Course and outcome in adolescent anorexia nervosa

Comorbidity between eating disorders and anxiety disorders: a review

OBJECTIVE

We conducted a critical literature review on studies assessing the prevalence of anxiety disorders (AD) in subjects with eating disorders (ED) (anorexia nervosa and bulimia nervosa). In the first part, we discuss methodological issues relevant to comorbidity studies between ED and AD. In the second part, taking into account these methodological considerations raised, we summarize the findings of these studies.

METHOD

We performed a manual and computerized search (Medline) for all published studies on comorbidity between ED and AD, limiting our search from 1985-2001 to get sufficiently homogeneous diagnostic criteria for both categories of disorders.

RESULTS

Too few studies include control groups and few studies have compared diagnostic subgroups of ED subjects, with scarce or conflicting results.

DISCUSSION

We discuss the results taking into account the methodological problems observed. We give guidelines for reviewing the results of published studies and planing future research.

Changes in Bone Turnover in Patients with Anorexia Nervosa during Eleven Weeks of Inpatient Dietary Treatment

Background: Many adolescents with anorexia nervosa suffer from severe osteopenia and osteoporosis. We hypothesized that individualized nutrition therapy may improve bone turnover in anorectic patients.

Methods: We studied 19 female patients [mean age, 14.2 ± 1.4 years; mean body weight, 39.3 ± 5.4 kg; mean body mass index (BMI), 14.2 ± 1.4 kg/m2] with anorexia nervosa (International Classification of Diseases-10: F50.0, F50.1) for a period of 3 months. Nutrition therapy began at the end of the first week and included individualized hypercaloric diets, high calcium intake (2000 mg/day), and administration of vitamin D (400 IU/day). Blood samples were taken at baseline and again in weeks 3, 7, and 11. We measured serum calcium, parathyroid hormone, bone formation and resorption markers, insulin-like growth factor 1 (IGF-1), and leptin.

Results: Mean BMI increased significantly, from 14.2 ± 1.4 to 17.1 ± 0.7 kg/m2 (P = 0.000001), during the course of treatment, whereas serum total calcium and phosphate concentrations remained unchanged. The bone formation markers procollagen-I carboxy-terminal propeptide and bone alkaline phosphatase almost doubled (P = 0.006). Both IGF-1 (P = 0.00001) and leptin (P = 0.000005) increased significantly by week 11. Parallel to this, the serum concentration of C-telopeptide, a bone resorption marker, decreased significantly (P = 0.009).

Conclusions: Nutritional rehabilitation, possibly as a result of increasing IGF-1 and leptin concentrations, may increase bone formation. It therefore provides additional objective evidence of the importance of nutrition for bone.

Outcome in adolescent anorexia nervosa

The present paper compares course and outcome of adolescent anorexia nervosa to that of adult onset forms. In recent studies earlier onset of anorexia nervosa was associated with higher recovery rates and a lower mortality, although even in adolescent patients anorexia nervosa takes a prolonged course. A chronic eating disorder bears a high risk of other comorbid psychiatric or personality disorders. The most prevalent disturbances were anxiety and affective disorders and anxious-fearful-obsessive personality disorders, respectively. Patients who substantially overcame their eating disorder did not differ from normal controls in respect to psychosocial functioning, e.g. family relationships, partnership and occupational status. These results should encourage us to treat the eating disorder vigorously.

Nonresponder anorectic patients after 6 months of multimodal treatment: predictors of outcome

Currently the therapy of anorexia nervosa is a relevant clinical problem. The percentage of patients who respond to short-term pharmacotherapy and psychotherapy is still low and the condition often leads to chronic pathology or death. The present study aims to determine outcome predictors beyond personality traits, eating psychopathology, or particular clinical features. Forty patients with restricter type anorexia nervosa were tested, at T0 and after 180 days, with psychometric tests and clinical evaluation instruments. Patients were then divided into two groups. One group included patients who showed relevant clinical improvement; the other included not-yet-improved patients. A lower Novelty Seeking, higher levels of Ascetism and Maturity Fears characterised the not-yet-improved group. Correlation showed evidence of diverse bonds between personality and psychopathology in the improved and not-yet-improved groups. The psychopathology of non-yet-improved patients seemed to be more linked to their temperamental features, whereas improved patients seemed to be more influenced by their character. Different levels of psychological functioning can be expressed. The present data suggest focusing pharmacotherapy and psychotherapy, even family counseling, with a progression more strictly related to the current personality functioning level and psychopathology of each patient.

Outcome predictors in anorectic patients after 6 months of multimodal treatment

BACKGROUND

Anorexia nervosa is a severe disorder that often responds poorly to treatment. At this time, little is known about pretreatment predictors of response.

METHODS

A sample of 42 restrictor type anorectics was tested at the assessment phase and after 180 days retested using the Temperament and Character Inventory and Eating Disorder Inventory 2 along with other clinical evaluation instruments. After 180 days of treatment with multimodal 'network' therapy, the patients were divided into two groups. The first group included patients who showed relevant clinical improvement; the second group included patients considered 'not yet responding'. Data collected from the not-yet-responding group were compared by the t test with the other group's data to evaluate prognostic indexes.

RESULTS

Diagnosis of personality disorder, which afflicted about 50% of patients, seemed not to be a relevant prognostic factor. However, a lower novelty seeking was characteristic of the nonresponder group. Higher levels of asceticism and maturity fears also characterized the nonresponder group.

CONCLUSION

Present data suggest some elements that could be useful to focus pharmacotherapy, psychotherapy and family counseling on the current psychopathology of each patient.

Unterschiede zwischen jugendlichen Patientinnen mit Anorexia und Bulimia nervosa im Hinblick auf psychologische und psychosoziale Merkmale

Zusammenfassung: Fragestellung: Die Studie widmet sich der Frage, inwieweit sich jugendliche Patientinnen mit Anorexia und Bulimia nervosa in psychologischen Merkmalen und Lebensverhältnissen unterscheiden. Methode: Die Krankengeschichten von 140 Patientinnen (110 mit Anorexia nervosa und 30 mit Bulimia nervosa), die in den Jahren 1982 bis 1992 in der Klinik für Kinder- und Jugendpsychiatrie der Universität Würzburg stationär behandelt wurden, wurden im Rahmen einer retrospektiven Studie ausgewertet. Alle Patientinnen erfüllen die Kriterien nach ICD-10 für Anorexia- oder Bulimia nervosa. Daten aus der Basis-Dokumentation und aus der multiaxialen Klassifikation (MAS) wurden herangezogen, standardisierte Verfahren wie der Anis-32, MMPI, BDI, HAWIK-R und HAWIE kamen zur Auswertung. Die Ergebnisse zeigen signifikante Unterschiede zwischen den beiden Stichproben. Das häufigste Alter bei erster stationärer Aufnahme war bei anorektischen Patientinnen 14,5 und bei bulimischen Patientinnen 16,5 Jahre. Die störungsspezifischen Symptome betreffend unterschieden sich die beiden Stichproben hinsichtlich ihres Essverhaltens im Faktor Bulimie des Anis-32. Beim Vergleich der Persönlichkeitsmerkmale beschrieben sich die anorektischen Patientinnen im MMPI weniger psychopathisch als die Bulimia nervosa Patientinnen. Im BDI war die depressive Symptomatik bei Anorexia nervosa als klinisch relevant einzustufen. Andere Charakteristika der anorektischen Patientinnen waren ein überdurchschnittlicher IQ, Überfürsorglichkeit innerhalb der familiären Beziehungen, vermehrte Trennungsängste und Kontaktstörungen in der Schule. Im Vergleich dazu zeigten die bulimischen Patientinnen häufiger Leistungs- und Disziplinierungsschwierigkeiten in der Schule, innerhalb der Familie wurde das Kontaktverhalten und die Kommunikation beeinträchtigter als bei Familien anorektischer Patientinnen erlebt.

Persönlichkeitsstörungen und psychiatrische Morbidität im Verlauf der adoleszenten Anorexia nervosa

Zusammenfassung: Fragestellung: Es war das Ziel der vorliegenden prospektiven Studie, den Verlauf der Essstörungssymptomatik und die psychiatrische (Ko-)Morbidität einschließlich der Persönlichkeitsstörungen bei jugendlichen Patienten, die die DSM-III-R-Kriterien für Anorexia nervosa erfüllten, in regelmäßigen Zeitabständen zu untersuchen. Zehn Jahre nach Entlassung konnten alle 39 Patienten (100%) sowie eine in Bezug auf Alter, Geschlecht und beruflichen Status parallelisierte Kontrollgruppe persönlich nachuntersucht werden.Methodik: Zur Erfassung der Essstörungssymptomatik wurde das Standardisierte Interview für Anorexia und Bulimia nervosa verwandt, das Composite International Diagnostic Interview für die Diagnostik der psychiatrischen (Ko-)Morbidität und das Strukturierte Klinische Interview für Persönlichkeitsstörungen. Ergebnisse: Im Vergleich zu der Kontrollgruppe litten zum Nachuntersuchungszeitpunkt signifikant mehr Patienten an einer psychiatrischen Störung, vorwiegend an einer Angststörung, affektiven Erkrankung oder Drogen- bzw. Alkoholabusus. Bei annähernd einem Viertel der Patienten wurden Persönlichkeitsstörungen, vorwiegend aus dem ängstlich-vermeidenden Formenkreis des DSM-III-R diagnostiziert.Schlussfolgerungen: Unsere Befunde weisen darauf hin, dass die Anorexia nervosa keine auf die Pubertät beschränkte, entwicklungsbedingte Erkrankung ist, sondern sowohl im Querschnitt als auch im Längsschnitt mit anderen psychiatrischen Erkrankungen assoziiert ist.

Reduced body fat in long-term followed-up female patients with anorexia nervosa

We aimed to evaluate both body composition and serum leptin levels in females with a past history of anorexia nervosa (AN) adjusted for their current body mass index (BMI). Twenty-three females with a past history of AN were followed-up 10 years after inpatient treatment and compared to 23 female controls of a similar age range matched for BMI on a one to one basis. Serum leptin levels were assessed and percent body fat (%BF) was determined via bioelectric impedance analysis. Differences of both %BF and leptin levels between cases and controls were tested under the hypothesis that cases have lower %BF and lower serum leptin levels than the controls. %BF was indeed lower in the cases compared to the controls (p < 0.05). However, differences in leptin levels between both groups just failed significance (p = 0.051). We conclude that body composition differs between long-term followed-up patients with AN and BMI- and gender-matched controls. Based on the finding that the former patients reported being more physically active, we assume that the higher physical activity levels in recovered patients with AN underlie the lower %BF.

Six-year course and outcome of anorexia nervosa

OBJECTIVE

Since there are discrepant findings in the literature, we studied the longer-term course in a large sample of 103 DSM-IV anorexia nervosa (AN) patients.

METHOD

Assessments were made at four points of time: beginning of therapy, end of therapy, 2-year follow-up, and 6-year follow-up. Self-rating scales as well as expert-rating interview data were used. Eating disorder-specific and general psychopathology were assessed. These data were also compared with data on the 6-year course of patients with bulimia nervosa and binge eating disorder, respectively, who were treated at the same institution at about the same time.

RESULTS

The participation rate at the two follow-ups was high (97.9% of those alive). The general pattern of results over time of those alive at 6-year follow-up was as follows: substantial improvement during therapy, moderate (in many instances nonsignificant) decline during the first 2 years posttreatment, and further improvement from 3 to 6 years posttreatment. At the time of the 6-year follow-up, 26.8% had AN, 9. 9% had bulimia nervosa-purging type (BN-P), 2.0% were classified as eating disorder not otherwise specified (ED-NOS), all diagnosed according to DSM-IV criteria; more than one half (55.4%) showed no major DSM-IV eating disorder. Based on an operationalized global outcome score at 6-year follow-up, 34.7% had a good outcome, 38.6% an intermediate outcome, 20.8% a poor outcome, and 6 of 101 persons (5.9%) were deceased. Body mass index was 17.9 +/- 2.8 at the 6-year follow-up; amenorrhea was still found in 23.9%.

DISCUSSION

In comparison to samples with bulimia nervosa or binge eating disorder, the 6-year course of anorexia nervosa was less favorable. Mortality was rather high and symptomatic recovery protracted; predictors of unfavorable 6-year course were the presence of binges during 4 weeks before index treatment, psychiatric comorbidity, and low body weight at discharge from index treatment.

Interrater reliability of a Danish version of the Morgan Russell scale for assessment of anorexia nervosa

OBJECTIVE

To study the interrater reliability of a Danish version of the Morgan Russell scale for assessment of patients with anorexia nervosa, and subsequently to clarify the existing rating instructions.

METHOD

Ten patients undergoing treatment for anorexia nervosa at a regional center participated and had their interview videotaped. Two interviews were reserved for a training phase only. The group of raters comprised eight clinicians, and measures of interrater reliability were computed using intraclass correlation coefficient (ICC).

RESULTS

The ICC for the total score was good (0.79), while reliability for the single items varied from poor to excellent (0.14-0.99). Internal consistency as expressed by Cronbach's coefficient alpha was acceptable (0.74).

DISCUSSION

The Morgan Russell scale stands out as an easily applied and reliable measure of severity of anorexia nervosa, though the rating instructions need clarification in some items.

Long-term course of anorexia nervosa: response, relapse, remission, and recovery

There is no predictable or normative long-term course associated with anorexia nervosa. Some Individuals achieve complete recovery; others are ravaged by a chronic disorder; and some die from it. Predicting course and outcome of anorexia nervosa is complicated by the intrinsic complexity of the disorder; a lack of shared terminology in studying the disorder; and a paucity of controlled clinical treatment studies. This manuscript provides a review of the current state of knowledge based on the long-term studies and discusses ways in which methodological issues limit our ability to generalize more confidently regarding the course and outcome of anorexia nervosa. In order to advance the field, we need to bridge the gap between treatment outcome studies and naturalistic follow-up studies. Further we need to devine more carefully and consistently the milestones of initial treatment response, relapse, remission, and recovery. Building on previous works, criteria for each of these terms are proposed. Based on existing studies, a discussion of treatment outcome and prognostic factors is provided. Finally, clinical recommendations are provided for the clinician who is responsible for the long-term care of an individual with anorexia nervosa.

Obesity, psychopathology and eating attitudes: are they related?

The aim of this study was to verify the link between psychopathological disorders and eating attitude in a clinical sample of 195 female obese subjects. A battery of psychological tests, including the Italian versions of the MMPI2, ASQ and EAT scales were administered to all the patients. We analyzed the link between psychopathological traits and eating attitudes by using both Multiple Regression analysis and non-parametric Segmentation Modeling. The results showed that psychopathological aspects, and depression in particular, are strongly linked to the eating attitude of clinically obese subjects. This is an important result also for therapeutic purposes, as it highlights the need for psychological support in diet therapy to intervene on the psychological perceptions and experiences of the patient.

Binge/purge symptoms and comorbidity in adolescents with eating disorders

OBJECTIVE

To identify the diagnostic subtypes of eating disorders (EDs), the psychiatric comorbid diagnoses, and associated specific and nonspecific psychopathology in a series of 120 adolescents undergoing standardized assessment for an ED.

METHOD

Consecutive patients referred to our large pediatric hospital for ED assessment completed a semistructured diagnostic interview for children and adolescents. The following self-report scales were administered to assess specific and nonspecific psychopathology: the Children's Depression Inventory (CDI), the Brief Symptom Inventory (BSI), the Eating Disorder Inventory 2 (EDI-2), and the Family Assessment Measure (FAM-III) of family functioning.

RESULTS

Female subjects with a mean age of 14.5 years and a mean body mass index (BMI) of 18.1 comprised 93% of the sample. The restrictive subtypes of anorexia nervosa (AN) (43%) and eating disorder not otherwise specified (EDNOS) (16%) were the most common diagnoses. Patients with restricting symptoms (R) could be grouped together because they were more similar to each other with respect to self-report symptoms of psychopathology than they were to patients with binge/purge (B/P) symptoms and vice versa. Patients with R endorsed significantly fewer subjective symptoms, both ED-specific and nonspecific, and rated their families functioning better than did B/P patients. Comorbid, current major depressive disorders and dysthymic disorders occurred in 66% of subjects, but depressive, dysthymic, and oppositional disorders occurred in 96% of those with B/P symptoms. Severity of the CDI was the best single discriminator between R and B/P subjects.

CONCLUSIONS

Adolescents with EDs in the early stage of their illness are similar to adults with EDs in the following ways: they meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for subtypes of EDs (excluding amenorrhea) and commonly have comorbid psychiatric disorders, especially depressive disorders. Patients with B/P symptoms can be distinguished from restricting subjects because they endorse significantly more ED-specific and nonspecific psychopathology and have a higher frequency of comorbid Axis I diagnoses (especially depressive disorders) than restricting patients. Oppositional defiant disorder (ODD) occurs more commonly in adolescents with EDs associated with B/P symptoms.

Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past 10 years

OBJECTIVE

To critically review the research in juvenile anorexia nervosa and bulimia nervosa over the past 10 years and highlight recent advances in normal development as it pertains to these disorders and their diagnosis, prevention, and treatment.

METHOD

Computerized search methods were combined with manual searches of the literature. A detailed review of the most salient articles is provided. Preference was given to studies involving children and adolescents that approached the subject from a developmental perspective.

RESULTS

The information from these studies is presented in a developmental framework. Research in eating disorders has progressed, but definitive longitudinal data are still absent from the literature. Research specific to treatment of child and adolescent eating disorders remains rare.

CONCLUSIONS

Data approaching eating disorders from a developmental perspective are available in only a few studies. Research is needed addressing normative data on the development of eating behavior and specific risk and resilience factors for pathology in specific developmental periods. Especially lacking are studies regarding the continuities and discontinuities of eating disturbances across the life span. Best documented are epidemiological studies of prevalence and incidence, long-term outcome in anorexia nervosa, and short-term treatment response in bulimia.