In search of predictors of dropout from inpatient treatment for anorexia nervosa

Self-image and treatment drop-out in eating disorders

INTRODUCTION

Drop-out from treatment is a serious problem in eating disorders which remains poorly understood. The present study investigated whether self-image and interpersonal theory could help to explain why eating disorder patients drop out of treatment.

METHOD

Intake data on eating disorder patients who terminated treatment prematurely (N=54) were compared with patients who had completed treatment (N=54) and those who were still in treatment after 12 months (N=54). Self-image was assessed using the structural analysis of social behaviour (SASB), and comparisons were made on demographic and clinical variables.

RESULTS

Patients who dropped out had initially presented with less negative self-image and fewer psychological problems compared with remainers. Low levels of SASB self-blame discriminated drop-outs from completers and remainers and significantly predicted treatment drop-out.

DISCUSSION

Drop-out in eating disorders appears to be a complex phenomenon, not necessarily as pathological as often assumed. There may be important differences in the treatment goals of drop-outs and therapists; patients who drop out may be choosing to disengage at a time when symptom improvement creates space for closer examination of interpersonal issues.

Treatment perception in adolescent onset anorexia nervosa: retrospective views of patients and parents

OBJECTIVE

To investigate perception of treatment in former patients with anorexia nervosa (AN) and their parents, and to determine whether this was related to outcome and treatment characteristics. Client satisfaction is important for treatment engagement and adherence.

METHOD

Forty-six (of 55) girls with adolescent onset AN, 33 mothers and 26 fathers participated in a follow-up study conducted 8.8 (SD 3.3) years after start of treatment. The former patients were assessed using diagnostic interviews. Only nine participants (19%) had an eating disorder (ED) at follow-up. Perception of treatment was assessed by questionnaires.

RESULTS

Parents reported having an overall positive perception of treatment. However, reports from former patients were significantly more negative than from the parents. In former patients, the "perception of therapists" total score and the items "therapists' knowledge of ED" and "usefulness of pediatric inpatient treatment" correlated with ED symptoms at follow-up. The perception of therapists' scores of the parents were not associated with the ED outcome of their daughters. More family therapy sessions were associated with the former patients' satisfaction with the therapists, while higher age at admission was associated with their mothers' satisfaction.

CONCLUSION

In spite of good ED outcome, former patients were only moderately satisfied with their treatment, whereas parental satisfaction was high.

Are obsessive-compulsive personality traits associated with a poor outcome in anorexia nervosa? A systematic review of randomized controlled trials and naturalistic outcome studies

OBJECTIVE

Obsessive-compulsive personality disorder (OCPD) traits are commonly associated with anorexia nervosa (AN). The aim of this review was to systematically search the literature to examine whether OCPD traits have an impact on the outcome of AN.

METHOD

A systematic electronic search of the literature (using Medline, PsycINFO, and the Cochrane Central Register of Controlled Trials) was undertaken to identify relevant publications (randomized controlled trials (RCT's) and naturalistic studies), until February 2006.

RESULTS

Eleven prospective longitudinal studies and 12 RCT's met criteria for inclusion. A meta-analysis was not feasible as the studies were too heterogeneous. Just over half of published longitudinal studies found that OCPD traits were associated with a negative outcome in AN. Additionally, results from three RCTs suggested that these traits may moderate outcome. OCPD traits were reduced after treatment in five RCTs.

CONCLUSION

There is tentative support to suggest that individuals with AN and concomitant OCPD traits have a poorer prognosis, and that these traits moderate outcome. A reduction in these traits may mediate this change. An individualized case formulation with treatment tailored to OCPD traits may improve the outcome of AN.

Drop-out rate in eating disorders: could it be a function of patient-therapist relationship?

OBJECTIVE

The factors influencing drop-out in eating disorders (ED) are still unclear. The aim of the present study was to determine whether compliance is strongly related to the patient-therapist relationship.

MATERIALS AND METHODS

During 14 months all new patients affected by EDs referring to our Specialist Service Center, were assessed and followed up, they underwent EAT 40, EDI II, and computerized case history for ED. Moreover, we collected data from therapist using the GCI scale, and we recorded as the patient perceived his weight (PPW).

RESULTS

We found that out of the 100 patients enrolled, 53 withdraw and when probability was predicted according to a digit model, it was not influenced by EDI-II subscales, age, sex, education, EAT-40 score, duration of the disorder and diagnosis while it significantly decreased when GCI scores increased and decreased when the PPW was altered.

CONCLUSION

These results seem to confirm that some psychological factors related to patient-therapist relationship can play a key role for a stable and continuous therapeutic program.

Psychopathological features of anorectic patients who dropped out of inpatient treatment as assessed by the Minnesota multiphasic personality inventory

Background

Anorexia nervosa often requires inpatient treatment that includes psychotherapeutic intervention in addition to physical and nutritional management for severe low body weight. However, such patients sometimes terminate inpatient treatment prematurely because of resistance to treatment, poor motivation for treatment, unstable emotions, and problematic behaviors. In this study, the psychopathological factors related to the personality of anorexic patients that might predict discontinuation of inpatient treatment were investigated using the Minnesota Multiphasic Personality Inventory (MMPI).

Methods

Subjects were 75 consecutive anorectic inpatients who received cognitive behavioral therapy with a behavior protocol governing privileges in a university hospital based general (not psychiatric) ward. The MMPI was done on admission for all patients. A comparison was done of patients who completed the process of inpatient treatment, including attainment of target body weight (completers), and patients who dropped out of inpatient treatment (dropouts). Results: No significant differences between completers (n = 51) and dropouts (n = 24) were found in the type of eating disorder, age of onset, duration of illness, age, or BMI at admission. Logistic regression analysis found the MMPI scales schizophrenia (Sc), hypomania (HYP), deviant thinking and experience, and antisocial attitude to be factors predicting completion or dropout.

Conclusion

Dropouts have difficulty adapting to inpatient treatment protocols such as our behavior protocol governing privileges because they have social and emotional alienation, a lack of ego mastery (Sc), emotional instability (HYP) and an antisocial attitude. As a result, they have decreased motivation for treatment, leave the hospital without permission, attempt suicide, or shoplift, which leads them to terminate inpatient treatment prematurely. Treatments based on cognitive behavioral therapy with a behavior protocol governing privileges should be carefully adopted for anorectic patients who exhibit the psychopathological elements identified in this study.

Predictors of weight maintenance after hospital discharge in adolescent anorexia nervosa

OBJECTIVE

To analyze variables that predict weight maintenance in adolescent anorexia nervosa.

METHOD

The Eating Attitudes Test, the Beck Depression Inventory, the Leyton Obsessional Inventory, the State and Trait Anxiety Inventory, and the Anorexia Nervosa Stages of Change Questionnaire were administered to 49 anorexia nervosa patients (mean age 14.3 years, SD 1.7) consecutively admitted to an eating disorder unit. They were evaluated at admission, at discharge, and after nine months follow-up.

RESULTS

At discharge, patients had improved in body mass index (p < .001), eating attitudes (p = .002), depressive symptomatology (p = .001), and motivation to change (p < .001). Patients with good weight maintenance at follow-up had higher body mass index (p = .017) at admission, lower abnormal eating attitudes (p = .035), depressive symptomatology (p = .026), and higher motivation to change (p = .004) at discharge. Logistic regression analysis showed a high motivation to change at discharge and a high body mass index at admission to be predictors of weight maintenance.

CONCLUSION

High motivation to change, low abnormal eating attitudes, depressive symptomatology at discharge, and high body mass index at admission are associated with weight maintenance in adolescent anorexia nervosa.

Factors affecting dropout in outpatient eating disorder treatment

OBJECTIVE

To evaluate the incidence and effects of factors potentially influencing eating disordered patients' dropping out of outpatient cognitive-behavioural therapy (CBT).

METHOD

Sixty-seven (64 female, 3 male) patients with eating disorders participated in the study. All patients followed a multidisciplinary team approach for a median period of 9 months. Several factors potentially affecting dropout were retrospectively assessed prior to treatment.

RESULTS

The dropout rate was significantly higher in patients with purging anorexia nervosa (AN) compared to those with restrictive AN, bulimia nervosa and eating disorder not otherwise specified (33% vs. 27%, 25% or 21%, respectively, p<0.05). Among several factors influencing dropout, there was a significant association of patient low cooperativeness, purging episodes, restrictive eating, use of several weight control practices and psychiatric co-morbidity in patients who dropped out compared to completers (all p<0.05).

CONCLUSIONS

In outpatient eating disorder treatment, non-compliance and premature interruption of therapy are affected primarily by factors which are related to patients' attitude and behaviour. These factors should be carefully addressed in patients with eating disorders to improve outcome.

[Comparison of inpatient and day clinic treatment of anorexia nervosa]

OBJECTIVES

Explorative comparison of short term outcomes of day clinic and inpatient treatment for anorexia nervosa.

METHODS

N = 13 consecutively admitted day clinic patients (anorexia nervosa; DSM IV) were matched with N = 13 inpatients (variables: age, duration of illness, gender, admission weight, subtype of anorexia nervosa). Results at discharge were compared using defined outcome criteria as well as scores of the SCL-90-R and EDI-2.

RESULTS

After inpatient treatment significantly more patients showed a good outcome (predefined criteria). Effect sizes also pointed to a superiority of inpatient treatment.

CONCLUSIONS

In the initial phase of therapy the structured and holding environment of an inpatient unit may be favourable for severely underweight anorexic patients. The interpretation of these results is limited due to the small sample size.

Short-term outcome of psychiatric inpatients with anorexia nervosa in the current care environment

OBJECTIVE

The current study describes the short-term outcome of 61 inpatients with anorexia nervosa (AN), utilizing a standardized protocol that could be completed by most patients within the typical length of stay (LOS) in an academic medical center in our geographic area.

METHOD

Patients were placed on disorder-specific and medication clinical pathways and completed questionnaires at admission and discharge. Diagnostic, historical, demographic, and treatment-related information was obtained.

RESULTS

Treatment was sufficient to resolve acute medical problems, initiate refeeding, and interrupt compensatory behaviors, but continued intensive treatment will be critical to full recovery. Patients were discharged at an average of 85% of ideal body weight (IBW). Twenty patients were discharged against medical advice (AMA). Clinical and demographic variables poorly predicted AMA status.

DISCUSSION

Attainable inpatient treatment goals in our care environment appear to be > or = 80% IBW at discharge, resolution of acute medical problems, and interruption of compensatory behaviors. Future research should examine whether shorter LOS increases readmission rates or long-term costs.

Drop outs from in-patient treatment of anorexia nervosa

OBJECTIVE

Aim of the study was to identify patient characteristics that distinguish drop outs and completers from in-patient treatment for anorexia nervosa.

METHOD

A total of 133 consecutively admitted in-patients with anorexia nervosa (age range 16-50 years; 92.5% women) were analysed using sociodemographic variables as well as measures of psychopathology (SCL-90-R, EDI-2) and interpersonal difficulties (IIP-C). Patients were treated in a multimodal treatment setting, combining cognitive-behavioural and psychodynamic components.

RESULTS

Patients, who reported fewer symptoms, were hospitalized before and had a comorbid depression stayed more often in psychotherapy. Patients dropping out of treatment (31.6%) showed a trend to higher levels of maturity fears. Subtype, age, duration of illness, comorbid personality disorders or previous drop outs were not predictive of dropping out.

CONCLUSION

Addressing the high ambivalence and maturity fears of anorexic patients should be an essential issue in psychotherapy with this patient group.

Predictors of rehospitalization after total weight recovery in adolescents with anorexia nervosa

OBJECTIVE

The current study analyzed the variables related to rehospitalization after total weight recovery in adolescents with anorexia nervosa.

METHOD

One hundred and one patients first admitted for inpatient treatment, aged 11-19 years, were followed up for 12 months after discharge.

RESULTS

Twenty-five subjects (24.8%) required readmission after complete weight recovery and 76 (75.2%) did not. Duration of disorder, weight loss, body mass index at first admission, and global body image distortion were similar in the two groups. Patients needing readmission had a lower rate of weight gain (p < .001), a lower mean age (p = . 007), a higher mean score on the Eating Attitudes Test (EAT; p = .009), and a higher percentage of hips overestimation (p = .049). In a stepwise logistic regression analysis, these three variables predicted readmission and correctly classified 77.6% of patients. Taken as discrete variables, age younger than 15 years old, EAT score above 55, and a rate of weight gain lower than 150 grams per day were associated with a higher percentage of readmissions.

DISCUSSION

The variables most clearly related to readmission were young age, abnormal eating attitudes, and a low rate of weight gain.

The parent experience of eating disorders: interactions with health professionals

The experiences of parents with a child with anorexia nervosa and/or bulimia nervosa were explored and this article aims to present one component of that study: parents' interactions with health professionals. The research was initiated after anecdotal stories from parents led the authors to undertake a literature review, which revealed a paucity of published research on this topic. Twenty-two interviews were conducted with volunteer parents from New South Wales, Australia. A descriptive qualitative design was used and themes were identified through in-depth analysis. Six themes were identified: finding help, feeling shut out, engagement, images portrayed, being resourceful and parents not prepared to give up. The implications for health professionals include that they acknowledge parental involvement in recovery. We urge the nursing profession, particularly mental health nurses, to work towards establishing collaborative partnerships between families & health professionals in order to achieve a better health outcome for all.

Readiness to change dietary restriction predicts outcomes in the eating disorders

This study examined the relationship between readiness and motivation to change eating disorder symptoms and clinical outcomes during and following intensive residential eating disorder treatment. Sixty-four women completed the Readiness and Motivation Interview (RMI) at baseline, and a subset of participants were reassessed at post-treatment (n=45) and at 6 month follow-up (n=38). The RMI provides readiness scores for each of four symptom domains: restriction, cognitive, bingeing, and compensatory strategies. RMI scores were used to predict decision to enroll in treatment, dropout, symptom change following treatment, and maintenance of symptom change at six-month follow-up. The extent to which participants did not want to make changes to their dietary restriction at baseline (restriction precontemplation) was the most consistent predictor of short-term clinical outcome. The extent to which participants reported changing their restriction for themselves versus others (restriction internality) predicted outcome at 6-month follow-up. These preliminary findings suggest that assessing client readiness and motivation to change dietary restriction is most useful in predicting short and long-term clinical outcomes.

Management of child and adolescent eating disorders: the current evidence base and future directions

Although eating disorders in children and adolescents remain a serious cause of morbidity and mortality, the evidence base for effective interventions is surprisingly weak. The adult literature is growing steadily, but this is mainly with regard to psychological therapies for bulimia nervosa and to some extent in the field of pharmacotherapy. This review summarises the recent research literature covering management in three areas, namely physical management, psychological therapies, and service issues, and identifies prognostic variables. Findings from the adult literature are presented where there is good reason to believe that these might be applied to younger patients. Evidence-based good practice recommendations from published clinical guidelines are also discussed. Suggestions for future research are made, focusing on 1) the need for trials of psychological therapies in anorexia nervosa, 2) applications of evidence-based treatments for adult bulimia nervosa to the treatment of adolescents, and 3) clarification of the benefits and costs of different service models.

The place of inpatient care in the treatment of anorexia nervosa: questions to be answered

BACKGROUND

The chance that an anorexia nervosa patient will be hospitalized depends more on circumstantial rather than on scientifically based factors. Although there is a lot of information on the treatment of anorexia nervosa patients in a residential setting, answers to questions relating to the "when," "where," and "how" of treatment are subjective. There is no clinical consensus and the paucity of controlled research is hampering the development of an evidence-based practice.

RESULTS

Increasing economic restraints through managed care policies limit the length of inpatient treatment, which leads to early discharge at a lower body weight, which leads to a higher likelihood of readmissions, which leads to increasing costs.

DISCUSSION

We will highlight important issues in the ongoing debate between economic demands and clinical challenges. Our goal is to stimulate critical reflections and systematic research.

A test of the continuity perspective across bulimic and binge eating pathology

OBJECTIVE

This article examines the continuity/discontinuity perspective of eating pathology among 375 women seeking treatment.

METHODS

Participants were categorized into five separate groups: obese nonbingers, subthreshold binge eating disorder (BED), BED, subthreshold bulimics, and bulimics. We tested whether differences in core eating pathology (drive for thinness, body dissatisfaction, current body image, body image ideal) and psychiatric symptoms (depression, interoceptive awareness) differentiated the groups quantitatively (supporting the continuity perspective) or qualitatively (supporting the discontinuity perspective).

RESULTS

Our results, overall, supported the continuity perspective of eating pathology. A discriminant function analysis using the eating pathology and psychiatric symptom variables as predictor variables found that one primary factor differentiated the five groups on both core eating pathology and psychiatric variables.

DISCUSSION

The implications of testing this model within a treatment-seeking sample are discussed.

What happens to eating disorder outpatients who withdrew from therapy?

OBJECTIVE

Dropouts are frequent among eating disorder (ED) patients, but less is known about their natural history. This paper assesses the outcome of outpatients who dropped out from a therapy programme and its possible causes.

MATERIAL AND METHODS

From 1992 to 1994, we assessed 222 ED subjects. Psychiatrists expert in EDs evaluated these subjects by defining baseline parameters and diagnosis was made according to the 3rd revisioned edition of the Diagnostic and Statistical Manual of Mental Disorders. One hundred and twenty-eight subjects (57%) dropped out during the treatment. In 1997, we contacted them, reassessed the same baseline parameters and asked for a self-judgment about their social and clinical condition during the previous 2-5 years. Patients were classified as "improved" and "not improved" (stationary or worse) according to their social, physical and psychological condition. The relation between baseline condition and outcome was determined statistically.

RESULTS

Seventy-one percent of subjects were "improved" and no deaths were recorded. A significant correlation was found between "duration of illness" and no treatment following a dropout.

DISCUSSION

The high percentage of improvement among dropouts was unexpected. Shorter duration of illness and lack of specific therapy in the improved patients suggest the existence of a subset of ED patients with acute onset and a spontaneous tendency to improve. This point obviously requires further investigation.