LEITERS TO THE EDITOR
clinical expertise in child custody cases in which allegations of child sexual abuse have been made . II. Prevalence rates of child sexual abuse and the precision of procedures designed to diagnose it. Family Law Quarterly, 25:381-409.
Imaging and Eating Disorders To the Editor: The article, " Neuroimaging in Child and Adolescent Psy chiatry" (Kuperman et al., 1990) discusses the use of single photon emission computed tomography (SPECT), especially in regard to the diagnosis of schizophrenia, attention-deficit hyperactivity disorder, and causes of perinatal ischemia. At our hospital, we have been fortunate to be able to perform technetium-99m-hexamethylpropyleneamine (Tc99m-HMPAO) SPECT imaging. We have performed this procedure on over 60 severely disturbed adolescents and have found it to have both diagnostic and prognostic use . While we were treating an anorexic patient who also had temporal lobe epilepsy, Signer and Benson (1990) published their article, "Three Cases of Anorexia Nervosa Associated with Temporal Lobe Epilepsy "; this prompted a review of our eating-disordered patients who had undergone SPECT imaging. The results were consistent with the literature, and as a diagnostic grouping, the results for the patien ts with eating disorders were among the most consistent regarding blood flow disturbance. All imaging was performed with the patient unstressed, this technique providing the most symmetric and reproducible results. SPECT imaging regional cerebral blood flow measurements were performed I hour after an intravenous injection of Tc-99m-HMPAO. The resulting images were analyzed by two independent observers and compared with a control group of 12 volunt eers from a young adult population. The results were reported as regional counts as a percentage of cerebellar counts; to be considered significa nt, the study sample had to have perfusion values in the region of interest at least two stand ard deviations from the mean (Hooper et aI., 1990). Although the literature describing brain imaging in eating disorders is limited, there has been some consistency to the results. In bulimic subjects, there appears to be a loss of the normal right hemisphere lateralization of cerebral blood flow and this loss of lateralization occurred primarily in the temporal lobes (Hagman et al., 1990). This study used positron emission tomography (PET). We performed SPECT imaging on six patients with eating disorders . Two anorexia nervosa patients demonstrated temporal hyperperfusion, although in opposite hemispheres. One bulimic patient demonstrated marked left temporal hyperperfusion, whereas another demonstrated no abnormality. Thu s, three of four patients with eating disorders demonstrated temporal hyperperfusion. The patient with temporal lobe epilepsy was studied while in remi ssion and demonstrated decreased frontal perfusion. Another patient who had suffered a head injury and demonstrated personality changes that included bulimic behavior had generalized hyperperfusion of both hemi spheres. Of the many patients who had undergone SPECT imaging, only one other demonstrated a temporal lobe hyperperfusion. This patient was diagnosed as dysthymic but was especially noted to be a picky eater. Trimble (1988) has suggested that the temporal lobes are important for the integration of sensory data related to body image. The finding then of altered temporal lobe perfu sion in a patient with an eating disorder is not unexpected. To the best of our knowledge, data regarding brain imaging studies in adolescents are lacking. This preliminary clinical data suggests altered cerebral perfu sion, as has been documented in studies involving adult patients. Future studies need to look at perfusion changes with disease state, as we have seen the disappearance of hypofrontality in two schizophrenic patients with treatment. Will the altered perfusion disappear with clinical improvement? Is the altered perfusion brought on by starvation, or is it in
990
response to bing ing? We do not belie ve that the perfusion changes are related to affective state, as most of the affective disorder patients do not demonstrate this lesion. The possibility of abnormal perfusion as a marker is raised by our dysthymic patient whose altered appetite was not in keeping with the severity of her other symptoms and may indicate an earl y eating disorder. Biopsychosocial factors are all imp ortant in the etiology of eating disorders, but the recent availability of brain imaging techniques sho uld provide new insight into the etiology of anorexia nervosa and bulimia. SPECT is an economical alternative to PET and may very well provide important diagnostic and prognostic information to the nonresearch physician in the future. Both parents and adolescents are not hesitant to be evaluated by this technology and are more likely to feel that an evaluation has been complete. Robert Drebit Maurice Blackman Alexander McEwan Tofael Chowdhury Child and Adolescent Services Association Edmonton, Alberta
REFERENCES
Hagm an, J. 0 ., Buchsbaum, M. S., Wu , J. C., Rao, S. J. , Reynolds, C . A. & Blinder, D. J. (1990), Comparison of regional brain metabolism in bulimia nervosa and affective disorder assessed with positron emission tomography. J. Affective Disord., 19:153-162. Hooper, H. R., McEwan, A. J., Lentle, B. C ., Kuchon, T. L. & Hooper, P. M. (1990), Interactive three dimen sional region of interest analysis ofHMPAO SPECT brain studies. J. Nucl. Med., 31:2046-2051. Kuperman, S., Gaffney, G. R., Hamdan-Allen, G., Preston, D. F. & Venkatesh, L. (1990), Neuroimaging in child and adolescent psychiatry . J. Am. Acad. Child Adolesc. Psychiatry, 29:159-172. Signer, S. F. & Benson, D. F. (1990), Three cases of anorexia nervosa associated with temporal lobe epilepsy. Am. J. Psychiatry, 147:235238 . Trimble, M. R. (1988), Body image and the temporal lobes. Br. J. Psychiatry, 153(Suppl 2):12-14.
Anorectic Family Dynamics To the Editor: We would like to present some of our observations on anorexia nervosa and the family-oriented treatment approach. The study was preformed in an outpatient private clinic from 1985 to 1989. Our observations are based on retrospective systematic chart review s of 10 patients who were chosen randomly from a population of 21 female anorectics and were treated for at least 2 years by the same psychiatrist. All the pat ients who were treated were ambulatory; therefore, their symptoms were, at the most, of moderate severity. We consider the anorectic syndrome to be moderate when we deal with pure anorexia nervosa with less than 2 years of amenorrhea and, at most, two hospitalizations in a general hospital because of the anorectic syndrome, excluding the following: I) schizophrenia, affective disorders; and 2) suicidal thoughts and attempts or other psychiatric disorders that require psychiatric hospitalization. These indices are in accordance with Kronenberg et al. (unpublished). The ages of the selected pat ients at the time of diagnosis ranged from 13 to 16 years. All were diagnosed according to the criteria of
DSM-lll-R. The importance of understanding anorexia nervosa as part of the inclusive family system was emphasized by Laseque (1964), who noted that any picture obtained solely on the basis of observing the J. Am. Acad. Child Adolesc. Psy chiatry, 31: 5, September 1992
clinical expertise in child custody cases in which allegations of child sexual abuse have been made . II. Prevalence rates of child sexual abuse and the precision of procedures designed to diagnose it. Family Law Quarterly, 25:381-409.
Imaging and Eating Disorders To the Editor: The article, " Neuroimaging in Child and Adolescent Psy chiatry" (Kuperman et al., 1990) discusses the use of single photon emission computed tomography (SPECT), especially in regard to the diagnosis of schizophrenia, attention-deficit hyperactivity disorder, and causes of perinatal ischemia. At our hospital, we have been fortunate to be able to perform technetium-99m-hexamethylpropyleneamine (Tc99m-HMPAO) SPECT imaging. We have performed this procedure on over 60 severely disturbed adolescents and have found it to have both diagnostic and prognostic use . While we were treating an anorexic patient who also had temporal lobe epilepsy, Signer and Benson (1990) published their article, "Three Cases of Anorexia Nervosa Associated with Temporal Lobe Epilepsy "; this prompted a review of our eating-disordered patients who had undergone SPECT imaging. The results were consistent with the literature, and as a diagnostic grouping, the results for the patien ts with eating disorders were among the most consistent regarding blood flow disturbance. All imaging was performed with the patient unstressed, this technique providing the most symmetric and reproducible results. SPECT imaging regional cerebral blood flow measurements were performed I hour after an intravenous injection of Tc-99m-HMPAO. The resulting images were analyzed by two independent observers and compared with a control group of 12 volunt eers from a young adult population. The results were reported as regional counts as a percentage of cerebellar counts; to be considered significa nt, the study sample had to have perfusion values in the region of interest at least two stand ard deviations from the mean (Hooper et aI., 1990). Although the literature describing brain imaging in eating disorders is limited, there has been some consistency to the results. In bulimic subjects, there appears to be a loss of the normal right hemisphere lateralization of cerebral blood flow and this loss of lateralization occurred primarily in the temporal lobes (Hagman et al., 1990). This study used positron emission tomography (PET). We performed SPECT imaging on six patients with eating disorders . Two anorexia nervosa patients demonstrated temporal hyperperfusion, although in opposite hemispheres. One bulimic patient demonstrated marked left temporal hyperperfusion, whereas another demonstrated no abnormality. Thu s, three of four patients with eating disorders demonstrated temporal hyperperfusion. The patient with temporal lobe epilepsy was studied while in remi ssion and demonstrated decreased frontal perfusion. Another patient who had suffered a head injury and demonstrated personality changes that included bulimic behavior had generalized hyperperfusion of both hemi spheres. Of the many patients who had undergone SPECT imaging, only one other demonstrated a temporal lobe hyperperfusion. This patient was diagnosed as dysthymic but was especially noted to be a picky eater. Trimble (1988) has suggested that the temporal lobes are important for the integration of sensory data related to body image. The finding then of altered temporal lobe perfu sion in a patient with an eating disorder is not unexpected. To the best of our knowledge, data regarding brain imaging studies in adolescents are lacking. This preliminary clinical data suggests altered cerebral perfu sion, as has been documented in studies involving adult patients. Future studies need to look at perfusion changes with disease state, as we have seen the disappearance of hypofrontality in two schizophrenic patients with treatment. Will the altered perfusion disappear with clinical improvement? Is the altered perfusion brought on by starvation, or is it in
990
response to bing ing? We do not belie ve that the perfusion changes are related to affective state, as most of the affective disorder patients do not demonstrate this lesion. The possibility of abnormal perfusion as a marker is raised by our dysthymic patient whose altered appetite was not in keeping with the severity of her other symptoms and may indicate an earl y eating disorder. Biopsychosocial factors are all imp ortant in the etiology of eating disorders, but the recent availability of brain imaging techniques sho uld provide new insight into the etiology of anorexia nervosa and bulimia. SPECT is an economical alternative to PET and may very well provide important diagnostic and prognostic information to the nonresearch physician in the future. Both parents and adolescents are not hesitant to be evaluated by this technology and are more likely to feel that an evaluation has been complete. Robert Drebit Maurice Blackman Alexander McEwan Tofael Chowdhury Child and Adolescent Services Association Edmonton, Alberta
REFERENCES
Hagm an, J. 0 ., Buchsbaum, M. S., Wu , J. C., Rao, S. J. , Reynolds, C . A. & Blinder, D. J. (1990), Comparison of regional brain metabolism in bulimia nervosa and affective disorder assessed with positron emission tomography. J. Affective Disord., 19:153-162. Hooper, H. R., McEwan, A. J., Lentle, B. C ., Kuchon, T. L. & Hooper, P. M. (1990), Interactive three dimen sional region of interest analysis ofHMPAO SPECT brain studies. J. Nucl. Med., 31:2046-2051. Kuperman, S., Gaffney, G. R., Hamdan-Allen, G., Preston, D. F. & Venkatesh, L. (1990), Neuroimaging in child and adolescent psychiatry . J. Am. Acad. Child Adolesc. Psychiatry, 29:159-172. Signer, S. F. & Benson, D. F. (1990), Three cases of anorexia nervosa associated with temporal lobe epilepsy. Am. J. Psychiatry, 147:235238 . Trimble, M. R. (1988), Body image and the temporal lobes. Br. J. Psychiatry, 153(Suppl 2):12-14.
Anorectic Family Dynamics To the Editor: We would like to present some of our observations on anorexia nervosa and the family-oriented treatment approach. The study was preformed in an outpatient private clinic from 1985 to 1989. Our observations are based on retrospective systematic chart review s of 10 patients who were chosen randomly from a population of 21 female anorectics and were treated for at least 2 years by the same psychiatrist. All the pat ients who were treated were ambulatory; therefore, their symptoms were, at the most, of moderate severity. We consider the anorectic syndrome to be moderate when we deal with pure anorexia nervosa with less than 2 years of amenorrhea and, at most, two hospitalizations in a general hospital because of the anorectic syndrome, excluding the following: I) schizophrenia, affective disorders; and 2) suicidal thoughts and attempts or other psychiatric disorders that require psychiatric hospitalization. These indices are in accordance with Kronenberg et al. (unpublished). The ages of the selected pat ients at the time of diagnosis ranged from 13 to 16 years. All were diagnosed according to the criteria of
DSM-lll-R. The importance of understanding anorexia nervosa as part of the inclusive family system was emphasized by Laseque (1964), who noted that any picture obtained solely on the basis of observing the J. Am. Acad. Child Adolesc. Psy chiatry, 31: 5, September 1992
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