration of three sensory modalities, sight, touch and body position
How it is tested: rubber hand test where subjects estimate position of left index finger before and after visuotactile stimulations.
Findings in anorexia nervosa: Patients with anorexia nervosa show impairment in two components of visuo-tactile-propioception integration

Interoceptive perception:
What it is: ability to identify and process internal bodily sensations such as heartbeart, intestinal activity, hunger, pain
How it is tested: participants are asked to count their own heartbeats and this count is compared to actual heart rate. 
Findings in anorexia nervosa: Patients with anorexia nervosa show impaired perception of heartbeat compared to controls

The authors note they found a relatively few well-designed studies of perception in anorexia nervosa. 

Although the number of studies is small, this review supports a multi-modal impairment in perception in patients with anorexia nervosa compared to controls.

The authors note perception is known to be processed through the brain parietal lobe. They propose that parietal lobe dysfunction may impair perception in anorexia nervosa. This perceptual impairment may contribute to the body image disturbance found in the illness.

Look for an expansion of studies of perception in anorexia nervosa. Pairing neuropsychological perception studies with advanced brain imaging research techniques may be powerful strategy.

Readers with more interest in this topic can access the free full-text manuscript by clicking on the citation link below.

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Gaudio S, Brooks SJ, & Riva G (2014). Nonvisual multisensory impairment of body perception in anorexia nervosa: a systematic review of neuropsychological studies. PloS one, 9 (10) PMID: 25303480