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

Illness duration and treatment outcome of intensive cognitive-behavioral therapy in adolescents with anorexia nervosa

OBJECTIVE

This study aimed to compare the effectiveness of an intensive treatment based on enhanced cognitive-behavioral therapy (CBT-E) in patients aged between 12 and 18 years with anorexia nervosa with a duration of illness <3 versus ≥3 years.

METHODS

One hundred and fifty-nine consecutively treated patients (n = 122 with illness duration <3 years and n = 37 ≥ 3 years) were enrolled in a 20-week intensive CBT-E program. All patients underwent assessment at admission, end of treatment (EOT), and 20-week follow-up. The following measures were used: body mass index (BMI)-for-age percentile and percentage of expected body weight (EBW), Eating Disorder Examination Questionnaire, Brief Symptom Inventory, and Clinical Impairment Assessment.

RESULTS

Approximately 81% of eligible patients began the program, with over 80% successfully completing it. Patients with a longer or shorter duration of illness did not show significantly different treatment outcomes. In detail, BMI-for-age percentile and percentage of EBW outcomes were significantly improved from baseline to EOT, remaining stable until 20-week follow-up in both groups. Similarly, in both groups, scores for eating disorder psychopathology, general psychopathology, and clinical impairment decreased significantly at EOT and remained stable from EOT to follow-up. Furthermore, a substantial percentage of adolescents in both groups achieved a good BMI outcome at EOT and 20-week follow-up, with approximately 60% maintaining a full response at the latter time point.

DISCUSSION

These findings suggest that intensive CBT-E appears to be an effective treatment for severely ill adolescent patients with anorexia nervosa, regardless of whether the duration of illness is shorter or longer than 3 years.

PUBLIC SIGNIFICANCE

Existing treatment outcome studies in adolescents, whether randomized controlled trials or longitudinal investigations, typically involve patients with less than 3 years of illness, while data on the treatment outcomes for adolescents with anorexia nervosa with an illness duration of 3 years or over is very limited. Our findings suggest that adolescents with anorexia nervosa, irrespective of the duration of their illness, can derive similar benefits from intensively CBT-E.

Hypercapnia in hospitalized children and adolescents with anorexia nervosa as a predictive marker for readmission: a prospective study

PURPOSE

To determine whether hypercapnia is associated with risk of hospital readmission related to anorexia nervosa (AN) in children and adolescents.

METHODS

We performed a prospective study of patients ≤ 18 years old admitted due to AN decompensation from November 2018 to October 2019. Both subtypes of AN, restricting subtype (AN-R) and binge-eating/purging subtype (AN-BP), were included. Study participants were evaluated upon admission, at discharge and six months after discharge. T-tests or Mann-Whitney U tests was used to compare means values. Pearson or Spearman correlations were used to measure the association between two variables. Logistic regression models were developed to evaluate the relationship between scoring methods and readmission.

RESULTS

Of the 154 persons admitted during the study period, 131 met the inclusion criteria. Median age was 15.1 years. At admission, 71% of participants were malnourished and 33 (25%) had been previously admitted. We observed a marked decrease in venous pH and stable pCO2 elevation during follow-up period. Hypercapnia at discharge was associated with a twofold increased likelihood of readmission and the odds of readmission increased as discharge pCO2 rose. These findings did not depend on AN subtype or participant sex. Electrolytes persisted within the normal range.

CONCLUSION

Hypercapnia and respiratory acidosis are common alterations in children and adolescents hospitalized due to AN decompensation. Hypercapnia persists for at least 6 months after discharge despite clinical improvement and is associated with higher odds of readmission. This is the first study to identify an abnormal laboratory finding as a potential predictor of readmission in AN.

LEVEL OF EVIDENCE

IV: Multiple time series without intervention.

Anorexia Nervosa in Adolescence: A Comprehensive Study of Multidimensional Factors Associated with Symptom Severity 1 Year Following the Diagnosis

The overarching goal of this study was to examine the unique contribution of psychological, familial, and friendship factors in explaining anorexia nervosa (AN) symptom severity 1 year following diagnosis among a sample of adolescent girls. A second objective was to determine whether friendship factors mediated the association between psychological and/or familial factors and AN symptom severity. This study included 143 adolescent girls under the age of 18 diagnosed with AN (M = 14.84, SD = 1.31). Participants were recruited from specialized eating disorder treatment programs. At admission (T1), participants completed a set of self-report questionnaires measuring psychological, familial, and friendship factors. AN symptom severity was assessed 1 year later (T2). Results of hierarchical regression analysis revealed that greater general psychological maladjustment at T1 (b = .26; se = .03; p = .00) was associated with greater AN symptom severity at T2. Greater alienation from friends at T1 (b = 1.20, se = .53, p = .03) also predicted greater AN symptom severity at T2, above and beyond the influence of adolescent girls' general psychological maladjustment. Finally, the mediating role of alienation from friends in the association between general psychological maladjustment at T1 and AN symptom severity at T2 was also identified. AN is a multidimensional disorder with a prognosis that involves both psychological and social factors. The results stemming from the present study shed light on the role of peer as a mechanism through which general psychological maladjustment is linked to AN symptom severity 1 year following diagnosis.

Therapeutic outcome and long-term naturalistic follow-up of female adolescent outpatients with AN: clinical, personality and psychopathology evolution, process indicators and outcome predictors

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness of growing prevalence in childhood and adolescence. Despite its severity, there are still no completely satisfactory evidence-based treatments. Follow-up studies represent the most effective attempt to enlighten treatment effectiveness, outcome predictors and process indicators.

METHODS

Seventy-three female participants affected with AN were assessed at intake (T0) and at 6 (T1) and 12 (T2) months of an outpatient multimodal treatment program. Nineteen participants were assessed 15 years after discharge (T3). Changes in diagnostic criteria were compared with the chi-square test. Clinical, personality and psychopathology evolution were tested with ANOVA for repeated measures, using the t-test or Wilcoxon test as post-hoc. T0 features among dropout, stable and healed participants were compared. Healed and unhealed groups at long-term follow-up were compared using Mann-Whitney U test. Treatment changes were correlated to each other and with intake features using multivariate regression.

RESULTS

The rate of complete remission was 64.4% at T2, and 73.7% at T3. 22% of participants maintained a full diagnosis at T2, and only 15.8% at T3. BMI significantly increased at each time-point. A significant decrease of persistence and increase in self-directedness were evidenced between T0 and T2. Interoceptive awareness, drive to thinness, impulsivity, parent-rated, and adolescent-rated general psychopathology significantly decreased after treatment. Lower reward dependence and lower cooperativeness characterized the dropout group. The healed group displayed lower adolescent-rated aggressive and externalizing symptoms, and lower parent-rated delinquent behaviors. BMI, personality and psychopathology changes were related with each other and with BMI, personality and psychopathology at intake.

CONCLUSION

A 12-months outpatient multimodal treatment encompassing psychiatric, nutritional and psychological approaches is an effective approach for the treatment of mild to moderate AN in adolescence. Treatment was associated not only with increased BMI but also with positive personality development, and changes in both eating and general psychopathology. Lower relational abilities may be an obstacle to healing. Approaches to treatment resistance should be personalized according to these finding.

Length of stay for anorexia nervosa: Systematic review and meta-analysis

OBJECTIVE

Evidence regarding global trends in length of stay for patients with anorexia nervosa is limited. The aim of this study is to conduct a meta-analysis examining the length of stay for anorexia nervosa patients globally, and to investigate moderators of the variance.

METHOD

Medline, EMBASE and PsycINFO were searched for studies published up to January 2019. Two independent reviewers assessed the eligibility of each report based on predefined inclusion criteria. A meta-analysis was performed to calculate a pooled mean length of stay using the random-effects model. Subgroup analyses and meta-regression were conducted to explore potential sources of heterogeneity between studies.

RESULTS

Of 305 abstracts reviewed, 71 studies met the inclusion criteria, generating 111 datasets. The pooled mean length of stay (95% confidence interval) was 76.3 days (73.3, 79.4) using the random-effects model, with marked variation across countries and time. Heterogeneity between studies was explained by age and admission body mass index.

CONCLUSIONS

This meta-analysis found that although clinical features do contribute to length of admissions for anorexia nervosa, there are also global and temporal variations. Future research should provide an in-depth analysis of why and how this variation exists and what the impact is on the well-being of people with anorexia nervosa.

Rehospitalization and "Revolving Door" in Anorexia Nervosa: Are There Any Predictors of Time to Readmission?

Objective: Anorexia nervosa (AN) is a severe psychiatric illness with multifactorial etiology and unsatisfactory treatment outcomes. Hospitalization is required for a substantial number of patients, and readmission (RA) commonly occurs. Some individuals need multiple hospitalizations sometimes over a short amount of time, thus, delineating the "revolving door" (RD) phenomenon. However, very little is known about readmissions and their frequency in AN. Therefore, we aimed to longitudinally investigate readmissions in AN in order to: (a) characterize patients with AN who need readmission (i.e., RA-AN), sometimes rapidly (RD-AN); (b) ascertain differences between RA-AN and non-RA-AN groups during baseline hospitalization; (c) investigate as to whether clinical or psychometric parameters worsened on RA; and (d) analyze predictors of time-to-readmission in AN. Methods: A total of 170 inpatients with AN were enrolled at their baseline hospitalization; all their subsequent rehospitalizations were recorded with a longitudinal design by which each patient has been observed for 3 years. Patients were classified as RD-AN if requiring a readmission <12 months since last discharge. Clinical characteristics were measured upon admission and discharge for each hospitalization, and at all time points, patients completed questionnaires assessing eating and general psychopathology, and body shape concerns. Results: Sixty-seven patients (39.4%) needed at least one readmission and 62 (92.5% of RA-AN) reported RD. Compared with non-RA-AN, those with RA-AN were younger, reported a shorter duration of illness, and were more frequently diagnosed with AN-BP. Also, greater severity of anxious and depressive symptoms and body shape concerns emerged in the RA-AN group. The outcome of baseline hospitalization did not differ between groups, and only depressive symptoms worsened at readmission. Shorter duration of AN and low weight gain during baseline hospitalization predicted early readmission but did not survive statistical control. In contrast, high scores on drive for thinness upon baseline hospital entry robustly predicted a shorter time to readmission even after statistical control. Discussion: Individuals with AN who require readmission do so over a short period notwithstanding a positive treatment outcome during their baseline hospitalization. Shorter time-to-readmission can be predicted mostly in case of marked drive for thinness and poor weight gain at baseline hospital admission.

Long-Term Outcome of Adolescent Anorexia Nervosa: Family Treatment Apartments Compared With Child Psychiatric Inpatient Treatment

Introduction: The family is rarely involved in treatment when the patient with anorexia nervosa (AN) is hospitalized. Family treatment apartment (FTA) represents an intervention that includes the family in the intensive treatment of AN. This study compares the short- and long-term outcomes of adolescents treated in FTA with those who received inpatient hospital care. In FTA, the parents are responsible for providing meal support, whereas in hospital care, the staff is responsible. Methods: Sixty-eight previous patients admitted during the period 1990-2009 participated in a follow-up, 43 from the FTA where the whole family is admitted for treatment and 25 from regular psychiatric inpatient care. The follow-up consisted of a personal meeting with structured interviews, measurement of height and weight, and self-rating questionnaires. Result: Readmissions due to weight loss within 6 months from discharge were less common in the FTA group. At follow-up, 14.2 years after admission, there was no difference in eating disorder pathology between the groups. There were significantly lower scores on general psychiatric pathology and significantly higher scores on quality of life in the FTA group. Discussion: The treatment in FTA aims to give the family the ability to handle AN when it is most challenging. FTA may thus provide a helpful context for treatment with a basic sense of security along with skills that could contribute to better general mental health at follow-up.

Relationship between eating disorder duration and treatment outcome: Systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis examine the contribution of duration to treatment outcome for eating disorders.

METHOD

Studies (n = 31) were identified that examined associations (r) between duration and 45 different outcomes. We were unable to extract r for seven studies (9 outcomes) and extracted r for 36 outcomes across 24 studies (2,349 participants). Indicators of treatment outcome were heterogeneous and thus a series of different meta-analyses, aimed at increasing homogeneity, were conducted.

RESULTS

First, we examined the average effect size for one primary eating disorder related outcome from each of the 24 studies. There was no association between duration and treatment outcome (r = .05, 95% CI: -.03:.13), with high heterogeneity. Second, we conducted three sub-group analyses to explore possible sources of heterogeneity (diagnosis: anorexia nervosa versus bulimia nervosa; nature of the outcome: binary versus continuous; or type of outcome: binary indicator of recovery, eating disorder psychopathology, weight gain). There was no significant moderation or associations between duration and outcome (ranging from .02-.08), with low to medium heterogeneity. Third, two stand-alone analyses examined outcomes related to weight gain (n = 8) and eating disorder psychopathology (n = 5), with nonsignificant rs of .23/-.06, respectively. High levels of heterogeneity were present.

DISCUSSION

Duration did not influence treatment outcome across any of our meta-analyses. Increasing homogeneity and power will allow more stable estimates of the impact of duration on outcome to be calculated; to this end, future treatment studies should include outcome related to weight gain (anorexia nervosa) and improvements in eating disorder psychopathology.

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 outcome and psychiatric comorbidity of adolescent-onset anorexia nervosa

OBJECTIVE

To assess the outcome of adolescents with anorexia nervosa (AN) about 20 years after first treatment.

METHODS

Sixty-two women diagnosed with AN during adolescence were invited to participate. Of these 62 patients, 38 agreed to participate and were assessed with a battery of questionnaires and interviews. A control group of 30 women of similar age was also assessed.

RESULTS

Of the patients who completed the full assessment, 13 (34%) presented some degree of eating disorder (ED) at follow-up (10 (26%) met full Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria for an ED and 3 (8%) showed partial remission of an ED). The remaining 25 (66%) patients had fully recovered from AN. The duration of untreated illness before admission was significantly associated with an increased risk of a current ED (odds ratio (OR) = 3.334 (1.3-8.7); p = .014). Of the patients who had recovered totally from their ED, 24% showed another psychiatric disorder. This percentage rose to 70% in patients with a current ED.

CONCLUSION

Sixty-six percent of adolescents who completed the assessment achieved remission of their AN. Comorbidity was more common in the current ED group. The variable that best predicted complete remission was the number of years without treatment, showing the importance of detection and early intervention.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

Outcomes of inpatient psychological treatments for children and adolescents with eating disorders at time of discharge: a systematic review

BACKGROUND

Recommended first line treatment for children and adolescent eating disorders is outpatient therapy. However, a significant number of children and adolescents with eating disorders continue to require inpatient treatment during the course of their illness. The effect of psychological treatments in an inpatient setting on outcomes at the time of discharge remains unclear. This paper presents the results of a review of the literature on outcomes at the time of discharge following inpatient psychological treatment for children and adolescents with eating disorders.

MAIN BODY

The majority of studies found were observational and of low quality. The most consistently reported positive outcome of inpatient treatment is weight gain. Results related to symptom change and motivation vary between studies. Within the inpatient setting, there is considerable heterogeneity in the types of treatments offered, goals of treatment, length of stay and outcomes measured.

CONCLUSION

There remains a paucity of high-quality studies examining the effect of psychological treatments provided to children and adolescents in an inpatient setting. The significant heterogeneity between studies makes it not possible to compare across studies. Future research should aim to resolve these deficiencies in order to better determine the specific factors that contribute to positive outcomes of inpatient treatment for children and adolescents with eating disorders.

Validation of a childhood eating disorder outcome scale

We developed and validated a childhood eating disorder outcome scale based on outcomes associated with body mass index standard deviation score (BMI-SDS). This prospective observational study included 131 children with eating disorders (aged 5-15 years). Participants' outcomes scales were completed at the first visit and at 1, 3, 6, and 12 months. The scale evaluated 12 outcomes: body weight change (BW), eating attitude (EA), fear of being fat (FF), body image distortion (BD), menstruation (ME), perceived physical condition (PC), attending school (AS), disease recognition by school (RS), family function (FA), disease recognition by parent (RP), social adaptation (SA), and relationships with friends (RF). Responses to all items were on a four-point Likert scale. Exploratory factor analysis was used to determine the number of factors based on the 12 outcomes. The relation between outcome scale scores and BMI-SDS over the 12-month follow-up period was analyzed. Two types of factors were extracted: disease-specific factors (EA, FF, BD) and biopsychosocial factors (BW, PC, AS, FA, SA, RF). Three items (ME, RS, RP) were excluded because they showed no significant loading effect. There was a significant negative correlation between the outcome scale and BMI-SDS, and changes in outcome scale scores from baseline to 12 months were significantly associated with improvement in BMI-SDS. We developed a childhood eating disorder outcome scale characterized by disease-specific and biopsychosocial factors. Biopsychosocial management combined with a therapeutic approach for disease-specific symptoms may support body weight recovery for children with eating disorders.

Children in Need-Diagnostics, Epidemiology, Treatment and Outcome of Early Onset Anorexia Nervosa

Knowledge of anorexia nervosa (AN) in childhood is scarce. This review gives a state-of-the-art overview on the definition, classification, epidemiology and etiology of this serious disorder. The typical features of childhood AN in comparison to adolescent AN and avoidant restrictive eating disorder (ARFID) are described. Other important issues discussed in this article are somatic and psychiatric comorbidity, differential diagnoses and medical and psychological assessment of young patients with AN. Special problems in the medical and psychological treatment of AN in children are listed, although very few studies have investigated age-specific treatment strategies. The physical and mental outcomes of childhood AN appear to be worse than those of adolescent AN, although the causes for these outcomes are unclear. There is an urgent need for ongoing intensive research to reduce the consequences of this debilitating disorder of childhood and to help patients recover.

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.

Outcome of childhood anorexia nervosa-The results of a five- to ten-year follow-up study

OBJECTIVE

Although admissions of children with anorexia nervosa (AN) are increasing, there remains a dearth of up-to-date knowledge of the course and outcome of early-onset AN. The aim of the present study was to investigate the outcomes of patients with AN onset before the age of 14.

METHOD

Sixty-eight consecutive former patients who met the DSM-IV criteria for AN and who had been treated at one of three German university hospitals were asked to participate in a follow-up study. Body mass index, body height, outcome of the eating disorder (ED), psychiatric morbidity, and health related quality of life (HRQoL) were assessed through a personal examination after an average time span of 7.5 years (range: 4.5-11.5 years) after admission.

RESULTS

One patient had died. Fifty-two subjects with a mean age of 12.5 (SD 1.0) years at admission and of 20.2 (SD 2.0) years at follow-up agreed to participate in the follow-up assessment, aggregating to 77.9% of the original sample. Approximately 41% of the participants had a good outcome, while 35% and 24% had intermediate and poor outcomes, respectively. Twenty-eight percent of the sample met the DSM-IV criteria for a current non-ED psychiatric disorder, and 64% met the criteria for a past non-ED psychiatric disorder. Mental HRQoL and ED-specific psychopathology was strongly associated with the outcome of AN. Average body height was below the normal range. A higher weight at admission was the only significant positive indicator of outcome.

DISCUSSION

Childhood AN is a serious disorder with an unfavorable course in many patients and high rates of chronicity and psychiatric comorbidity in young adulthood. Early detection and intervention are urgently needed.