The relationship between psychopathology, eating disorder diagnosis, and clinical outcome at 10-year follow-up in anorexia nervosa

Personality trait risk factors for attempted suicide among young women with eating disorders

Objective

Clinical observations and a review of the literature led us to hypothesize that certain personality and character traits could provide improved understanding, and thus improved prevention, of suicidal behaviour among young women with eating disorders.

Method

The clinical group consisted of 152 women aged between 18 and 24 years, with DSM-IV anorexia nervosa/restrictive type (AN-R = 66), anorexia nervosa/purging type (AN-P = 37), bulimia nervosa/non-purging type (BN-NP = 9), or bulimia nervosa/purging type (BN-P = 40). The control group consisted of 140 subjects. The assessment measures were the Minnesota Multiphasic Personality Inventory—second version (MMPI-2) scales and subscales, the Beck Depression Inventory (BDI) used to control for current depressive symptoms, plus a specific questionnaire concerning suicide attempts.

Results

Suicide attempts were most frequent in subjects with purging behaviour (30.0% for BN-P and 29.7% for AN-P). Those attempting suicide among subjects with eating disorders were mostly students (67.8%). For women with AN-R the scales for ‘Depression’ and ‘Antisocial practices’ represented significant suicidal risk, for women with AN-P the scales for ‘Hysteria’, ‘Psychopathic deviate’, ‘Shyness/Self-consciousness’, ‘Antisocial Practices’, ‘Obsessiveness’ and ‘Low self-esteem’ were risk indicators and for women with BN-P the ‘Psychasthenia’, ‘Anger’ and ‘Fears’ scales were risk indicators.

Conclusion

This study provides interesting results concerning the personality traits of young women with both eating disorders and suicidal behaviour. Students and those with purging behaviour are most at risk. Young women should be given more attention with regard to the risk of suicide attempts if they: (a) have AN-R with a tendency to self-punishment and antisocial conduct, (b) have AN-P with multiple physical complaints, are not at ease in social situations and have antisocial behaviour, or (c) if they have BN-P and tend to be easily angered with obsessive behaviour and phobic worries. The MMPI-2 is an interesting assessment method for the study of traits indicating a risk of suicidal behaviour in young subjects, after controlling for current depressive pathology.

The management of anorexia nervosa

The severity of anorexia nervosa can vary from mild to life threatening. It is sometimes transient but often chronic. Such variety of disorder requires variety of response. The clinician must choose the right treatment to offer at the right time. The literature contains plenty of advice but most of this is based upon experience and opinion rather than on systematic research and treatment trials. For the most part, this paper will be no exception. Anorexia nervosa is a disorder which is distinct from other psychiatric syndromes but is of uncertain cause. In the face of this uncertainty, treatment tends to be informed by the favoured formulation of the clinician, usually some sort of ‘multifactorial theory’. Again this paper is no exception. It will concentrate upon the management of anorexia nervosa in late adolescence and adulthood. The treatment of children requires a different approach (Lask & Bryant-Waugh, 1993). The emphasis of the paper will be upon what can go wrong as well as what may be the best interventions to offer. Often the things that go wrong have more to do with the context of treatment and the way in which it is offered rather than with the treatment intervention itself.

Psychiatric co-morbidity in women presenting across the continuum of disordered eating

OBJECTIVE

To compare the prevalence and correlates of psychiatric co-morbidity across a large sample of college women without an eating disorder, those at high risk for an eating disorder and women diagnosed using DSM-5 criteria for an eating disorder.

PARTICIPANTS

549 college women aged 18-25.

METHODS

Data from the Eating Disorder Examination, the Structured Clinical Interview for DSM-IV Axis I disorders and self-report questionnaires were analyzed using logistic regression for categorical data and ANCOVA for continuous measures.

RESULTS

Eating disordered symptomatology was strongly associated with anxiety disorders, mood disorders and insomnia. These co-morbidities (type and severity) tend to increase with eating disorder symptom severity.

CONCLUSIONS

Prevention and treatment programs for eating disorders need to address the high levels of mood, anxiety and sleep problems in this population. The findings on insomnia are novel and suggest that sleep disturbance may play an integral role in eating-related difficulties.

General psychopathology in anorexia nervosa: the role of psychosocial factors

The aim of the present study was to investigate psychosocial correlates of comorbid psychopathology. Data were collected from a total of 90 female inpatients with anorexia nervosa (AN). Higher levels of general psychopathology were detected in depression, interpersonal sensitivity, obsessive-compulsive and anxiety subscales of the Symptom Checklist (SCL)-90. Regression analysis also revealed that higher levels of psychopathology across SCL-90 subscales in AN patients are significantly associated with an earlier age of onset of the condition, higher levels of anorectic psychopathology as measured by Eating Disorders Examination, lower self-esteem as measured by Multidimensional Self-Esteem Inventory and social support levels as measured by Quality of Social Network and Social Support Questionnaire. Considering the high levels of general psychopathology in people with AN, routine clinical practice should aim for a comprehensive assessment of such. Given the strong association between psychosocial factors such as self-esteem, social support and general psychopathology, psychological therapies could play an important role in facilitating emotional recovery.

An evaluation of the effectiveness and short-term stability of an innovative Australian day patient programme for eating disorders

There is a dearth of literature evaluating day patient treatment for eating disorders based upon the targeted goals of treatment, to conclude that day patient programmes are effective. This study aimed to explore the effectiveness of an innovative day patient programme by examining whether the seven key treatment goals improved across treatment and were maintained 3 months after discharge. Of the 58 participants who completed measures assessing BMI, eating disorder cognitions, behaviours, core beliefs, readiness to change, quality of life and perpetuating factors at admission, discharge and follow-up, 44 completed the day programme with 14 non-completers. The results demonstrated that all seven treatment goals improved across treatment and the improvements were maintained or further improved at 3 month follow-up. The results are discussed in context of the published day patient programme literature with implications for future research to maximise optimal treatment outcomes from day patient treatment.

The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM

Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder (ED) diagnosis. In this meta-analysis, the authors aimed to inform Diagnostic and Statistical Manual of Mental Disorders revisions by comparing the psychopathology of EDNOS with that of the officially recognized EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). A comprehensive literature search identified 125 eligible studies (published and unpublished) appearing in the literature from 1987 to 2007. Random effects analyses indicated that whereas EDNOS did not differ significantly from AN and BED on eating pathology or general psychopathology, BN exhibited greater eating and general psychopathology than EDNOS. Moderator analyses indicated that EDNOS groups who met all diagnostic criteria for AN except for amenorrhea did not differ significantly from full syndrome cases. Similarly, EDNOS groups who met all criteria for BN or BED except for binge frequency did not differ significantly from full syndrome cases. Results suggest that EDNOS represents a set of disorders associated with substantial psychological and physiological morbidity. Although certain EDNOS subtypes could be incorporated into existing Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) categories, others-such as purging disorder and non-fat-phobic AN-may be best conceptualized as distinct syndromes. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

A pilot study of personality pathology in patients with anorexia nervosa: modifiable factors related to outcome after hospitalization

OBJECTIVE

To assess improvement in aspects of personality in patients hospitalized with anorexia nervosa (AN) and its relationship to improved depression, body mass index (BMI), and eating disorder outcome after treatment.

METHOD

Twenty females hospitalized with AN completed intake and discharge assessments of BMI, depression and eating disorder severity, as well as personality pathology with the Minnesota Multiphasic Personality Inventory (MMPI-2) and the Revised NEO Personality Inventory (NEO PI-R). Clinical outcome for a subset of patients at 1-year post-hospitalization was determined.

RESULTS

The only factor that predicted better versus worse outcome at 1-year post-hospitalization was change in Low Self-Esteem (LSE) from the MMPI-2. Improved LSE from admission to discharge predicted remission at 1-year post-hospitalization, while worsening LSE predicted relapse. Regardless of outcome, NEO PI-R Neuroticism remained pathologically elevated in AN patients during hospitalization.

DISCUSSION

Pathological levels of neuroticism may represent a vulnerability factor for AN. In contrast, self-esteem appears to be a modifiable factor that predicts outcome following hospitalization, and may be an important target for treatment.

Eighty-five per cent of what? Discrepancies in the weight cut-off for anorexia nervosa substantially affect the prevalence of underweight

BACKGROUND

DSM-IV cites <85% of expected body weight (EBW) as a guideline for the diagnosis of anorexia nervosa (AN) but does not require a specific method for calculating EBW. The purpose of the present study was to determine the degree to which weight cut-off calculations vary across studies, and to evaluate whether differential cut-offs lead to discrepancies in the prevalence of individuals who are eligible for the AN diagnosis.

METHOD

Two coders independently recorded the EBW calculation methods from 99 studies that either (a) compared individuals with AN to those with subclinical eating disorders or (b) conducted AN treatment trials. Each weight cut-off was applied to a nationally representative (n=12001) and treatment-seeking (n=189) sample to determine the impact of EBW calculation on the proportion who met the AN weight criterion.

RESULTS

Coders identified 10 different EBW methods, each of which produced different weight cut-offs for the diagnosis of AN. Although only 0.23% of the national sample met the lowest cut-off, this number increased 43-fold to 10.10% under the highest cut-off. Similarly, only 48.1% of treatment seekers met the lowest cut-off, whereas 89.4% met the highest.

CONCLUSIONS

There is considerable variance across studies in the determination of the AN weight cut-off. Discrepancies substantially affect the proportion of individuals who are eligible for diagnosis, treatment and insurance reimbursement. However, differences may not be fully appreciated because the ubiquitous citation of the 85% criterion creates a sense of false consensus.

Time to remission for eating disorder patients: a 2(1/2)-year follow-up study of outcome and predictors

The aim of the present study was to analyse outcome, time to remission, and predictors of time to remission in a cohort of Danish eating disorder patients. Seventy-eight patients (35 anorexic, 30 bulimic and 13 unspecified eating disorder patients) were interviewed 2(1/2) years after initial assessment. Method of assessment was Eating Disorder Examination (EDE), Longitudinal Interval Follow-up Evaluation of Eating Disorders (LIFE-EAT-II), Eating Disorder Inventory (EDI), Symptom Check List (SCL-90R), Present State Examination (PSE) and the Structured Clinical Interview for DSM-III-R Axis-II (SCID-II). Method of analysis was Kaplan-Meier estimate of survival, Log Rank test and Cox regression analysis. In total 48.7% reached remission with mean time to remission at 27 months. A trend difference between the diagnostic groups when measuring time to remission was found, i.e. patients with unspecified eating disorders remitted faster than bulimic (BN) patients who in turn remitted faster than anorexic (AN) patients. Body mass index (BMI) at baseline was the best predictor of time to remission for the total sample. Predictors differed when looking at diagnostic groups separately. Final outcome was comparable with earlier studies while relapse frequency was low. Patients with AN remitted faster than found in earlier survival analysis studies, while the remission rate for BN patients was comparable with earlier studies. Despite the prognostic value of BMI for the total sample, predictor analysis implied more disorder diversity than homogeneity.

Outcomes of eating disorders: a systematic review of the literature

OBJECTIVE

The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center systematically reviewed evidence on factors associated with outcomes among individuals with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) and whether outcomes differed by sociodemographic characteristics.

METHOD

We searched electronic databases including MEDLINE and reviewed studies published from 1980 to September, 2005, in all languages against a priori inclusion/exclusion criteria and focused on eating, psychiatric or psychological, or biomarker outcomes.

RESULTS

At followup, individuals with AN were more likely than comparisons to be depressed, have Asperger's syndrome and autism spectrum disorders, and suffer from anxiety disorders including obsessive-compulsive disorders. Mortality risk was significantly higher than what would be expected in the population and the risk of suicide was particularly pronounced. The only consistent factor across studies relating to worse BN outcomes was depression. A substantial proportion of individuals continue to suffer from eating disorders over time but BN was not associated with increased mortality risk. Data were insufficient to draw conclusions concerning factors associated with BED outcomes. Across disorders, little to no data were available to compare results based on sociodemographic characteristics.

CONCLUSION

The strength of the bodies of literature was moderate for factors associated with AN and BN outcomes and weak for BED.

Psychopathological features of patients with prolonged anorexia nervosa as assessed by the Minnesota Multiphasic Personality Inventory

OBJECTIVE

The duration of illness is quite long in some anorexia nervosa (AN) patients. In the present study, we investigated the psychopathological features of patients with prolonged AN as assessed by the Minnesota Multiphasic Personality Inventory-1 (MMPI-1).

METHODS

Fifty-five AN patients completed the MMPI-1 on admission to Kyushu University Hospital from 1999 to 2002. The patients were divided into three groups on the basis of their illness duration: a short-term group, less than 5 years of illness duration (n=31); a middle-term group, from 5 to 10 years (n=14); and a prolonged group, 10 years or more (n=10).

RESULTS

The prolonged group scored significantly higher on the MPPI-1 scales of hysteria (Hy), low back pain (Lb) and family conflict than the short-term group.

DISCUSSION

AN patients whose illness duration was prolonged characteristically had more hysteria with family conflict. This should be considered in their treatment.

Eating disorders and personality: A methodological and empirical review

Methodological approaches utilized to evaluate models of the relationship between personality and eating disorders, as well as empirical support for each model, are reviewed. Limited prospective research suggests that negative emotionality, perfectionism, drive for thinness, poor interoceptive awareness, ineffectiveness, and obsessive-compulsive personality traits are likely predisposing factors. Limited family study research suggests that obsessive-compulsive personality disorder (OCPD) and anorexia nervosa share a common familial liability. Potential pathoplastic personality factors include Cluster B personality disorders and OCPD, which predict a poorer course and/or outcome, and histrionic personality traits and self-directedness, which predict a more favorable course and/or outcome. Future research should focus upon sophisticated prospective and family study research in order to best evaluate competing models of the eating disorder-personality relationship.

Anorexia nervosa: definition, epidemiology, and cycle of risk

Anorexia nervosa is a debilitating psychiatric disorder with profound biological, psychological, and social consequences. After an initial evaluation of the most widely used diagnostic criteria for anorexia nervosa, this paper reviews genetic and environmental risk factors for the development of anorexia with special emphasis on gene environment interplay and the impact of adverse perinatal events.

Time course of symptom remission in eating disorders

OBJECTIVE

The study was carried out to test whether time to remission varies for different eating disorder symptoms.

METHOD

Sixty-five patients (35 anorexic patients and 30 bulimic patients) treated with psychotherapy were interviewed 2 1/2 years after initial assessment.

RESULTS

The anorexic physical symptoms remitted before the psychological symptoms of anorexia and bulimia nervosa, as did the bulimic behaviors: binging and purging. Nonpurging compensatory behavior and obsession with weight and shape were the last symptoms to remit. Differences between the anorexic and bulimic groups were found between the remission order of psychological symptoms.

DISCUSSION

In spite of different treatments and symptoms between patients, the results support the notion of a common pattern in the process of change including a long and stepwise course. The results detail a template of the course to recovery for eating disorders.

Review of studies evaluating psychotherapy in bulimia nervosa: The influence of research methods

The purpose of the study was to test if design and research methods of studies predict outcome results of bulimia nervosa. Fifty-seven articles on outcome of bulimia nervosa were found through MEDLINE and PSYCHINFO databases and 25 were included in the statistical analysis. Percentages of patients with a good outcome ranged from 24% to 74% with a mean of 51.1%. The variables best predicting outcome were time to follow-up and number of symptoms evaluated in definition of good outcome whereas dropout, design of studies, treatments, and sample characteristics did not predict significantly. The implications of these findings are discussed.

Significant linkage on chromosome 10p in families with bulimia nervosa

Bulimia nervosa (BN) is strongly familial, and additive genetic effects appear to contribute substantially to the observed familiality. In turn, behavioral components of BN, such as self-induced vomiting, are reliably measured and heritable. To identify regions of the genome harboring genetic variants conferring susceptibility to BN, we conducted a linkage analysis of multiplex families with eating disorders that were identified through a proband with BN. Linkage analysis of the entire sample of 308 families yielded a double peak, with the highest nonparametric multipoint maximum LOD score (MLS), of 2.92, on chromosome 10. Given the high heritability of self-induced vomiting and the reliability with which it can be measured, we performed linkage analysis in a subset (n=133) of families in which at least two affected relatives reported a symptom pattern that included self-induced vomiting. The highest MLS (3.39) observed was on chromosome 10, between markers D10S1430 and D10S1423. These results provide evidence of the presence of a susceptibility locus for BN on chromosome 10p. Using simulations, we demonstrate that both of these scores, 2.92 and 3.39, meet the widely accepted criterion for genomewide significance. Another region on 14q meets the criterion for genomewide suggestive linkage, with MLSs of 1.97 (full sample) and 1.75 (subset) at 62 centimorgans from p-ter.

Outcome in adolescent anorexia nervosa

The present paper compares course and outcome of adolescent anorexia nervosa to that of adult onset forms. In recent studies earlier onset of anorexia nervosa was associated with higher recovery rates and a lower mortality, although even in adolescent patients anorexia nervosa takes a prolonged course. A chronic eating disorder bears a high risk of other comorbid psychiatric or personality disorders. The most prevalent disturbances were anxiety and affective disorders and anxious-fearful-obsessive personality disorders, respectively. Patients who substantially overcame their eating disorder did not differ from normal controls in respect to psychosocial functioning, e.g. family relationships, partnership and occupational status. These results should encourage us to treat the eating disorder vigorously.

Eating disorders in adolescents and young adults

Adolescence and young adulthood mark the convergence of substantial biologic and social change. Individuals differ in their innate capacity to tolerate change. Research suggests that some of the personality characteristics that are fundamental to individuals with eating disorders may render them particularly vulnerable to the impact of a changing body and changing social demands. The fact that eating disorders emerge primarily during adolescence and often run a protracted course can deprive the afflicted individual of the core social, emotional, and biologic developmental processes that normally occur during this time of life.

Outcome of severe anorexia nervosa patients receiving inpatient treatment in Japan: an 8-year follow-up study

Sixty-one subjects with anorexia nervosa (AN) were followed for a minimum of 4 years after discharge (mean 8.3 years). They were evaluated using the Morgan-Russell Outcome Assessment Scale. Thirty-one (51%) were categorized as having good outcome, eight (13%) as intermediate, 15 (25%) as poor, and seven (11%) had died. As predictors of outcome, later onset (after 20 years of age) and low minimum body mass index were associated with poor prognosis. The outcome of AN in Japan is relatively similar to those in Western countries, irrespective of different sociocultural backgrounds and health systems.

MMPI-2 in the inpatient assessment of women with eating disorders

The MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) reveals similar patterns across all Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) eating-disorder diagnoses. In this study, 550 women with eating disorders completed the MMPI-2. The 3 highest mean elevations for all eating-disorder diagnostic groups occurred on the same scales in the same order: 2, 7, and 3. The modal code for all groups was 2-7/7-2. However, multivariate analyses using the 16 validity and clinical scales, as well as the 27 content and supplementary scales, indicated that the MMPI-2 also distinguishes among eating disorders, especially in that patients with restricting anorexia report less psychopathology than other groups. These results are compared with the results of past eating-disorder research that used the older MMPI (Hathaway & McKinley, 1983).

MMPI-A in the inpatient assessment of adolescents with eating disorders

The MMPI-A (Butcher et al., 1992), like the older MMPI (Hathaway & McKinley, 1983), distinguishes between anorexia and bulimia. In this study, 245 adolescent girls diagnosed with anorexia, bulimia, or eating disorder not otherwise specified completed the MMPI-A. Multivariate analyses revealed significant differences between anorexia and bulimia on the MMPI-A's validity, clinical, content, and supplementary scales, particularly suggesting multiple impulse control problems among bulimic patients. However, profiles were also more homogeneous across eating disorder groups than in studies using the older MMPI, with high points involving some combination of Scales 1, 2, 3, and 0 for two thirds of the patients in this study. Implications are considered for understanding the common and differential psychopathology of eating disorders.

Personality and affectivity characteristics associated with eating disorders: a comparison of eating disordered, weight-preoccupied, and normal samples

The purpose of this study was to assess the relative contribution of personality and emotional experience to self-reported eating attitudes in a group of patients with clinically diagnosed eating disorders, a weight-reduction training group (Weight Watchers), and a control group without body weight problems. Participants in this study (N = 114) completed Estonian versions of the Eating Disorder Inventory-2 (EDI-2; Garner, 1991), NEO Personality Inventory (Costa & McCrae, 1989), and Positive Affect and Negative Affect Schedule, Expanded Form (Watson & Clark, 1994). Data demonstrated validity of the Estonian version of EDI-2 in its ability to identify problems on a continuum of disordered eating behavior. Among the Big Five personality dimensions, Neuroticism made the largest contribution to EDI-2 subscales. Two other dimensions, Openness to Experience and Conscientiousness, also predispose individuals to eating problems. Personality traits made a larger contribution to the self-reported eating pathology than the self-rated effects experienced during the last few weeks. It was argued that personality dispositions have a larger relevancy in the etiology of eating disorders than emotional state.

Long-term course of anorexia nervosa: response, relapse, remission, and recovery

There is no predictable or normative long-term course associated with anorexia nervosa. Some Individuals achieve complete recovery; others are ravaged by a chronic disorder; and some die from it. Predicting course and outcome of anorexia nervosa is complicated by the intrinsic complexity of the disorder; a lack of shared terminology in studying the disorder; and a paucity of controlled clinical treatment studies. This manuscript provides a review of the current state of knowledge based on the long-term studies and discusses ways in which methodological issues limit our ability to generalize more confidently regarding the course and outcome of anorexia nervosa. In order to advance the field, we need to bridge the gap between treatment outcome studies and naturalistic follow-up studies. Further we need to devine more carefully and consistently the milestones of initial treatment response, relapse, remission, and recovery. Building on previous works, criteria for each of these terms are proposed. Based on existing studies, a discussion of treatment outcome and prognostic factors is provided. Finally, clinical recommendations are provided for the clinician who is responsible for the long-term care of an individual with anorexia nervosa.

Construction and validation of an anorexia nervosa scale on the MMPI

The article describes the construction and validation of an anorexia nervosa subscale (ANOR) on the Minnesota Multiphasic Personality Inventory (MMPI). The female subjects included 42 anorexic patients, 56 normal controls and 56 patient controls. Using an empirical discrimination procedure, 60 items contribute to the total homogeneity of the scale and the Chronbach's alpha is 0.86. The five items common with the Hysteria scale represent the highest number of common items with the main MMPI clinical scales. Crossvalidation findings support the results. Content analyses indicate that the ANOR covers important features of anorexia nervosa like a fear of sexual matters, disturbed social relations, rigidity, a depressed mood, low self esteem and a dissatisfaction with appearance.

Psychopathology in obese subjects with and without binge-eating disorder and in bulimic subjects

The present study was conducted with three groups of 15 subjects each, obese subjects diagnosed with Binge Eating Disorder, obese subjects without diagnosis of Binge Eating Disorder, and bulimic subjects. The aim was to compare the three groups on a battery of self-administered tests for psychodiagnostic screening. Analysis showed a clear pattern: patients with bulimia nervosa had higher pathological scores in the specific area of eating disorders than did obese patients, whereas patients with Binge Eating Disorder tended to score lower than patients with bulimia nervosa and higher than did the obese patients. This general pattern is very similar to the findings recently reported in the literature and suggests the adoption of a clinical approach which takes into account the different characteristics of the three groups.

A comparative analysis of Minnesota Multiphasic Personality Inventory profiles of anorexia nervosa at hospital admission, discharge, and 10-year follow-up

The assessment of personality variables measured by the Minnesota Multiphasic Personality Inventory (MMPI), was compared in a sample of 52 female inpatients with anorexia nervosa at the time of hospitalization, discharge from hospital, and 10 years after treatment. Admission MMPI scores were significantly higher than scores both at discharge and 10 years later. There were no significant overall differences between discharge and follow-up evaluation. Discharge, but not admission, MMPI scores were positively correlated with 10-year follow-up study on seven of 10 clinical MMPI scales (all but hypochondriasis, masculinity/femininity, and hypomania). At follow-up evaluation, eating disorder poor outcome was associated with higher MMPI scores. There was no significant difference on admission MMPI scores between the four outcome groups; however, patients who recovered had a greater decrease in MMPI scores at the 10-year follow-up study compared with poor outcome patients. The long-term outcome of anorexia nervosa was largely unrelated to the severity of psychopathology during the acute phase of the illness. These results suggest that persistent personality features are best measured following treatment of acute symptomatology of anorexia nervosa.

Follow-up investigation of family relations in patients with anorexia nervosa

In a group of 22 formerly anorectic inpatients (follow-up 3.8 years after treatment) and in a control group of 24 paralleled young women, the subjective perception of the family structure was assessed using the "Subjective Family Image (SFI)", in order to investigate the question whether the family structure of former anorectics differs from the controls and whether individual development of the former inpatients is associated with the experienced family structure. Empirical results are in favor of the following two hypotheses: 1) Compared to the control group, formerly anorectic inpatients experience family relationships as more complicated and less satisfying. The quality of family relationships in the patient group is reduced, even at the time of follow-up. 2) Individual outcome (individual course of the illness) and quality of family relationships at time of follow-up are associated. Patients with a good outcome experience family relationships as more positive than patients with a poor outcome. The accordance of these findings to other empirical results and their implications for clinical practice are discussed.

The predictive value of depression in anorexia nervosa. Results of a seven-year follow-up study

This study investigated the predictive value of depression in patients with adolescent anorexia nervosa. Thirty-four anorectic inpatients were assessed for DSM-III-R comorbid major depression at admission and at 3-year and 7-year follow-ups. Two standardized instruments, the Zung Self-rating Depression Scale and the Hamilton Depression Rating Scale, were applied to improve objective rating of depression. The findings suggest that severity of depressive symptoms at admission does not correlate with the severity of depression at follow-up, initial depressive psychopathology is not a valid prognostic indicator for the outcome of the eating disorder and at follow-up there is a highly significant relationship between depression and the outcome of anorexia nervosa. Patients with persisting eating disorder are also very likely to suffer from comorbid depression.

Ten-year follow-up of anorexia nervosa: clinical course and outcome

The clinical course and outcome of anorexia nervosa are presented in a 10-year follow-up study of 76 severely ill females with anorexia nervosa who met specific diagnostic criteria and had participated in a well-documented hospital treatment study. Information was obtained on 100% of the subjects. A comprehensive assessment was made in 93% of the living subjects in specific categories of weight, eating and weight control behaviours, menstrual function, anorexic attitudes, and psychological, sexual, social and vocational adjustment. Five subjects had died, which gives a crude mortality rate of 6.6%. Standardized mortality rates demonstrated an almost 13-fold increase in mortality in the anorexia nervosa subjects. Only eighteen (23.7%) were fully recovered. Sixty-four per cent developed binge-eating at some time during their illness, 57% at least weekly. Twenty-nine (41%) were still bulimic at follow-up. The high frequency and chronicity of the bulimic symptoms plus the high rate of weight relapse (42% during the first year after hospital treatment) suggest that intensive intervention is needed to help anorexics restore and maintain their weight within a normal range and to decrease abnormal eating and weight control behaviours.