Eating Disorders: Assessment, Understanding, and Treatment Strategies

1
Eating Disorders Assessment, Understanding, and
Treatment Strategies

• Terry Schwartz MD
• Medical Director UCSD Eating Disorders Program
• Asst Clinical Professor UCSD
• Elise Curry Psy.D.
• Program Manager
• UCSD IOP

2
ASSESSMENT AND TREATMENT STRATEGIES FOR EATING
DISORDERS

• Terry Schwartz MD
• Medical Director UCSD Outpatient Eating Disorders
  Program
• Assistant Clinical Professor UCSD Dept Of
  Psychiatry

3
DSM IV Criteria for Anorexia Nervosa

• Preoccupation with body shape, weight/size
• lt85 ideal BW
• Fear of becoming fat despite low weight
• Loss of 3 consecutive periods in women
• Types restricting,binge/purge,purge

4
Anorexia Nervosa

• Most homogenous psychiatric disorder
• 90-95 female
• Onset teenage years puberty
• Monotonous puzzling symptoms
• Poor response to treatment
• Highest mortality rate
• 50 to 80 contribution of genes
• Many women diet, few develop AN predisposing
  factors

5
DSM IV criteria for Bulimia Nervosa

• Recurrent episodes of binge eating, characterized
  by eating an excessive amount of food within a
  discrete period of time and by a sense of lack of
  control over eating during the episode
• Recurrent inappropriate compensatory behavior in
  order to prevent weight gain, such as
  self-induced vomiting or misuse of laxatives,
  diurética, enemas, or other medications
  (purging) fasting or excessive exercise
• The binge eating and inappropriate compensatory
  behaviors both occur, on average, at least twice
  a week for 3 months
• Self-evaluation is unduly influenced by body
  shape and weight

6
Psychological Correlates of Anorexia Nervosa

• Poor self concept
• Obsessive compulsive and avoidant personality
  style
• Perfectionistic, obsessive, harm avoidant traits
• Family dynamics enmeshment, anxiety,
• over-achievers
• Troubles with major life transitions
• an attempt to regress, avoid development
• Difficulty managing and expressing anger
• Cognitive distortions
• Ego-syntonic nature of disease

7
Psychological Correlates of Bulimia Nervosa

• Poor self concept
• Chaotic developmental history, parental deficit
• ambiguous communication styles
• Affective regulation problems
• Cognitive distortions
• Ego-dystonic nature of disease
• Impulsivity, substance abuse, self harm, sexual
  acting out, shop lifting

8
Cognitive Flexibility

• Anorexia Nervosa
• ? Perceptual rigidity
• ? Cognitive rigidity
• AN Weight recovery
• No changes
• AN Full recovery
• Partial improvement in cognitive flexibility
  tasks

• Bulimia Nervosa
• Slowness in cognitive shifting tasks
• Fluctuations in Perceptual task

9
Scope of The Problem

• Prevalence increasing
• AN .5-2
• BN 3-4
• AN BN More common westernized cultures
• 10 of eating disordered individuals in treatment
  are male
• 5-20 of AN patients die (disorder or suicide)

10
Scope of the problem continued

• Highest death rate from any mental health
  condition (AN)
• Increasing incidence in elementary age children
  (8-11 year old)
• The incidence of bulimia in 10-39 year old women
  TRIPLED between 1988 and 1993.
• There has been a rise in incidence of anorexia in
  young women 15-19 in each decade since 1930.

11
Primary Causes of Death in Patients with Eating
Disorders
12
Outcome Data for EDs

• Data mixed results due to design of studies
• AN 10 yr 50 rec, 20-30 improved but still
  symptomatic, 10-20 chronic, up to 10 mortality
• BN 10yr 50-70 rec, 30 some improvement, 20
  chronic

13
Outcomes for EDS

• Some studies show ave of 7 years to rec
• Less than 1 year of treatment has poorer
  prognosis
• Chronicity, OCPD, purging in AN associated with
  worse outcome

14
Biological underpinnings of eating disorders

• Genetics
• Neurobiological correlates
• Neuropsychiatric
• Brain imaging in AN

15
Genetic Correlates of Bulimia Nervosa

• Twin studies
• 5ht2A receptor gene alteration
• Family history of affective, anxiety, substance
  abuse d/o

16
Genetic Correlates in Anorexia Nervosa

•  
• Family and twin studies
• Serotonin receptor gene
• Variation in Dopamine 2 receptor gene
• Chrom 1 and 10
• Family history of OCD, OCPD, AN
•  

17
Neuroendocrine correlates of Bulimia Nervosa

• Serotonin (5HT1A receptor)
• Endogenous opiate response to binge purge
• ?DA

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Neuroendocrine Correlates of Anorexia Nervosa

• Serotonin (5HT2A receptor)
• Dopamine
• Endogenous opiate response to starvation
• Hypothalamus dysfunction (satiety, amenorrhea)

19
Altered Dopamine function and psychiatric
correlates

• Compare normal to psychiatric conditions
• AN increased DA sensitivity, hyper responsive
• Addict reduced DA sensitivity, takes a lot to
  stimulate
• Obesity DA sensitivity inversely proportional to
  weight (high weight, low DA sensitivity)

20
Altered Reward Processing in Women Recovered from
Anorexia Nervosa

• RAN may have difficulties differentiating
  positive and negative feedback.
• The exaggerated activity of the caudate, a region
  involved in linking action to outcome, may
  constitute an attempt at strategic rather than
  hedonic means of responding to reward stimuli.
• Researchers hypothesize that individuals with AN
  have an imbalance in information processing, with
  impaired ability to identify the emotional
  significance of a stimulus, but increased traffic
  in neurocircuits concerned with planning and
  consequences.
• Wagner A., Aizenstein H., Venkatraman V. ,Fudge
  J, (2007) Altered Reward Processing in Women
  recovered from Anorexia Nervosa. Am J Psychiatry
  2007 1641842-1849

21
Neuropsychiatric correlates of Eating Disorders

• Iowa gambling task AN vs CW Differences seen on
  fMRI
• AN Neuropsych testing difficulties with set
  shifting, flexibility
• AN Detail focus, to the point of missing global
  (Janet Treasure)
• AN vs BN
• Use in clinical practice

22
Dopamine function and motivation/behavior

• DA cell fires in response to salient
  environmental stimuli (rewarding, aversive,
  novel)
• DA encodes motivation and appropriate choices
• Part of apparatus that makes value judgments and
  makes correct decision in response to a stimuli
• Disturbances of brain DA - altered activity,
  reward, motivation

23
Iowa Gambling Task

• CW distinguished between wins and losses
• AN have similar response to wins and losses
• Perhaps overactive DA response to both Wins and
  Losses
• Difficulty discriminating positive and negative
  stimuli?
• Clinical implications
• AN may be unable to discriminate pleasurable and
  aversive stimuli
• May be very oversensitive to stimuli
• Cannot learn easily learn from experience
• May explain why it is difficult to use reward to
  motivate people with AN

24
Nancy Zuckers work on Social Cognition in AN

• Experimental Tasks
• 1) Rec ANs rated people as heavier than they
  are. Faces less attractive (like Autism)
• 2) Rec AN valued faces less than controls, valued
  heavy bodies less, valued thin bodies more.
• 3) Free viewing eye tracking AN spent less time
  on eyes and more time on the mouth (like autism)

25
Kate Tchanturias work on AN and Theory of Mind

• ANs were impaired on social cognitive tasks.
• Emotional theory of mind to know what someone
  else is feeling.
• ANs showed impairment in the ability to infer
  about another persons thoughts, beliefs, or
  intentions.
• Similarities to autism reduced empathy and
  increased ability to systematize

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Treatment Implications

• Practice social problem solving (process group)
• Assertiveness role plays
• Practice social problem solving in ambiguous
  social situations like friend making, dating etc.
• Practice decision making.
• Create social competence training for skill
  building (Autism research)

27
Brain Imaging in OCDSaxena 2003

• Structural (CT, MRI) variable findings
• Resting PET FDG
• OFC is involved in sensory integration, in
  representing the affective value of reinforcers,
  and in decision-making and expectation.2 In
  particular, the human OFC is thought to regulate
  planning behavior associated with sensitivity to
  reward and punishment.
• 5 of 9 studies elevated metabolism in OFC
• 3 found elevated activity in basal ganglia,
  thalamus
• PET FDG before/after SSRI, CBT, neurosurgery
• 8 of 10 pre to post-treatment studies decreases
  in OFC and/or caudate in responders to treatment
• Symptom provocation using PET, fMRI consistent
  increases in glucose metabolism or rCBF in OFC,
  caudate, anterior cingulate, thalamus
• Suggestion of dysfunction of OFC-subcortical
  circuits

28
Primary taste cortex (rostral insula) represent
taste (temperature, texture) of food in the mouth
that is independent of hunger, and thus of reward
value. Secondary regions (orbitofrontal cortex,
OFC) compute the hedonic value of foodRolls, 2005
29
Recovered AN Altered fMRI Response to food
challenge

• Pictures food anterior cingulate cortex and
  medial prefrontal (Uher 2003)-anxiety/stress
• Taste sugar and water insula, caudate-putamen,
  anterior cingulate (Wagner 2007)
• Taste sugar and artificial sweetener insula,
  caudate (Oberndorfer, Frank, in preparation)

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Psychopharm in EDs
31
Pharmacology for AN

• No drug has been FDA approved for AN
• No drug has shown major improvement in the
  starvation phase
• Meds tried and failed for appetite enhancement
  (typical antipsychotic, Li, THC derivatives)
• SSRIs generally not helpful in acute starvation,
  though some benefit on comorbid disorders

32
Pharmacology for AN Continued

• Prozac mixed data for rec-AN
• Atypical antipsychotic medications
• GI meds to aid physical symptoms
• BCP/hormones no evidence of benefit

33
Pharmacology for BN

• Serotonin re-uptake inhibitors
• ?SNRIs
• AEDs (topiramate, ?zonisamide)
• Antipsychotics
• Mood stabilizers
• reglan, H2 blockers
• ?? Stimulants (with caution)

34
BREAK
35
Medical Consequences of AN and BN
36
Physical Complications of Anorexia Nervosa
37
Physical Complications of Anorexia Nervosa, Cont.
38
Physical Complications of Anorexia Nervosa, Cont.
39
Physical Complications of Bulimia Nervosa
40
Physical Complications of Bulimia Nervosa, cont.
41
Amenorrhea and Osteopenia

• Most serious complication of prolonged amenorrhea
  is osteopenia, or reduced bone mass

42
Osteopenia and Osteoporosis

• Osteopenia refers to decreased quantity of
  normally mineralized bone
• Osteoporosis is clinical syndrome consisting of
  decreased bone mass, disruption in normal bone
  architecture with decreased bone strength,
  pathological fractures, pain and disability
• Osteoporosis defined as greater than 2.5 SD below
  the mean for young adult women
• Osteopenia 1-2.5 SD below young adult ref

43
Bone Density and Fractures

• Each SD decrease in bone density doubles the
  fracture risk
• DEXA is most widely used method for measuring
  bone density
• May be compared with age-matched children and
  adolescents (Z scores)

44
Bone Loss Treatment Strategies

• No therapies proven effective for bone loss in
  women with AN.
• Estrogen/BCPDecision on estrogen
  individualized, but no convincing data that
  estrogen alone increases bone density in AN
  population.May give false sense of security!
• Potential therapies under study
• IGF-I
• DHEA
• Testosterone
• Bisphosphonates

45
Osteoporosis Treatment

• Weight gain
• Calcium supplementation improves bone mass
  (1500-2000mg/day)
• Vitamin D
• Moderate weight-bearing exercise increases bone
  mass
• When medically stable, wt bearing exercises 3-4
  times per week

46
Medical/Psychiatric evaluation and treatment
strategies for Anorexia Nervosa

• Assess for comorbidity
• /- Serotonin reuptake inhibitors
• Atypical antipsychotics
• Reglan, h2 blockers
• Screening labs electrolytes, Ca, Mg, Phos,
  BUN/Cr, CBC, LFTs, TFTs, UA, hematology
• Bone densomitry (DEXA)
• ECG
•  

47
Medical evaluation for Bulimia Nervosa

• Assess for comorbidity
• Screening labs electrolytes, Ca, Mg, Phos,
  BUN/Cr, CBC, LFTs, TFTs, UA, hematology
• Dexa
• ECG
• Dental
•  
•  

48
AN Hospital vs Outpatient TreatmentFrom
American Psychiatric Association Guidelines for
the Treatment of Eating Disorders
49
Referral to Higher level of care

• Pt is failing lower level.
• Pts weight loss is continuing in spite of
  treatment
• Pt is unable to stop bingeing/purging.
• Pts physical symptoms warrant greater
  supervision (fainting, dehydration, heart
  palpitations)
• Pt is resisting current level of care

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REFEEDING COMPLICATIONS

• Normal food
• Peripheral edema
• Bloating or discomfort
• Reflux
• Rare gastric dilitation
• Nasogastric feeding
• Seldom indicated
• Nasal, esophageal erosion
• Central hyperalimentation
• Rarely indicated
• Pneumothorax, infection, metabolic disturbances

51
Eating behavior in AN After weight restoration

• Hypermetabolic even after weight restoration
• RAN need 50 to 60 kcal/kg/day
• BAN need 40 to 50 kcal/kg/day
• 50 kg women 2000 to 3000 kcal/day
• Probably normalizes in long term
• Probable contribution to high rate of relapse
• Degree of osteopenia depends on age of onset and
  duration of amenorrhea
• Adolescence is critical time for bone mass
  acquisition
• Approx 60 of peak bone mass is accrued during
  adolescence
• Little net gain in bone mass after 2 yrs
  post-menarche
• Peak bone mass achieved by end of second decade
• Stereotypic food choices, ritualized eating,
  calorie counting
• Delusionary quality
• Nothing else is more important

52
Methods of Treatment

• Regular Weight restoration
• 2 to 3 lbs/wk inpatient
• 1 to 2 lbs/wk day-hospital
• 1 lb/wk outpatient
• Nutritional Teaching
• Provide patient support
• Prevention from vitamin and mineral deficiency
• Prevention of osteoporosis
• Aim for high Ca intake
• Vitamin D to aid in Ca absorption vegetarians
  may need supplements
• Eat iron-containing foods, especially important
  for vegetarians

53
lunch
54
Countertransference Issues

• Feeling angry at the patient for not recovering
• Thinking this is willful behavior
• Blaming the parents
• Feeling incompetent
• Giving up hope for the patient
• Not taking the disorder seriously

55
Coping with Countertransference Issues

• Practice patient acceptance The average recovery
  rate is 7 years.
• Have compassion for the suffering
• of the patient.
• See their behavior as part of the disorder, not
  personal toward you.
• Practice good self-care.

56
Important tips for physicians when talking to
patients with EDs

• Terry Schwartz MD

57
Live Demo
58
Process live demo
59
Obesity/BED
60
Binge Eating Disorder

• Recurrent episodes of binge eating (see BN)
• The binge eating episodes are associated with
  three (or more) of the following
• Eating much more rapidly than normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not feeling
  physically hungry
• Eating alone because of being embarrassed by how
  much one is eating
• Feeling disgusted with oneself, depressed, or
  very guilty after overeating
• Marked distress regarding binge eating is present
• 2 days/week for 6 months

61
Obesity

• BMI gt 30
• 32.2 of American adults, increasing in children
• Increasing in past 30 years by 50 per decade
• Major successful treatment advances in treatment
  of complications of obesity, but minimal success
  in treatments for obesity itself

62
Is Obesity a psychiatric disorder (BED)?

• Medical/Metabolic issues
• Am J Psych 2007 Issues for DSM V Should
  obesity be included as a brain Disorder
• Major limitation to treatment of obesity is long
  term behavioral compliance
• Diets major cause of ED, including BED (recall
  starvation study)
• Individual biological risks genetic/heritability

63
BED and Neurochemistry

• Serotonin, endogenous opiates, cannabinoids
• Certain foods impact nucleus accombens DA,
  opiate
• Neuropsych similar to addicts ie follow immed
  reward over long term results during gambling
  type tasks (with excitable reward)

64
Food for affect regulation

• Neurochemical stimulation
• Anxiety, depression, anger, boredom, agitation
  etc
• Endogenous response to food (or starvation) may
  predispose to AN or BED/BN

65
Literature Review Treatment for BED

• International J of EDs May 2007
• 26 studies reviewed Med plus BWL, meds alone,
  BWL alone
• Meds plus BWL best, short term

66
Psychosocial treatments

• CBT
• CBT plus BWL
• BWL alone
• Group therapy
• Indiv therapy
• 12 step/self help

67
Medical treatments for BED/obesity

• No magic pill!
• Sibutramine
• Orlastat
• Acomplia
• Phentermine
• Gastric Bipass
• Stimulants

68
Medical treatments for BED/obesity continued

• No magic pill!
• ? SSRIs, SNRIs
• ?Wellbutrin
• ? Topiramate
• ? Zonisamide

69
What about psych meds and weight gain

• Need to know and be truthful with ED patients!
• SSRIs
• SNRIs
• Atypical Antipsychotic Medications
• Typical Antipsychotic Medications
• Mood Stabilizers
• TCAs, MAOIs

70
BREAK
71
Eating Disorders in special populations

• Children
• Teens
• Males

72
ED IN KIDS TEENS
73
What about the kids?

• Pre-pubertal Eating Disorder
• Childhood Onset Eating Disorder
• Early Onset Eating Disorder

74
What Are We NOT Talking About?

• DSM-IV Feeding and Eating Disorders of Infancy or
  Early Childhood
• Pica
• Rumination Disorder
• Feeding disorder of infancy or childhood

75
Anorexia NervosaDSM-IV

• Refusal to maintain body weight above a minimally
  normal weight for age and height. lt85 of IBW
• Intense fear of gaining weight or becoming fat
• Disturbance in the way ones body weight or shape
  is experienced
• Amenorrhea absence of at least three consecutive
  menstrual cycles

76
Weight Loss vs Weight Maintenance

• DSM-IV criteria excludes children who have not
  reached the critical level of lt85
• Failure to gain appropriate weight with growth
• Malnutrition can lead to poor growth

77
Body Image

• May be more tricky to assess
• How can it be evaluated?
• Childrens expression of body image
• Standard tools
• Clinical Interview
• Somatic symptoms
• Abdominal pain or discomfort
• Feeling of fullness
• Nausea
• Loss of appetite

78
Amenorrhea

• Primary vs Secondary
• Pubertal delay
• Evaluation may include pelvic ultrasound
• Height
• Weight
• Weight/height ratio
• Ovarian volume
• Uterine volume
• Conventional target weight and weight/height may
  be too low to ensure ovarian and uterine maturity

79
Alternative Criteria for ED in Children
Byant-Waugh and Lask 1995

• Alternative classification for the range of
  eating disorders of childhood
• Excessive preoccupation with weight or shape
  and/or food intake which is accompanied by
  grossly inadequate, irregular or chaotic food
  intake

80
Byant-Waugh and Lask 1995 Criteria for Anorexia
Nervosa

• Failure to make appropriate weight gains, or
  significant weight loss
• Determined weight loss (e.g., food avoidance,
  self-induced vomiting, excessive exercising,
  abuse of laxatives).
• Abnormal cognitions regarding weight and/or
  shape.
• Morbid preoccupation with weight and/or shape.

81
Related ED Behaviors in Children

• Anorexia nervosa
• Food avoidant emotional disorder
• Selective eating
• Functional dysphagia
• Bulimia nervosa
• Pervasive refusal syndrome

82
Early behavioral risk factors for EDs

• PICA BN
• Picky Eater BN, some AN
• Digestive problems AN
• Subsyndromal symptoms of EDs can predate

83
Incidence and Demographics

• Anorexia in this age range is considered to be
  rare, but appears to be increasing
• Males may constitute a higher proportion of cases
  in childhood as opposed to in adolescence or
  adulthood
• 19-30 of childhood cases
• 5-10 of adolescent or adult cases

84
WHY?
85
Biological

• Genetics
• Higher rate of AN, BN and ED NOS in first degree
  relatives
• Cross-transmitted
• High heritability
• Medication
• Trials suggest serotonin and dopamine systems
  contribute

• Imaging
• Gordon et al, 1997
• 15 girls ages 8-16 with AN
• Regional cerebral blood blow radioisotope scans
• 13/15 had unilateral temporal lobe hypoperfusion
• Lask et al, 2005
• significant association between unilateral
  reduction of blood flow in the temporal region
  and
• impaired visuospatial ability,
• impaired visual memory
• enhanced speed of information processing

86
Psychological

• Personality traits
• Anxious
• Obsessional
• Perfectionistic
• Susceptibility factors
• Obsessions
• Perfectionism
• Symmetry
• Exactness
• Negative affect, harm avoidance
• Preoccupations with weight, body image and food

87
SOCIAL
88
Prognosis

• Long term follow up of patients with early onset
  anorexia nervosa (Bryant-Waugh et al, 1987)
• 30 children with anorexia nervosa followed for
  mean duration of 7.2 years
• Mean age at onset 11.7 years
• 19/30 (60) with a good outcome
• 10/30 remained moderately to severely impaired
• Poor prognostic factors included
• Early age at onset (lt11 years)
• Depression during the illness
• Disturbed family life and one parent families
• Families in which one or both parents had been
  married before

89
Treatment Challenges (especially for the very
young)

• Very little data or literature on treatment
• Few inpatient or outpatient programs for kids
  under 12 or 13 years old
• Only 1 we are aware of.
• Little data or clinical experience
• Family Therapy

90
Family therapy

• Maudsley Family Therapy
• Systemic Family Therapy

91
Family Therapy

• Required with Adolescents
• Maudsley Family Therapy
• Systemic Family Therapy
• Couples
• Family involvement to motivate pt for treatment
  (case example)

92
Systemic Family Therapy

• Underlying belief if you fix the system, the
  symptom will no longer be needed.
• The eating disorder is serving a function in the
  family.
• The symptom bearer is trying to help the family
  (unconsciously).

93
Methods for Systemic Family Therapy

• Circular questioning
• Therapist is curious observer, not expert.
• Discuss communication patterns within the family.
• Involve all family members in the discussion,
  even small children.
• Do not pathologize family or symptom bearer.

94
Maudsley Family Therapy

• Behavioral Family Therapy

95
Maudsley Family Therapy

• Agnostic toward etiology
• Involves parents, rather than a parent-ectomy
• Food is medicine
• Initial focus on symptoms
• Parents are responsible for weight restoration.
• Non-authoritarian therapist stance
• Separation of child from illness

96
Maudsley Family Therapy

• Phase I (sessions 1 - 10) Weight restoration,
  re-feeding focus.
• Phase II (sessions 11 - 16) Transfer control
  back to adolescent gradually.
• Phase III (sessions 17 - 20) Focus on adolescent
  developmental issues, termination.

97
Maudsley Family Therapy

• Session 1 Funeral session
• Goals engage the family, obtain history of how
  AN came to be, find out how AN has affected each
  family member, assess family functioning, reduce
  blame, raise anxiety concerning AN.
• Interventions Greet family in sincere but grave
  manner, externalize the AN, orchestrate intense
  scene, charge parents with the task of re-feeding.

98
Session 2 Family Meal

• Instructions to parents bring a meal that would
  be appropriate for your childs nutritional
  needs.
• Goals assess family structure as it may affect
  ability of parents to re-feed patient, provide an
  opportunity for parents to successfully feed
  patient, assess family process during meal.
• Interventions bring the symptom alive and
  present in the room, one more bite, align patient
  with siblings for support.

99
Males and EDS
100
Males and EDs

• Less common than in females, but increasing
  (approx 10 of EDS occur in men)
• They have a job or profession that demands
  thinness. Male models, actors.
• Cultural pressures to be V shaped

101
Males and EDS

• More in common with female EDs than differences
• Lower testosterone may predispose to ED
• Fears regarding sexuality
• More common in homosexual men
• Conflict over sexual identity
• Avoidant, passive, negative reactions from peers
  as children

102
Males and EDs

• Athletes/profession with weight requirements
• 110 male to female ratio
• BED similar rates male/female, though women more
  distressed about it, more guilt

103
Males and EDs

• They were fat or overweight as children
  (different than females).
• They have been dieting. Dieting is one of the
  most powerful eating disorder triggers for both
  males and females.

104
Males and EDs

• They participate in a sport that demands
  thinness. Runners and jockeys are at higher risk
  than football players and weight lifters.
• Wrestlers who try to shed pounds quickly before a
  match so they can compete in a lower weight.
• Body builders are at risk if they deplete body
  fat and fluid reserves to achieve high definition

105
Special Assessment and Treatment Strategies for
Chronic AN

• Problems accumulate, may become irreversible
  after as early as 6 mos
• Poor Prognosis
• Risk benefit assessment of ED
• Harm reduction

106
Treatment issues in Chronic EDs

• Legal aspects
• Case examples

107
Q and A, discussion