Characteristics of anorexia nervosa-related deaths in Norway (1992-2000): data from the National Patient Register and the Causes of Death Register

Causes of death in patients with a history of severe anorexia nervosa

OBJECTIVE

This study reports causes of death for a cohort of 35 patients with severe anorexia nervosa (AN), who were treated between 2012 and 2020, and descriptive information on their medical and psychological comorbidities is provided.

METHODS

Three hundred and seventy patient names were submitted to the National Death Index (NDI). The NDI reviewed whether a death certificate matching each patient's identifying information existed, and if it existed, specific causes of death were noted. The original group of 370 patients consisted of 229 individuals who had been treated voluntarily and 141 who had been treated involuntarily.

RESULTS

Thirty-five patients, from the 370 (9.4%) submitted to the NDI, with an initial diagnosis of AN, were confirmed deceased. Most (83%) were female with an average age of 38.5 years (SD:12.7) and average body mass index (BMI) of 12.8 kg/m² (SD:2.4). The total number of patients, with AN listed as a cause of death, was 24 (69%). Two patients died as a result of suicide. Twenty-eight (80%) of the patients had a specific medical disease listed as a cause of death, with the most frequent being cardiovascular, metabolic, or gastrointestinal.

CONCLUSIONS

AN is associated with a substantial risk of death from many medical causes. However, two (5.7%) of our sample died by suicide, a rate considerably lower than previously reported.

Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995-2010

Elevated mortality risk in anorexia nervosa has been established, but less is known about the outcomes of bulimia nervosa and binge eating disorder. In this follow-up study we determined mortality in adults (N=2450, 95% women) admitted to the eating disorder clinic of the Helsinki University Central Hospital in the period 1995-2010. Most of the patients (80.7%) were outpatients. For each patient four controls were selected and matched for age, sex and place of residence. The matching was taken into account by modelling end-point events using Cox's proportional hazard model. The hazard ratio (HR) for all-cause mortality was 6.51 (95% CI 3.46-12.26) in broad anorexia nervosa (AN), 2.97 (95% CI 1.90-4.65) in broad bulimia nervosa (BN), and 1.77 (95% CI 0.60-5.27) in binge eating disorder (BED). Mortality risk in broad AN was highest during the first years after admission but declined thereafter, while in broad BN the mortality risk started to rise two years after the first admission. The HR for suicide was elevated both in broad AN (HR 5.07; 95% CI 1.37-18.84) and in broad BN (HR 6.07; 95% CI 2.47-14.89). Results show that eating disorders are associated with increased mortality risk even when specialised treatment is available.

A Review of Anorexia and Bulimia Nervosa for the Forensic Pathologist

Anorexia nervosa (AN) and, to a much lesser extent, bulimia nervosa (BN) are psychiatric illnesses that carry the highest mortality rates compared to other psychiatric illnesses. They tend to be chronic disorders with many acute fair-ups that have profound negative impact on the body as a whole. Many medical complications can arise acutely and chronically following excessive dieting, purging, over exercising, abuse of medications such as diuretics and laxatives or any combination of these. In contrast to the profound effects eating disorders can have, the postmortem findings and testing can be subtle to nonexistent and may be overshadowed by trauma (in the case of suicides), natural disease (in the case of diabetes and alcoholism) and postmortem shifts (in electrolyte testing and toxicology). A full understanding of how eating disorders affect the body in the acute, chronic, and refeeding stages is needed to properly certify these deaths.

Adolescent inpatient psychiatric admission rates and subsequent one-year mortality in England: 1998-2004

BACKGROUND

Adolescence is a time of very rapid change not only in physical but also psychological development. During the teenage years there is a reported rise in the prevalence of psychiatric disorders. The aim of this study was to investigate age- and sex-specific National Health Service (NHS) hospital inpatient admission rates for psychiatric conditions in adolescents in England, and to examine their mortality within one year of discharge.

METHOD

Using a record-linked NHS Hospital Episode Statistics (HES) dataset for England, and linked death certificates, age- and sex-specific admission rates and subsequent mortality rates were analysed by single year of age for people aged 10-19 years.

RESULTS

There were similar numbers of admissions for males and females: 29,595 and 28,188 respectively. Admission rates increased substantially with increasing age, from .2 per 1000 population per year aged 10 years to 2.2 per 1000 aged 19 years. There was no appreciable difference in death rates for males and females in the year following discharge--males .23% (based on 68 deaths), females .18% (52 deaths). However, these death rates were significantly higher than those found in the general population of equivalent age: expressed as standardised mortality ratios (SMRs), setting the SMRs for males and females in the general population each as 100, the SMR in the psychiatric population were 518 (95% CI 402-657) for males and 937 (692-1225) for females. The diagnostic groups with the highest mortality were development disorders (SMR 3017, 95% CI 1757-4831), eating disorders (SMR 1103, 443-2272), and affective disorders (SMR 940, 589-1423).

CONCLUSION

Adolescent psychiatric disorders represent a serious public health issue, with a steep rise in hospital admissions during the teenage years, and a six-fold increased death rate within one year of discharge compared to the general population of the same age.

Irreversibility of cardiac autonomic dysfunction in female adolescents diagnosed with anorexia nervosa after short- and long-term weight gain

Anorexia nervosa (AN) patients may present with cardiac autonomic system dysfunction. Power spectral analysis of heart rate variability (HRV) is a reliable noninvasive examination for the quantitative assessment of the central sympathovagal interaction that modulates cardiovascular autonomic function. In the present study, HRV parameters were assessed in female adolescent AN inpatients in the malnourished phase at admission, at discharge when achieving weight restoration, and 24-36 months after discharge, when considered remitted. Nineteen normal-weight female controls were similarly assessed. Spectral analysis of HRV was done with the fast Fourier transform algorithm. At admission and discharge, patients underwent routine laboratory examinations and responded to questionnaires assessing eating-related preoccupations, behaviors, and personality attributes, depression and anxiety. Compared with the controls, AN patients had significantly lower heart-rate and HRV, lower total power and low frequency components, elevated high frequency components, and decreased low to high frequency power ratio as assessed with the power spectral analysis at all three evaluation points. These disturbances were not correlated with the baseline laboratory and psychometric measures. Our preliminary findings suggest that female adolescent AN inpatients may have a cardiovascular autonomic dysfunction in the form of vagal abnormality present not only in malnourished patients, but also persisting following short-term and long-term weight restoration.