What is remission in adolescent anorexia nervosa? A review of various conceptualizations and quantitative analysis

Overvaluation of shape and weight in adolescents with anorexia nervosa: does shape concern or weight concern matter more for treatment outcome?

BACKGROUND

Overvaluation of shape and weight is a key diagnostic feature of anorexia nervosa (AN); however, limited research has evaluated the clinical utility of differentiating between weight versus shape concerns. Understanding differences in these constructs may have important implications for AN treatment given the focus on weight regain. This study examined differences in treatment outcome between individuals whose primary concern was weight versus those whose primary concern was shape in a randomized controlled trial of treatment for adolescent AN.

METHODS

Data were drawn from a two-site randomized controlled trial that compared family-based treatment and adolescent focused therapy for AN. Chi-square tests and logistic regression analyses were conducted.

RESULTS

Thirty percent of participants presented with primary weight concern (n = 36; defined as endorsing higher Eating Disorder Examination (EDE) Weight Concern than Shape Concern subscale scores); 60 % presented with primary shape concern (n = 72; defined as endorsing higher EDE Shape Concern than Weight Concern scores). There were no significant differences between the two groups in remission status at the end of treatment. Treatment did not moderate the effect of group status on achieving remission.

CONCLUSIONS

Results suggest that treatment outcomes are comparable between adolescents who enter treatment for AN with greater weight concerns and those who enter treatment with greater shape concerns. Therefore, treatment need not be adjusted based on primary weight or primary shape concerns.

Relapse from remission at two- to four-year follow-up in two treatments for adolescent anorexia nervosa

OBJECTIVE

Long-term follow-up studies documenting maintenance of treatment effects are few in adolescent anorexia nervosa (AN). This exploratory study reports relapse from full remission and attainment of remission during a 4-year open follow-up period using a convenience sample of a subgroup of 65% (n = 79) from an original cohort of 121 participants who completed a randomized clinical trial comparing family-based therapy (FBT) and adolescent-focused individual therapy (AFT).

METHOD

Follow-up assessments were completed up to 4 years posttreatment (average, 3.26 years). Available participants completed the Eating Disorder Examination as well as self-report measures of self-esteem and depression at 2 to 4 years posttreatment.

RESULTS

Two participants (6.1%) relapsed (FBT: n = 1, 4.5%; AFT: n = 1, 9.1%), on average 1.98 years (SD = 0.14 years) after remission was achieved at 1-year follow-up. Ten new participants (22.7%) achieved remission (FBT: n = 1, 5.9%; AFT: n = 9, 33.3%). Mean time to remission for this group was 2.01 years (SD = 0.82 years) from 1-year follow-up. There were no differences based on treatment group assignment in either relapse from full remission or new remission during long-term follow-up. Other psychopathology was stable over time.

CONCLUSION

There were few changes in the clinical presentation of participants who were assessed at long-term follow-up. These data suggest that outcomes are generally stable posttreatment regardless of treatment type once remission is achieved. Clinical trial registration information-Effectiveness of Family-Based Versus Individual Psychotherapy in Treating Adolescents With Anorexia Nervosa; http://www.clinicaltrials.gov/; NCT00149786.

Comparison of 2 family therapies for adolescent anorexia nervosa: a randomized parallel trial

IMPORTANCE

Anorexia nervosa (AN) is a serious disorder with high rates of morbidity and mortality. Family-based treatment (FBT) is an evidence-based therapy for adolescent AN, but less than half of those who receive this approach recover. Hence, it is important to identify other approaches to prevent the development of the chronic form of AN for which there is no known evidence-based treatment.

OBJECTIVE

To compare FBT with systemic family therapy (SyFT) for the treatment of adolescent-onset AN.

DESIGN, SETTING, AND PARTICIPANTS

Research in Anorexia Nervosa (RIAN) is a 2-group (FBT and SyFT) randomized trial conducted between September 2005 and April 2012. Interviewers were blinded to the treatment condition. A total of 564 adolescents receiving care at 6 outpatient clinics experienced in the treatment of AN were screened. Of these, 262 adolescents did not meet the inclusion criteria and 138 declined to participate; hence, 164 adolescents (aged 12-18 years) of both sexes meeting the criteria for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, AN (except for amenorrhea) were enrolled. Three participants were withdrawn from FBT and 7 were withdrawn from SyFT after serious adverse events occurred.

INTERVENTIONS

Two manualized family therapies with 16 one-hour sessions during 9 months. Family-based therapy focuses on the facilitation of weight gain, whereas SyFT addresses general family processes.

MAIN OUTCOMES AND MEASURES

The primary outcomes were percentage of ideal body weight (IBW) and remission (≥95% of IBW). The a priori hypothesis was that FBT would result in faster weight gain early in treatment and at the end of treatment (EOT).

RESULTS

There were no statistically significant differences between treatment groups for the primary outcome, for eating disorder symptoms or comorbid psychiatric disorders at the EOT or follow-up. Remission rates included FBT, 33.1% at the EOT and 40.7% at follow-up and SyFT, 25.3% and 39.0%, respectively. Family-based therapy led to significantly faster weight gain early in treatment, significantly fewer days in the hospital, and lower treatment costs per patient in remission at the EOT (FBT, $8963; SyFT, $18 005). An exploratory moderator analysis found that SyFT led to greater weight gain than did FBT for participants with more severe obsessive-compulsive symptoms.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that FBT is the preferred treatment for adolescent AN because it is not significantly different from SyFT and leads to similar outcomes at a lower cost than SyFT. Adolescents with more severe obsessive-compulsive symptoms may receive more benefits with SyFT.

TRIAL REGISTRATION

clinicaltrials.gov Identifier NCT00610753.

Specialized inpatient treatment of adult anorexia nervosa: effectiveness and clinical significance of changes

BACKGROUND

Previous studies have predominantly evaluated the effectiveness of inpatient treatment for anorexia nervosa at the group level. The aim of this study was to evaluate treatment outcomes at an individual level based on the clinical significance of improvement. Patients' treatment outcomes were classified into four groups: deteriorated, unchanged, reliably improved and clinically significantly improved. Furthermore, the study set out to explore predictors of clinically significant changes in eating disorder psychopathology.

METHODS

A total of 435 inpatients were assessed at admission and at discharge on the following measures: body-mass-index, eating disorder symptoms, general psychopathology, depression and motivation for change.

RESULTS

20.0-32.0% of patients showed reliable changes and 34.1-55.3% showed clinically significant changes in the various outcome measures. Between 23.0% and 34.5% remained unchanged and between 1.7% and 3.0% deteriorated. Motivation for change and depressive symptoms were identified as positive predictors of clinically significant changes in eating disorder psychopathology, whereas body dissatisfaction, impulse regulation, social insecurity and education were negative predictors.

CONCLUSIONS

Despite high rates of reliable and clinically significant changes following intensive inpatient treatment, about one third of anorexia nervosa patients showed no significant response to treatment. Future studies should focus on the identification of non-responders as well as on the development of treatment strategies for these patients.

The therapeutic process in psychological treatments for eating disorders: a systematic review

OBJECTIVE

For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled.

METHOD

Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified.

RESULTS

Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated.

DISCUSSION

As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

Eating disorders in children and adolescents: state of the art review

Despite their high prevalence, associated morbidity and mortality, and available treatment options, eating disorders (EDs) continue to be underdiagnosed by pediatric professionals. Many adolescents go untreated, do not recover, or reach only partial recovery. Higher rates of EDs are seen now in younger children, boys, and minority groups; EDs are increasingly recognized in patients with previous histories of obesity. Medical complications are common in both full and subthreshold EDs and affect every organ system. No single cause of EDs has emerged, although neurobiological and genetic predispositions are emerging as important. Recent treatment paradigms acknowledge that they are not caused by families or chosen by patients. EDs present differently in pediatric populations, and providers should have a high index of suspicion using new Diagnostic and Statistical Manual, 5th edition diagnostic criteria because early intervention can affect prognosis. Outpatient family-based treatment focused on weight restoration, reducing blame, and empowering caregivers has emerged as particularly effective; cognitive behavioral therapy, individual therapy, and higher levels of care may also be appropriate. Pharmacotherapy is useful in specific contexts. Full weight restoration is critical, often involves high-calorie diets, and must allow for continued growth and development; weight maintenance is typically inappropriate in pediatric populations. Physical, nutritional, behavioral, and psychological health are all metrics of a full recovery, and pediatric EDs have a good prognosis with appropriate care. ED prevention efforts should work toward aligning with families and understanding the impact of antiobesity efforts. Primary care providers can be key players in treatment success.

Rank perception and self-evaluation in eating disorders

OBJECTIVES

Heightened sensitivity to social comparison and negative self-evaluation have been implicated in the development and maintenance of eating disorders (EDs). This study used behavioral tasks, as well as self-report measures, to examine processing of social rank-related cues and implicit self-concept in participants with EDs.

METHOD

Fifty healthy participants (HCs), 46 people with an ED, and 22 people recovered from an ED (REC) undertook an attentional bias task using social rank-related cues and an implicit self-evaluation task. In addition, they completed self-report measures of social comparison, submissive behavior, and shame.

RESULTS

People with EDs showed vigilance toward social rank-related stimuli and lower implicit positive self-evaluation than HCs. Self-report data confirmed the behavioral findings and showed that people with EDs had higher levels of unfavorable social comparison, submissive behaviors, and external and internal shame than HCs. People who had recovered from an ED showed an intermediate profile between the two groups.

DISCUSSION

People with EDs have heightened sensitivity to social rank-related cues and impaired self-evaluation at an automatic level of processing. Some of these biases remain in people who have recovered. Interventions which aim to remediate social threat sensitivity and negative bias about self and others might be of benefit in EDs.

"Doing the impossible": the process of recovery from chronic anorexia nervosa

In this study, we aimed to explore the process of recovery over time from the perspective of those who had fully recovered from chronic anorexia nervosa (AN), using stringent recovery criteria. Eight women, assessed as fully recovered from chronic AN, told their story of the process of recovery. Data were analyzed using the qualitative method, narrative inquiry. Recovery was identified as a long and complex process that spanned four phases: from being unable or unready to change, to experiencing a tipping point where motivation increased and changed in quality, allowing the women to take action against the AN and finally allowing them to reflect and rehabilitate. Results provide a framework for understanding this complex process. Findings suggest that full recovery from chronic AN is possible and emphasize the importance of hope, motivation, self-efficacy, and support from others in the recovery process.

What does remission tell us about women with eating disorders? Investigating applications of various remission definitions and their associations with quality of life

OBJECTIVE

To compare remission rates, determine level of agreement and identify quality of life (QoL) distinctions across a broad spectrum of remission definitions among patients with eating disorders (ED).

METHODS

Women (N=195; 94 AN, 24 BN, and 77 EDNOS) from inpatient and partial hospital ED programs participated in a study of treatment outcomes. Remission rates were evaluated with percentages, kappa coefficients identified level of agreement and Mann-Whitney-Wilcoxon tests with Bonferroni corrections determined differences in quality of life between remitted and not remitted patients by remission definition.

RESULTS

Depending on remission definition used, the percent of remitted patients varied from 13.2% to 40.5% for AN, 15.0% to 47.6% for BN and 24.2% to 53.1% for EDNOS. Several definitions demonstrated "very good" agreement across diagnoses. Remission was associated with higher quality of life in psychological, physical/cognitive, financial and work/school domains on a disease-specific measure, and in mental but not physical functioning on a generic measure.

CONCLUSIONS

Remission rates vary widely depending on the definition used; several definitions show strong agreement. Remission is associated with quality of life, and often approximates scores for women who do not have an eating disorder. The ED field would benefit from adopting uniform criteria, which would allow for more accurate comparison of remission rates across therapeutic interventions, treatment modalities and facilities. We recommend using the Bardone-Cone criteria because it includes assessment of psychological functioning, was found to be applicable across diagnoses, demonstrated good agreement, and was able to distinguish quality of life differences between remitted and not remitted patients.

Prognostic value of rapid response to enhanced cognitive behavioral therapy in a routine clinic sample of eating disorder outpatients

OBJECTIVE

This study examined whether rapid response to enhanced cognitive behavioral therapy (CBT-E) was associated with superior treatment outcomes in a transdiagnostic sample of patients with an eating disorder.

METHOD

Participants were 105 patients with a primary eating disorder diagnosis who received individual CBT-E at a community-based outpatient clinic. Patients completed measures of eating disorder and related pathology at baseline and post-treatment. The Eating Disorder Examination-Questionnaire (EDE-Q) was administered at baseline and again, on average, 4.6 weeks after commencing treatment to assess rapid response to CBT-E. Patients achieving reliable change on the EDE-Q at this point were classified as rapid responders.

RESULTS

No baseline differences distinguished rapid and nonrapid responders. Rapid responders had significantly lower scores on EDE-Q global at post-treatment, were more likely to achieve full remission, and required significantly fewer treatment sessions than nonrapid responders. One-quarter of the nonrapid responders went on to achieve full remission. There were no group differences on measures of anxiety and depression symptoms at the end of treatment.

DISCUSSION

Early change in treatment is encouraged to achieve the best possible prognosis in CBT-E. Those who did not achieve rapid response still had an overall significant improvement in symptoms from pretreatment to post-treatment, but a lower rate of full remission. Nonrapid responders are an important group of patients to study because they offer researchers an opportunity to improve clinical decision-making and treatment outcomes for patients who are at risk of suboptimal response.

Do end of treatment assessments predict outcome at follow-up in eating disorders?

OBJECTIVE

To examine the predictive value of end of treatment (EOT) outcomes for longer term recovery status.

METHOD

We used signal detection analysis to identify the best predictors of recovery based on outcome at EOT using five different eating disorder samples from randomized clinical treatment trials. We utilized a transdiagnostic definition of recovery that included normalization of weight and eating related psychopathology.

RESULTS

Achieving a body weight of 95.2% of expected body weight by EOT is the best predictor of recovery for adolescents with anorexia nervosa (AN). For adults with AN, the most efficient predictor of weight recovery (BMI > 19) was weight gain to greater than 85.8% of ideal body weight. In addition, for adults with AN, the most efficient predictor of psychological recovery was achievement of an eating disorder examination (EDE) weight concerns score below 1.8. The best predictor of recovery for adults with Bulimia Nervosa (BN) was a frequency of compensatory behaviors less than two times a month. For adolescents with BN, abstinence from purging and reduction in the EDE restraint score of more than 3.4 from baseline to EOT were good predictors of recovery. For adults with binge eating disorder, reduction of the Global EDE score to within the normal range (<1.58) was the best predictor of recovery.

DISCUSSION

The relationship between EOT response and recovery remains understudied. Utilizing a transdiagnostic definition of recovery, no uniform predictors were identified across all eating disorder diagnostic groups.

Temperamental factors predict long-term modifications of eating disorders after treatment

BACKGROUND

Eating Disorders (EDs) are complex psychiatric pathologies characterized by moderate to poor response to treatment. Criteria of remission and recovery are not yet well defined. Simultaneously, personality plays a key role among the factors that determine treatment outcome. The aim of the present research is to evaluate the possibility of temperamental and character traits to predict the long-term outcome of ED.

METHOD

A sample of 25 AN and 28 BN female patients were re-assessed face-to-face after a minimum 5-years-follow-up through SCID-I, EDI-2 and TCI-R. Regression Analyses were performed to ascertain the possibility of TCI-R dimensions at the first visit to predict the long-term outcome.

RESULTS

Clinical and psychopathological symptoms significantly decreased over the time and 23% of participants no longer received a categorical ED diagnosis after at least 5 years of follow-up. TCI-R dimensions failed to predict the absence of a DSM-IV-TR diagnosis in the long term, but Novelty Seeking, Harm Avoidance and Reward Dependence demonstrated to predict the clinical improvement of several EDI-2 scales.

CONCLUSIONS

Our results support the idea that temperamental dimensions are relevant to the long-term improvement of clinical variables of ED. Low Novelty Seeking is the strongest predictor of poor outcome.

The role of the pediatrician in family-based treatment for adolescent eating disorders: opportunities and challenges

Empiric research supports that family-based treatment (FBT) is an effective treatment for adolescents with eating disorders. This review outlines the role of the pediatrician in FBT for adolescent eating disorders, specifically focusing on how pediatric care changes during treatment, and discusses current challenges and misconceptions regarding FBT. Although FBT introduces unique challenges to pediatricians trained in earlier eating disorder treatment approaches, effective support of the approach by pediatricians is critical to its success.

Efficacy of family-based treatment for adolescents with eating disorders: a systematic review and meta-analysis

OBJECTIVE

To systematically review and quantitatively evaluate the efficacy of Family-Based Treatment (FBT) compared with individual treatment among adolescents with eating disorders.

METHOD

The literature was reviewed using the MEDLINE search terms "family therapy AND Anorexia Nervosa," and "family therapy AND Bulimia Nervosa". This produced 12 randomized controlled trials involving adolescents with eating disorders and family therapy which were reviewed carefully for several inclusion criteria including: allocation concealment, intent-to-treat analysis, assessor blinding, behavioral family therapy compared with an individual therapy, and adolescent age group. References from these articles were searched. Only three studies met these strict inclusion criteria for meta-analysis. A random effects model and odds ratio was used for meta-analysis, looking at "remission" as the outcome of choice.

RESULTS

When combined in a meta-analysis, end of treatment data indicated that FBT was not significantly different from individual treatment (z = 1.62, p = 0.11). However, when follow-up data from 6 to 12 months were analyzed, FBT was superior to individual treatment (z = 2.94, p < 0.003), and heterogeneity was not significant (p = 0.59).

DISCUSSION

Although FBT does not appear to be superior to individual treatment at end of treatment, there appear to be significant benefits at 6-12 month follow-up for adolescents suffering from eating disorders.

Purging behavior in anorexia nervosa and eating disorder not otherwise specified: a retrospective cohort study

Purging behavior in eating disorders is associated with medical risks. We aimed to compare remission rates in purging and non-purging females with anorexia nervosa (AN) and eating disorder not otherwise specified (EDNOS) in a large retrospective single center cohort. A total of 339 patients with AN and 266 patients with EDNOS were included in the study. The proportion of subjects with purging behavior at least once a week during the last 3 months was similar in the two groups: 22% in AN and 24% in EDNOS. Remission was defined by a goal weight ≥85% of ideal body weight and no reported purging behavior in the last 6 months. The median time from onset to remission for patients with AN was 7 years for the non-purging vs. 11 years for the purging patients. The purging AN patients with both vomiting and laxative abuse displayed the poorest course. Among EDNOS patients, the time to remission was also significantly longer for purging patients compared to non-purging patients. Thus, in line with previous studies, we found that purging behavior is associated with delayed time to remission in treatment-seeking AN and EDNOS patients. This study provides evidence to support the retention of the diagnostic sub-typing in AN.

Recovery from disordered eating: sufferers' and clinicians' perspectives

OBJECTIVE

Disagreement exists on how to define recovery from eating disorders. Definitions typically include a combination of physical, cognitive, emotional, psychological and social factors. However, none provides multidimensional recovery models, addressing and comparing sufferers' and clinicians' viewpoints. This study investigates those recovery perspectives.

METHOD

Two-hundred and thirty-eight participants (individuals with eating difficulties and clinicians working in the field) completed a checklist, rating the importance of somatic, psychological, emotional, social, eating-related and body experience-related recovery criteria.

RESULTS

Recovery criteria fell into meaningful factors (psychological-emotional-social, weight-controlling behaviours, non-life-threatening and life-threatening features and evaluation of one's own appearance). Sufferers and clinicians agreed on the ranking of importance of these factors. However, sufferers considered 'psychological-emotional-social' and 'evaluation of one's own appearance' criteria as more important to recovery than clinicians.

DISCUSSION

Findings are discussed in relation to existing research, together with study limitations and future research. Clinical implications are outlined, focusing on the facilitation of recovery.

The clinical utility of personality subtypes in patients with anorexia nervosa

OBJECTIVE

Elucidation of clinically relevant subtypes has been proposed as a means of advancing treatment research, but classifying anorexia nervosa (AN) patients into restricting and binge-eating/purging types has demonstrated limited predictive validity. This study aimed to evaluate whether an approach to classifying eating disorder patients on the basis of comorbid personality psychopathology has utility in predicting treatment response and readmission in patients with AN.

METHOD

Data were collected from 154 AN patients (M [SD] age = 25.6[9.4] years; 95.5% female; 96.8% Caucasian) at admission, discharge, and 3 months postdischarge from intensive treatment. Latent profile analysis of personality traits assessed at admission was performed to classify participants into personality subtypes, which were then used to predict outcomes at discharge and risk of readmission.

RESULTS

The best fitting model identified 3 personality subtypes (undercontrolled, overcontrolled, low psychopathology) that contributed significantly to multivariate models predicting study outcomes. Undercontrolled patients were more likely to have a poor outcome at discharge than overcontrolled (OR = 3.56, p = .01) and low psychopathology patients (OR = 11.23, p < .001). Undercontrolled patients also had a greater risk of discharge against medical advice (HR = 2.08, p = .02) and readmission than overcontrolled patients (HR = 3.76, p = .009). Binge-eating/purging versus restricting subtypes did not predict discharge against medical advice or readmission in the multivariate models.

CONCLUSIONS

Findings support the clinical utility of personality subtypes in AN. Future work is needed to identify mechanisms that explain diminished treatment response in undercontrolled patients and to develop interventions for this high-risk group.

Calculation of expected body weight in adolescents with eating disorders

OBJECTIVE

To examine the agreement between three methods to calculate expected body weight (EBW) for adolescents with eating disorders: (1) BMI percentile, (2) McLaren, and (3) Moore methods.

METHODS

The authors conducted a cross-sectional analysis of baseline information from adolescents seeking treatment of disordered eating at The University of Chicago. Adolescents (N = 373) aged 12 to 18 years (mean = 15.84, SD = 1.72), with anorexia nervosa (n = 130), bulimia nervosa (n = 59), or eating disorder not otherwise specified (n = 184). Concurrence between the BMI percentile, McLaren, and Moore methods was assessed for agreement above or below arbitrary cut points used in relation to hospitalization (75%), diagnosis (85%), and healthy weight (100%). Patterns of absolute discrepancies were examined by height, age, gender, and menstrual status. Limitations to some of these methods allowed comparison between all 3 methods in only 204 participants.

RESULTS

Moderate agreement was seen between the 3 methods (κ values, 0.48-0.74), with pairwise total classification accuracy at each cut point ranging from 84% to 98%. The most discrepant calculations were observed among the tallest (>75th percentile) and shortest (<20th percentile) cases and older ages (>16 years). Many of the most discrepant cases fell above and below 85% EBW when comparing the BMI percentile and Moore methods, indicating disagreement on possible diagnosis of anorexia nervosa.

CONCLUSIONS

These methods largely agree on percent EBW in terms of clinically significant cut points. However, the McLaren and Moore methods present with limitations, and a commonly agreed-upon method for EBW calculation such as the BMI percentile method is recommended for clinical and research purposes.

Moderators and mediators of remission in family-based treatment and adolescent focused therapy for anorexia nervosa

Few of the limited randomized controlled trails (RCTs) for adolescent anorexia nervosa (AN) have explored the effects of moderators and mediators on outcome. This study aimed to identify treatment moderators and mediators of remission at end of treatment (EOT) and 6- and 12-month follow-up (FU) for adolescents with AN (N = 121) who participated in a multi-center RCT of family-based treatment (FBT) and individual adolescent focused therapy (AFT). Mixed effects modeling were utilized and included all available outcome data at all time points. Remission was defined as ≥ 95% IBW plus within 1 SD of the Eating Disorder Examination (EDE) norms. Eating related obsessionality (Yale-Brown-Cornell Eating Disorder Total Scale) and eating disorder specific psychopathology (EDE-Global) emerged as moderators at EOT. Subjects with higher baseline scores on these measures benefited more from FBT than AFT. AN type emerged as a moderator at FU with binge-eating/purging type responding less well than restricting type. No mediators of treatment outcome were identified. Prior hospitalization, older age and duration of illness were identified as non-specific predictors of outcome. Taken together, these results indicate that patients with more severe eating related psychopathology have better outcomes in a behaviorally targeted family treatment (FBT) than an individually focused approach (AFT).

A 1-year follow-up of a multi-center treatment trial of adults with anorexia nervosa

OBJECTIVE

To examine maintenance of recovery following treatment in an adult anorexia nervosa (AN) population.

METHOD

One year follow-up of a randomized clinical trial with 122 participants treated with: cognitive behavioral therapy (CBT), drug therapy (fluoxetine), or a combination (CBT+fluoxetine) for 12 months. Participants were assessed at baseline, end of treatment, and follow-up. The primary outcomes were weight and the global scores from the Eating Disorder Examination (EDE) separately and combined.

RESULTS

Fifty-two participants completed the follow-up. Mean weight increased from end of treatment to follow-up. Seventy-five percent (75%) of those weight recovered at end of treatment maintained this recovery at follow-up. Recovery of eating disorder psychopathology was stable from end of treatment to follow-up, with 40% of participants with a global EDE score within normal range. Using the most stringent criteria for recovery, only 21% of the completer sample was recovered.

DISCUSSION

The findings suggest that while adults with AN improve with treatment and maintain these improvements during follow-up, the majority is not recovered. Additionally, further research is needed to understand barriers to treatment and assessment completion.

Evaluation of family treatment models for eating disorders

PURPOSE OF REVIEW

Interest in the effectiveness of family interventions for eating disorders has increased over the past 5 years. This review considers the theoretical justification and current evidence base for the use of family treatments for eating disorders in children and adolescents.

RECENT FINDINGS

Family-based treatment is the best studied treatment. It has the strongest evidence base for effectiveness for anorexia nervosa in adolescents. Family-based treatment can be delivered in several formats and doses, and preliminary data suggest it can be disseminated by training and manuals. There is a more limited evidence base demonstrating the usefulness of family interventions for bulimia nervosa in adolescents.

SUMMARY

The implications of the findings of this review are that family interventions are the current first-line treatment for adolescent anorexia nervosa and promising for adolescent bulimia nervosa. Pilot studies suggest that family interventions can be disseminated in diverse clinical settings.

Examining the match between assessed eating disorder recovery and subjective sense of recovery: preliminary findings

This study examined how individuals, clinically assessed as fully or partially recovered from an eating disorder (ED), subjectively perceived themselves in terms of stage of change in the recovery process. Individuals formerly seen for an ED at a Midwestern clinic were recruited. Using validated definitions of recovery, 18 were fully recovered (physical, behavioural and psychological recovery), and 15 were partially recovered (only physical and behavioural recovery); these groups were compared on overall stage of change and confidence related to this stage, dieting stage of change and internality of motivation. The fully and partially recovered groups endorsed being fully recovered (overall and for dieting) at similar rates. There were trends for the fully recovered group seeking change primarily for themselves and being more confident in their stage of change choice. Results have implications for approaches when a client's assessed recovery stage does not match her subjective sense of recovery and for better understanding recovery from an ED.

When have eating disordered patients recovered and what do the DSM-IV criteria tell about recovery?

Lack of consensus about criteria for recovery from eating disorders results in greatly varying percentages of recovered patients. Outcome studies not only use different criteria for recovery, but also quite different instruments, rendering their results incomparable. The same problem occurs among studies of predictors for recovery from eating disorders. Without consensus on criteria for recovery, it is not clear which goals of treatment are important to realize full recovery. In order to develop larger consensus on criteria for recovery, this study critically analyzes the most important outcome scores and the criteria for recovery deduced from the DSM-IV.

Gender differences in outcome of eating disorders: a retrospective cohort study

Eating disorders (EDs) are uncommon in males. The majority of outcome studies on ED have not presented gender-specific results, mostly because of small study samples or exclusion of males. Furthermore, psychometric tools and outcome criteria used in ED have mainly been validated for females only. The objective of this study was to evaluate gender differences in weight restoration in different EDs. We studied the male representation and outcome in a large retrospective single centre cohort, the Funen Anorexia Nervosa Study (FANS). A total of 1015 patients were included in the study. A total of 356 (35%) patients were diagnosed with anorexia nervosa (AN), 298 (29%) with eating disorder not otherwise specified (EDNOS) and 361 (36%) with bulimia nervosa (BN). The male fractions in AN and EDNOS were similar, but significantly lower in BN. When remission was defined as body weight restoration to at least 85% of ideal body weight (IBW) and no self-reported binge or purgative behaviors in six months, the median time from onset to remission for patients with AN was significantly shorter for males: 7 years for females vs. 3 years for males. Among patients with a 5 years history of disease, remission rates in AN were 39% for females vs. 59% for males. The median time to remission for patients with EDNOS was similar to that of AN: 6 years for females vs. 3 years for males. In patients with EDNOS, 45% of the females remitted within 5 years vs. 77% of the males. With regard to body weight restoration and remission of purging behavior, this study suggests a better outcome for males than for females.

Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa

CONTEXT

Evidence-based treatment trials for adolescents with anorexia nervosa are few.

OBJECTIVE

To evaluate the relative efficacy of family-based treatment (FBT) and adolescent-focused individual therapy (AFT) for adolescents with anorexia nervosa in full remission.

DESIGN

Randomized controlled trial.

SETTING

Stanford University and The University of Chicago (April 2005 until March 2009).

PARTICIPANTS

One hundred twenty-one participants, aged 12 through 18 years, with DSM-IV diagnosis of anorexia nervosa excluding the amenorrhea requirement. Intervention Twenty-four outpatient hours of treatment over 12 months of FBT or AFT. Participants were assessed at baseline, end of treatment (EOT), and 6 months' and 12 months' follow-up posttreatment.

MAIN OUTCOME MEASURES

Full remission from anorexia nervosa defined as normal weight (≥95% of expected for sex, age, and height) and mean global Eating Disorder Examination score within 1 SD of published means. Secondary outcome measures included partial remission rates (>85% of expected weight for height plus those who were in full remission) and changes in body mass index percentile and eating-related psychopathology.

RESULTS

There were no differences in full remission between treatments at EOT. However, at both the 6- and 12-month follow-up, FBT was significantly superior to AFT on this measure. Family-based treatment was significantly superior for partial remission at EOT but not at follow-up. In addition, body mass index percentile at EOT was significantly superior for FBT, but this effect was not found at follow-up. Participants in FBT also had greater changes in Eating Disorder Examination score at EOT than those in AFT, but there were no differences at follow-up.

CONCLUSION

Although both treatments led to considerable improvement and were similarly effective in producing full remission at EOT, FBT was more effective in facilitating full remission at both follow-up points.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00149786.

All better? How former anorexia nervosa patients define recovery and engaged in treatment

The purpose of this study was to explore how individuals with anorexia nervosa (AN) engage in treatment and define recovery. A mixed methods design was used to triangulate the experience of 20 women with a history of AN. Interview data were analysed thematically to explore frequency of emergent themes and current eating disorder psychopathology was assessed using standardized self-report measures. Participants' mean age was 29.35 (SD = 12.11). Participants' scores were indicative of persistent psychopathology. Those with more involvement in treatment choice had better motivation to change and normalized eating. Participants' definition of recovery mapped on well to current research conceptualizations, though a substantial proportion of the group expressed some ambivalence around the concept. Results are interpreted in the context of self-determination theory of motivation and suggest that patients should be involved collaboratively in the formulation of shared goals and concepts of recovery in treatment settings.

Perfectionism across stages of recovery from eating disorders

OBJECTIVE

This study examined perfectionism in relation to recovery from eating disorders by comparing different conceptualizations of perfectionism across healthy controls and fully recovered, partially recovered, and active eating disorder cases, where full recovery was defined using physical, behavioral, and psychological indices.

METHOD

Participants were primarily young adult females; 53 active eating disorder cases, 15 partially recovered cases, 20 fully recovered cases, and 67 healthy controls. Participants completed questionnaires assessing trait perfectionism, perfectionistic self-presentation style, and frequency of perfectionism cognitions, as well as a diagnostic interview to determine lifetime and current eating disorder diagnoses.

RESULTS

A robust pattern emerged whereby the fully recovered individuals and healthy controls had similar levels of perfectionism that were significantly lower than the perfectionism levels of the partially recovered and active individuals with eating disorder, who were comparable to each other.

DISCUSSION

These findings have implications for more clearly defining eating disorder recovery and for the role perfectionism may play in achieving full recovery.

Defining recovery from an eating disorder: Conceptualization, validation, and examination of psychosocial functioning and psychiatric comorbidity

Conceptually, eating disorder recovery should include physical, behavioral, and psychological components, but such a comprehensive approach has not been consistently employed. Guided by theory and recent recovery research, we identified a "fully recovered" group (n = 20) based on physical (body mass index), behavioral (absence of eating disorder behaviors), and psychological (Eating Disorder Examination-Questionnaire) indices, and compared them with groups of partially recovered (n = 15), active eating disorder (n = 53), and healthy controls (n = 67). The fully recovered group was indistinguishable from controls on all eating disorder-related measures used, while the partially recovered group was less disordered than the active eating disorder group on some measures, but not on body image. Regarding psychosocial functioning, both the fully and partially recovered groups had psychosocial functioning similar to the controls, but there was a pattern of more of the partially recovered group reporting eating disorder aspects interfering with functioning. Regarding other psychopathology, the fully recovered group was no more likely than the controls to experience current Axis I pathology, but they did have elevated rates of current anxiety disorder. Results suggest that a stringent definition of recovery from an eating disorder is meaningful. Clinical implications and future directions regarding defining eating disorder recovery are discussed.

Short-term outcome of anorexia nervosa in adolescents after inpatient treatment: a prospective study

The current study describes the short-term outcome of adolescent inpatient population suffering from anorexia nervosa (AN) and analyzes the clinical predictors of poor outcome in these patients. Fifty-seven female AN patients (mean = 15.8, SD = 1.3) admitted for inpatient treatment to a specialized eating disorder unit at a university medical center were reassessed 1 year after being discharged. Assessments were made at the beginning and at the end of the inpatient treatment as well as at the 1-year follow-up. Self-rating data and expert-rating interview data were obtained. Adequate data for 55 (96.5%) cases allowed for the assignment of an outcome category. A total of 28.1% of the patients' cases showed a good outcome, meaning the patients fully recovered, and 8.8% had an intermediate outcome, and 59.6% of the patients' cases had a poor outcome. Significant predictors of poor outcome included the patient's BMI at the beginning of the treatment as well as psychiatric comorbidity, and purging behavior. Adolescent AN is a severe disorder with a poor outcome in a substantial amount of adolescents.

Remission of eating disorder during pregnancy: five cases and brief clinical review

Eating disorder during pregnancy is associated with a diversity of adverse outcomes and is of potential danger to both mother and child. There is, however, a tendency for remission of the eating disorder during pregnancy with improvement of symptoms such as restrictive dieting, binging and purging, and some women actually manage to put the disease behind them. This case report describes five women with different eating disorders and focuses on the symptomatology during pregnancy and in the months postpartum. The discussion deals with the possible psychological, social and endocrinological reasons for remission and the subsequent relapse, the definition of recovery and the factors which should alert health care professionals of the at-risk pregnancies in cases of undisclosed eating disorder. Furthermore, therapeutic interventions are proposed.

An integrative quantitative model of factors influencing the course of anorexia nervosa over time

OBJECTIVE

To identify factors influencing the course of anorexia nervosa (AN) over time.

METHOD

Former female patients with AN (36 remitted and 24 nonremitted) and 31 healthy females responded to standardized interviews and self-rating questionnaires. Remitted patients maintained normal eating, normal weight, and regular menses for the past 12 months. Patients not fulfilling these criteria were considered nonremitted.

RESULTS

Using logistic regression, we identified that number of hospitalizations, duration of ambulatory treatment, past vegetarianism, past anxiety, and childhood sexual abuse differentiated remitted from nonremitted patients, predicting nonremission. A similar analysis identified that elevated follow-up vegetarianism and eating-related concerns and lower body mass index (BMI) differentiated remitted from nonremitted patients, contributing to nonremission. Univariate analyses identified that remitted patients had elevated anxiety and eating-related obsessionality compared with the controls, suggesting these variables to potentially predispose to AN.

DISCUSSION

Elevated anxiety and eating-related obsessionality may increase the risk for the development of AN and for nonremission.

Leptin, ghrelin, and endocannabinoids: potential therapeutic targets in anorexia nervosa

Anorexia nervosa (AN) has the highest mortality rate between psychiatric disorders, and evidence for managing it is still very limited. So far, pharmacological treatment has focused on a narrow range of drugs and only a few controlled studies have been performed. Furthermore, the studies have been of short duration and included a limited number of subjects, often heterogenic with regard to stage and acute nutritive status. Thus, novel approaches are urgently needed. Body weight homeostasis is tightly regulated throughout life. With the discovery of orexigenic and anorectic signals, an array of new molecular targets to control eating behavior has emerged. This review focuses on recent advances in three important signal systems: leptin, ghrelin, and endocannabinoids toward the identification of potential therapeutical breakthroughs in AN. Our review of the current literature shows that leptin may have therapeutic potentials in promoting restoration of menstrual cycles in weight restored patients, reducing motor restlessness in severely hyperactive patients, and preventing osteoporosis in chronic patients. Ghrelin and endocannabinoids exert orexigenic effects which may facilitate nutritional restoration. Leptin and endocannabinoids may exert antidepressive and anxiolytic effects. Finally, monitoring serum concentration of leptin may be useful in order to prevent refeeding syndrome.

Costs of remission and recovery using family therapy for adolescent anorexia nervosa: a descriptive report

This paper reports on the costs of overall treatment for a cohort of adolescent patients with AN treated with a similar regimen consisting of inpatient medical stabilization, outpatient family therapy, and psychiatric medications for co-morbid psychiatric conditions. Most of the costs associated with outcome were secondary to medical hospitalization. However, the overall costs per remission varied widely depending on the threshold used. However, compared to costs described for adults with AN, adolescent treatment costs appear to be lower when families are used effectively to aid in treatment.

The course of illness following inpatient treatment of adults with longstanding eating disorders: a 5-year follow-up

OBJECTIVE

The objectives of this article were to study the course and outcome of longstanding eating disorders (ED) 5 years after completing treatment and to identify subgroups of patients with different course and outcome.

METHOD

A total of 77 patients with a mean age of 30 years were assessed at the beginning and end of in-patient therapy and at 1-, 2- and 5-year follow-up, respectively.

RESULTS

Of the 90% who participated in the 5-year follow-up, 46 patients (61%) had improved, and 30 (39%) did not meet diagnostic criteria for an ED. Cluster analysis identified a group of patient with no improvement over time.

CONCLUSION

Overall, the course is favourable, but a subgroup of patients with no improvement over time may need intensified treatment efforts.

Classification of child and adolescent eating disturbances. Workgroup for Classification of Eating Disorders in Children and Adolescents (WCEDCA)

OBJECTIVE

: The purpose of this article is to summarize major conceptual and clinical variables related to age-appropriate and developmentally appropriate classification of eating problems and disorders in children and adolescents.

METHOD

A review of current classifications and related literature in child development is provided. Problems with current classification schemes are identified and discussed.

RESULTS

Current classifications are inadequate to address the clinical and research needs of children and adolescents with eating disturbances and disorders.

CONCLUSION

A range of possible changes in classification strategies for eating disorders in children and adolescents are described.

Predictors of dropout and remission in family therapy for adolescent anorexia nervosa in a randomized clinical trial

OBJECTIVE

The purpose of this study is to explore the predictors of dropout and remission in the treatment of adolescent anorexia nervosa (AN) using family therapy.

METHOD

Data derived from a randomized clinical trial comparing short and long term family therapy for adolescents with AN were used. A rotated component analysis was employed to reduce the number of variables and to address problems of collinearity and multiple testing. Dropout was defined as participating in less than 80% of the assigned therapy. Participants were classified as remitted if they obtained an ideal body weight greater than 95% and a global eating disorder Examination score within two standard deviations of community norms at the end of 12 months.

RESULTS

Co-morbid psychiatric disorder and being randomized to longer treatment predicted greater dropout. The presence of co-morbid psychiatric disorder, being older, and problematic family behaviors led to lower rates of remission. A reduction of child behavioral symptoms, a decline in problematic family behaviors, and early weight gain were all within treatment changes that increased the chance of remission.

CONCLUSION

Co-morbid psychiatric disorder, family behaviors, and early response to treatment are important factors when predicting dropout and remission in family therapy for adolescent AN.

What is recovery in adolescent anorexia nervosa?

OBJECTIVE

The principal aim of this study is to describe the types of problems faced in defining recovery from anorexia nervosa (AN) as well as to illustrate the magnitude that various definitions have on recovery rates for AN.

METHOD

Comparative rates of recovery from AN using a range of definitions (percent ideal body weight, psychological recovery, and combinations of these variables) were calculated using long-term outcome data from a study of adolescents treated for AN. In addition, a Kaplan-Meier survival analysis was used to model recovery over the long-term follow-up period.

RESULTS

Recovery rates varied highly, depending on the definition used, from 57.1% to 94.4%. Using survival analysis, the mean time to remission for weight (>85% ideal body weight) was 11.3 months, significantly shorter than for Eating Disorder Examination score recovery at 22.6 months (log rank = 16.1, p = 0.0001).

CONCLUSION

Agreement of definitions of recovery may be dependent on specific goals of a particular study or treatment; however, in order to compare and contrast categorical outcomes, a consistent definition of recovery is needed in the literature. Both weight and psychological symptoms appear to be important in a definition of recovery.