Differences between adolescents and young adults at presentation to an eating disorders program

An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents

The authors examined the natural history of threshold, subthreshold, and partial eating disorders in a community sample of 496 adolescent girls who completed annual diagnostic interviews over an 8-year period. Lifetime prevalence by age 20 years was 0.6% and 0.6% for threshold and subthreshold anorexia nervosa (AN), 1.6% and 6.1% for threshold and subthreshold bulimia nervosa (BN), 1.0% and 4.6% for threshold and subthreshold binge-eating disorder (BED), and 4.4% for purging disorder (PD). Overall, 12% of adolescents experienced some form of eating disorder. Subthreshold BN and BED and threshold PD were associated with elevated treatment, impairment, and distress. Peak age of onset was 17-18 years for BN and BED and 18-20 years for PD. Average episode duration in months was 3.9 for BN and BED and 5.1 for PD. One-year recovery rates ranged from 91% to 96%. Relapse rates were 41% for BN, 33% for BED, and 5% for PD. For BN and BED, subthreshold cases often progressed to threshold cases and diagnostic crossover was most likely for these disorders. Results suggest that subthreshold eating disorders are more prevalent than threshold eating disorders and are associated with marked impairment.

Clarifying criteria for cognitive signs and symptoms for eating disorders in DSM-V

OBJECTIVE

This article reviews literature relevant to challenges in clinical ascertainment of cognitively-based diagnostic criteria of anorexia nervosa (AN) and bulimia nervosa (BN) to examine whether revision might enhance their clinical utility.

METHOD

We performed a systematic literature search to identify publications relevant to clinical evaluation of cognitive symptoms of AN and BN.

RESULTS

The literature supports several reasons that individuals with an eating disorder may not endorse cognitive symptoms, despite their presence. These include limited insight, minimization, or denial, as well as intentional concealment related to perceived stigma, social desirability, or investment in maintaining behavioral symptoms. We also identified reasons that the word "refusal" in AN criterion A may render its application problematic.

DISCUSSION

We conclude that specific guidance for ascertainment of cognitive signs for AN and BN in the absence of patient disclosure or endorsement, longitudinal evaluation, and/or collateral data may improve clinical utility of these diagnostic criteria.

Burden of eating disorders in 5-13-year-old children in Australia

OBJECTIVE

To collect nationally representative epidemiological data on early-onset eating disorders (EOEDs) in children.

DESIGN

Prospective, active surveillance using the Australian Paediatric Surveillance Unit with key informant design.

SETTING

Child health specialists in Australia (July 2002 to June 2005).

PATIENTS

Incident cases of EOEDs in children aged 5-13 years.

MAIN OUTCOME MEASURES

Disease rates, demographic characteristics, clinical features and complications, hospitalisation, psychological comorbidity, and concordance of clinical features with Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) criteria.

RESULTS

We identified 101 children aged 5-13 years with EOEDs (median age, 12.2 years; range, 5.5-13.9 years), of whom one in four were boys. Most were hospitalised (78%), and the mean duration of hospitalisation was 24.7 days (range, 1-75 days). More than 70% of inpatients were admitted to specialised eating disorder units in paediatric teaching hospitals. Among inpatients, 37% met DSM-IV diagnostic criteria for anorexia nervosa; although 61% had life-threatening complications of malnutrition, only 51% met weight criteria. Psychological symptoms were similar to those in adults with anorexia nervosa: 67% of inpatients met both psychological diagnostic criteria for anorexia nervosa (fear of weight gain/fatness and misperception of body shape). Of 19 postmenarchal girls, 18 had secondary amenorrhoea. Nasogastric feeding was used in 58% of inpatients, and 34% received psychotropic medications.

CONCLUSIONS

This is the first prospective national study of EOEDs. It demonstrates the limitations of applying DSM-IV diagnostic criteria for anorexia nervosa to young children; the high proportion of boys affected by EOEDs; and the significant psychological comorbidity and high frequency of hospitalisation associated with EOEDs. Potentially life-threatening medical complications are common at presentation, suggesting possible missed diagnoses and a need for education of health professionals. The study underlines the severity of EOEDs and the need for joint medical and psychiatric specialist management.

Do adolescents with eating disorder not otherwise specified or full-syndrome bulimia nervosa differ in clinical severity, comorbidity, risk factors, treatment outcome or cost?

OBJECTIVE

We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ from those with bulimia nervosa (BN) in clinical features, comorbidity, risk factors, treatment outcome or cost.

METHOD

Adolescents with EDNOS (n = 24) or BN (n = 61) took part in a trial of family therapy versus guided self-care. At baseline, eating disorder symptoms, risk factors, and costs were assessed by interview. Patients were reinterviewed at 6 and 12 months.

RESULTS

Compared with EDNOS, BN patients binged, vomited and purged significantly more, and were more preoccupied with food. Those with EDNOS had more depression and had more current and childhood obsessive-compulsive disorder. 66.6% of EDNOS versus 27.8% of BN patients were abstinent from bingeing and vomiting at 1 year. Diagnosis did not moderate treatment outcome. Costs did not differ between groups.

CONCLUSION

EDNOS in adolescents is not trivial. It has milder eating disorder symptoms but more comorbidity than BN.

Diagnosing eating disorders in adolescents: a comparison of the eating disorder examination and the development and well-being assessment

OBJECTIVE

To compare the diagnostic properties of the Eating Disorder Examination (EDE) and the online version of the Development and Well-Being Assessment (DAWBA).

METHOD

Fifty-Seven adolescents (mean age 15.7 years) who attended consecutive assessments at a specialist eating disorders clinic completed the DAWBA, the EDE, and a standard clinical assessment with a multidisciplinary team. Cohen's Kappas were used to make pairwise comparisons between the diagnoses generated by the three assessments.

RESULTS

Participants had anorexia nervosa (n = 30), eating disorders NOS (n = 21) or no eating disorder (n = 6) according to the clinical diagnosis. Agreement between the clinical and DAWBA diagnoses was moderate (kappa = 0.59), agreement between the DAWBA and EDE diagnoses was fair (kappa = 0.21), and agreement between the clinical and EDE diagnoses was poor (kappa = 0.10). The EDE did not identify an eating disorder in 20 participants (35% of the sample) who were clinically assessed as cases.

CONCLUSION

Computerized measures using multiple informants may be more suitable for assessing clinical samples of adolescents with anorexia nervosa or eating disorders NOS than individual interviews with young people.

How do adolescents with bulimia nervosa rate the acceptability and therapeutic relationship in family-based treatment?

OBJECTIVE

To describe therapeutic alliance and treatment acceptability ratings of adolescents with bulimia nervosa (BN) participating in family-based treatment (FBT-BN) and to explore how participant characteristics relate to these constructs.

METHOD

Adolescents with BN (n = 80) in a randomized controlled trial comparing FBT-BN and individual supportive psychotherapy (SPT), completed the Eating Disorder Examination, Rosenberg Self-esteem Scale, and Beck Depression Inventory prior to treatment. The Helping Relationship Questionnaire, patient expectancy for treatment, treatment suitability, and self-reported estimates of improvement ratings were obtained at multiple points throughout treatment.

RESULTS

Therapeutic alliance and treatment acceptability ratings were positive in both treatments and generally did not differ. Within FBT-BN, more severe eating disorder symptomatology pretreatment was related to lower alliance ratings mid-treatment (p < .05). However, reductions in binge and purge behaviors over the course of treatment were not related to alliance or acceptability for participants in FBT-BN (all p's > .10).

CONCLUSION

Contrary to expectations of FBT-BN, adolescents receiving both treatments develop a strong alliance with the therapist.

Geographical clustering of eating disordered behaviors in U.S. high school students

OBJECTIVE

The aim of this study was to determine if eating disorder behaviors geographically clustered among U.S high school students.

METHOD

Our sample consisted of 15,349 high school students who responded to the 1999 Youth Risk Behavior Study (YRBS). Weight control and eating disordered behaviors under investigation included dieting, exercising, fasting, using diet pills, and purging to control weight in the last 30 days. We calculated pairwise odds ratios (PWORs) to determine the degree of within-county clustering.

RESULTS

Among all participants, adjusted analyses revealed that having any weight control or eating disorder symptom, severe restricting, dieting, exercising, and diet pill use each showed significant clustering (p < .05). Purging did not significantly cluster by county. The magnitude of clustering was stronger for female students than male students.

CONCLUSION

The significant clustering of weight control and eating disorder behavior in U.S. high school students confirms evidence of a social contagion effect of eating disorders.

The addition of a parent and clinician component to the eating disorder examination for children and adolescents

OBJECTIVE

Our goal was to evaluate the addition of parent and clinician reports to the eating disorder examination (EDE) when used with children and adolescents.

METHOD

The EDE was completed with 117 children and adolescents with eating disorders (mean age 14.95 +/- 1.91 years). A slightly modified version of the EDE was completed with parents, and clinician summary scores were assigned. Repeated measures analysis was used to compare child, parent, and clinician scores.

RESULTS

In those 70 participants with anorexia nervosa (AN) or eating disorder not otherwise specified with a restrictive pattern (EDNOS-R), child scores were significantly lower than parent scores and clinician scores on restraint and weight concerns. On eating concerns and shape concerns, child scores were lower than clinician scores. Participants with bulimia nervosa (BN) or eating disorder not otherwise specified with binge eating or purging (EDNOS-BP), reported more restraint and shape concerns than parents (n = 47), but their scores did not differ from clinician ratings. No differences were seen in this group on weight concerns or eating concerns.

CONCLUSION

Parent and clinician reports are particularly important when assessing children and adolescents with AN or EDNOS-R, but may be less critical for those with BN or EDNOS-BP.

Anorexia nervosa in Asian-American adolescents: do they differ from their non-Asian peers

OBJECTIVE

This study reports on the clinical characteristics and phenomenology of anorexia nervosa (AN) in Asian-American adolescents, and compares them with a non-Asian sample.

METHOD

Data were obtained from a family therapy trial for adolescents with AN. Demographic details were collected and participants assessed on a series of structured interviews. Data from Asian participants were compared with that from non-Asians.

RESULTS

Asians scored lower on all the Eating Disorder Examination (EDE) subscales, significantly on the restraint subscale (1.48 vs. 2.80, p = 0.016) and weight concerns subscale (1.35 vs. 2.30, p = 0.026). They also scored higher on the Family Environment Scale achievement orientation subscale (6.50 vs. 4.81, p = 0.011).

CONCLUSION

Asians are demographically similar to their non-Asian peers but tend to come from higher-income families who were more achievement oriented. EDE scores suggest Asians tend to report fewer symptoms. The apparent lack of fat-phobia among Asians could be related to this overall under-reporting of symptoms.

Early identification and treatment of eating disorders: prodrome to syndrome

The onset of eating disorder psychopathology is most common in the adolescent age group. Acute psychopathology or subsyndromal eating disorders are perhaps less intractable in these young patients. Subsyndromal eating disorders in children and adolescents are not only clinically significant in their present state, but may represent legitimate candidates for preventive efforts in light of: (i) a risk of progression from subthreshold anorexia nervosa (SAN) to AN or subthreshold bulimia nervosa (SBN) to BN; (ii) the detrimental effects on outcome of delaying treatment; and (iii) the refractory, severe nature of eating disorders once the diagnostic threshold is crossed. Moreover, children and adolescents with SAN and SBN may in fact be exhibiting early 'caseness' of these disorders. Given that AN is notoriously difficult to treat, and there are limited efficacy data for adolescent BN, attempts to disrupt these disorders in what is arguably their early phases is an important goal in preventing more chronic and treatment-resistant forms of these disorders. Future research should address whether the best interventions for SAN and SBN should be derived from the prevention or intervention fields.

How do children with eating disorders differ from adolescents with eating disorders at initial evaluation?

PURPOSE

To compare the clinical presentation of children with eating disorders (ED) to that of adolescents with ED.

METHODS

Demographic, medical, and psychiatric data of all 959 in- and outpatients (85 males, 874 females) 8-19 years of age diagnosed with ED that presented to an academic center between 1997 and 2005 were examined via retrospective record review. Young patients (n = 109) were defined as aged < 13 years at presentation, and older patients (n = 850) > or = 13 years and < 20 years.

RESULTS

Compared with older adolescents (mean 15.6 years, SD 1.4), younger patients (mean 11.6 years, SD 1.2) were more likely to be male (chi2 = 9.25, p < .005) or diagnosed with eating disorder not otherwise specified (EDNOS) (chi2 = 5.09, p < or = .05), and less likely to be diagnosed with bulimia nervosa (BN) (chi2 = 13.45, p < or = .001). There were no significant differences in anorexia nervosa (AN) diagnoses between groups. Young patients were less likely to report purging (chi2 = 26.21, p < .001), binge eating (chi2 = 26.53, p < .001), diet pill (chi2 = 13.31, p < .001) or laxative use (chi2 = 6.82, p < .001) when compared with older teens. Young patients weighed less in percentage ideal body weight (p < .05), had a shorter duration of disease (p < .001), and had lost weight more rapidly than older adolescent patients (p < or = .001).

CONCLUSIONS

There are important diagnostic and gender differences in younger patients. Young ED patients presented at a lower percentage of ideal body weight and had lost weight more rapidly, which may put them at higher risk for future growth sequelae than their older counterparts.

Do supplementary items on the eating disorder examination improve the assessment of adolescents with anorexia nervosa?

OBJECTIVE

Given that adolescents with anorexia nervosa (AN) typically have lower scores on the Eating Disorder Examination (EDE) than expected, the current study examined whether the inclusion of eight supplementary items developed by the authors of the EDE better captured the symptoms of adolescents with AN.

METHOD

A dataset consisting of EDEs from 86 adolescents was examined by 3 primary methods: (1) baseline subscale scores were compared before and after the addition of the supplementary items, (2) the internal consistency of the EDE with the addition of these items was examined, and (3) each of these items was compared before and after treatment.

RESULTS

After the addition of the supplementary items, the Eating Concern and Weight Concern subscales were significantly increased, whereas the Restraint subscale was significantly decreased, and the Shape Concern subscale was unchanged. Internal consistency was improved on the Eating Concern, Weight Concern, and Shape Concern subscales, and was decreased on the Restraint subscale. Three of eight items showed a significant decrease with treatment.

CONCLUSION

Although the addition of some of these eight supplementary items better captured the psychopathology of adolescents with AN, scores were still substantially below expected, indicating that the exploration of other methods of assessment is needed.

Denial and minimization in adolescents with anorexia nervosa

OBJECTIVES

This study examines symptoms of denial in 86 adolescents with anorexia nervosa (AN) using a dataset from a family therapy trial.

METHOD

Using the Restraint subscale of the Eating Disorders Examination (EDE) at baseline, participants were divided into deniers (n = 15), minimizers (n = 21), and admitters (n = 50). These subgroups were compared with analysis of variance (ANOVA; Tukey post-hoc analysis) on a variety of assessment and treatment variables at baseline and at 12 months.

RESULTS

Although body mass index (BMI) was not significantly different, all subscale scores of the EDE were lower in the deniers compared with the admitters (p = .0001 for all subscales) at baseline. Minimizers also scored lower than admitters on 3 of 4 subscales (p = .0001 for the Restraint, Weight Concern, and Shape Concern subscales of the EDE). At baseline and at 12 months, there were no significant differences on the Youth Self-Report or the Child Behavior Checklist. At 12 months, the only significant difference was in the Restraint subscale, with deniers still scoring lower than admitters (p = .015).

CONCLUSION

Denial and minimization appear to be common processes occurring in adolescents with AN and present difficulties in assessment.

Cognitive-behavioral therapy for adolescents with binge eating syndromes: a case series

OBJECTIVE

Published empirically based studies of psychotherapies for bulimia nervosa (BN) have been conducted solely with adult populations. The current study extends the extant literature by piloting a version of cognitive-behavioral therapy (CBT) for BN adapted for an adolescent population.

METHOD

The participants were referred for treatment for binge eating and purging behaviors at a university clinic. Patients received pretreatment and posttreatment interviews assessing the frequency of their binge eating and purge behaviors, and they also completed pretreatment and posttreatment assessments with the Eating Disorders Examination (EDE).

RESULTS

Results indicated significant reductions in the frequency of binge eating from pretreatment to posttreatment. Furthermore, all subscale scores of the EDE showed significant declines from pretreatment to posttreatment.

CONCLUSION

The authors concluded that CBT adapted for adolescents with bulimic symptoms appears to be a promising intervention worthy of further study in adolescents.

Evaluation of a healthy-weight treatment program for bulimia nervosa: a preliminary randomized trial

OBJECTIVE

Conduct a randomized treatment trial to test whether healthy dieting maintains bulimic symptoms or effectively reduces this eating disturbance.

METHODS

Female participants (n=85) with full- and sub-threshold bulimia nervosa were randomly assigned to a 6-session healthy dieting intervention or waitlist condition and assessed through 3-month follow-up.

RESULTS

Relative to control participants, intervention participants showed modest weight loss during treatment and demonstrated significant improvements in bulimic symptoms that persisted through follow-up.

DISCUSSION

These preliminary results suggest that this intervention shows potential for the treatment of bulimia nervosa and may be worthy of future refinement and evaluation. Results also provide experimental evidence that dieting behaviors do not maintain bulimia nervosa, suggesting the need to reconsider maintenance models for this eating disorder.

Ipecac syrup abuse, morbidity, and mortality: isn't it time to repeal its over-the-counter status?

PURPOSE

To review and address the abuse of ipecac, describing its epidemiology, toxicity, clinical characteristics, and laboratory assessment.

METHODS

A Medline search (1980-2003) for Ipecac abuse and Ipecac toxicity, n = 34.

RESULTS

Ipecac abuse occurs predominantly among adolescent and young adult females who are either experimenting with purging or have an eating disorder. Psychiatric comorbidity is common. Death can occur and is usually of cardiac origin. Morbidity includes myocarditis with arrhythmias, myositis, gastroesophageal pathology, including Mallory Weiss tears, diarrhea, and metabolic abnormalities (alkalosis, hypokalemia, dehydration). The injuries can reverse with cessation of ipecac use. A high index of suspicion is needed for early detection. Classic findings are abnormal EKG and echocardiography and/or elevation of muscle enzymes (CPK, adolase). Emetine, the alkaloid in ipecac, can be confirmed in serum, urine, and tissue by high performance liquid chromatography.

CONCLUSIONS

Ipecac abuse is dangerous, even deadly. However, if abuse is discontinued, cardiac and muscle damage tends to reverse. Were ipecac syrup to remain an over- the-counter medication, or become a prescription medication, more stringent warning labels ought to be included and further education be provided about its toxicity and potential for abuse. Removing ipecac from the over-the-counter category would best eliminate its potential for abuse.

Anorexia nervosa among children and adolescents

This update on anorexia nervosa among children and adolescents focuses on the current diagnostic criteria for the disorder, its history, epidemiology, and etiology. Consideration is given to the required medical evaluation and differential diagnosis. The medical complications, morbidity, and mortality that may ensue are described, and the corresponding pathophysiology explained. The review concludes with information on treatment and prognosis and a proposal on the appropriate role for the pediatrician in the management of anorexia nervosa.

Prospective relations between bulimic pathology, depression, and substance abuse: unpacking comorbidity in adolescent girls

To elucidate the processes that contribute to the comorbidity between bulimic pathology, depression, and substance abuse, the authors tested the temporal relations between these disturbances with prospective data from adolescent girls (N = 496). Multivariate analyses indicated that depressive symptoms predicted onset of bulimic pathology but not of substance abuse, bulimic symptoms predicted onset of depression but not of substance abuse, and substance abuse symptoms predicted onset of depression but not of bulimic pathology. Results suggest that the comorbidity arises because certain disorders are risk factors for the other disorders. Findings also provide support for select etiologic theories and further establish the clinical significance of these conditions by showing that they increase risk for onset of other psychiatric disturbances.

Adolescents and eating disorders: an examination of a day treatment program

OBJECTIVE

In this study, we report on our day treatment program (DTP) for adolescents and young adults with eating disorders (EDs).

METHOD

Data for the 82 female patients in DTP were examined, compared across ED diagnosis and by age (adolescents vs. young adults). At admission, patients completed the Eating Disorder Inventory-2 (EDI-2) and the Beck Depression Inventory (BDI) and the Family Adaptability and Cohesion Evaluation Scale- II (FACES-II).

RESULTS

Forty-nine percent of patients successfully completed the day program and 13% required hospitalization following day treatment. Overall, there were no significant differences between the adolescents and adults at discharge of the day program.

DISCUSSION

With shortened inpatient (IP) hospitalizations, DTPs can provide the long-term care required by many adolescent patients for psychological and physical recovery. This may be particularly important for the development of children and adolescents.

Chronic fatigue syndrome and eating disorders: concurrence or coincidence?

In this report we present four patients who were found to have both an eating disorder and the chronic fatigue syndrome (CFS). Two of the patients presented for evaluation of an eating disorder and also had CFS, while two of the patients presented for evaluation of CFS and also had an eating disorder. In all four patients the eating disorder preceded the CFS. We consider the question of whether the occurrence of these two disorders in the same patients is merely a coincidence; whether an eating disorder can act as a precipitant for CFS, perhaps through the exacerbation of an underlying vascular instability; and whether overlapping etiologies may predispose some adolescents to develop both disorders. We also discuss similarities (including diagnostic dilemmas, cultural influences, psychological correlates, demographic similarities, perceptual biases, and cardiovascular effects) encountered in the management of both of these disorders.

Treatment of eating disorders in a division of adolescent medicine

We present a report on a study of 638 adolescent patients with eating disorders treated at the North Shore University Hospital between 1980 and 1994. Data from the study are presented in this paper, together with a discussion of the implications for treatment in adolescent medicine settings.

Childhood and adolescent anorexia nervosa

Eating disorders are common during childhood and adolescence. Early intervention is associated with the best prognosis. Treatment interventions that focus on achieving ideal body weight and use various family therapy approaches are most likely to be effective. Much remains to be learned about the origin of AN, but there are promising recent advances.

Bulimia in children and adolescents

Although there have been many recent advances in research, much work remains to be done in the area of child and adolescent eating disorders. More data are needed regarding the normal development of eating behavior, resilience and risk factors for eating pathology, and treatment studies in children and adolescents. The best studied areas include epidemiology, short-term treatment for bulimia nervosa (BN), and outcome in anorexia nervosa. A case report of the single blind use of repetitive transcranial magnetic stimulation in a patient with BN has been reported, but its safe use in children and adolescents remains to be established.