The presented thesis deals with problems of eating disorders (hereinafter abbreviated to EDs). The theoretical framework is the Social Construction of Reality; a concept saying that the individual perceives reality - as a phenomenon formed and determined socially - in the way it is presented by the "power structures" of the society. The thesis pays special attention to the aetiology of these disorders, laying emphasis on family factors. The aim of the thesis refers to one of the topics resulting from my Bachelor thesis, when it appeared worthwhile to work up in detail the problem of subjectively seen factors substantial for onset of EDs. Thus the aim of the thesis was to map which factors the persons suffering from EDs as well as members of their families consider to be significant for onset of the disease - either their own or their daughter´s /sister´s on one hand and EDs generally on the other hand - and what led them to take their stand, in so doing two ranges of time were mapped. The set of persons under review was represented by the same respondents as in case of research for the Bachelor thesis. In order to ensure mapping of the above-mentioned problem in the most possible complex way, a qualitative research strategy was chosen. The necessary data was obtained by employing the technique of deep semi-structured interviews, then the data was processed using qualitative analysis of the respondents´ statements. Part of the research work was also confrontation of the collected and processed data with specialised resources. On the basis of the results of our research it is evident that the factor causing onset and development of the respondents´ or their daughter´s/sister´s EDs mentioned most often is family background. Unlike the Bachelor thesis, this factor was rather mentioned as one of many; it is not so dominant any longer. This may be explained by the fact that the patients spoke about their situations under the influence of other factors that experts had been emphasising. As for EDs generally, then the respondents mostly mentioned desire to be slim, which, however, has now substantially fallen into the shade. This may be explained by the respondents´ experience with EDs. It may be said that in taking their standpoints, family members were much more influenced by information from specialised resources than the persons suffering from EDs themselves, who mostly took their stand on the basis of their own conviction. Our research shows that for persons suffering from EDs, family background was not a source of information on the problem of these disorders. The research pointed out the importance of engaging the family in solving the problem of EDs as well as the necessity of individual approach to each case of this disease. The presented thesis may be a helpful source of information not only for people interested in the problem of EDs; it may also serve as materials for instruction in the medical social field, and last but not least it can be used to bring more information to the general public.

La crise de boulimie est vécue comme une perte de contrôle par les patientes atteint de boulimie (BN), d’anorexie avec crise de boulimie (ANB) et d’hyperphagie boulimique. Si ces patientes présentent effectivement des performances dégradées aux tâches neuropsychologiques évaluant les mécanismes du contrôle cognitif modulant la tendance à s’engager dans des actions sans prendre en compte leurs conséquences, la méthodologie employée ne permet pas de séparer les mécanismes propres à la crise de boulimie de ceux plus généraux du trouble. La comparaison des performances à une batterie de tâches évaluant les différents mécanismes du contrôle cognitif, de patientes BN, ANB, anorexiques restrictives avec des sujets sains en conditions alimentaire et neutre révèle que les crises de boulimie seraient liées à un contrôle cognitif perturbé par un surplus attentionnel vers les stimuli alimentaires lors de la réalisation de tâches intuitives, déséquilibrant la modulation de ce contrôle sur la tendance générale à choisir des options risquées ou immédiates explicites. En modifiant la séquence d’ingestion des aliments au cours de la crise de boulimie pour augmenter leurs compétences de contrôle faisant défaut en situation alimentaire, des patientes répondant faiblement à la thérapie comportementale et cognitive ont diminué spontanément de 44% les quantités ingérées et la moitié d’entre elles a guéri. Si ces résultats nécessitent confirmation par une étude en imagerie fonctionnelle, ils montrent l’utilité de modéliser finement les mécanismes de traitement automatique de l’information pour améliorer les thérapies actuelles / Binge eating episodes are experienced by bulimic (BN), anorexic binging subtype (ANB) and binge eating disorder (BED) patients as periods of loss of control. This feeling is corroborated by the impaired behavioral performances to neuropsychological tasks assessing cognitive control but these results do not allow separating the mechanisms that are specific to the binge from those related to the whole psychopathology of the disorder. The goal of this thesis is to identify these mechanisms, to build a model explaining the occurrence of binges and to design and test a new behavioral intervention to treat directly binges. BN, ANB and anorexic restrictive subtype patients as well as matched controls underwent a battery of neuropsychological tasks performed in food and neutral conditions. Comparison of performances between the two conditions exhibited an impairment in food condition of intuitive mechanisms of cognitive control due to a higher attention paid to food stimuli. This results in an unbalanced modulation of the general trend to choose risky or immediate options when explicitly mentioned. Another group of ANB, BN and BED patients modified the sequence of ingestion of foods during the binge in order to train themselves to recruit the impaired mechanisms of cognitive control identified at the previous step. They experienced a spontaneous reduction of 44% of food intake during binges and half of them recovered from binges. While these results need to be confirmed by a functional neuroimaging study, they stress the importance of modeling precisely the instantaneous automated mechanisms that mediate behavior in order to improve current therapies

L’anorexie mentale (AN), un trouble du comportement alimentaire multifactoriel, se traduit par une perte de poids. La sévère dénutrition retrouvée dans l’AN est associée à des altérations métaboliques induisant une dérégulation de l’axe intestin cerveau. Les mécanismes physiopathologiques sont encore mal connus. Le travail de cette thèse était de mieux appréhender les dysfonctions de l’axe intestin cerveau en évaluant le métabolisme protéique de divers tissus (hypothalamus, côlon et estomac) dans un modèle murin d’anorexie par une approche protéomique. Le premier travail a permis de mieux caractériser le modèle d’anorexie nommé activity-based anorexia (ABA) en fonction du sexe. Puis les différentes analyses protéomiques ont permis de constater une adaptation tissu dépendant des mécanismes régulant l’équilibre énergétique, avec une activité cérébrale potentiellement augmentée au détriment des fonctions digestives. Chez les souris femelles ABA, il a été constaté une augmentation d’expression de protéines mitochondriales au niveau de l’hypothalamus et à l’inverse, une diminution du métabolisme protéino-énergétique au niveau colique avec un rôle de la voie de signalisation mTOR. L’autophagie était augmentée dans ces deux tissus. Ensuite, nous avons démontré un ralentissement de la vidange gastrique secondaire à la dénutrition, et l’analyse protéomique a permis de constater une augmentation du stress oxydant au niveau de l’antre des souris ABA femelles. Ces altérations peuvent contribuer aux troubles fonctionnels gastro intestinaux. En conclusion, nos études soulignent des mécanismes d’adaptation tissu dépendants dans l’anorexie, qui devront être ultérieurement approfondis. / Anorexia nervosa, a multifactorial eating disorder, is a major public health problem and results in a severe body weight loss. The severe malnutrition observed in anorectic patients is associated with metabolic alterations inducing disturbance of the gut-brain axis. However, involved mechanisms remained poorly understood. The aim of the present thesis was to better understand the alterations of the gut-brain axis in the activity-based anorexia (ABA) model by evaluating the protein metabolism of various tissues (hypothalamus, colon and stomach) by proteomic approach. Firstly, we have better characterized the response to ABA model according to sex. Then, different proteomic analyses were performed using female C57BL/6 mice. Our results revealed a tissue-dependent adaptation of protein and energy metabolism with an increased hypothalamic activity and a decrease in the gastrointestinal tract. Indeed, ABA mice exhibited an increased expression of proteins involved in mitochondrial metabolism at the level of the hypothalamus, and conversely a decrease of proteins involved in protein and energy metabolism in colonic mucosa with a key role of the mTOR signaling pathway. Both in hypothalamus and colon, autophagy was increased. We were also able to show that gastric emptying was delayed in ABA mice that is mainly due to malnutrition. In addition, proteomic analysis revealed an increase in gastric oxidative stress in female ABA mice. These alterations may contribute to the gastrointestinal functional disorders frequently described in anorexia nervosa. In conclusions, our study underlined tissue-dependent adaptive metabolic process during anorexia that should be further explored.

Bakgrund: Anorexia nervosa är en sjukdom som innebär en förvrängd kroppsuppfattning och ett sjukligt förhållningssätt till mat. Att vara förälder till ett barn med psykiska sjukdomar innebär ofta ett svårt lidande. Först när man besitter kunskap om föräldrarnas unika erfarenheter kan sjuksköterskan möta och hjälpa dem. Den teoretiska referensramen som användes var familjefokuserad omvårdnad.   Syfte: Syftet var att undersöka erfarenheter av att vara förälder till en ungdom med anorexia nervosa.    Metod: Allmän litteraturstudie baserad på åtta kvalitativa artiklar, från databaserna Cinahl och PsycINFO, analyserades enligt Kristenssons (2014) modell.    Resultat: Analysen resulterade i två huvudkategorier och sex subkategorier. En huvudkategori var känslomässiga erfarenheter med subkategorierna förnekelse, missnöje med primärvården, skuld och skam samt maktlöshet och oro. Gemensamt för dessa subkategorier var att de grundade sig i okunskap om sjukdomen och/eller behandlingen samt bristande kommunikation med vårdpersonal. Den andra huvudkategorin var erfarenheter av sociala konsekvenser med subkategorierna ensamhet och isolering samt förändringar i familjesystemet. Gemensamt för dessa var att sjukdomen hade en negativ inverkan på familjens normala rutiner.    Slutsats: De flesta föräldrar vittnade om att anorexin hade en inverkan på hela familjesystemet men att multi-family therapy kunde minska ensamhetskänslan och lidandet.

Die vorliegende Arbeit entwickelt einen Vorschlag für einen neuen, kompakteren Fragebogen mit dem Akronym „BaFEK-45“ zur Diagnostik von Essstörungen, der auf einer statistischen Analyse von Daten aus fünf bereits etablierten Fragebogen (ANIS, EAT – 26, FBeK, EDI – 2, EDES) mit einer Gesamtzahl von 231 Items basiert. Dabei wurden die Antworten von Patientinnen aus den 1990er- und 2000er-Jahren der Klinik und Poliklinik für Psychiatrie, Psychotherapie und Psychosomatik des Kindes- und Jugendalters der Universität Leipzig ausgewertet. Auf Grundlage zweier „Signalfragen“ zu Ess-Anfällen wurden die Fragebogen-Serien in drei Gruppen (anorektisch, bulimisch und grenzwertig) eingeteilt, daraufhin konnte eine Analyse zu den Unterschieden im Antwortverhalten zwischen eben diesen Gruppe vorgenommen werden. Nach einem auf dieser Analyse basierenden Auswahlverfahren wurden die verbliebenen Items einer mehrstufigen Faktorenanalyse und kritischen inhaltlichen Differenzierung unterzogen. An deren Ende steht der o.g. Vorschlag eines neuen Diagnostikinstruments, das sich aus 45 Fragen in fünf Skalen zusammensetzt.

This study seeks to explore anorexia nervosa as experienced within the South African coloured community in the specific. It represents an examination of themes within the participants’ depictions, discovering those themes that concur with existent literature, as well as discerning novel themes within the target group. Literature proves to yield varied results with regard to anorexia as presented in diverse cultures. Sufficient awareness is lacking within the South African context, where a scarcity of available literature that explores the experiences of the coloured anorexic individual necessitates the need for the current study. The contributing factors are viewed to involve societal, cultural, and familial aspects, all of which are situated within a systemic frame of reference. Systems theory provides the foundation within which these factors are explored, aiming to provide the reader with in-depth knowledge as to the functioning of the anorectic patient. It should be noted that these factors are interconnected, influencing each other in a circular manner. Attention is awarded to not only larger systems of societal and cultural influences, but also serves to encompass the functioning of the anorectic within the familial system. The reciprocity that exists within and between sub-systems is investigated, with the focus being the interrelatedness between members. Recursive feedback and associated processes are examined as they relate to the development and maintenance of anorexia. A qualitative research design was applied, where semi-structured interviews served as the chosen data collection strategy. Interviews were conducted at the hospital where they received treatment, and aimed to extract the meanings inherent in the participants’ experiences. A limited availability of diagnosed coloured anorexic individuals resulted in two willing participants partaking in the study. Thematic networks enabled the researcher to explore their representations in depth, leading to the subsequent organising of themes for further analysis. Two global themes emerged upon examination, the first of which was identified as “familial impact and patterns”, consisting of organising themes of relational positioning and interactional processes. Organising themes of expectations and internal emotional states constitute the second global theme of “control”. These themes are supported by a variety of basic themes, all of which serve to enhance the understanding of the organising themes, contributing to the respective global themes. Extensive exploration of the discovered themes followed, with the investigation proceeding within a systems theory framework. A conclusive discussion serves the purpose of bringing the exploration to a close. Relevant literature is incorporated into the discussion, providing the reader with an integrated understanding of the findings of the study within the broader field of anorexia nervosa. Copyright / Dissertation (MA)--University of Pretoria, 2008. / Psychology / unrestricted

Die Dissertation handelt von der Arbeit mit essgestörten Patientinnen und deren Unzufriedenheit mit dem eigenen Körper. Als Vergleichsgruppen wurden junge Mädchen aus der Sekundarstufe I und aus Sportvereinen untersucht. Die Ausführungen sind Resultat der langjährigen Beschäftigung mit den Themen Essstörungen (Anorexia nervosa, Bulimie u.a.) bei Mädchen in der Pubertät. Während meiner Tätigkeit als Kinder- und Jugendlichenpsychotherapeutin in einer Klinik für Essstörungen und in meiner Praxis für Psychotherapie offenbarte sich mir die dramatische Körper- und Gefühllosigkeit der erkrankten Mädchen. In vielen Therapiesitzungen fiel der Satz: Ich kann mich nicht fühlen, ich weiß nicht, wie sich mein Körper anfühlt. Der fehlenden Körperwahrnehmung wollte ich nachgehen und erkrankte, nicht-erkrankte und sportlich-aktive Mädchen u.a. hinsichtlich ihrer Einstellungen gegenüber dem eigenen Körper, ihrer familialen Beziehungen und ihrer sportlichen Aktivität befragen. Mit dieser qualitativen Körperuntersuchung und den gewonnenen Ergebnissen verfolge ich primär das Ziel, den Mädchen und Frauen zu helfen, die verzweifelt einen Ausweg suchen aus dem pathologischen Teufelskreis: Wie schlank muss ich sein, um geliebt zu werden" So gilt es einerseits, dem Bewusstsein Rechnung zu tragen, dass sich Modediktat, Schönheitsideal, Selbstwertproblematik nicht mit autoaggressiv-destruktiver Abmagerung lösen lässt. Andererseits braucht das Gesundheitswesen ausreichende finanzielle Mittel, um der hohen Sterblichkeitsrate bei Magersucht präventiv entgegenzuwirken. In diesem Sinne hoffe ich zu der Einsicht beizutragen, dass die Behandlung einer schweren Erkrankung wie Anorexia nervosa nicht ohne Psychotherapie, medizinische Betreuung, Ernährungstherapie und v.a. nicht ohne Körpertherapie prognostisch möglich ist. Die Arbeit zeigt, dass jegliches Fehlen von stärkender Körperwahrnehmung den Behandlungserfolg massiv in Frage stellt.

Introduction : Cette thèse est issue de réflexions et d'expériences cliniques suite à un travail avec des femmes souffrant d'un trouble des conduites alimentaires (TCA) et accédant à la maternité. Dans notre recherche, parmi les différentes méthodes de Procréation Médicalement Assistée (PMA), nous avons choisi d'étudier une population ciblée : les femmes ayant recours à la pompe à la GnRH pour concevoir leurs enfants. Hypothèse principale : il existerait un grand nombre de femmes, souffrant ou ayant souffert d'un TCA, qui auraient recours à la pompe à GnRH. Hypothèse secondaire : le TCA maternel aurait des influences sur le désir d'enfant, la grossesse et les interactions précoces mère-enfant. Objectif principal : évaluer un groupe de femmes souffrant d'un TCA, enceintes après utilisation de la pompe à GnRH, à partir du 4ème mois de grossesse et jusqu'à la 8ème semaine du post-partum. Objectifs secondaires : obtenir des données scientifiques à propos des femmes souffrant d'un TCA et ayant recours à la pompe à GnRH, afin de mieux éclairer le parcours de soin de ces patientes dans les services de PMA ; obtenir des données scientifiques sur le vécu de la grossesse par les femmes TCA ; obtenir des données scientifiques sur la présence et la gravité des TCA durant la grossesse et en post-partum ; évaluer la prévalence de la dépression du postpartum chez les femmes souffrant d'un TCA. Critère d'évaluation principal : comparaison du groupe d'étude avec deux groupes témoins, l'un composé de femmes exemptes de TCA devenues enceintes par des méthodes de PMA autres que la pompe à GnRH, et l'autre composé de femmes exemptes de TCA devenues enceintes spontanément. Critères d'évaluation secondaires : évaluation de l'évolution du TCA, en pré et postnatal, par l'hétéro-questionnaire EDE ; évaluation du vécu de la grossesse par des entretiens semi-structurés ; évaluation des représentations maternelles par l'IRMAG ; évaluation de l'état psychique en pré et postnatal par l'auto-questionnaire HAD ; évaluation de l'anxiété par l'utilisation du STAI ; évaluation du risque de survenue d'une dépression du postpartum par l'auto-questionnaire EPDS. Cette étude est observationnelle et prospective : étape prénatale - 3 évaluations, entre 16 et 20 semaines d'aménorrhée (SA), entre 24 et 28 SA et entre 28 et 32 SA ; étape postnatale - 1 évaluation, à la 8ème semaine environ du postpartum. Conclusion : on constate que le TCA maternel peut être un facteur de risque en ce qui concerne la grossesse et les interactions précoces mère-bébé. L'utilisation de la pompe à GnRH par les femmes souffrant d'un TCA devrait être considéré comme un véritable enjeu de santé publique, requérant évaluation, prévention et prise en charge pluridisciplinaire de la grossesse jusqu'au post-partum. / Introduction: This thesis is the result of reflexions and clinical experiences from our work of pregnancy in women suffering from lifetime eating disorders (ED). Among different methods of assisted reprodutive technology (ART), we chose to study a special population: women seeking GnRH pulsatile administration treatment. Main hypothesis: there is an important rate of women with a lifetime ED seeking GnRH pulsatile administration treatment . Secondary hypothesis: maternal ED have influences on the desire for a child, pregnancy and early mother-child interactions. Main objective: to evaluate pregnant women with a lifetime ED after seeking GnRH pulsatile administration treatment, from the 4th month of pregnancy until the 8th week of postpartum. Secondary objectives: to obtain scientific data about women with lifetime ED seeking GnRH pulsatile administration treatment ; to better inform the multidisplinary care of these patients in the ART services ; to obtain scientific data about the experience of pregnancy in women with a lifetime ED and about the presence and severity of ED during pregnancy and postpartum ; to estimate the prevalence of postpartum depression in these women. Design: A descriptive comparative three-group design in which collected data were compared - one of women with lifetime ED who became pregnant after GnRH pulsatile administration treatment, one of women without lifetime ED who became pregnant after using other ART methods , one of women without lifetime ED who had a spontaneous pregnancy. Evaluation criteria: EDE to evaluate ED during the pre- and post-natal period ; clinical semi-structured interviews to evaluate how the pregnancy is experienced ; IRMAG to evaluate maternal representations ; HAD to evaluate anxiety and depression during the pre and postnatal period ; STAI to evaluate anxiety ; EPDS to evaluate risk of postpartum depression. This study is observational and prospective: during the prenatal period - 3 evaluations were conducted, between 16 and 20 weeks of amenorrhea (SA), between 24 and 28 SA and between 28 and 32 SA ; during the postnatal period - 1 evaluation was conducted around the 8th week. Conclusion: Eating disorders and GnRH pulsatile administration can be considered as a real public health issue, requiring strategies to address prevention, identification and multidisciplinary care for these women during pregnancy and postpartum. An eating disorder screening tool should be included in the initial intake, because these patients may be at a higher risk for negative maternal and fetal outcomes than non eating disorder patients.

Obesity prevalence continues to increase worldwide, yet few safe and effective treatment options are available suggesting there needs to be a greater emphasis on preventing rather than treating obesity. This research investigated the association of obesity predisposing SNPs and a gene score with nutrient consumption patterns including total energy intake and macronutrient distribution in a European ancestry population as well as discussing an evolutionary perspective on eating disorders using current epidemiological evidence to identify genes which may be involved. The association of two of the 14 obesity predisposing SNPs and the gene score with BMI was confirmed in the EpiDREAM population. Novel associations between two SNPs located in or near BDNF (rs6265 and rs1401635) were found with total fat, MUFA, and PUFA intake. Rs1401635 was also associated with total energy and trans fat intake. Novel associations of rs6235 (PCSK1) and the gene score were found with total energy intake. The novel associations found indicate that food related behaviours are one of the mechanisms of action through which obesity predisposing SNPs cause obesity and therefore warrant further investigation. The lack of association among all genes and the modest association of the gene score show that mechanisms other than food consumption are important. The investigation of the evolutionary history of eating disorders revealed that the adapted to flee famine hypothesis is a plausible theory explaining anorexia nervosa while the thrifty genotype hypothesis provides a possible explanation for bulimia nervosa and binge eating disorder. These evolutionary theories can be applied to identify new candidate genes as well as phenotypic traits to investigate to better understand the genetic architecture of eating disorders. Understanding genes associated with disordered eating patterns may highlight future areas for obesity prevention. / Thesis / Master of Science (MSc) / A large percentage of the risk of developing obesity or an eating disorder (anorexia nervosa, bulimia nervosa, and binge eating disorder) is determined by genetics. For obesity, many genes have been identified as influencing risk, but the mechanisms through which the genes work are largely unknown. For eating disorders, gene identification efforts have been mostly unsuccessful and no mechanisms of action have been determined. In the first component of this thesis we found an association between previously identified obesity risk genes and food intake, specifically the total number of calories consumed per day and the percentage of calories from total fat and fat subtypes. These results support that food related behaviours are possible mechanisms of action which need to be further investigated. In the second half of the thesis we viewed eating disorder behaviours from an evolutionary perspective. We concluded that there are theories that possibly explain eating disorder behaviours including being able to live off of small quantities of food as well as binging. These evolutionary theories can be applied to identify new genes to study in the context of eating disorders as well as different definitions of eating disorders.

Objective: Reductions of gray matter volume and cortical thickness in anorexia nervosa (AN) are well documented. However, findings regarding the integrity of white matter (WM) as studied via diffusion weighted imaging (DWI) are remarkably heterogeneous, and WM connectivity has been examined only in small samples using a limited number of regions of interest. The present study investigated whole-brain WM connectivity for the first time in a large sample of acutely underweight patients with AN. Method: DWI data from predominantly adolescent patients with acute AN (n ¼ 96, mean age ¼ 16.3 years) and age-matched healthy control participants (n ¼ 96, mean age ¼ 17.2 years) were analyzed. WM connectivity networks were generated from fiber-tractography-derived streamlines connecting 233 cortical/subcortical regions. To identify group differences, network-based statistic was used while taking head motion, WM, and ventricular volume into account. Results: Patients with AN were characterized by 6 WM subnetworks with abnormal architecture, as indicated by increased fractional anisotropy located primarily in parietal-occipital regions and accompanied by reduced radial diffusivity. Group differences based on number of streamlines reached only nominal significance. Conclusion: Our study reveals pronounced alterations in the WM connectome in young patients with AN. In contrast to known reductions in gray matter in the acutely underweight state of AN, this pattern does not necessarily indicate a deterioration of the WM network. Future studies using advanced MRI sequences will have to clarify interrelations with axonal packing or