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Ramsay S, Allison K, Temples HS, Boccuto L, Sarasua SM. Inclusion of the severe and enduring anorexia nervosa phenotype in genetics research: a scoping review. J Eat Disord 2024; 12:53. [PMID: 38685102 PMCID: PMC11059621 DOI: 10.1186/s40337-024-01009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Anorexia nervosa has one of the highest mortality rates of all mental illnesses. For those who survive, less than 70% fully recover, with many going on to develop a more severe and enduring phenotype. Research now suggests that genetics plays a role in the development and persistence of anorexia nervosa. Inclusion of participants with more severe and enduring illness in genetics studies of anorexia nervosa is critical. OBJECTIVE The primary goal of this review was to assess the inclusion of participants meeting the criteria for the severe enduring anorexia nervosa phenotype in genetics research by (1) identifying the most widely used defining criteria for severe enduring anorexia nervosa and (2) performing a review of the genetics literature to assess the inclusion of participants meeting the identified criteria. METHODS Searches of the genetics literature from 2012 to 2023 were performed in the PubMed, PsycINFO, and Web of Science databases. Publications were selected per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The criteria used to define the severe and enduring anorexia nervosa phenotype were derived by how often they were used in the literature since 2017. The publications identified through the literature search were then assessed for inclusion of participants meeting these criteria. RESULTS most prevalent criteria used to define severe enduring anorexia nervosa in the literature were an illness duration of ≥ 7 years, lack of positive response to at least two previous evidence-based treatments, a body mass index meeting the Diagnostic and Statistical Manual of Mental Disorders-5 for extreme anorexia nervosa, and an assessment of psychological and/or behavioral severity indicating a significant impact on quality of life. There was a lack of consistent identification and inclusion of those meeting the criteria for severe enduring anorexia nervosa in the genetics literature. DISCUSSION This lack of consistent identification and inclusion of patients with severe enduring anorexia nervosa in genetics research has the potential to hamper the isolation of risk loci and the development of new, more effective treatment options for patients with anorexia nervosa.
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Affiliation(s)
- Sarah Ramsay
- Healthcare Genetics and Genomics Program, School of Nursing, Clemson University, Clemson, SC 29634, USA.
| | - Kendra Allison
- School of Nursing, Clemson University , Clemson, SC 29634, USA
| | - Heide S Temples
- School of Nursing, Clemson University , Clemson, SC 29634, USA
| | - Luigi Boccuto
- Healthcare Genetics and Genomics Program, School of Nursing, Clemson University, Clemson, SC 29634, USA
| | - Sara M Sarasua
- Healthcare Genetics and Genomics Program, School of Nursing, Clemson University, Clemson, SC 29634, USA
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Hemmingsen SD, Lichtenstein MB, Sjögren M, Gudex C, Larsen PV, Støving RK. Cognitive performance in hospitalized patients with severe or extreme anorexia nervosa. Eat Weight Disord 2023; 28:86. [PMID: 37864583 PMCID: PMC10590307 DOI: 10.1007/s40519-023-01585-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/29/2023] [Indexed: 10/23/2023] Open
Abstract
PURPOSE Severe malnourishment may reduce cognitive performance in anorexia nervosa (AN). We studied cognitive functioning during intensive nutritional and medical stabilization in patients with severe or extreme AN and investigated associations between weight gain and cognitive improvement. METHODS A few days after admission to a specialized hospital unit, 33 patients with severe or extreme AN, aged 16-42 years, completed assessments of memory, cognitive flexibility, processing speed, and attention. Mean hospitalization was 6 weeks. Patients completed the same assessments at discharge (n = 22) following somatic stabilization and follow-up up to 6 months after discharge (n = 18). RESULTS The patients displayed normal cognitive performance at admission compared to normative data. During nutritional stabilization, body weight increased (mean: 11.3%; range 2.6-22.2%) and memory, attention, and processing speed improved (p values: ≤ 0.0002). No relationship between weight gain and cognitive improvement was observed at discharge or follow-up. CONCLUSIONS Cognitive performance at hospital admission was normal in patients with severe or extreme AN and improved during treatment although without association to weight gain. Based on these results, which are in line with previous studies, patients with severe or extreme AN need not be excluded from cognitively demanding tasks, possibly including psychotherapy. As patients may have other symptoms that interfere with psychotherapy, future research could investigate cognitive functioning in everyday life in patients with severe AN. TRIAL REGISTRATION NUMBER The study is registered at clinicaltrials.gov (NCT02502617). LEVEL OF EVIDENCE Level III, cohort study.
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Affiliation(s)
- Simone Daugaard Hemmingsen
- Centre for Eating Disorders, Odense University Hospital, Odense, Denmark.
- Research Unit for Medical Endocrinology, Odense University Hospital, Odense, Denmark.
- Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Open Patient Data Explorative Network (OPEN), Odense, Denmark.
| | - Mia Beck Lichtenstein
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Centre for Digital Psychiatry, Region of Southern Denmark, Odense, Denmark
| | - Magnus Sjögren
- Institute for Clinical Science, Department of Psychiatry, Umeå University, Umeå, Sweden
| | - Claire Gudex
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient Data Explorative Network (OPEN), Odense, Denmark
| | - Pia Veldt Larsen
- Mental Health Services in the Region of Southern Denmark, Vejle, Denmark
| | - René Klinkby Støving
- Centre for Eating Disorders, Odense University Hospital, Odense, Denmark
- Research Unit for Medical Endocrinology, Odense University Hospital, Odense, Denmark
- Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient Data Explorative Network (OPEN), Odense, Denmark
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Hemmingsen SD, Daugaard N, Sjögren M, Lichtenstein MB, Gudex C, Piil F, Støving RK. Cognitive Flexibility in Hospitalized Patients with Severe or Extreme Anorexia Nervosa: A Case-Control Study. J Pers Med 2023; 13:1000. [PMID: 37373990 DOI: 10.3390/jpm13061000] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/08/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVE To investigate whether cognitive inflexibility could be identified using the Wisconsin Card Sorting Test (WCST) in patients with severe and extreme anorexia nervosa (AN) compared to healthy control participants (HCs). METHOD We used the WCST to assess 34 patients with AN (mean age: 25.9 years, mean body mass index (BMI): 13.2 kg/m2) 3-7 days after admission to a specialized nutrition unit and 34 HCs. The Beck Depression Inventory II and the Eating Disorder Inventory 3 were distributed. RESULTS The patients displayed more perseveration than HCs controlled for age and years of education, with moderate effect sizes (perseverative responses (%): adjusted difference = -7.74, 95% CI: -14.29-(-1.20), p-value: 0.021; perseverative errors (%): adjusted difference = -6.01, 95% CI: -11.06-(-0.96), p-value: 0.020). There were no significant relationships between perseveration and depression, eating disorder symptoms, illness duration, or BMI. DISCUSSION Patients with severe and extreme AN demonstrated lower cognitive flexibility compared to HCs. Performance was not related to psychopathology or BMI. Patients with severe and extreme anorexia nervosa may not differ from less severe patients in cognitive flexibility performance. As this study exclusively focused on patients suffering from severe and extreme AN, potential correlations might be masked by a floor effect.
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Affiliation(s)
- Simone Daugaard Hemmingsen
- Centre for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark
- Research Unit for Medical Endocrinology, Odense University Hospital, 5000 Odense, Denmark
- Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Open Patient Data Explorative Network (OPEN), 5000 Odense, Denmark
| | - Nicolaj Daugaard
- Department of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
| | - Magnus Sjögren
- Institute for Clinical Science, Department of Psychiatry, Umeå University, 901 87 Umeå, Sweden
| | - Mia Beck Lichtenstein
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Centre for Digital Psychiatry, Region of Southern Denmark, 5000 Odense, Denmark
| | - Claire Gudex
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Open Patient Data Explorative Network (OPEN), 5000 Odense, Denmark
| | - Frederikke Piil
- Centre for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark
- Research Unit for Medical Endocrinology, Odense University Hospital, 5000 Odense, Denmark
- Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, 5000 Odense, Denmark
| | - René Klinkby Støving
- Centre for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark
- Research Unit for Medical Endocrinology, Odense University Hospital, 5000 Odense, Denmark
- Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Open Patient Data Explorative Network (OPEN), 5000 Odense, Denmark
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Abstract
LEARNING OBJECTIVES After completing this activity, practitioners will be better able to:• Discuss the growing body literature emphasizing moderation and harm-reduction in patients with severe and enduring anorexia nervosa (SE-AN)• Outline and discuss the legal, ethical, and medical challenges inpatient providers face when treating patients with SE-AN. ABSTRACT Patients with severe and enduring anorexia nervosa (SE-AN) present numerous clinical and ethical challenges for the hospital psychiatrist. Patients typically come to the hospital in a state of severe medical compromise. Common difficulties in the period of acute medical stabilization include assessment of decision-making capacity and the right to decline treatment, as well as legally complex decisions pertaining to administering artificial nutrition over the patient's objection. Following acute medical stabilization, the psychiatric consultant must decide whether psychiatric hospitalization for continued treatment is indicated, and if so, whether involuntary hospitalization is indicated. The standard of care in these situations is unclear. Pragmatic issues such as lack of appropriate facilities for specialized treatment are common. If involuntary hospitalization is not approved or not pursued, there may be difficulty in determining whether, when, and how to involve palliative care consultants to guide further management. These cases are complex and largely reside in a medico-legal and ethical gray area. This article discusses the difficulties associated with these cases and supports a growing body of literature emphasizing moderation and harm-reduction in patients with SE-AN. Physician-assisted dying (PAD) is also discussed.
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Hemmingsen SD, Jensen NA, Larsen PV, Sjögren JM, Lichtenstein MB, Støving RK. Cortisol, Depression, and Anxiety Levels Before and After Short-Term Intensive Nutritional Stabilization in Patients With Severe Anorexia Nervosa. Front Psychiatry 2022; 13:939225. [PMID: 35903636 PMCID: PMC9314772 DOI: 10.3389/fpsyt.2022.939225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/15/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Depression and anxiety are well-known comorbid conditions in patients with anorexia nervosa (AN). Hypercortisolemia in patients with AN may be pathogenic and contribute to depression and anxiety symptomatology. OBJECTIVE The aim of this study was to investigate short-term changes in cortisol levels and depression and anxiety symptomatology following intensive re-nutrition in patients with severe AN and hospitalized in a specialized unit. Furthermore, we investigated the potential association between cortisol levels and psychometric parameters. METHODS A total of 36 patients with AN were enrolled in the study. Nine dropped out before follow-up. Patients underwent paraclinical and psychometric examinations at admission and discharge. Measurements included plasma cortisol, cortisol binding globulin (CBG), 24-h urine cortisol, and self-report questionnaires regarding eating disorder, depression, anxiety, and stress symptoms. Patients were hospitalized in the unit for somatic stabilization and intensive re-nutrition. Mean admission length was 41 days. The study was registered at ClinicalTrials.gov (NCT02502617). RESULTS Cortisol levels in blood and urine did not change from admission to discharge in patients with severe AN. Symptoms of depression, anxiety, stress, and eating disorder remained elevated at discharge. There were no associations between changes in cortisol levels and changes in psychometrics. DISCUSSION Our results suggest that short-term intensive re-nutrition did not alter hypothalamic-pituitary-adrenal axis activity or mental health in patients with severe AN. Long-term stabilization and longer follow-up after hospital discharge may be needed to detect changes in cortisol levels and whether these changes are associated with depression and anxiety symptomatology. Greater knowledge about cortisol levels and mental health in patients with severe AN may help in the development of new treatment choices for the chronically ill patients. Future studies could investigate whether cortisol-lowering drugs have a therapeutic effect on mental health in AN.
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Affiliation(s)
- Simone Daugaard Hemmingsen
- Center for Eating Disorders, Odense University Hospital, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.,Research Unit for Medical Endocrinology, Department of Clinical Research, Open Patient Data Explorative Network (OPEN), University of Southern Denmark, Odense, Denmark
| | - Nikolai Arndal Jensen
- Center for Eating Disorders, Odense University Hospital, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.,Research Unit for Medical Endocrinology, Department of Clinical Research, Open Patient Data Explorative Network (OPEN), University of Southern Denmark, Odense, Denmark
| | - Pia Veldt Larsen
- Mental Health Services in the Region of Southern Denmark, Vejle, Denmark
| | - Jan Magnus Sjögren
- Psychiatric Center Ballerup, Copenhagen, Denmark.,Department of Clinical Sciences, Umeå University, Umeå, Sweden
| | - Mia Beck Lichtenstein
- Centre for Telepsychiatry, Region of Southern Denmark, Vejle, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - René Klinkby Støving
- Center for Eating Disorders, Odense University Hospital, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.,Research Unit for Medical Endocrinology, Department of Clinical Research, Open Patient Data Explorative Network (OPEN), University of Southern Denmark, Odense, Denmark
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Broomfield C, Stedal K, Touyz S. The Neuropsychological Profile of Severe and Enduring Anorexia Nervosa: A Systematic Review. Front Psychol 2021; 12:708536. [PMID: 34408714 PMCID: PMC8365190 DOI: 10.3389/fpsyg.2021.708536] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/30/2021] [Indexed: 11/13/2022] Open
Abstract
Characteristics of Severe and Enduring Anorexia Nervosa (SE-AN) are being investigated to differentiate the patients experiencing SE-AN from those at earlier stages of the AN disease. The current systematic review was the first step in exploring neuropsychological functioning as a potentially identifying characteristic for long-term presentations. With a subgroup of AN patients reflecting a unique neuropsychological profile that is proportionate to the quantity of patients that go on to develop SE-AN, it was the aim of this review to assess neuropsychological functioning in the later stage of the disease. In accordance with PRISMA guidelines, a literature search was conducted using four electronic databases (PsycINFO, MEDLINE, Web of Science, and Scopus) for neuropsychological research on AN participants with a seven or more year illness duration. Datasets that met inclusion criteria were screened for SE-AN participants (N = 166) and neuropsychological data extracted together with potentially confounding variables and information required to conduct a quality assessment. In research investigating decision-making, participants with a SE-AN presentation demonstrated significantly lower functioning compared to healthy controls. There was conflicting evidence for differences in intellectual functioning and set-shifting abilities with no variability indicated in central coherence, memory, attention, reasoning, or processing speed. If findings from this preliminary analysis are confirmed through empirical research, implications include earlier identification of SE-AN patients and more effective treatment development.
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Affiliation(s)
| | - Kristin Stedal
- Regional Department for Eating Disorders, Oslo University Hospital, Ullevål, Norway
| | - Stephen Touyz
- Inside Out Institute, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
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