Body dissatisfaction moderates weight curves in the inpatient treatment of Anorexia Nervosa

Depressive symptoms and weight change in inpatients with anorexia nervosa: A cross-lagged panel model

OBJECTIVE

Anorexia nervosa (AN) is marked by a high rate of comorbid depression, which raises the question whether depressive symptoms may adversely affect treatment outcome. Thus, we examined whether depressive symptoms at admission would predict weight change from admission to discharge in a large sample of inpatients with AN. In addition, we also explored the reverse direction, that is, whether body mass index (BMI) at admission would predict changes in depressive symptoms.

METHODS

A sample of 3011 adolescents and adults with AN (4% male) who received inpatient treatment at four Schoen Clinics was analyzed. Depressive symptoms were measured with the Patient Health Questionnaire-9.

RESULTS

BMI significantly increased and depressive symptoms significantly decreased from admission to discharge. BMI and depressive symptoms were unrelated at admission and discharge. Higher BMI at admission predicted smaller decreases in depressive symptoms and higher depressive symptoms at admission predicted larger weight gain. The latter effect, however, was mediated by longer length of stay.

CONCLUSION

Results indicate that depressive symptoms do not adversely affect weight gain during inpatient treatment in persons with AN. Instead, higher BMI at admission is predictive of smaller improvements in depressive symptoms but this effect seems to be negligible in terms of clinical relevance.

The Family Caregiving Environment Associates with Adolescent Patients' Severity of Eating Disorder and Interpersonal Problems: A Cross-Sectional Study

The quality of family interactions may be a critical factor for restrictive eating disorders (REDs). Adolescent patients with RED have interpersonal problems that can be inferred by observing their behaviours during family interactions. To date, the assessment of the association among RED severity, interpersonal problems, and patients' interactive behaviours in the family is partially explored. This cross-sectional study aimed to explore how adolescent patients' interactive behaviours observed during the Lausanne Trilogue Play-clinical version (LTPc) were associated with both RED severity and interpersonal problems. Sixty adolescent patients completed the EDI-3 questionnaire to assess RED severity using the Eating Disorder Risk Composite (EDRC) and Interpersonal Problems Composite (IPC) subscales. Moreover, patients and their parents took part in the LTPc, and patients' interactive behaviours were coded as participation, organization, focal attention, and affective contact in all the LTPc four phases. A significant association emerged between patients' interactive behaviours during the LTPc triadic phase and both EDRC and IPC. Better patients' organization and affective contact significantly correlated with lower RED severity and fewer interpersonal problems. These findings suggest that investigating the quality of family relationships and patients' interactive behaviours may contribute to better identifying adolescent patients at risk for more severe conditions.

Weight suppression and body mass index at admission interactively predict weight trajectories during inpatient treatment of anorexia nervosa

OBJECTIVE

Weight suppression refers to the difference between an individual's current and highest body weight at their current height. Higher weight suppression has been found to predict weight gain in both non-clinical samples and patients with eating disorders. Few studies also have reported interactive effects between weight suppression and current body mass index when predicting weight gain.

METHODS

In this retrospective study, we analyzed clinical records of inpatients with anorexia nervosa (N = 2191, 97% female) and tested whether weight suppression and body mass index at admission would interactively predict different weight trajectories during treatment.

RESULTS

Body weight increased non-linearly during treatment. Higher weight suppression predicted larger weight gain but the nature of this effect depended on body mass index at admission. In patients with a relatively low body weight at admission, those with high weight suppression started at a lower weight and showed a nearly linear and steeper weight gain than those with low weight suppression. In patients with a relatively high body weight at admission, those with high weight suppression started at a similar weight and showed a non-linear and larger weight gain than those with low weight suppression.

CONCLUSION

Findings further support that weight suppression is a robust predictor of weight gain in addition to-and in interaction with-current body weight. As weight suppression can easily be assessed at admission, it may help to anticipate treatment course and outcome in patients with anorexia nervosa.

Influence of Identity Development on Weight Gain in Adolescent Anorexia Nervosa

BACKGROUND

Anorexia Nervosa (AN) typically begins during early adolescence, an important phase of personality development. A substantial proportion of adolescent AN patients shows impaired personality functioning, which might be a relevant but understudied aspect of illness severity. The developmental status of identity as key element of personality is suggested to influence inpatient treatment outcome in adolescents with AN.

METHODS

This study analyzed existing data of N = 60 adolescents with AN. Multilevel models assessed the influence of identity functioning, measured by the Assessment of Identity Development in Adolescence (AIDA) at admission, on weight gain [BMI (body mass index), BMI-SDS (BMI standard deviation score)] during 10 weeks of inpatient treatment. Moreover, the influence of other indicators of illness severity, i.e., eating disorders and comorbid psychopathologies, was explored.

RESULTS

As expected, higher AIDA scores negatively influenced the course of weight gain. A similar effect was observed for other psychopathology measures, especially body image distortion. In general, higher weight at admission was associated with less weight gain. Higher weight at admission was also predicted by higher other psychopathology measures, but not AIDA scores.

CONCLUSION

The course of weight gain during inpatient treatment was hampered in adolescent AN patients who have difficulties developing a stable identity. Unlike other aspects of psychopathology, this was independent of the initial weight. Thus, in addition to the level of underweight and other aspects of psychopathology, difficulties in identity development constitute a relevant aspect of illness severity in AN. This recommends consideration of identity development during treatment.

Inpatient weight curve trajectory as a prognostic factor among adolescents with anorexia nervosa: a preliminary report

OBJECTIVE

To investigate the predictive value of weight restoration trajectories for relapse within the first year after discharge from inpatient treatment among adolescents with AN.

METHODS

Forty four inpatient adolescents (5 boys, 39 girls) aged 11-18 (M 14.85, SD 1.87) diagnosed with anorexia were assessed at admission and discharge from a general hospital inpatient ward. Re-hospitalizations within 1 year of discharge were recorded. Factors assessed included 1/BMI at admission, 2/BMI at discharge, 3/percent from target weight (PFTW) at discharge, 4/length of hospitalization, and 5/a weight restoration trajectory measuring weight drops during inpatient weight restoration (rates of negative cubic variation in body weight (NCV).

RESULTS

Logistic regression indicated that negative cubic variation rates (NCV) predicted re-hospitalization. PFTW was found only marginally significant.

CONCLUSION

Variations in weight restoration during inpatient treatment may be used to identify patients at risk for relapse. NCV can alert clinicians to initiate early relapse prevention interventions before discharge. Level of Evidence Level III, cohort study.

The Roy Adaptation Model: A Theoretical Framework for Nurses Providing Care to Individuals With Anorexia Nervosa

Using a nursing theoretical framework to understand, elucidate, and propose nursing research is fundamental to knowledge development. This article presents the Roy Adaptation Model as a theoretical framework to better understand individuals with anorexia nervosa during acute treatment, and the role of nursing assessments and interventions in the promotion of weight restoration. Nursing assessments and interventions situated within the Roy Adaptation Model take into consideration how weight restoration does not occur in isolation but rather reflects an adaptive process within external and internal environments, and has the potential for more holistic care.

Maximal Strength Training as a Therapeutic Approach in Long-Standing Anorexia Nervosa: A Case Study of a Woman With Osteopenia, Menstrual Dysfunction, and Compulsive Exercise

In persons with anorexia nervosa (AN), compulsive exercise and osteopenia are common symptoms. Although treatment of osteopenia besides weight regain is lacking, maximal strength training (MST) has been found to be effective in other populations. Such training has not been prescribed to those with AN due to uncertainty of tolerance. We therefore examined use of MST in a woman with long-standing AN, osteopenia, menstrual dysfunction, and compulsive exercise. The MST intervention consisted of four exercises: three sets of five repetitions maximum (RM), 3 times per week for 16 weeks. We examined muscle strength, bone mineral density (BMD), AN psychopathology, and compulsive exercise at baseline, posttest, and 6-month follow-up. Attendance rate was 100%. The subject improved muscle strength by 20% to 40%. BMD in lumbar spine improved by 4% to posttest, and by 8% from baseline to 6-month follow-up. The BMD T-scores shifted from values classified as osteopenic to normal values throughout the course of the intervention, despite continuance of menstrual dysfunction and lack of weight gain. No changes in AN psychopathology or levels of compulsive exercise were detected. Perceived psychological benefits including new bodily experiences were self-reported by the subject, emphasizing the importance of close follow-up by competent instructors.

Trajectories of Change in Body Weight During Inpatient Treatment for Anorexia Nervosa

BACKGROUND

Identifying distinct trajectories of change in body weight during inpatient treatment for anorexia nervosa (AN) may provide knowledge about the process of weight restoration and may help detect optimal body weight response patterns among individuals who are at risk for not achieving weight restoration or leaving treatment prematurely.

OBJECTIVE

This study explored the extent to which distinct trajectories of change in body weight existed among individuals during inpatient treatment for AN.

DESIGN

Group-based trajectory modeling was used to identify distinct trajectories of change in body weight among 500 individuals receiving inpatient treatment for AN.

RESULTS

Four distinct trajectories were identified: weight gain ( n = 197), treatment resistant ( n = 177), weight plateau ( n = 82), and weight fluctuate ( n = 44).

CONCLUSION

Clinically, it is important to consider the heterogeneity of changes in body weight during inpatient treatment to help guide interventions and outcomes.

Inpatient Treatment for Adolescents with Anorexia Nervosa: Clinical Significance and Predictors of Treatment Outcome

This study evaluated the clinical significance as well as predictors of outcome for adolescents with severe anorexia nervosa (AN) treated in an inpatient setting. Body mass index (BMI), eating disorder (ED) symptoms [Eating Disorder Inventory-2 (EDI-2)], general psychopathology and depression were assessed in 238 patients at admission and discharge. BMI increased from 14.8 + 1.2 to 17.3 + 1.4 kg/m(2). Almost a fourth (23.6%) of the patients showed reliable changes, and 44.7% showed clinically significant changes (EDI-2). BMI change did not significantly differ between those with reliable or clinically significant change or no reliable change in EDI-2. Length of stay, depression and body dissatisfaction were negative predictors of a clinically significant change. Inpatient treatment is effective in about two thirds of adolescents with AN and should be considered when outpatient treatment fails. About one third of patients showed significant weight gain, but did not improve regarding overall ED symptomatology. Future studies should focus on treatment strategies for non-responders.

Identifying neuroanatomical signatures of anorexia nervosa: a multivariate machine learning approach

BACKGROUND

There are currently no neuroanatomical biomarkers of anorexia nervosa (AN) available to make clinical inferences at an individual subject level. We present results of a multivariate machine learning (ML) approach utilizing structural neuroanatomical scan data to differentiate AN patients from matched healthy controls at an individual subject level.

METHOD

Structural neuroimaging scans were acquired from 15 female patients with AN (age = 20, s.d. = 4 years) and 15 demographically matched female controls (age = 22, s.d. = 3 years). Neuroanatomical volumes were extracted using the FreeSurfer software and input into the Least Absolute Shrinkage and Selection Operator (LASSO) multivariate ML algorithm. LASSO was 'trained' to identify 'novel' individual subjects as either AN patients or healthy controls. Furthermore, the model estimated the probability that an individual subject belonged to the AN group based on an individual scan.

RESULTS

The model correctly predicted 25 out of 30 subjects, translating into 83.3% accuracy (sensitivity 86.7%, specificity 80.0%) (p < 0.001; χ 2 test). Six neuroanatomical regions (cerebellum white matter, choroid plexus, putamen, accumbens, the diencephalon and the third ventricle) were found to be relevant in distinguishing individual AN patients from healthy controls. The predicted probabilities showed a linear relationship with drive for thinness clinical scores (r = 0.52, p < 0.005) and with body mass index (BMI) (r = -0.45, p = 0.01).

CONCLUSIONS

The model achieved a good predictive accuracy and drive for thinness showed a strong neuroanatomical signature. These results indicate that neuroimaging scans coupled with ML techniques have the potential to provide information at an individual subject level that might be relevant to clinical outcomes.

Body-weight perception and related preoccupations in a large national sample of adolescents

OBJECTIVES

This study aimed to investigate the association between body-weight (BW) perception, weight preoccupation and behaviour, including weight control practices and compulsive over-eating episodes, across gender and actual BW classes.

DESIGN

This study used a cross-sectional observational study.

PARTICIPANTS

A large, nationally representative sample of 6404 ninth-grade French adolescents was randomly selected from schools throughout France.

METHODS

Weight and height were measured, and BW preoccupation, BW control practices and compulsive over-eating were self-reported using standardized questionnaires.

RESULTS

Nearly one-third of adolescents misperceived their BW. Misperception was more frequent among girls than boys (42.2% vs. 27.3%, P < 0.01). Underestimation of BW among overweight adolescents, like BW overestimation among underweight adolescents, was associated with less preoccupation with weight and fewer weight control practices than accurate perception of BW. Normal weight adolescents who overestimated their BW were more likely to declare weight preoccupations (ORa = 8.66 [6.67-11.25]), dieting (ORa = 4.81 [3.68-6.27]) and recurrent compulsive over-eating episodes (ORa = 2.36 [1.72-3.23]) compared with their counterparts who correctly estimated their BW.

CONCLUSION

Our study underlines the role of these associations in each category of actual BW (underweight, normal weight and overweight) in a large national sample.

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.