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Concept: Body dysmorphic disorder


Orthorexia nervosa describes a pathological obsession with proper nutrition that is characterized by a restrictive diet, ritualized patterns of eating, and rigid avoidance of foods believed to be unhealthy or impure. Although prompted by a desire to achieve optimum health, orthorexia may lead to nutritional deficiencies, medical complications, and poor quality of life. Despite its being a distinct behavioral pattern that is frequently observed by clinicians, orthorexia has received very little empirical attention and is not yet formally recognized as a psychiatric disorder. In this review, we synthesize existing research to identify what is known about the symptoms, prevalence, neuropsychological profile, and treatment of orthorexia. An examination of diagnostic boundaries reveals important points of symptom overlap between orthorexia and anorexia nervosa, obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder (OCPD), somatic symptom disorder, illness anxiety disorder, and psychotic spectrum disorders. Neuropsychological data suggest that orthorexic symptoms are independently associated with key facets of executive dysfunction for which some of these conditions already overlap. Discussion of cognitive weaknesses in set-shifting, external attention, and working memory highlights the value of continued research to identify intermediate, transdiagnostic endophenotypes for insight into the neuropathogenesis of orthorexia. An evaluation of current orthorexia measures indicates a need for further psychometric development to ensure that subsequent research has access to reliable and valid assessment tools. Optimized assessment will not only permit a clearer understanding of prevalence rates, psychosocial risk factors, and comorbid psychopathology but will also be needed to index intervention effectiveness. Though the field lacks data on therapeutic outcomes, current best practices suggest that orthorexia can successfully be treated with a combination of cognitive-behavioral therapy, psychoeducation, and medication.

Concepts: Psychology, Anorexia nervosa, Eating disorders, Psychiatry, Body dysmorphic disorder, Obsessive–compulsive disorder, Obsessive–compulsive personality disorder, Orthorexia nervosa


Eating disorders, such as anorexia nervosa and bulimia nervosa, are common and severe mental illnesses of unknown etiology. Recently, we identified a rare missense mutation in the transcription factor estrogen-related receptor alpha (ESRRA) that is associated with the development of eating disorders. However, little is known about ESRRA function in the brain. Here, we report that Esrra is expressed in the mouse brain and demonstrate that Esrra levels are regulated by energy reserves. Esrra-null female mice display a reduced operant response to a high-fat diet, compulsivity/behavioral rigidity, and social deficits. Selective Esrra knockdown in the prefrontal and orbitofrontal cortices of adult female mice recapitulates reduced operant response and increased compulsivity, respectively. These results indicate that Esrra deficiency in the mouse brain impairs behavioral responses in multiple functional domains.

Concepts: Brain, Anorexia nervosa, Eating disorders, Nuclear receptor, Mouse, Body dysmorphic disorder, Bulimia nervosa, Maudsley Family Therapy


Background. In recent years, there has been an explosion in the number of technical and medical diagnostic platforms being developed. This has greatly improved our ability to more accurately, and more comprehensively, explore and characterize human biological systems on the individual level. Large quantities of biomedical data are now being generated and archived in many separate research and clinical activities, but there exists a paucity of studies that integrate the areas of clinical neuropsychiatry, personal genomics and brain-machine interfaces. Methods. A single person with severe mental illness was implanted with the Medtronic Reclaim(®) Deep Brain Stimulation (DBS) Therapy device for Obsessive Compulsive Disorder (OCD), targeting his nucleus accumbens/anterior limb of the internal capsule. Programming of the device and psychiatric assessments occurred in an outpatient setting for over two years. His genome was sequenced and variants were detected in the Illumina Whole Genome Sequencing Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory. Results. We report here the detailed phenotypic characterization, clinical-grade whole genome sequencing (WGS), and two-year outcome of a man with severe OCD treated with DBS. Since implantation, this man has reported steady improvement, highlighted by a steady decline in his Yale-Brown Obsessive Compulsive Scale (YBOCS) score from ∼38 to a score of ∼25. A rechargeable Activa RC neurostimulator battery has been of major benefit in terms of facilitating a degree of stability and control over the stimulation. His psychiatric symptoms reliably worsen within hours of the battery becoming depleted, thus providing confirmatory evidence for the efficacy of DBS for OCD in this person. WGS revealed that he is a heterozygote for the p.Val66Met variant in BDNF, encoding a member of the nerve growth factor family, and which has been found to predispose carriers to various psychiatric illnesses. He carries the p.Glu429Ala allele in methylenetetrahydrofolate reductase (MTHFR) and the p.Asp7Asn allele in ChAT, encoding choline O-acetyltransferase, with both alleles having been shown to confer an elevated susceptibility to psychoses. We have found thousands of other variants in his genome, including pharmacogenetic and copy number variants. This information has been archived and offered to this person alongside the clinical sequencing data, so that he and others can re-analyze his genome for years to come. Conclusions. To our knowledge, this is the first study in the clinical neurosciences that integrates detailed neuropsychiatric phenotyping, deep brain stimulation for OCD and clinical-grade WGS with management of genetic results in the medical treatment of one person with severe mental illness. We offer this as an example of precision medicine in neuropsychiatry including brain-implantable devices and genomics-guided preventive health care.

Concepts: Medicine, Gene, Full genome sequencing, Mental disorder, Psychiatry, Mental illness, Body dysmorphic disorder, Personal genomics


Body dysmorphic disorder (BDD) is a debilitating disorder characterized by an excessive pre-occupation with an imagined or very slight defect in one’s physical appearance. Despite the overall success of cognitive behavioural therapy (CBT) in treating BDD, some people do not seem to benefit as much from this approach. Those with high overvalued ideation (OVI), for instance, have been shown to not respond well with CBT. The purpose of this study was to evaluate the efficacy of an inference-based therapy (IBT) in treating BDD. IBT is a cognitive intervention that was first developed for obsessive-compulsive disorder with high OVI, but whose focus on beliefs can also apply to a BDD population. IBT conceptualizes BDD obsessions (e.g., ‘I feel like my head is deformed’) as idiosyncratic inferences arrived at through inductive reasoning processes. Such primary inferences represent the starting point of obsessional doubt and the treatment focuses on addressing the faulty inferences that maintain the doubt. Thirteen BDD participants, of whom 10 completed, underwent a 20-week IBT for BDD. The participants improved significantly over the course of therapy, with large diminutions in BDD and depressive symptoms. OVI also decreased throughout therapy and was not found to be related to reduction in BDD symptoms. Although a controlled-trial comparing CBT with IBT is needed, it is proposed that IBT constitutes a promising treatment alternative for BDD especially in cases where OVI is high. Copyright © 2011 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: An inference-based therapy (IBT) may be effective in treating BDD. Unlike CBT, in IBT, overvalued ideation does not appear to negatively impact decrease in BDD symptomatology.

Concepts: Psychology, Cognitive behavioral therapy, Logic, Reasoning, Body dysmorphic disorder, Inductive reasoning, Deductive reasoning, Obsessive–compulsive disorder


Previous research in eating disorders suggests that treatment satisfaction is closely related to the manner in which care is delivered. The present research is a systematic in depth study of health professional characteristics preferred by AN-patients.

Concepts: Health care, Health care provider, Nutrition, Patient, Anorexia nervosa, Eating disorders, Body dysmorphic disorder, Bulimia nervosa


Family based-treatments have the most empirical support in the treatment of adolescent anorexia nervosa; yet, a significant percentage of adolescents and their families do not respond to manualized family based treatment (FBT). The aim of this open trial was to conduct a preliminary evaluation of an innovative family-based approach to the treatment of anorexia: Acceptance-based Separated Family Treatment (ASFT). Treatment was grounded in Acceptance and Commitment Therapy (ACT), delivered in a separated format, and included an ACT-informed skills program. Adolescents (ages 12-18) with anorexia or sub-threshold anorexia and their families received 20 treatment sessions over 24 weeks. Outcome indices included eating disorder symptomatology reported by the parent and adolescent, percentage of expected body weight achieved, and changes in psychological acceptance/avoidance. Half of the adolescents (48.0%) met criteria for full remission at the end of treatment, 29.8% met criteria for partial remission, and 21.3% did not improve. Overall, adolescents had a significant reduction in eating disorder symptoms and reached expected body weight. Treatment resulted in changes in psychological acceptance in the expected direction for both parents and adolescents. This open trial provides preliminary evidence for the feasibility, acceptability, and efficacy of ASFT for adolescents with anorexia. Directions for future research are discussed.

Concepts: Family, Anorexia nervosa, Eating disorders, The Adolescents, Body dysmorphic disorder, Bulimia nervosa, Maudsley Family Therapy, Body weight


BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) has commonly been described in psychiatric disorders. Although several studies have found positive associations between abnormal eating patterns during childhood and ADHD, there is a lack of studies on ADHD and Eating Disorders (ED). The aims of this exploratory study were 1) to assess the ADHD symptoms level in ED and to ascertain whether there are differences among ED subtypes; 2) to analyze whether the presence of ADHD symptoms is associated with more severe eating disorder symptoms and greater general psychopathology; and 3) to assess whether the ADHD symptoms level is associated with specific temperament and character traits. METHODS: 191 female ED patients were included. Assessment was carried out with the EDI-2, ASRS-v1.1, the SCL-90-R and the TCI-R. RESULTS: The ADHD symptoms level was similar in bulimia, eating disorder not otherwise specified and binge eating subtypes, and lower in anorexic patients. Obsessiveness and Hostility were significantly positively associated with ADHD symptoms. A path model showed that ADHD was associated with high Novelty Seeking and low Self-Directedness, whereas ED severity was influenced by ADHD severity and low Self-Directedness. CONCLUSIONS: Bingeing/purging ED subtypes have a high ADHD symptoms level, also related with more severe eating, general and personality psychopathology.

Concepts: Educational psychology, Anorexia nervosa, Eating disorders, Mental disorder, Abnormal psychology, Psychiatry, Body dysmorphic disorder, Bulimia nervosa


Prominent theories suggest that compulsive behaviors, characteristic of obsessive-compulsive disorder and addiction, are driven by shared deficits in goal-directed control, which confers vulnerability for developing rigid habits. However, recent studies have shown that deficient goal-directed control accompanies several disorders, including those without an obvious compulsive element. Reasoning that this lack of clinical specificity might reflect broader issues with psychiatric diagnostic categories, we investigated whether a dimensional approach would better delineate the clinical manifestations of goal-directed deficits. Using large-scale online assessment of psychiatric symptoms and neurocognitive performance in two independent general-population samples, we found that deficits in goal-directed control were most strongly associated with a symptom dimension comprising compulsive behavior and intrusive thought. This association was highly specific when compared to other non-compulsive aspects of psychopathology. These data showcase a powerful new methodology and highlight the potential of a dimensional, biologically-grounded approach to psychiatry research.

Concepts: Scientific method, Psychology, Greek loanwords, Mental disorder, Psychiatry, Body dysmorphic disorder, Obsessive–compulsive disorder, Compulsive behavior


Although research addressing body size misperception has focused on socio-cognitive processes, such as internalization of the “ideal” images of bodies in the media, the perceptual basis of this phenomenon remains largely unknown. Further, most studies focus on body size per se even though this depends on both fat and muscle mass - variables that have very different relationships with health. We tested visual adaptation as a mechanism for inducing body fat and muscle mass misperception, and assessed whether these two dimensions of body space are processed independently. Observers manipulated the apparent fat and muscle mass of bodies to make them appear “normal” before and after inspecting images from one of four adaptation conditions (increased fat/decreased fat/increased muscle/decreased muscle). Exposure resulted in a shift in the point of subjective normality in the direction of the adapting images along the relevant (fat or muscle) axis, suggesting that the neural mechanisms involved in body fat and muscle perception are independent. This supports the viability of adaptation as a model of real-world body size misperception, and extends its applicability to clinical manifestations of body image disturbance that entail not only preoccupation with thinness (e.g., anorexia nervosa) but also with muscularity (e.g., muscle dysmorphia).

Concepts: Muscle, Dimension, Adipose tissue, Anorexia nervosa, Eating disorders, Normal distribution, Body dysmorphic disorder, Muscle dysmorphia


The course of eating disorders is often protracted, with fewer than half of adults achieving recovery from anorexia nervosa or bulimia nervosa. Some argue for palliative management when duration exceeds a decade, yet outcomes beyond 20 years are rarely described. This study investigates early and long-term recovery in the Massachusetts General Hospital Longitudinal Study of Anorexia and Bulimia Nervosa.

Concepts: Sociology, Anorexia nervosa, Eating disorders, Vomiting, Body dysmorphic disorder, Bulimia nervosa, Maudsley Family Therapy, Culture-specific syndromes