Long-term follow-up of adolescent onset anorexia nervosa in northern Sweden

Impaired implicit learning in adults with anorexia nervosa

OBJECTIVE

Cognitive alterations play an important role in the pathophysiology and treatment of anorexia nervosa (AN). Previous studies suggest that some implicit learning processes may be inhibited in AN. However, this has not yet been fully explored. The purpose of this study is to analyze implicit learning in patients with AN in comparison to healthy controls.

METHODS

In this pilot-study, a total of 21 patients diagnosed with AN and 21 matched controls were administered the weather prediction task (WPT), a probabilistic implicit category learning task that consists of two sub-variants. During the feedback (FB) version of the task, participants learn associations between tarot cards and weather outcomes via an operant learning model through which they receive immediate FB on their answers, whereas during the paired associate (PA) variant, participants are directly asked to memorize given associations.

RESULTS

AN patients showed selective impairment on the FB task where they scored significantly lower both in comparison to controls (p = .001) who completed the same task and when compared to their own performance on the PA variant (p = .006). Clinical measures showed no significant correlations with test scores.

DISCUSSION

Our results demonstrate implicit FB learning deficiencies in adult patients with AN. These impairments may have an impact on the effect of psychotherapeutic interventions and could partially explain the lack of treatment response in AN. Further studies are necessary to derive when and through which mechanisms these alterations originate, and to what extent they should be considered during treatment of the disorder.

PUBLIC SIGNIFICANCE

Cognitive impairments pose a challenge in the management of anorexia nervosa. Improved comprehension of cognitive alterations could lead to a greater understanding of the disease and adaptation of psychotherapeutic treatments. In this study, we found that implicit feedback learning in anorexia nervosa is impaired compared to healthy controls. This could indicate the necessity of treatment adaptations in the form of therapy tools without feedback and a larger focus on psychoeducation.

Long-term outcome in males with anorexia nervosa: A prospective, sex-matched study

OBJECTIVE

The objective of this study is to report on the 5.5-years outcome of anorexia nervosa (AN) in male adolescent inpatients and compare it to the outcome of female adolescent inpatients with AN.

METHOD

Diagnostic eating disorder outcome was assessed by the Structured Inventory of Anorexic and Bulimic Syndromes (DSM-IV) in 20 males and 20 females matched for AN diagnosis, age at treatment, and length of follow-up. For documentation, follow-up scores of the Eating Disorder Inventory and the Brief Symptom Inventory are reported.

RESULTS

Diagnostic outcome did not differ between sexes. Four male and six female participants had AN at follow-up. One male and four females had crossed to bulimia nervosa, and five males and three females to eating disorder not otherwise specified. Remission was found in 10 males and 7 females. Effect sizes were mostly small. At follow-up females had higher scores than males with large effect sizes for drive for thinness (Cohen's d = 0.86) and body dissatisfaction (d = 1.07).

DISCUSSION

Few significant sex differences were found. Additional research involving larger samples of males and a broader range of assessed outcomes (e.g., drive for muscularity) in both sexes is urgently needed.

Severe and enduring anorexia nervosa: Update and observations about the current clinical reality

Several objectives underlie the current article. First, to review historical diagnostic issues and clinical strategies for treating SE-AN. Second, to provide an overview of recent evidence informed strategies and clinical innovations for the treatment of SE-AN. Third, based on the authors' collective clinical and research experience, we offer eight observations that we believe capture the current clinical experience of patients with SE-AN. Some of these observations represent empirically testable hypotheses, but all are designed to generate a meaningful discussion about the treatment of this group of individuals with eating disorders. Finally, we hope to call clinicians, scientists, professional organizations, advocates, and policy makers to action to attend to critical issues related to the care of individuals with SE-AN. We believe that an international discussion could clarify areas of need for these patients and identify opportunities for clinical innovation that would enhance the lives of individuals with SE-AN and their families.

Changes in disordered eating behaviors over 10 or more years: A meta-analysis

OBJECTIVE

The present meta-analysis evaluated changes in individuals' risk of engaging in distinct disordered eating behaviors (DEBs) in the long-term.

METHOD

Longitudinal studies assessing changes in DEBs via ≥2 assessments with a time lag of ≥10 years were included. Risk ratios were calculated for baseline to 10-14.9-year (M = 11.04) follow-up and baseline to ≥15-year (M = 18.62) follow-up changes in the use of binge eating, multiple purging, self-induced vomiting, laxatives, diuretics, diet pills, compensatory exercising, fasting/dieting, and multiple DEBs; Cohen's d was used for continuous binge-eating plus purging variable changes. Subgroup and meta-regression analyses tested whether eating disorder (ED) clinical sample versus nonclinical sample status, female versus male sex/gender, higher versus lower study bias, and baseline mean age and body mass index influenced overall effect magnitude for analyses with sufficient data.

RESULTS

Seventeen studies (26 [sub]samples) were included. Overall, individuals' risk of engaging in various restrictive eating and other compensatory behaviors decreased over time and the magnitudes of risk reductions for the use of certain compensatory DEBs were larger over longer follow-up durations. Specifically, for significant DEB change models, risk reductions spanned from 20.0-39.8% for 10-year follow-up and 24.7-74.8% for ≥15-year follow-up. However, nuances were found in the nature of these DEB changes as a function of DEB type, follow-up length, ED versus nonclinical sample composition, and baseline mean age.

CONCLUSIONS

These findings provide important information that can help identify treatment priorities and suggest that targeted and tailored preventative ED treatments warrant consistent implementation at the community-level, particularly for youth.

Long-term follow up of hospitalized pediatric anorexia nervosa restricting type

BACKGROUND

Information on long-term follow up of childhood-onset anorexia nervosa is scarce. This study investigated long-term (>10 years) course, outcome and prognostic factors for hospitalized childhood-onset anorexia nervosa restricting type (ANR).

METHODS

Forty-one ANR girls admitted to a single regional center participated. Median age at first admission was 13.3 years (range, 8.6-15.6 years). The longitudinal clinical course was retrospectively determined for a median follow-up period of 17.1 years (range, 10.4-21.1 years). We analyzed physical, psychological, and social variables to predict partial remission (PR) and full remission (FR).

RESULTS

The completion rate of follow up >10 years was high at 97%. At final evaluation (n = 38), distribution of prognosis was as follows: FR, n = 27 (71%); PR, n = 6 (16%); and non-remission, n = 5 (13%). The cumulative ratio of PR and FR increased during the first 5-6 years, and gradually reached a plateau at around 10 years. More than 10 years after the onset, one patient eventually achieved FR, and one patient died. Seven patients were rehospitalized and two died due to suicide during the entire follow up. On multivariate analysis, family disorders/problems rating score was a significant predictor of PR and FR.

CONCLUSIONS

This study included hospitalized ANR children aged ≤15 years, the youngest cohort ever reported. Long-term prognosis is generally favorable, but the mortality rate was 5%. Careful long-term follow up >10 years is needed to evaluate outcome of childhood-onset ANR, and family therapy is important in high-risk patients with family disorders/problems.

Anorexia nervosa

Anorexia nervosa (AN) is a psychiatric condition characterized by severe weight loss and secondary problems associated with malnutrition. AN predominantly develops in adolescence in the peripubertal period. Without early effective treatment, the course is protracted with physical, psychological and social morbidity and high mortality. Despite these effects, patients are noted to value the beliefs and behaviours that contribute to their illness rather than regarding them as problematic, which interferes with screening, prevention and early intervention. Involving the family to support interventions early in the course of the illness can produce sustained changes; however, those with a severe and/or protracted illness might require inpatient nursing support and/or outpatient psychotherapy. Prevention programmes aim to moderate the overvaluation of 'thinness' and body dissatisfaction as one of the proximal risk factors. The low prevalence of AN limits the ability to identify risk factors and to study the timing and sex distribution of the condition. However, genetic profiles, premorbid features, and brain structures and functions of patients with AN show similarities with other psychiatric disorders and contrast with obesity and metabolic disorders. Such studies are informing approaches to address the neuroadaptation to starvation and the other various physical and psychosocial deficits associated with AN. This Primer describes the epidemiology, diagnosis, screening and prevention, aetiology, treatment and quality of life of patients with AN.

And then what happened? A 5-year follow-up of eating disorder patients

BACKGROUND

Eating disorders (EDs) show a varying course and outcome. Within 10 years, between half and three-quarters of patients recover from their disorder. There is, however, a lack of consensus in how to define recovery.

AIMS

The aim of the present naturalistic study was to assess clinical and full recovery in ED patients 5 years after initiated treatment at a specialized outpatient unit for EDs.

METHODS

Data was collected at three time points: after the investigation period (T1), at the end of treatment (T2) and 5 years after the beginning of treatment (T3). Data at T1 and T2 were collected from patient records, and at T3 using a questionnaire. The number of participants was 71 and response rate 78%.

RESULTS

At T3, the proportion in clinical recovery was 83.1%, with no significant differences between diagnostic groups. The proportion in full recovery, i.e. in addition to a subjective account of being fully recovered, presenting no physical, behavioural or psychological ED symptoms, was 40.8%.

CONCLUSIONS

For most ED patients, outpatient treatment is sufficient to enable recovery. How to define and measure recovery still warrants discussion.

Clinical Problems Encountered in the Treatment of Adolescents with Anorexia Nervosa 1Both authors contributed equally

The conceptualization of anorexia nervosa (AN) depends on the diagnostic criteria. Most patients with teenage onset AN seem to remit within 3–10 years depending on the definitions of recovery. The mortality of adolescent onset anorexia nervosa (AN) has fortunately decreased over the last two decades. Based on randomized controlled trials, we review different treatments including individual and group psychotherapy, family therapy, psychopharmacology, and hormone therapy. Treatment settings vary over time for any individual patient. Despite high rates of inpatient treatment, the respective evidence for effectiveness is meager. In underage patients with severe AN clinical, ethical and legal aspects need to be dealt with systematically if intermittent compulsory treatment is deemed necessary. The prolonged and frequently chronic course of AN often entails therapeutic discontinuity; the transition into adulthood requires a graded therapeutic concept that considers the severity of the disorder, developmental and chronological age, and parental involvement. Finally, we consider future clinical and research options to improve treatment and outcome of this eating disorder.

Long term remission of anorexia nervosa: factors involved in the outcome of female patients

BACKGROUND

Anorexia nervosa (AN) is usually marked by difficult recovery.

OBJECTIVE

To elicit, describe and characterize factors involved in successful AN remission for at least five years and post-recovery life.

METHODS

A qualitative study design using semi-structured interviews according to grounded theory methodology was used. An intentional sample of 15 information rich AN patients was selected using two sampling procedures: the criterion and "snowball" techniques. Qualitative interviews were audiotaped, transcribed, and entered into a content analysis. Researchers coded transcripts and developed themes.

RESULTS

Four core parameters were found to be associated with remission: (i) 'motivation to change/stimuli'; (ii) 'empowerment/autonomy'; (iii) 'media related factors'; (iv) 'treatment factors'. Clinical remission can be associated with residual symptoms.

CONCLUSIONS

The recovery model involves not only one, but rather a set of inter-active variables, each one can partially explain remission. Media factors can take a new role on recovery. Remission, however, can be followed by remnants of the disease and functional limitations.

Somatic problems and self-injurious behaviour 18 years after teenage-onset anorexia nervosa

The aim of this study was to study long-term outcome of physical health and self-injurious behaviour (SIB) in anorexia nervosa (AN). Fifty-one adolescent-onset AN cases, originally recruited after community screening, and 51 matched controls (COMP) were interviewed regarding somatic problems and SIB and physically examined 18 years after AN onset, at mean age 32 years. Six individuals had an eating disorder (ED). No one had died. The AN group weighed less than the COMP group. The frequency of somatic problems did not differ between groups. Dental enamel lesions and shorter than expected stature occurred only in the AN group. Dysdiadochokinesis was overrepresented in the AN group and age of AN onset was lower among those with the neurological deficit. Severe SIB occurred only in the AN group, predominantly during adolescence. To conclude, somatic problems were common in both groups. Most individuals in the AN group had recovered from their ED, but weight revealed a persistent restricted eating behaviour.

Empirical classification of eating disorders

Current diagnostic criteria for anorexia nervosa (AN) and bulimia nervosa (BN) account for a minority of individuals with clinically significant disorders of eating, raising concerns about the clinical utility of current definitions. This review examines evidence for the validity of current and alternative approaches to defining eating disorders and implications for draft criteria for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Although this review largely supports the predictive validity of distinctions among AN, BN, and the newly proposed binge eating disorder (BED), it also highlights that our tendency to "study what we define" has created a gap between the problems that people have and what we know about those problems. Future research on the causes and consequences of eating disorders should include more heterogeneous groups to enable identification of meaningful boundaries that distinguish between disorders based on etiological and predictive validity.

Adolescent eating disorders: treatment and response in a naturalistic study

This naturalistic study investigated the treatment and outcome of adolescents with eating disorders (EDs) in the community. Clinicians from a practice-research network provided data on ED symptoms, global functioning, comorbidity, treatment, and outcome for 120 adolescents with EDs. ED "not otherwise specified" was the most common ED diagnosed. After an average of 8 months of treatment, about one third of patients had recovered, with patients with anorexia nervosa showing the most improvement. Clinicians utilized a range of psychotherapy interventions and two thirds of the patients had received adjunct psychoactive medication. Although CBT showed the strongest association with outcome in a subsample characterized by poor relational/personality functioning, dynamic therapy was associated with better global outcome in the overall sample.

Update on course and outcome in eating disorders

OBJECTIVE

To review recent studies describing eating disorder course and outcome.

METHOD

Electronic and manual searches were conducted to identify relevant articles published since 2004.

RESULTS

Twenty-six articles were identified. For anorexia nervosa (AN), most patients ascertained through outpatient settings achieved remission by 5-year follow-up. Inpatient treatment predicted poor prognosis as inpatient samples demonstrated lower remission rates. Outcome differed between bulimia nervosa (BN) and eating disorders not otherwise specified (EDNOS), including binge eating disorder (BED), for shorter follow-up durations; however, outcomes appeared similar between BN and related EDNOS by 5-year follow-up. Greater psychiatric comorbidity emerged as a significant predictor of poor prognosis in BN, whereas few prognostic indicators were identified for BED or other EDNOS.

DISCUSSION

Results support optimism for most patients with eating disorders. However, more effective treatments are needed for adult AN inpatients and approximately 30% of patients with BN and related EDNOS who remain ill 10-20 years following presentation.

Reproduction and offspring status 18 years after teenage-onset anorexia nervosa--a controlled community-based study

OBJECTIVE

To study reproduction in a representative group of anorexia nervosa (AN) cases.

METHOD

Fifty-one adolescent-onset AN cases (48 women; three men), originally recruited after community screening, and 51 matched comparison cases (COMP) were interviewed 18 years after AN onset at a mean age of 32 years, regarding pregnancies and early development of the children.

RESULTS

The results of the 48 AN and 48 COMP group women are reported in the present study. Six women still had an eating disorder (ED), none of whom had become a mother. Twenty-seven women in the AN group and 31 women in the COMP group had children. Three women had an ED during pregnancy. Mean age at birth of the first child was lower in the AN group. Five AN women reported postpartum depression. Children in the AN group had significantly lower birth weight than the children in the COMP group. No other complications during pregnancy and the neonatal period differed across groups. Feeding difficulties were not overrepresented among the children of the AN group.

DISCUSSION

Adults who had recovered from teenage-onset AN did not differ in most aspects from matched controls with respect to pregnancies and development of their offspring.

Adolescent-onset anorexia nervosa: 18-year outcome

BACKGROUND

The long-term outcome of anorexia nervosa is insufficiently researched.

AIMS

To study prospectively the long-term outcome and prognostic factors in a representative sample of people with teenage-onset anorexia nervosa.

METHOD

Fifty-one people with anorexia nervosa, recruited by community screening and with a mean age at onset of 14 years were compared with 51 matched comparison individuals at a mean age of 32 years (18 years after disorder onset). All participants had been examined at ages 16 years, 21 years and 24 years. They were interviewed for Axis I psychiatric disorders and overall outcome (Morgan-Russell assessment schedule and the Global Assessment of Functioning).

RESULTS

There were no deaths. Twelve per cent (n=6) had a persisting eating disorder, including three with anorexia nervosa. Thirty-nine per cent of the anorexia nervosa group met the criteria for at least one psychiatric disorder. The general outcome was poor in 12%. One in four did not have paid employment owing to psychiatric problems. Poor outcome was predicted by premorbid obsessive-compulsive personality disorder, age at onset of anorexia nervosa and autistic traits.

CONCLUSIONS

The 18-year outcome of teenage-onset anorexia nervosa is favourable in respect of mortality and persisting eating disorder.

A pilot study of a family-based treatment for adolescent anorexia nervosa: 18- and 36-month follow-ups

The current study evaluated the outcome of family-based treatment for female adolescents with anorexia nervosa (N = 32), at the Anorexia-Bulimia Outpatient Unit in Göteborg, Sweden. Patients/parents were assessed pre-treatment, at 18- and 36-month follow-ups concerning eating disorder symptoms, general psychopathology, family climate and BMI. At the 36-month follow-up, 75% of the patients were in full remission with reduction in eating disorder symptoms and internalizing problems and they experienced a less distant and chaotic atmosphere in their families. These results show that family-based treatment appears to be effective in adolescent anorexia nervosa patients regarding areas examined in this study.

Group work with female survivors of childhood sexual abuse: evidence of poorer outcomes among those with eating disorders

OBJECTIVE

This study explored levels of depression and self-esteem after childhood sexual abuse (CSA) group treatment for survivors with and without histories of eating disorders (ED).

METHODS

Fifty adult female survivors completed a 15-week CSA group treatment program and were assessed at intake, pre-group treatment, discharge, and six months follow-up using the Beck Depression Inventory, the Generalized Contentment Scale and the Index of Self-Esteem. They were also asked to report on their CSA histories and comorbid psychiatric issues including histories of ED.

RESULTS

Survivors with reported histories of anorexia nervosa or bulimia nervosa were significantly more depressed (minimum p<.05) and tended to have significantly less self-esteem (minimum p<.10) at discharge and six-month follow-up than those without ED. The size of these effects suggested their potential clinical significance as well. Seven to nine of every ten clients with histories of ED were more depressed and had lower self-esteem than the typical client without ED at discharge and at six-month follow-up.

CONCLUSION

The findings suggest that CSA treatment programs should assess survivors for ED as they might benefit from a more specialized focus on their emotional responses to the abuse.

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.

Outcome of eating disorders

Both Anorexia Nervosa (AN) and Bulimia Nervosa (BN) are marked by a serious course and outcome in many of the afflicted individuals. In AN, there are an almost 18-fold increase in mortality including a high suicide rate, chronic courses in approximately 20 per cent of the cases, and more than half of the patients showing either a complete or a partial eating disorder in combination with another psychiatric disorder or another psychiatric disorder without an eating disorder. Mitigating factors of the outcome include onset of the disorder during adolescence and longer duration of follow-up. Vomiting, bulimia and purgative abuse, chronicity, and obsessive-compulsive features represent unfavourable prognostic factors in various studies. The longer-term outcome of BN is only slightly better result as compared to AN; however, the rate of mortality is low. Diagnostic crossover from bulimia nervosa to other eating disorders is a rather rare phenomenon, whereas the high rates of partial eating disorders may explain a large proportion of chronic courses. Social adjustment and the quality of personal relationship normalize in the majority of the affected patients. At present, the study of prognostic factors in bulimia nervosa does not allow any definite conclusions.

A longitudinal study of perfectionism in adolescent onset anorexia nervosa-restricting type

This longitudinal study analyses self-reported perfectionism, eating disorders and psychiatric symptoms during recovery from anorexia nervosa (AN). With a recovered design, a group of 68 previous patients with AN was studied in two follow-up studies, 8 and 16 years after 1st admission to Child and Adolescent Psychiatry (CAP). Levels of perfectionism stayed the same while eating disorder symptoms and psychiatric symptoms decreased during recovery. Levels of perfectionism were inversely related to duration of remission so that individuals that had short illness duration had lower levels of perfectionism at both follow-ups. Patients with initial high levels of perfectionism may be at risk for a long illness duration which we recommend clinicians to acknowledge.

Causes of adolescent onset anorexia nervosa: patient perspectives

This qualitative study describes the perspectives of former anorexia nervosa (AN) patients with respect to why they believed they developed AN. Previous patients with initial treatment in child and adolescent psychiatric clinics in northern Sweden were interviewed 8 and 16 years after initial assessment. The question, "What do you think today about the reasons why you got AN?" was asked at both interviews. Content analyze was used to categorize the answers. Causes were attributed to self, family, and socio-cultural stressors outside of the family. Most common were high own demands and perfectionism. At the second follow-up there were more answers in the family categories. The results agreed with results from risk-factor research.

Patient perspectives of recovery in adolescent onset anorexia nervosa

The aim of this qualitative study was to describe the patients' perspective of the recovery process from anorexia nervosa. On average 16 years after initial assessment at child and adolescent psychiatric clinics, 68 women were interviewed about what they attributed as important factors in the recovery process of their adolescent onset anorexia nervosa. The answers were coded using content analysis. Those having recovered (n = 58) were able to describe clear turning points in their history and mentioned as most important aspects in their recovery: friends, own decisions, activities, treatment, family of origin, and own family.