Treatment of Anxiety and Anorexia Nervosa in Adolescents

Anorexia nervosa (AN) is an eating disorder characterized by a morbid fear of weight gain and
a perception of being overweight despite objective evidence of weight loss and malnutrition.
It has been estimated that almost 0.9% of women will suffer from AN at some point in their
lives, and most cases of AN arise during adolescence. Even with appropriate treatment, only
about half of patients with AN will have a full recovery, 30% partial recovery, and 20% will
progress to having a chronic illness. Earlier, more aggressive treatment with appropriate
nutritional recovery during adolescence offers the best chance of a full recovery. Treatment
of AN is complicated by the high rate of comorbid psychiatric diagnoses, the physical and
cognitive effects of the attendant malnutrition, and the lack of effective pharmacologic
interventions. Approximately 75% of patients with AN have a comorbid psychiatric illness,
including depression, obsessive compulsive disorder, and anxiety. Anxiety disorders in
particular share attributes with AN, including perfectionism, rigidity, compulsivity, and
harm avoidance in addition to trait anxiety. Complicating treatment, the risk and severity of
patients' anxiety is enhanced by a lower body mass index (BMI), and this low BMI is the
likely reason why standard medication treatments for generalized anxiety, such as selective
serotonin reuptake inhibitors are ineffective. In order to address these treatment
challenges, we propose to study the tolerability, feasibility and efficacy of a
non-pharmacologic interventions for anxiety in adolescents with AN: omega-3 polyunsaturated
fatty acid (PUFA) supplementation.

Over the past 15 years, there has been an interest in possible associations between fish oil
and affective illness, particularly depression. Low plasma levels of docosahexaenoic acid, an
essential fatty acid found in fish oil, are associated with low concentrations of
cerebrospinal fluid 5-hydroxyindolacetic acid (5-HIAA), a marker of central nervous system
serotonin turnover. Epidemiologically, those populations with higher fish oil consumption
tend to have lower rates of depression, and reported low levels of fish consumption have been
associated with a greater risk of depression in women. It has been hypothesized that omega-3
PUFAs alter brain phospholipid composition and enhance membrane fluidity, and this is
supported by evidence that supplementation with omega-3 PUFAs decreases brain water proton
transverse relaxation times in patients with bipolar disorder. The association with
depression and the proposed mechanism of action elicited some interest regarding associations
between omega-3 PUFAs and anxiety disorders. Supplementation trials have shown mixed results,
with no effects for obsessive compulsive disorder in patients taking maximum doses of
selective serotonin reuptake inhibitors, and another showing decreased anxiety symptoms in 22
patients enrolled in a substance abuse treatment program. Recently, Kiecolt-Glaser and
colleagues described a decrease in test-related anxiety symptoms in a non-clinical sample of
medical students related to supplementation with omega-3 PUFAs. Although there has been some
interest in the use of omega-3 PUFA supplementation as an adjunctive treatment for anorexia
nervosa, there have been no systematic trials.

Inclusion Criteria:

Females admitted to Nationwide Children's Hospital Eating Disorder Partial Hospitalization
Program

Exclusion Criteria:

1. Inability to take pills

2. Co-morbid medical conditions affecting appetite and weight (e.g., inflammatory bowel
disease, cancer, cystic fibrosis)

3. Co-morbid psychiatric conditions affecting appetite and weight (e.g., bipolar
disorder, substance abuse)

4. Currently taking fish oil supplements

5. Inability to participate in study for 12 consecutive weeks.