Time course of symptom remission in eating disorders

Weight gain and eating disorder symptoms among individuals with atypical anorexia nervosa

OBJECTIVE

The purpose of this study was to examine the association between weight gain and eating disorder (ED) symptoms among adults receiving treatment for atypical anorexia nervosa (AAN), to determine whether those who had a higher percent of expected body weight (%EBW) at discharge exhibited lower ED symptoms than those who gained less weight, and to compare this group to a matched sample of patients with anorexia nervosa (AN).

METHOD

Participants were 96 adults receiving treatment at an ED treatment facility between December 2020 and May 2023. The Eating Disorder Examination-Questionnaire (EDE-Q) was completed at admission and discharge, and %EBW was obtained at admission and discharge.

RESULTS

All EDE-Q subscale scores improved from admission to discharge for patients with AAN and patients with AN. Neither %EBW at discharge nor weight gain were associated with EDE-Q subscale scores for those with AAN. For patients with AN, %EBW at discharge and weight gain were associated with EDE-Q Restraint at discharge.

CONCLUSIONS

Weight restoring to a higher level and gaining more weight were not associated with EDE-Q scores at discharge for AAN. Further research is needed to determine how weight restoration using intensive treatment settings affects remission and recovery in patients with AAN.

A benchmark study of a combined individual and group anorexia nervosa therapy program

OBJECTIVE

Anorexia nervosa (AN) is a treatment-resistant illness. Up to half of the patients show limited or no significant treatment response. First, we aimed to describe a new stepped-care outpatient treatment combining group and individual therapy (CIGAN) with a strong focus on normalizing eating and weight and in vivo meal support for adults with moderate to severe AN. Second, we aimed to compare CIGAN with specialized treatments of Specialized Supportive Clinical Management (SSCM) and the Maudsley model of AN (MANTRA).

METHOD

The study includes 137 adults with moderate to severe AN and the primary outcome (BMI) at six and twelve months was compared with the outcomes published for SSCM and MANTRA using the Chi-squared test and Student's t-test. The paired t-test and Cohen's d were used to compare the within-group follow-up data with the baseline data.

RESULTS

CIGAN patients changed significantly on all outcome measures at 6 and 12 months, with effect sizes on BMI of 1.37 and 1.51 and on the weight of 1.36 and 1.60, respectively. Except for the 12-month comparison with MANTRA, patients had a higher BMI and larger BMI increase at both 6 and 12 months than SSCM (BMI p = 0.002 and 0.023, BMI increase p < 0.001 and 0.003) and MANTRA (BMI p = 0.031 and 0.168, BMI increase p < 0.001 and 0.037).

DISCUSSION

CIGAN, including a stepped care approach, is a promising treatment, and further research on the effective elements is warranted.

Practitioners' perspectives on ethical issues within the treatment of eating disorders: Results from a concept mapping study

OBJECTIVE

Treating patients with eating disorders (EDs) is associated with an array of ethical concerns, including balancing patients' health and autonomy, access to care, and use of harm-reduction versus recovery-oriented treatment models. The primary aim of the current study is to gain a better understanding of ethical issues faced by ED practitioners by using a concept mapping, or Q-sort, approach.

METHOD

A total of 12 practitioners completed the brainstorming phase and generated statements regarding ethical issues they faced while treating patients with EDs. A subsequent 38 practitioners completed a sorting task, where they created and labeled piles, into which they grouped each statement. Of those 38 participants, 30 rated both the frequency with which they encountered each ethical issue and its impact on patient care.

RESULTS

A total of six clusters emerged: Insufficient Level of Care, Lack of Evidence-Based Practice, Insurance Barriers, Family Involvement, Patient Autonomy, and Limited Access to Expertise. Lack of Evidence-Based Practice, Insurance Barriers, and Insufficient Level of Care was the most frequent problem faced by ED practitioners, whereas Insurance Barriers and Patient Autonomy had the greatest impact.

DISCUSSION

Findings outline frequent and impactful areas of ethical concern that arise when treating patients diagnosed with EDs. Practitioners most commonly reported that patient- and insurance-driven factors limited patient access to appropriate care. Regulations supporting the provision of evidence-based care should be emphasized in public health policy and advocacy efforts, given their impact in limiting the delivery of adequate patient care.

Identifying duration criteria for eating-disorder remission and recovery through intensive modeling of longitudinal data

OBJECTIVE

Outcome states, such as remission and recovery, include specific duration criteria for which individuals must be asymptomatic. Ideally, duration criteria provide predictive validity to outcome states by reducing symptom-return risk. However, available research is insufficient for deriving specific recommendations for remission or recovery duration criteria for eating disorders.

METHOD

We intensively modeled the relation between duration criteria length and rates of remission, recovery, and subsequent symptom return in longitudinal data from a treatment-seeking sample of women with anorexia nervosa (AN) and bulimia nervosa (BN). We hypothesized that the length of the duration criterion would be inversely associated with both rates of remission and recovery and with subsequent rates of symptom return.

RESULTS

Generalized estimating equations supported our hypotheses for all investigated eating-disorder features except for symptom return when using the Psychiatric Status Rating for AN.

DISCUSSION

We recommend that 6 months be used for remission definitions applied to binge eating, purging, and BN symptom composite measures, whereas no duration criteria be used for low weight and AN symptom composites. We further recommend that 6 months be used for recovery definitions applied to BN symptom composites and AN symptom composites, whereas 18 months be used for individual symptoms of binge eating, purging, and low weight. The adoption of these duration criteria into comprehensive definitions of remission and recovery will increase their predictive validity, which in turn, maximizes their utility.

Remission in adolescents with bulimia nervosa: Empirical evaluation of current conceptual models

OBJECTIVE

The few randomized clinical trials (RCTs) investigating adolescent treatment for bulimia nervosa (BN) suggest variability in both rates of, and criteria for remission. The current study examined reactivity in remission rates, relative to various conceptualizations of remission in a single RCT data set.

METHOD

A data set of adolescents with BN who participated in an RCT (N = 110) was used to evaluate remission models based upon behavioral symptoms (e.g., binge eating), psychological symptoms (Eating Disorder Examination [EDE] scores), and combinations of these criteria.

RESULTS

At end-of-treatment (EOT), a remission model defined by behavioral symptom abstinence plus meaningful reduction in EDE global scores yielded comparable remission rates to a model defined by behavioral abstinence alone (i.e., 29% remitted). Participants with higher EOT EDE global scores were less likely to be abstinent from behavioral symptoms at 6- and 12-month follow-up (ps < .001).

DISCUSSION

Reduction in psychological symptoms with behavioral abstinence did not inform remission status at EOT, over and above behavioral symptom change alone. However, psychological symptom improvement by EOT may predict positive prognosis in posttreatment assessment. Results underscore the necessity of including psychological symptom improvement, as well as consistency across research and practice, in defining remission in adolescent BN.

Perspectives on Involuntary Treatment of Anorexia Nervosa

Involuntary treatment of anorexia nervosa is an option in cases in which the patient's life or other people's lives are at risk or, in some countries, to prevent the deterioration of the illness. Involuntary treatment is often regarded as controversial and has been intensely debated, although typically with few references to documented knowledge. This paper provides a research perspective of the topic by examine data in the field of the involuntary treatment of anorexia nervosa to pinpoint present knowledge as well as areas demanding clinical action or research attention. The prevalence of involuntary treatment in general as well as specific measures is described and possible early markers of patients at risk of involuntary treatment are discussed. Studies including patients' perspectives of involuntary treatment show the complexity of this treatment, its initiation, and its consequences. To qualify future discussions, improve current practice, and minimize involuntary treatment in general as well as on an individual level, at least four areas need attention: (i) the present specific symptoms of anorexia nervosa and their imminent consequences, (ii) illness history, (iii) overall psychiatric symptoms and general functioning, and (iv) contextual sphere of the patient. In particular, the last two require attention from both clinicians and researchers. Furthermore, critical evaluation of the attitudes of both patients and health care professionals toward each other and the treatment is recommended.

Feasibility of Implementing a Family-Based Inpatient Program for Adolescents With Anorexia Nervosa: A Retrospective Cohort Study

Background: Manualized Family Based Therapy (FBT) is the treatment of choice for adolescent anorexia nervosa, but it is an outpatient treatment. Very little research has examined whether or how the principles of FBT might be successfully adapted to an inpatient setting, and there is little other evidence in the literature to guide us on how to best treat children and adolescents with eating disorders (EDs) while in hospital. This paper describes and provides treatment outcomes for an intensive inpatient program that was designed for the treatment of adolescents less than 18 years of age with severe anorexia nervosa, based on the principles of FBT. Each patient's family was provided with FBT adapted for an inpatient setting for the duration of the admission. Parents were encouraged to provide support for all meals in hospital and to plan meal passes out of hospital. Methods: A retrospective cohort study was conducted that examined the outcomes of 153 female patients admitted over a 5-year period. Outcome data focused primarily on weight change as well as psychological indicators of health (i.e., depression, anxiety, ED psychopathology). Results: Paired t-tests with Bonferroni corrections showed significant weight gain associated with a large effect size. In addition, patients showed improvements in scores of mood, anxiety, and ED psychopathology (associated with small to medium effect sizes), though they continued to display high rates of body dissatisfaction and some ongoing suicidality at the time of discharge. Conclusion: This study shows that a specialized inpatient program for adolescents with severe EDs that was created using the principles of FBT results in positive short-term medical and psychological improvements as evidenced by improved weight gain and decreased markers of psychological distress.

Desired weight and treatment outcome among adolescents in a novel family-based partial hospitalization program

The purpose of the current study was to investigate desired weight percentage and weight difference percentage and their association with treatment outcome in a novel family-based partial hospitalization program. Twenty-six adolescents with anorexia nervosa or subthreshold anorexia nervosa between the ages of 12 and 19 completed the Eating Disorder Examination (EDE) at intake and upon completion from a partial hospitalization program in which parents played a large role in the recovery process, consistent with family-based treatment principles. Lower desired weight percentage at baseline was associated with higher scores on the restraint subscale of the EDE at end of treatment. Higher weight difference percentage (greater desire to lose weight) at baseline was associated with higher scores on all EDE subscales and global score at end of treatment. Neither desired weight percentage nor weight difference percentage at baseline were associated with treatment dropout or percent expected body weight at end of treatment. In a family-based program, participants' desired weight may be related to eating disorder thoughts (for example, shape or weight concerns) but not to behavioral outcomes such as weight gain or treatment dropout, which may be more directly under the influence of the parents.

The adolescent onset anorexia nervosa study (ANABEL): Design and baseline results

The anorexia nervosa adolescent longitudinal biomarker assessment study (ANABEL) is a 2-year longitudinal study.

OBJECTIVE

Evaluate several clinical, biochemical, immunological, psychological, and family variables and their interactions in adolescent onset eating disorders (EDs) patients and their 2-year clinical and biological outcome. This article illustrates the framework and the methodology behind the research questions, as well as describing general features of the sample.

METHODS

A longitudinal study of 114 adolescents with EDs seeking treatment was performed. Only adolescents were selected during 4 years (2009-2013). The variables were collected at different times: baseline, 6, 12, 18, and 24 months of the start of treatment. Diagnoses were completed through the semi-structured Kiddie-Schedule for Affective Disorders and Schizophrenia interview.

RESULTS

At baseline, the mean age was 15.11 (SD = 1.36). The mean ED duration was 10 months (SD = 5.75). The mean body mass index was 16.1 (SD = 1.8). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis at baseline for restrictive anorexia nervosa was 69.6%, 17.4% for purgative anorexia nervosa, and 24.3% for other specified feeding disorder. At 12 months, 19.4% were in partial remission, whereas at 24 months, 13.8% had fully recovered and 29.2% had partially recovered.

CONCLUSIONS

There was an acceptable physical and psychopathological improvement during the first year of treatment, with recovery being more evident during the first 6 months.

Body representation disturbances in visual perception and affordance perception persist in eating disorder patients after completing treatment

Body image disturbances (BID) are a key feature of eating disorders (ED). Clinical experience shows that BID exists in patients who Completed their Eating Disorder Treatment (CEDT), however studies concerning BID in CEDT patients are often limited to cognition and affect, measured by interviews and questionnaires. The current study is the first systematic study investigating the full scope of the mental body representation, including bodily attitudes, visual perception of body size, tactile perception, and affordance perception in CEDT patients. ED patients (N = 22), CEDT patients (N = 39) and healthy controls (HC; N = 30) were compared on BID tasks including the Body Attitude Test (BAT), Visual Size Estimation (VSE), Tactile Estimation Task (TET), and Hoop Task (HT). Results on the BAT show higher scores for ED patients compared to CEDT patients and HC but no difference between CEDT patients and HC. Both ED and CEDT patients show larger overestimations on the VSE and HT compared to HC, where ED patients show the largest overestimations. No group differences were found on the TET. The results indicate the existence of disturbances in visual perception and affordance perception in CEDT patients. Research focussing on more effective treatments for ED addressing multiple (sensory) modalities is advised.

Metasynthesis of the Views about Treatment of Anorexia Nervosa in Adolescents: Perspectives of Adolescents, Parents, and Professionals

BACKGROUND

Anorexia nervosa in adolescents can be a difficult-to-treat disease. Because qualitative research is a well-established method for deepening our understanding of subjective experiences, such as eating disorders and their treatment, we sought to perform a systematic review of qualitative studies to synthesize the views of adolescents with this disease, their parents, and their healthcare providers about its treatment.

METHODS

We performed a thematic synthesis to develop the central themes that summarize all of the topics raised in the articles included in our review. The quality of the articles was assessed by the Critical Appraisal Skills Program.

RESULTS

We included 32 articles from seven different countries. Two central themes were inductively developed from the analysis: (1) the treatment targets (i.e., symptoms and patients in context), and (2) a therapeutic tool-a relationship, specifically the core concept of the therapeutic relationship.

CONCLUSION

Our results underline the difficulty in establishing a therapeutic alliance, the barriers to it, especially the risk that professionals, adolescents, and parents will not converse about treatment; although such a dialogue appears to be an essential component in the construction of a therapeutic alliance.

Predictors of psychological outcome in patients with eating disorders: A routine outcome monitoring study

BACKGROUND

Identifying predictors of psychological outcome for patients with eating disorders may improve the effectiveness of treatment. Patients with different pre-treatment characteristics and symptoms may benefit from different therapies. This study aimed to identify potential predictors of treatment outcome in a large naturalistic cohort of patients with an eating disorder.

METHOD

The study sample included patients (N = 1153) with all types of eating disorders who were receiving residential, day, or outpatient treatment. Remission was defined by means of four different indicators based on the Eating Disorder Examination-Questionnaire global score: 1. achieving reliable change; 2. showing a 50% reduction in baseline symptom severity; 3. reaching the clinical significance cut-off point; and 4. a combination of indicators 2 and 3. Potential predictor variables were investigated in univariate and multivariate Cox regression models.

RESULTS

Different predictors were found for the four outcome criteria. Patients with high levels of interpersonal distrust at baseline were less likely to have achieved reliable change in eating disorder psychopathology. Higher self-esteem and less body dissatisfaction at baseline was independently associated with a symptom reduction of more than 50% and/or reaching the clinical significance cut-off point. Contrary to our expectations, no differences in outcome were found between the eating disorder subtypes.

DISCUSSION

Clinically, it is important to reduce the risk of poor outcome and to achieve a rapid response in treatment using an intervention designed for this purpose, such as shared decision making or an intervention directed at self-esteem or body image, which may act as a catalyst for change. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:863-873).

Effectivenes of a track-based model for treating eating disorders in a general psychiatric hospital

Due to comorbid disorders or the degree of severity of their eating disorder, individuals may not warrant treatment at a specialty eating disorder facility. This article examines the effectiveness of a track-based model for treating eating disorders at a general inpatient psychiatric hospital. One hundred seventy-six patients who participated on the Eating Disorder Track and completed the Eating Disorder Inventory-3 (EDI; Garner, 2004) were examined to determine whether their eating disorder symptoms improved over the course of their treatment. Results indicated that patients significantly improved across all eating disorder risk scales and psychological scales measured by the Eating Disorder Inventory. This suggests that patients who may not meet the criteria for attending a specialty eating disorder program may receive an alternative form of treatment for their eating disorder that is effective in reducing their eating disorder symptomatology. The hope is that providing more treatment options will expand the reach of eating disorder treatments to more individuals who need specialized care for these disorders.

Favorable effects of clearly defined interventions by parents at the start of treatment of adolescents with restrictive eating disorders

OBJECTIVE

To study the effect of clearly defined and decisive parental interventions at the start of treatment of restrictive eating disorders (ED) in adolescents.

METHOD

Forty-seven adolescents with ED (anorexia nervosa = 6, bulimia nervosa = 1, EDNOS = 40) and their families participated. Parents were advised to (1) keep the adolescent home from school, (2) eat all meals together with the adolescent, (3) prevent any form of exercise, and (4) prevent vomiting during the first week of treatment. Weight change was followed up to three months and EDE-Q administered at start of treatment and at three months.

RESULTS

Thirty (64%) of the families accomplished all four interventions during the first week of treatment. Their adolescents gained ∼ 1 kg of weight at one week, 2 kg at one month, and 4 kg at three months while adolescents in families who did not accomplish all four interventions gained only 1.4 kg up to three months. Scores on the EDE-Q decreased during treatment and in adolescents of families who accomplished all four interventions they were in the range of a reference population.

DISCUSSION

Decisive parental management of eating disturbed behaviors at the start of treatment of adolescents with ED promotes later clinical outcome. The finding supports the view that family based therapies are effective in adolescent ED. Results has to be followed up for evaluation of the long term effects of this type of intervention.

Long-term outcome in anorexia nervosa in the community

OBJECTIVE

Few studies have assessed outcomes of anorexia nervosa (AN) outside clinical settings. We aimed to assess mortality, recovery, and socio-demographic outcomes of AN in a community sample.

METHOD

Women in the nationwide FinnTwin16 cohort (born 1975-1979) were followed for 10 years after baseline diagnostic assessment (mean age at follow-up 34 years, N = 2188). We compared women with lifetime DSM-IV AN (N = 40) with unaffected women from the same cohort.

RESULTS

None of the women with AN had died and 88% were weight-recovered (BMI ≥ 18.5 kg/m(2) ), but their mean BMI (22.0 kg/m(2) ) was lower than among unaffected women (24.0 kg/m(2) , p = 0.008). University degrees (38 vs. 29%, p = 0.26), sickness absence during the past year (median 5 vs. 3 days, p = 0.21), or unemployment or disability pension (5 vs. 4%, p = 0.62) did not significantly differ between AN probands and their unaffected peers. More women with AN were still studying (15 vs. 4%, p = 0.003), and half of them had children, as compared to 66% of unaffected women (p = 0.05).

DISCUSSION

The long-term prognosis of AN in the community appears promising. Weight-restoration is common and socio-demographic outcomes are generally favorable. However, women with a history of AN may be less likely to have children.

Evaluating reliable and clinically significant change in eating disorders: comparisons to changes in DSM-IV diagnoses

Assessing clinically meaningful change is valuable for treatment planning, monitoring course of illness and evaluating outcome. Although DSM eating disorder (ED) diagnoses have been criticized for poor clinical utility, instability, and uncertainty, remission/change of diagnosis is often the standard for evaluating outcome. We tested the validity of the clinically significant reliable change index (CS/RCI) compared to change in DSM-IV ED-diagnoses. We investigated if CS/RCI was concordant to diagnostic change and compared explained variance on measures at follow-up. Using a database for specialized ED treatment in Sweden the sample contained 1042 female patients (246 adolescents/796 adults). CS/RCI was calculated for the Clinical Impairment Assessment (CIA) and the Eating Disorder Examination Questionnaire (EDE-Q). CS/RCI explained more variance in gain scores for psychopathology measures than diagnostic change (DSM-IV). Average agreement between diagnostic change and CS/RCI was 62% and 60% for CIA and EDE-Q, respectively. Diagnostic change always resulted in more positive outcome than CS/RCI. Together with clinical judgment, CS/RCI is a valuable method for determining clinically significant changes in clinical practice and research. It is economically sound and results are easily interpreted and communicated to patients.

Is weight gain really a catalyst for broader recovery?: The impact of weight gain on psychological symptoms in the treatment of adolescent anorexia nervosa

The main aims of this study were to describe change in psychological outcomes for adolescents with anorexia nervosa across two treatments, and to explore predictors of change, including baseline demographic and clinical characteristics, as well as weight gain over time. Participants were 121 adolescents with anorexia nervosa from a two-site (Chicago and Stanford) randomized controlled trial who received either family-based treatment or individual adolescent supportive psychotherapy. Psychological symptoms (i.e., eating disorder psychopathology, depressive symptoms, and self-esteem) were assessed at baseline, end of treatment, 6-month, and 12-month follow-up. Conditional multilevel growth models were used to test for predictors of slope for each outcome. Most psychological symptoms improved significantly from baseline to 12 month follow-up, regardless of treatment type. Depressive symptoms and dietary restraint were most improved, weight and shape concerns were least improved, and self-esteem was not at all improved. Weight gain emerged as a significant predictor of improved eating disorder pathology, with earlier weight gain having a greater impact on symptom improvement than later weight gain. Adolescents who presented with more severe, complex, and enduring clinical presentations (i.e., longer duration of illness, greater eating disorder pathology, binge-eating/purging subtype) also appeared to benefit more psychologically from treatment.

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.

The efficacy of a brief group CBT program in treating patients diagnosed with bulimia nervosa: a brief report

OBJECTIVE

The aim of the study was to evaluate the efficacy of a brief group cognitive behavior therapy (CBT) program in treating a large cohort of patients diagnosed with bulimia nervosa.

METHOD

Treatment outcome defined as reductions in bulimia related behavioral symptoms and bulimia related distress was examined in 205 consecutive new patients enrolled in an eight-session group CBT program.

RESULTS

Significant reductions in eating disorder pathology were found on all measures of bulimia related behavioral symptoms, as well as on all measures of bulimia related distress.

DISCUSSION

There is strong evidence for the efficacy of brief group CBT in treating patients with bulimia nervosa.

Factors associated with recovery from anorexia nervosa

Previous studies of prognostic factors of anorexia nervosa (AN) course and recovery have followed clinical populations after treatment discharge. This retrospective study examined the association between prognostic factors--eating disorder features, personality traits, and psychiatric comorbidity--and likelihood of recovery in a large sample of women with AN participating in a multi-site genetic study. The study included 680 women with AN. Recovery was defined as the offset of AN symptoms if the participant experienced at least one year without any eating disorder symptoms of low weight, dieting, binge eating, and inappropriate compensatory behaviors. Participants completed a structured interview about eating disorders features, psychiatric comorbidity, and self-report measures of personality. Survival analysis was applied to model time to recovery from AN. Cox regression models were used to fit associations between predictors and the probability of recovery. In the final model, likelihood of recovery was significantly predicted by the following prognostic factors: vomiting, impulsivity, and trait anxiety. Self-induced vomiting and greater trait anxiety were negative prognostic factors and predicted lower likelihood of recovery. Greater impulsivity was a positive prognostic factor and predicted greater likelihood of recovery. There was a significant interaction between impulsivity and time; the association between impulsivity and likelihood of recovery decreased as duration of AN increased. The anxiolytic function of some AN behaviors may impede recovery for individuals with greater trait anxiety.

Accuracy of self-reported body weight and height in remitted anorexia nervosa

BACKGROUND

The literature reflects contradictory evidence on the ability of persons with anorexia nervosa (AN) to accurately report body weight and height. Furthermore, it is currently unknown if individuals are able to correctly report their weight and height following weight recovery from AN.

OBJECTIVE

This study examined the accuracy of self-reported body weight and height following remission from anorexia nervosa (RAN).

DESIGN

Individuals included women with RAN (n = 45), anorexia nervosa (AN; n = 23), and controls (CON; n = 71). Subjective body mass index (BMI; kg/m(2)) was calculated from self-reported weight and height; objective BMI was calculated using values obtained with standard measures.

RESULTS

Subjective weights were significantly less than objective weights for the RAN and CON groups (p < .005). These groups reported being taller resulting in lower subjective BMIs (p < .001). The AN group did not significantly differ on subjective and objective weight, height, or BMI.

CONCLUSIONS

Results highlight the importance of objective measures for early identification/relapse prevention.

Changes in body image during inpatient treatment for eating disorders predict outcome

This study investigated changes and predictors during inpatient treatment of 55 adult in a transdiagnostic sample of patients with eating disorders. Patients were assessed at admission and discharge with the Body Attitude Test (BAT), Symptom Check List 90 Revised, Circumplex of Interpersonal Problems, Body Mass Index (BMI) and Eating Disorder Inventory 2 (EDI-2). Significant changes were found in all measures. Regression analyses showed that BAT changes during treatment were the strongest predictor of EDI-2 changes. No predictors of changes in BMI were found. Improvement of body image is important for the efficacy of inpatient treatment.

Self-change in eating disorders: is "spontaneous recovery" possible?

A limited series of community studies including non-treatment-seekers has shown that a considerable number of eating disorder patients do not enter the health care system but can be considered "clinically recovered" (remission of major symptoms) if followed up long enough. The possibility of "spontaneous recovery" (overcoming an eating disorder without professional treatment or formal help) often faces scepticism on the part of professionals. Clearly, self-change is an underestimated pathway to recovery from an eating disorder, but open-minded clinicians can learn a lot from it. Active coping and making use of one's "recovery capital" are key features of self-change even if maintenance of change is associated with social support and positive life changes.

Male experiences of life after recovery from an eating disorder

The aim of this study was to describe how former male patients perceive life after recovery from an eating disorder. A qualitative method with a phenomenographic approach was used to identify ways of experiencing recovery. Two descriptive categories were developed: body acceptance and self-worth. Six conceptions describe how recovered patients now relate in a balanced way to exercise and food, using strategies to avoid relapse. With a sense of self-acceptance and autonomy, they now appreciate their social life. Some perceive recovery as coping with remaining impulses to diet or exercise. Others experience themselves as totally free from the eating disorder.

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.

Course and outcome of eating disorders in a primary care-based cohort

OBJECTIVE

To study the course and outcome of patients with eating disorder detected in primary care.

METHOD

General practitioners (GP's) provided information on the course and outcome of eating disorders in patients (n = 147) diagnosed with anorexia nervosa (AN) or bulimia nervosa (BN) identified during a Dutch nationwide primary care-based incidence study. The research team determined the outcome based on the data provided by the GP's. The mean duration of the follow-up was 4.8 years.

RESULTS

About 57% of the patients initially diagnosed with AN and 61% of those diagnosed with BN were fully recovered. AN binge/purge subtype (ANBP) demonstrated the most extended median survival time of all diagnostic subgroups (the point at which half of the group has reached full recovery). Diagnostic crossover was low. A younger age at detection predicted recovery at outcome for AN and BN. One patient (AN) died.

DISCUSSION

The results of this study on differences in outcome and low crossover support the diagnostic distinction between AN and BN in the DSM-IV. Early detection is of major importance for a favorable outcome.

Identifikation von erfolgsrelevanten Veränderungen im Prozess einer Körperbildtherapie

Zusammenfassung. Theoretischer Hintergrund: Mehrere Studien belegen gute Ergebnisse für Interventionen zur Verbesserung des Körperbildes bei Patientinnen mit Essstörungen; jedoch fehlen Prozessanalysen der relevanten Wirkfaktoren. Fragestellung: Erfolgsrelevante Veränderungen von Klärungs- und Bewältigungserfahrungen sowie symptomspezifische Intrasession-Veränderungen werden im Verlauf einer standardisierten Körperbildtherapie untersucht. Methode: 54 Patientinnen mit Essstörungen füllten vor und nach jeder Gruppensitzung die Body Image States Scale zur Erfassung der State-Körperunzufriedenheit und am Sitzungsende den Stundenbeurteilungsbogen mit den Wirkfaktoren „Einsicht/Klärung” und „Problembewältigung” aus. Ergebnisse: Bei gleichen Eingangswerten zeigten sich erfolgsabhängige Verläufe für die Körperunzufriedenheit nach Sitzungsende und die erlebte Problembewältigung. Sowohl Klärungs- als auch Problembewältigungsprozesse sind mit der Intrasession-Verbesserung der Körperunzufriedenheit assoziiert. Schlussfolgerungen: Während beide Erfolgsgruppen profitieren, bedarf der differenziell günstigere Verlauf der erfolgreicheren Patienten weiterer und erweiterter Forschung.

Psychological correlates of fasting and vigorous exercise as compensatory strategies in undergraduate women

Vigorous exercise and fasting are commonly used compensatory behaviors. However, it is unknown how non-clinical individuals who engage in one or both of these compensatory behaviors differ from one another. This research compared women who engaged in both fasting and vigorous exercise as compensatory strategies (n=76) with women who engaged in either fasting (n=56) or excessive exercise (n=82) and women who employed no compensatory strategies (n=113) on body image/eating and psychological symptomatology. Participants completed questionnaires assessing body dissatisfaction, restrained eating, thin-ideal internalization, depression, self-esteem, and general psychological distress. Women who utilize any compensatory strategies report significantly greater body dissatisfaction and restrained eating than women who use no compensatory strategies at all. Moreover, fasting as a compensatory behavior is associated with more significant psychological and behavioral symptoms than vigorous exercise as a compensatory behavior. Implications of these findings for clinical intervention and research are discussed.

Hypnotic alteration of body image in the eating disordered

A driving force in an eating disorder like anorexia nervosa has been a distorted body image. The psychobiological dynamics of eating disorders have demonstrated significant hypnotic phenomena such as forms of dissociation, hallucination, time distortion and catalepsy, and therefore, pose hypnosis as a good fit for particular parts of treatment. Presented here are four hypnotic approaches designed to inspire the establishment of a reality based body image in the eating disordered individual. Conditional prerequisites for application of these interventions are described and case examples illustrate each approach. A discussion on some of the rationale for formulating these strategies is offered.

State self-esteem ratings in women with bulimia nervosa and bulimia nervosa in remission

OBJECTIVE

Bulimia nervosa (BN) is associated with low self-esteem. This study was designed to assess whether low self-esteem persists in nondepressed individuals who have recovered from BN (BN-R).

METHOD

Study groups included BN (n = 22), BN-R (n = 20), and healthy controls (n = 42). Participants were medication-free, and none met criteria for current major depression. Assessment instruments included the State Self-Esteem Scale (SSES), a self-rating scale designed to measure state-related changes in self-esteem.

RESULTS

Consistent with previous reports, SSES scores for BN were lower than for controls (p < .001). For BN-R, SSES scores were higher than for BN (p < .001), but lower than for controls (p < .025). For BN-R, scores on the SSES Appearance subscale were inversely correlated with ratings of dietary restraint (p < .005).

CONCLUSION

This study provides new evidence for persistent low self-esteem following recovery from BN. Follow-up studies are needed to assess whether low self-esteem contributes to recurrent dieting and risk for relapse.

Temporal patterns of recovery across eating disorder subtypes

OBJECTIVE

To compare patterns of recovery in individuals with index episodes of anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

Using Kaplan-Meier methods and Cox proportional hazards models, comparisons were conducted that were conditional on duration of eating disorder from onset and included a conservative recovery criterion of 3 asymptomatic years. Data collection was retrospective and from two of the international Price Foundation genetic studies on 901 individuals with eating disorders.

RESULTS

Using Kaplan-Meier methods, 11% of those with index AN and 10% of those with index BN met recovery criteria at 10 years. At 15 years, 16% of those with index AN and 25% of those with index BN met recovery criteria. In a Cox proportional hazards model the index BN group had three times the rate of recovery at 10-14 years (p=0.01) than the index AN group.

CONCLUSIONS

Initially the probability of recovery was greater for those with index AN, but as the duration of the eating disorder lengthened those with BN had higher probabilities of recovery. Replication of these results with prospective data using similarly stringent recovery criteria and methods is required to confirm trends.

Neuropsychological study of underweight and "weight-recovered" anorexia nervosa compared with bulimia nervosa and normal controls

OBJECTIVE

To compare executive, memory and visuospatial functioning of DSM-IV anorexia nervosa (AN), bulimia nervosa (BN), and normal controls (NC).

METHOD

A comparison of women involving: (i) 16 AN with body mass indices (BMI) < or = 17.5 kg/m(2); (ii) 12 AN with BMI > 18.5 kg/m(2) for at least 3 months; (iii) 13 BN; and (iv) 16 NC participants was performed with groups of similar age and intelligence. Groups were assessed with EDE-12, MADRS, HAMA, Cognitive Drug Research (CDR) battery, and Bechara tasks.

RESULTS

Significant impairments in CDR Power of Attention were present in underweight AN and BN participants. CDR Morse Tapping was significantly impaired in all clinical groups. The BN and weight-recovered AN groups were significantly impaired on CDR immediate word recall. The BN group alone was significantly impaired on CDR delayed word recall.

CONCLUSION

Attentional impairment is similar in AN and BN. Impaired motor tasks in AN persist after "weight-recovery" and are similar to impairments in BN. BN may be discriminated from AN on word recall.

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.

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

OBJECTIVE

The current article evaluated models of remission in anorexia nervosa (AN).

METHOD

A dataset from 86 adolescents with AN was used to model definitions of remission by using (a) Morgan-Russell categories, (b) criteria proposed by Pike, (c) criteria proposed by Kordy, et al. (d) DSM-IV-text revision criteria, (e) other weight thresholds, (f) psychological symptoms (Eating Disorder Examination [EDE] scores), and (g) combinations of these.

RESULTS

The mean age was 15.2 +/- 1.6 years. Remission rates varied from 3% to 96% depending on the method used. Combining percent ideal body weight and EDE scores appeared to reduce the variability in rates, capture the most meaningful aspects of remission, and avoid the pitfalls of other methods.

CONCLUSION

These methods of defining remission produce a wide range of outcomes, demonstrating the importance of defining remission consistently. Weight and psychological variables combined appear most important in defining remission.