Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro / A anorexia nervosa (AN) é um transtorno alimentar com alta morbi-mortalidade, que atinge principalmente adolescentes do sexo feminino. A AN é caracterizada por uma distorção na imagem corporal que leva a restrição alimentar, e, consequentemente, perda de peso e diversas complicações clínicas como um estado de hiperagregabilidade plaquetária. O óxido nítrico (NO) é produzido a partir do aminoácido catiônico L-arginina através de uma família de enzimas denominadas NO-sintases (NOS) e funciona como um protetor cardiovascular modulando várias funções como relaxamento endotelial e função plaquetária. O objetivo dessa dissertação é avaliar a via L-arginina-NO na AN, bem como investigar o ciclo da uréia, a função plaquetária, e o estresse oxidativo em pacientes com AN. O transporte de L-arginina, a produção de guanosina monofosfato cíclica (GMPc), a atividade e a expressão das isoformas da NOS, iNOS e eNOS, o estresse oxidativo (formação de substâncias reativas ao ácido tiobarbitúrico - TBARS e atividade da superóxido dismutase - SOD), bem como a atividade plaquetária foram avaliados nas plaquetas dos pacientes com AN. Nas hemácias, a atividade e a expressão da NOS, a atividade da arginase e o estresse oxidativo foram investigados. Os níveis plasmáticos de aminoácidos e marcadores de estresse oxidativo no soro foram também analisados. Nossos resultados demonstram que na AN o influxo de L-arginina via sistema y+L, a produção de GMPc e a atividade da NOS estão diminuídos nas plaquetas em relação aos controles. Ainda nas plaquetas dos pacientes com AN, a expressão das isoformas da NOS bem como a atividade plaquetária não se mostrou alterada em relação aos controles. Nas hemácias destes pacientes, observou-se reduzida atividade da NOS e uma elevada função da arginase. A expressão das isoformas da NOS em hemácias não foi afetada pela AN. A concentração plasmática de L-arginina estava reduzida em pacientes com AN. A formação de TBARS nas plaquetas, hemácias e no soro não estava alterada em pacientes com AN enquanto que a atividade da SOD mostrou-se alterada. Assim, apesar da baixa produção de NO, os pacientes anoréticos apresentam um mecanismo cardioprotetor compensatório independente do NO a ser investigado. As descobertas aqui apresentadas contribuem para uma melhor compreensão da fisiopatologia da AN. / The anorexia nervosa (AN) is an eating disorder with high morbi-mortality, that reaches mainly adolescents of the feminine sex. AN is characterized by a distortion of the corporal image that leading to alimentary restriction, and, consequently, loss of weight and diverse clinical complications such as a state of platelet increased aggregation. The nitric oxide (NO) is produced from the cationic amino acid L-arginine through an enzyme family named NO-synthase (NOS) and functions as a cardiovascular protector modulating many functions as endothelial relaxation and platelet activity. The objective of this thesis is to assess the L-arginine-NO pathway in AN, as well as to investigate the cycle of the urea, the platelet function, and the oxidative stress in patients with AN. The L-arginine transport, the production of cyclic guanosine monophosphate (cGMP), the activity and the expression of isoforms of NOS, iNOS and eNOS, the oxidative stress (formation of thiobarbituric acid-reactive substances TBARS and superoxide dismutase activity SOD), as well as the platelet function were assessed in platelets from patients with AN. In erythrocytes, the activity and expression of the NOS, the activity of arginase and the oxidative stress were investigated. Plasma amino acid levels and markers of oxidative stress in serum were also assessed. Our results have demonstrated that in AN the L-arginine influx by y+L system, the production of cGMP and activity of NOS are diminished in platelets in relation to controls. Yet in platelets from patients with AN, the expression of NOS isoforms as well as the platelet activity dont show altered. In erythrocytes from these patients, was seen reduced activity of NOS and raised function of arginase. The expression of NOS isoforms in erythrocytes were not affected by AN. The plasmatic concentration of L-arginine was diminished in AN patients. The TBARS formation in platelets, erythrocytes and serum, were not altered in patients with AN, while that the SOD activity was altered. Therefore, although of the low production of NO, the patients with AN presents an NO-independent compensatory cardioprotector mechanisms to be investigated. The discoveries presented in this study contribute for a better understanding of the physiopathology of AN.

Introdução: O uso de questionários auto-aplicáveis para avaliar o prejuízo da funcionalidade em indivíduos com Transtornos Alimentares (TAs) apresenta importantes limitações devido à natureza egossintônica dos sintomas, particularmente na anorexia nervosa (AN) do subtipo restritivo. A Functioning Assessment Short Test (FAST) pode ser um instrumento útil para a avaliação dessa população, uma vez que é pontuada pelo entrevistador e abrange diversos aspectos da funcionalidade em pacientes psiquiátricos. Objetivo: O objetivo do presente estudo foi comparar a funcionalidade de pacientes com TA de subtipos restritivo e purgativo através da escala FAST. Também analisamos as propriedades psicométricas da FAST nesta população específica. Método: Uma amostra consecutiva de 36 mulheres com diagnóstico de anorexia nervosa, bulimia nervosa ou síndromes parciais, de acordo com critérios do DSM-IVTR, e 29 controles saudáveis foram incluídas. As pacientes foram agrupadas, de acordo com presença de sintomas purgativos, em grupo restritivo (RP) e grupo purgativo (PP) de TA. A funcionalidade foi avaliada através da FAST e da Global Assessment of Functioning Scale (GAF). Os sintomas específicos de TA foram aferidos com as escalas Eating Attitudes Test (EAT), Bulimic Investigatory Test of Edinburgh (BITE) e Body Shape Questionnaire (BSQ). Também foram aplicadas a Symptom Checklist-90 (SCL- 90) e a Hamilton Depression Rating Scale (17-HDRS). Resultados: A média dos escores totais da FAST na população de pacientes em estudo foi significativamente maior (41.62± 13.94) que a encontrada em indivíduos do grupo controle (8.14± 5.02) em todos os domínios (p<0.001), mesmo após controle para variáveis de confusão com modelo de regressão linear múltipla. Não houve diferença nos escores totais da FAST, nem em suas subescalas, entre as pacientes de subtipo restritivo (39.70 ± 15.96) e subtipo purgativo de TA (43.54 ± 11.92) (p= 0.44). No entanto, na área de finanças, o grupo RP não foi diferente dos controles. O alfa de Cronbach da FAST na amostra foi de 0.865 e a correlação entre a FAST e a GAF foi forte (r = -0.92, p <0.01). Conclusão: A avaliação da funcionalidade em pacientes com TA requer cautela. A FAST parece ser um instrumento útil para isto, uma vez que avalia domínios específicos do funcionamento, identifica o nível de prejuízo em cada área e não é autoaplicável. Com esta avaliação objetiva, o grupo de TA de subtipo restritivo apresentou prejuízo no funcionamento global semelhante ao encontrado no subtipo purgativo. / Introduction: The use of self-report questionnaires in people with eating disorders (EDs) has limitations derived from egosyntonic nature of symptoms, particularly in restrictive type of anorexia nervosa (AN). In this context, the Functioning Assessment Short Test (FAST) is an interviewer scored scale that covers several aspects of functionality in psychiatric patients, and therefore could be a useful instrument for evaluation of individuals with EDs. Objective: To examine functionality of restrictive and purgative subtypes of eating disorders’ (ED) patients with Functioning Assessment Short Test (FAST) and its psychometric properties in this population. Method: A consecutive sample of 36 adult female patients with diagnosis of ED, according to DSM-IV-TR, and 29 healthy controls were included. Patients were divided into restrictive (RP) and purgative (PP) groups according to presence of purgative symptoms. Functioning was assessed by the FAST and the Global Assessment of Functioning Scale (GAF) instruments. ED’s symptoms were evaluated with Eating Attitudes Test (EAT), Bulimic Investigatory Test of Edinburgh (BITE) and Body Shape Questionnaire (BSQ). We also used Symptom Checklist-90 (SCL-90) and Hamilton Depression Rating Scale (17-HDRS). Results: The mean scores of FAST show that purgative and restrictive groups of ED patients together scored significantly higher (41.62± 13.94) than controls (8.14± 5.02) on all domains (p<0.001), even after controlling for possible confounding factors with multiple linear regression model. No differences were found on total and subscales scores of FAST between restrictive (39.70 ± 15.96) and purgative (43.54 ± 11.92) groups (p= 0.44). However RP group did not differ from controls in finances domain. The Cronbach’s alpha of FAST for the total sample was 0.865 and correlation between FAST and GAF (r = -0.92, p <0.01) was strong. Conclusion: FAST scale appears to be a useful instrument that assesses specific domains of functioning, identifies level of disability in each area and is not self-reported. With this objective evaluation restrictive and purgative subtypes of ED presented similar global impairment.

Orientador: Heloisa André Pontes / Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Filosofia e Ciências Humanas / Made available in DSpace on 2018-08-17T13:04:35Z (GMT). No. of bitstreams: 1 Silva_DanielaFerreiraAraujo_D.pdf: 3618993 bytes, checksum: 6b462d863f9f233f3a22b46cd7419a9b (MD5) Previous issue date: 2011 / Resumo: Esta tese surgiu do interesse em pesquisar em maior profundidade alguns aspectos da intrincada relação entre corporificação, gênero e assujeitamento, através da análise do conjunto de perturbações denominadas "transtornos alimentares". No contexto contemporâneo em que o corpo torna-se alvo privilegiado de investimento e intervenção, assumindo centralidade nos processos de construção identitária, uma investigação antropológica destas perturbações permite pensar como a constituição de sujeitos corporificados é perpassada por múltiplas normatividades de gênero, classe, regionalidade, raça e etnicidade, presentes na socialidade cotidiana e nas práticas e discursos biomédicos. Tomando como eixo central a composição de três histórias de vida, em colaboração com mulheres que tiveram experiências pessoais com transtornos alimentares, é possível ter acesso ao processo através do qual pessoas vivenciam formas particulares de assujeitamento, compostas por distintas articulações entre múltiplas dimensões de poder, deforma inseparável, constituindo-se, assim, como sujeitos de ação em meio a conformações e resistências. Ainda que o fio condutor da tese encontre-se nas histórias de vida, escritas ao longo de quatro anos em colaboração com três interlocutoras voluntárias, sua trama é composta pelos diversos percursos teóricos e empíricos de uma etnografia multi-situada (HANNERZ, 2003), que transitou pelo universo de comunidades virtuais brasileiras sobre transtornos alimentares, um serviço ambulatorial de um hospital universitário, congressos de psiquiatria, uma vasta bibliografia e uma agência feminista de base comunitária para tratamento, educação e prevenção de transtornos alimentares na Nova Zelândia. / Abstract The aim of this thesis is to investigate in greater depth some aspects of the intricate relation between embodiment, gender and subjectification, through the analysis of the group of perturbations named "eating disorders". In the contemporary context, in which the body becomes the privileged target of investment and intervention, assuming a central role in the processes of identity construction, an anthropological investigation of these perturbations allows us to evaluate how the constitution of embodied subjects is fraught with multiple normativities of gender, class, regionality, race and ethnicity, present in daily sociality and in biomedical practices and discourses. Taking as a central axis the composition of three life-histories, in collaboration with women who had personal experiences with eating disorders, it is possible to gain access to the process by means which persons live particular forms of subjectification, composed by distinct inseparable articulations of multiple dimensions of power, becoming, thus, subjects of agency amidst conformation and resistance. If the connecting thread of the thesis is found in the life histories, written with the voluntary research collaborators along four years, its warp is the woven out of the different theoretical and empirical paths of a multi-sited ethnography (HANNERZ, 2003), along the universe of Brazilian virtual communities about eating disorders, an outpatient treatment unit at an University hospital, Psychiatry congresses, a wide bibliography and a feminist community based service for the education, prevention and counseling for eating difficulties in New Zealand. / Doutorado / Estudos de Gênero / Doutor em Ciências Sociais

Transtornos Alimentares (TA) são transtornos mentais considerados graves. Dentre eles, Anorexia Nervosa e Bulimia Nervosa compartilham sintomas e características psicopatológicas como hábitos desregulados de alimentação, métodos extremos para controle do peso, e preocupações exageradas com a forma e o peso corporal. Os TA compartilham ainda sintomas comuns em outros transtornos psiquiátricos, como Depressão e Ansiedade. Pesquisas sobre o tema devem levar em conta este amplo espectro de sintomas. A meditação é uma prática que tem recebido crescente atenção de pesquisadores de diversas áreas de saúde. Dentro da área de Psiquiatria, a meditação mindfulness tem sido estudada como terapia complementar para diversos transtornos, sendo os mais pesquisados os transtornos de ansiedade, a depressão e a dependência química. Alguns programas baseados em mindfulness já demonstraram resultados positivos em pacientes com Compulsão Alimentar e Bulimia Nervosa. Este é um projeto que teve a intenção de desenvolver e mensurar os efeitos de uma nova intervenção baseada em meditação mindfulness para pacientes internados na Enfermaria de Comportamentos Alimentares (ECAL) do Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A hipótese primária foi que o treinamento em mindfulness diminuiria sintomas de ansiedade e depressão, em comparação com os pacientes que seguiram o tratamento usual da enfermaria. O projeto todo teve duração de três anos, sendo dividido em fase piloto, fase grupo controle e fase grupo intervenção. Cada fase aconteceu em diferentes períodos de tempo, para que um número adequado de indivíduos fosse alcançado para fins de pesquisa. Avaliações foram feitas sempre nos mesmos períodos para os três grupos: durante a primeira semana de internação e após 8 semanas, ou antes, se o paciente recebesse alta. Os resultados do grupo piloto foram positivos e ajudaram a delinear os exercícios que compuseram o programa aplicado na intervenção. A comparação dos resultados do grupo controle com o grupo intervenção apresentou significativa diferença para os índices de ansiedade (p < 0,01), depressão (p < 0,03), capacidade de agir com atenção (p < 0,01) e atitudes alimentares relacionadas a dietas (p < 0,04). Como previsto e em linha com outras pesquisas utilizando mindfulness para indivíduos com TA menos grave, este protocolo de oito sessões demonstrou efeito positivo e significativo apesar dos desafios de trabalhar com esta população neste contexto. Estes resultados dão suporte a novas pesquisas que poderão testá-los e compreender melhor a duração dos efeitos terapêuticos deste treinamento. Também, devem ser considerados aprimoramentos necessários, como refinamento dos exercícios, capacitação de outros terapeutas no protocolo e treinamento em mindfulness para outros profissionais envolvidos / Eating disorders (ED) are considered severe mental disorders. Anorexia Nervosa and Bulimia Nervosa are disorders that share symptoms and psychopathological characteristics such as deregulated feeding habits, extreme methods for weight control and exaggerated concerns about shape and weight. Eating Disorders also share common symptoms with other psychiatric disorders such as depression and anxiety. Research on eating disorders should take into account this wide spectrum of symptoms. Meditation is a practice that has received increasing attention from researchers in various areas of healthcare. Within the area of Psychiatry, mindfulness meditation has been studied as a complementary therapy for many disorders, and the most researched are anxiety, depression and addiction. Some mindfulness-based programs have already shown promising results in patients with Binge Eating Disorder and Bulimia Nervosa. This research project aimed to measure the effects of a mindfulness meditation intervention delivered to patients admitted to the Eating Disorders Ward at the Institute of Psychiatry in the Clinical Hospital for the Medical School, University of São Paulo. The primary hypothesis was that mindfulness training would lower symptoms measuring anxiety and depression compared to inpatients that received treatment as usual. The entire project was conducted during three years, with a pilot group phase, a control group phase and an intervention group phase. Each phase happened in different periods of time so the study could recruit a suitable number of participants. Assessments were made for all groups during the first week of admission and at eight weeks (or earlier if the patient were to be discharged). Pilot results were positive and helped delineate exercises that would be part of the main study intervention protocol. The final analysis comparing control and intervention group showed significant differences for measures in anxiety (p < 0.01), depression (p < 0.03), acting with awareness (p < 0.01) and dieting attitudes (p < 0.04). As hypothesized and in line with previous research with less severe eating disorders samples, this novel eight week program showed a positive and significant effect despite the challenges of working with this population and in this setting. These findings will inform future research which will need to replicate the findings, understand more about the durability of the effects and consider the resource allocation (eg staff training) needed to offer this promising intervention in this setting

Essstörungen sind prävalente psychische Störungen mit schwerwiegenden, oftmals langfristigen Auswirkungen auf die psychische und körperliche Gesundheit. Eine zunehmende Anzahl von klinischen Studien dokumentiert die Wirksamkeit verschiedener psychotherapeutischer Ansätze für spezifische Essstörungen. Im vorliegenden Themenheft 5 werden die Wirksamkeit von neuen Ansätzen zur Einzeltherapie und zur internet-basierten Rückfallprophylaxe, die Patientensicht auf die Therapie sowie die Relevanz von Faktoren des therapeutischen Prozesses bei verschiedenen Essstörungen beleuchtet. Weiterer Forschungsbedarf besteht insbesondere hinsichtlich des Prozesses und der Dissemination evidenzbasierter Psychotherapie für Essstörungen. / Eating disorders are prevalent psychiatric disorders with severe and longstanding 15 implications for mental and physical health. An increasing number of clinical studies documents the efficacy of certain psychotherapeutic approaches for specific eating disorders. This special issue addresses the efficacy of novel approaches in face-to-face individual therapy and Internet-based relapse prevention, patient views of treatment, and the relevance of therapeutic process factors for diverse eating disorders. Further research is particularly 20 warranted regarding the process and dissemination of evidence-based psychotherapy for eating disorders.

Objective: For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled. Method: Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified. Results: Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated. Discussion: As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

Bakgrund: Ett av sex par har någon gång upplevt problem relaterat till fertilitet under sina reproduktiva år och efter 30 års ålder är infertilitet vanligare hos kvinnor än hos män. Flera delar av menstruationscykeln består av energikrävande processer som exempelvis ägglossning och produktion av könshormoner. Näringsbrist och låg energitillgänglighet leder till brist på substrat till dessa energikrävande processer och i västvärlden orsakas låg energitillgänglighet vanligen av en ätstörning som anorexia nervosa, vilket kan leda till funktionell hypotalamisk amenorré (FHA) hos kvinnor. FHA resulterar i en minskad frisättning av könshormonerna östrogen och progesteron vilket kan leda till infertilitet. En av 20 kvinnor har erfarenhet av ätstörning under graviditeten men få studier har undersökt hur en historik med ätstörning påverkar fertilitet och graviditet. Syfte: Syftet med studien var att undersöka om FHA hos kvinnor med anoreci leder till nedsatt fertilitet och komplikationer vid en eventuell graviditet. Metod: En litteratursökning genomfördes på PubMed och Web of Science med sökorden amenorrhea, fertility, eating disorders, anorexia nervosa, reproduction (1999-2021). Resultat: Åtta studier inkluderades och resultatet visade att kvinnor med anorexi födde färre barn och hade större sannolikhet för att ha genomgått fertilitetsbehandling än friska kvinnor i kontrollgruppen. Vidare visade resultatet att kvinnor med anorexi oftare rapporterade komplicerade graviditeter med till exempel lägre fostertillväxt, prematur födsel och kejsarsnitt. Slutsats: Utifrån resultatet i den aktuella litteraturstudien kan konkluderas att kvinnor med FHA på grund av en ätstörning har lägre fertilitet än friska kvinnor. Kvinnor med ätstörning upplever i högre utsträckning mer komplicerade graviditeter och även fosterutvecklingen verkar påverkas negativt och därför kan tätare kontroller under och efter graviditet vara nödvändigt för dessa kvinnor. Resultatet kan vidare tolkas som att den negativa påverkan på reproduktionsförmågan kan vara reversibel när ätstörninssymptomen behandlats. / Background: One in six couples has sometime during their reproductive years experienced problems related to fertility and after the age of 30, infertility is more common in somen than in men. Several parts of the menstrual cycle require a lot of energy, such as ovulation and the production of sex hormones. Malnutrition and low energy availability is usually caused by an eating disorder such as anorexia nervosa, which can lead to functional hypothalamic amenorrhea (FHA) in women. FHA leads to a reduced release of the sex hormones estrogene and progesterone, which leads to infertility. One in 20 women have experience of an eating disorder during pregnancy, but few studies have examined how a history og eating disorder affects fertility and pregnancy. Aim: The aim of this study was to investigate whether FHA in women with anorexia nervosa leads to reduced fertility and complications in a potential pregnancy.  Method: A literature search was made on PubMed and Web of Science with the keyword´s amenorrhea, fertility, eating disorders, anorexia nervosa reproduction (1999-2021). Results: Eight studies were included, and the results showed that women with anorexia gave birth to fewer children and were more likely to have experienced fertility treatment than healthy women in the control group. Furthermore, the results showed that women with anorexia more often reported more complicated pregnancies with, e.g., lower fetal growth, premature birth, and cesarean section. Conclusion: Based on the results of the current literature study, it can be concluded that women with FHA due to an eating disorder have lower fertility than healthy women. Women with an eating disorder experience more complicated pregnancies and fetal development also seems to be negatively affected and therefore more frequent checks during and after pregnancy may be necessary fore these women. The results can further be interpreted as that the negative impact on reproductive health is reversible when symptoms of eating disorder are treated.

Hintergrund: Anorexia nervosa (AN), allgemein als Magersucht bezeichnet, gehört zu den häufigsten psychischen Erkrankungen im Kindes- und Jugendalter. Dabei kommt es aufgrund einer gestörten Wahrnehmung der eigenen Figur zu einem erheblichen, selbst herbeigeführten Gewichtsverlust. Die Mehrheit der Patientinnen muss aufgrund der Schwere der Erkrankung mindestens einmal stationär behandelt werden. Cortisol ist ein lebenswichtiges Steroidhormon, das dafür sorgt, dass der menschliche Körper länger andauernde Belastungen bewältigen kann. Halten diese Stresssituationen jedoch zu lange an, kann es erhebliche Störungen des Stoffwechsels, des Wachstums, der Reproduktion und der Immunkompetenz verursachen. Cortisol und seine Stoffwechselprodukte werden überwiegend mit dem Urin ausgeschieden. Die Bestimmung der Urincortisolkonzentration (UCC) gehört daher zur klinischen Standarddiagnostik. In der Forschung hat sich die UCC als zuverlässige Methode zur Untersuchung des Stresshormons bei gesunden Probanden und psychischen Erkrankungen bewährt. Auch im Haar kann das Stresshormon nachgewiesen werden. Hauptsächlich gelangt es aus dem Blut in die Zellen des wachsenden Haarschaftes. Haaranalysen werden seit langer Zeit als zuverlässige Methode in der Forensik und Toxikologie angewandt. Mittlerweile hat sich die Analyse von Haarproben zur Bestimmung der Haarcortisolkonzentration (HCC) auch in der Forschung als valide Methode etabliert. Dabei bietet diese nicht-invasive und leicht durchführbare Methode einen retrospektiven Blick auf die Langzeitausschüttung von Cortisol. In zahlreichen Studien wurde bei AN eine Erhöhung des Stresshormons Cortisol nachgewiesen (sog. Hypercortisolismus). Dabei scheinen sich der Hypercortisolismus, die körperlichen Symptome und die psychischen Veränderungen in einer komplexen Krankheitspathologie wechselseitig zu beeinflussen. Mehrere Studien konnten bei AN bereits eine erhöhte Cortisolausscheidung im Urin nachweisen, die mit zunehmender Gewichtsnormalisierung rückläufig ist. Die HCC wurde bei AN bisher nur in einer Querschnittstudie untersucht. Entgegen des bekannten Hypercortisolismus konnte hier eine signifikant niedrige HCC nachgewiesen werden. Fragestellung: Die vorliegende Studie untersucht die HCC bei Patientinnen mit AN zum ersten Mal in einer Längsschnittstudie. Durch Beobachtung von Patientinnen über den Verlauf einer stationären, krankheitsbildspezifischen Therapie und zusätzlicher Erhebung der UCC als Vergleichsvariable sollte die Anwendbarkeit der HCC bei AN untersucht werden. Material und Methoden: Neben der Anwendung psychopathologischer Testverfahren (EDI-2) und regelmäßiger Bestimmung des BMI wurde wöchentlich durch einen 24-h-Sammelurin die UCC bestimmt. Eine Substichprobe gab am Ende des durchschnittlich 13-wöchigen Therapiezeitraumes eine Haarprobe ab, anhand derer eine monatliche HCC bestimmt wurde. Die Analyse der Urinproben erfolgte mittels immunochemischer Verfahren, die Haarproben wurden mittels Hochleistungsflüssigkeitschromatographie mit Tandem-Massenspektrometrie analysiert. Durch individuelle Zuordnung einer medianen UCC zu jeder HCC wurden für jede Patientin schließlich drei HCC-UCC-Wertepaare erzeugt, die den Anfang, die Mitte und das Ende der stationären Therapie abbildeten. Ergebnisse: Insgesamt nahmen 33 Patientinnen des Zentrums für Essstörungen der Klinik und Poliklinik für Kinder- und Jugendpsychiatrie und -psychotherapie teil (Stichprobe 1), wobei 16 Patientinnen der Entnahme einer Haarprobe zustimmten (Stichprobe 1a). Während der stationären Therapie kam es zu einer leitliniengerechten Gewichtsrehabilitation. Die UCC war deutlich erhöht und fiel während des Therapieverlauf signifikant ab. Die HCC zeigte hingegen keine Veränderung. Bei der Korrelation der HCC mit der medianen UCC konnte lediglich ein Trendeffekt nachgewiesen werden. Separate Analysen der einzelnen Zeitabschnitte ergaben eine signifikante Korrelation von HCC und UCC am Ende der stationären Therapie. Bei Analyse des EDI-2 korrelierte die Unzufriedenheit mit dem eigenen Körper zu Beginn und am Ende der Therapie mit der UCC, jedoch nicht mit der HCC. Haareigenschaften und Haarbehandlungen hatten keinen Einfluss auf die HCC. Schlussfolgerungen: Insgesamt konnte die UCC den bekannten Hypercortisolismus abbilden und bildete eine valide Grundlage für die Überprüfung der HCC bei AN. Trotz ihres Absinkens blieb die UCC nach erfolgreicher Gewichtsrehabilitation erhöht. Zudem konnte eine Korrelation der UCC mit einer zentralen psychopathologischen Veränderung bei AN nachvollzogen werden. Dies bestätigt die Hypothese einer komplexen Krankheitspathologie mit somatischen und psychiatrischen Einflussfaktoren auf den Hypercortisolismus. Bei einem Literaturvergleich der HCC mit gesunden Probanden konnte kein Hypercortisolismus nachvollzogen werden. Insgesamt konnte die HCC die UCC insbesondere in der Phase der akuten Erkrankung und beginnenden Gewichtsrehabilitation nicht zuverlässig abbilden. Nach Gewichtsnormalisierung schienen sich HCC und UCC jedoch wieder dem bei gesunden Probanden bestätigten Verhältnis anzunähern. Als Ursache für diese fehlende Korrelation kommen trophische Störungen des Haarwachstums bei AN in Betracht. So ist aufgrund eines verminderten Haarwachstums eine gestörte Einlagerung des Hormons in den Haarschaft möglich. Auch enzymatische Störungen des Cortisolabbaus werden diskutiert. Ein gestörtes Gleichgewicht des Enzyms 11-β-HSD, welches die Umwandlung von Cortisol zu Cortison (und umgekehrt) katalysiert, scheint ebenfalls die Einlagerung in das Haar zu beeinflussen. Insgesamt ergaben sich zahlreiche Hinweise, dass die HCC entgegen den Studienergebnissen bei gesunden Probanden und anderen stressassoziierten Zuständen bzw. Erkrankungen nicht zur Untersuchung des Hypercortisolismus bei AN im akuten Erkrankungszustand und im Verlauf einer stationären Therapie angewendet werden kann. Eine Nutzung dieser Methode zur Untersuchung gewichtsrehabilitierter Patientinnen bleibt offen und bedarf weiterer Forschungen. / Background: Anorexia nervosa (AN) is one of the most common mental disorders in children and adolescents. Disturbances in the way in which one´s body shape is experienced lead to a severe self-inflicted weight loss. Majority of patients need to be treated in hospital at least once in a lifetime. Cortisol is an essential adrenal cortical hormone, which enables human organism to cope with long-lasting stress. However, perseverative stress can cause abnormalities in metabolism, growth, reproduction and the immune system. Cortisol and its metabolites are excreted renal predominantly. Therefore, analyzing urinary cortisol concentration (UCC) is part of good clinical practice and proved of value in research. Recently, the assessment of long-term cortisol concentration via hair samples has been shown to be a sensitive cortisol parameter too. According to the multicompartment model diffusion of cortisol from blood capillaries into the growing hair cells of the follicle represents the main pathway of cortisol incorporation into the hair. Hair cortisol concentrations (HCC) offer a retrospective view that is easily accessible. Numerous studies have used hair cortisol successfully to examine changes in long-term cortisol levels in a number of psychiatric diseases. Underweight patients with AN are known to have increased cortisol levels (hypercortisolism). Cortisol levels were found to correlate with both physical and mental symptoms in a complex interplay. Most studies reported a urinary hypercortisolism in AN and a significant decrease in cortisol levels during weight gain. So far, the only other study that examined HCC in AN found lower HCC compared to healthy controls, which is contradictory to the existing literature. Aim: The aim of this study was to investigate whether HCC in acutely ill AN patients reflects a well-established classic cortisol measure (UCC) using a longitudinal study design over the course of inpatient weight-restoration treatment. Methods: Therefore, after admission every patient provided a weekly 24-h-urine sample. The corresponding body weight was measured on each day of collection. After the last urine collection, a hair sample was taken for analyzing a monthly HCC. Additionally, eating disorder symptoms were measured by EDI-2. Hair samples were analyzed by a LC-MS/MS-based method. The determination of cortisol concentration in urine was performed by using a competitive immuneenzymatic colorimetric method. As urinary cortisol was measured weekly while hair cortisol values were reflecting cortisol levels over one month, we calculated the median urinary cortisol corresponding to each monthly hair cortisol value individually. In sum, we matched three pairs of median UCC and HCC for each patient, representing the beginning, middle and end of the therapy. Results: The cohort in our longitudinal analysis consisted of a total of 33 patients who participated for 13 weeks on average. A subsample of 16 patients provided a hair sample after inpatient treatment. UCC was increased and revealed the expected decrease during weight gain while HCC showed no significant change. Tested for associations between HCC and UCC there was a trend effect for UCC on HCC. Separate correlation analyses per time-period showed a significant correlation between UCC and HCC for the third time period at the end of the therapy. Disaffection with the own body correlated with UCC, but not with HCC at the beginning and end of inpatient therapy. Hair treatment had no effect on HCC. Discussion: In summary UCC proved to be a reliable cortisol measure in our sample. Despite reduction, UCC remained increased after weight-restoration and correlated with eating disorder symptoms. This confirms the supposed complex interplay of hypercortisolism with physical and mental symptoms. Compared to cortisol levels of previously reported healthy females HCC was normal in AN and did not decline significantly during weight-restoration. Overall HCC did not reflect UCC, particularly with regard to the phase of acute starvation and incipient weight gain. However, association of HCC and UCC seemed to approximate healthy conditions after weight restoration. One possible explanation for lack of correlation might be trophic disturbances of hair in AN. Studies reported that scalp hair in AN show a higher percentage of hair in the telogen (resting) phase, which implies no further hair follicle activity, consequently less hair growth, and less storage of hormones like cortisol in hair. Furthermore, disturbances of the activity of 11-β-HSD-enzymes, converting cortisol in cortisone and vice versa, might influence the incorporation of cortisol in hair too. Altogether we suggest that incorporation of cortisol into the hair might be impaired due to factors associated with underweight and undernutrition in AN. Our data demonstrate that HCC does not reflect hypercortisolism in individuals suffering from acute AN, while after some weight gain it may proof to be a useful measurement of long-term cortisol levels.

Bakgrund: Man kan se att en stor andel unga kvinnor lider av ätstörning samtidigt som det ä rbrist på kunskap om vilka hälsopromotiva åtgärder som är viktiga vid tillfrisknande. Syftet med studien var att undersöka vilka hälsofrämjande faktorer som bidragit till att unga kvinnor tagit sig ur en ätstörning. Metod: Kvalitativ metod med snöbollsurval och bekvämlighetsurval användes för att nå deltagarna. 17 kvinnor i åldrarna 19-59 år medverkade i studien. Öppna brev användes för att samla in data. De öppna breven analyserades enligt kvalitativinnehållsanalys med latent ansats där författarna tog ut meningsbärande enheter, koder, kategorier och teman. Analysen resulterade i tre huvudteman: Jag och min starka kropp, En främjande och glädjefylld miljö där jag kan vara mig själv och “Det löser sig nog -”stärkande insatser. Sex subteman skapades: Inom mig, Lyssna på kroppens olika behov, Balans mellan krav och stöd från betydelsefulla människor i min närhet, Faktorer i minomgivning, Konsten att sköta kosten och Professionell personal och preventiva verktyg som resurs. Resultat: Det som framkommer i resultatet är att flera olika faktorer främjade hälsa hos de unga kvinnorna och bidrog till att de tillfrisknande från ätstörning. Dessa faktorer var; att acceptera den man är och ge sig själv kärlek. Att få stöd och uppmuntran från nära. Aktiviteter och positiva sammanhang. Matstöd och preventiva åtgärder på klinik samt vägledning av utbildad personal. Slutsats: Riskåldern för att drabbas av ätstörning är 13-30 år och därför är det viktigt att jobba med hälsofrämjande insatser redan i ung ålder. I den här studien framkom det att flera olika faktorer är viktiga för tillfrisknande från ätstörning men även för att stärka hälsa hos kvinnor som är friska. / Backgound: A large population of young women suffers from eating disorders and at the same time there is a lack of knowledge about which health promotive tools are important in the fight to get well. The aim of the study was to investigate which health promoting factors that contributed to the womens recovery. Methods: Qualitative method with snowball sampling and convenience sampling was used to find the participants. 17 women in the age of 19-59 years participated in the study. Data was collected by open letters and then analyzedwith latent qualitative content analysis where the authors arranged meaning units, codes, categories, sub-themes and themes. The analysis resulted in three main themes: Me and my strong body, An encouraging and joyful environment where I can be myself and "It will all be alright" - strong efforts. Six sub-themes were created: Within me, Listening to the different needs of the body, Balance between demands and support from important people in my environment, Factors in my environment, The art of manage the diet and Professional staff and preventive tools as a resource. Results: What is evident in the results is that several factors promote health for the young women and contributed to the recovery from eating disorders. To accept who you are and give yourself love. To get support and encouragement from near. Activities and positive contexts. Food support and preventive methods at the clinic and guidance of healthcare professionals. Conclution: Most common age to suffer from eating disorder is 13-30 years old. Therefore, it is important to work with health promotive efforts at a young age. In this study, it emerged that several factors are important for recovery from eating disorders, but also for strengthening the health of women who are healthy.

Bakgrund: Ätstörningar anses vara ett allvarligt psykiatriskt tillstånd som kan vara potentiellt livshotande och åsamka omfattande samt mångårigt lidande. Anorexia nervosa (AN) bedöms som komplext och involverar psykiska som fysiska dimensioner av personers hälsa. Tillståndet är omdiskuterat som den mest svårbehandlade psykiskiatriska sjukdomen. Flertalet studier har lyft debatten avseende behandlingsåtgärder som generellt sett tenderar att vara sprungna ur ett mer traditionsenligt angreppssätt. Begränsningar tycks således föreligga av individers subjektiva erfarenheter vid vårdkontakt. Den samtida psykiatriska vården syftar till att stärka individers förmåga till återhämtning samt meningsfullt liv, varför det kan betraktas som väsentligt att erhålla utökad förståelse inför personer med anorexia nervosas erfarenheter för att anpassa omvårdnadsåtgärder samt förhållningssätt utifrån behov, person samt situation. Syfte: Studien syftade till beskriva personer med anorexia nervosas erfarenheter av vård. Metod: En metasyntes har genomförts med stöd av Polit och Becks niostegsmodell samt Roséns principer för att erhålla en systematik. Databaserna CINAHL, APA Psychinfo samt PubMed har nyttjats. Sammantaget medförde urvalsprocessen 13 vetenskapliga artiklar. Analys: Dataunderlaget analyserades med kvalitativ innehållsanalys och genererade tolv underteman, fyra teman och ett övergripande huvudtema. Resultat: Ett huvudtema utkristalliserades: De yttre och inre elementens inverkan samt samverkan vid vårdkontakt och återhämtning utifrån ett inifrånperspektiv. Med tillhörande fyra teman *En vård som motverkar sitt syfte med förvärvning av besvär i relation till personcentrering, *Ett hotfullt och konfliktfyllt behandlingssystem i relation till trygghet samt frigörelse, *Omgivningens och vårdpersonalens inverkan, förhållningssätt samt attityder i relation till återhämtning, *Den inre dialogen och striden i relation till återhämtningsprocessen. Slutsats: Utfallet från metasyntesen konstaterade att upplevelser och erfarenheter kunde skiljas åt mellan personer med AN samt influeras av såväl inre som yttre elements samverkan liksom inverkan. För att främja erfarenheter samt det unika behovet tycktes ett mer personcentrerat- och återhämtningsinriktat resonemang vara essentiellt.