Is amenorrhea a clinically useful criterion for the diagnosis of anorexia nervosa?

Unit of Clinical Dietetics, Department of Internal medicine, “Alma Mater” University of Bologna, Policlinico S. Orsola, Via Massarenti, 9, I-40138 Bologna, Italy
Behaviour Research and Therapy (Impact Factor: 3.85). 12/2008; DOI: 10.1016/j.brat.2008.08.007

ABSTRACT Aim of the study was to evaluate the clinical characteristics and the treatment outcome of underweight patients with eating disorder (ED) not otherwise specified without amenorrhea (EDNOS-WA), compared with classical anorexia nervosa (AN) cases. Seventy-three consecutive female patients (57 AN, and 16 EDNOS-WA) were evaluated before and after a 20-week cognitive behaviour inpatient treatment (CBT-I). Assessment included anthropometry, the Eating Disorder Examination (EDE), the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), and the Temperament and Character Inventory (TCI). At logistic regression analysis, amenorrhea was only predicted by baseline BMI and intense exercise, not by psychopathological variables. Response to CBT-I was good and similar between groups, without differences in the dropout rate or time-to-dropout. Our data lend support to the hypothesis that the criterion “amenorrhea” is of no clinical utility in the diagnosis and treatment of AN and could be removed in the forthcoming DSM-V proposal.

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    • "The diagnostic relevance of amenorrhoea is highly questionable (Abraham et al. 2005 ; Dalle Grave et al. 2008 ; Garfinkel et al. 1996 ; Keating, 2009). However, from a treatment perspective there may be important implications for the hormonal milieu of the patient and their capacity to respond to pharmacotherapy. "
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    ABSTRACT: Major depression (MD) and anorexia nervosa (AN) often present comorbidly and both share some affective symptoms, despite obvious phenotypic differences. In the illness phase, pathophysiological evidence indicates similar abnormalities in both clinical groups including dysfunction in the serotonin (5-HT) system (of which some abnormalities persist following recovery) and between 60% and 80% of patients in both groups present with significant hyperactivity of the hypothalamo-pituitary-adrenal (HPA) axis. First-line approach to treatment for MD involves modulation of the 5-HT system using selective serotonin reuptake inhibitors (SSRIs). For AN, treatment with SSRIs has been shown to be considerably less effective compared to MD. Both illnesses show marked dysregulation in the HPA axis. A consequence of SSRI treatment is a reduction and/or normalization of indices of the HPA axis [i.e. cortisol, adrenocorticotropic hormone (ACTH)], which is consistent with recovery levels in both clinical groups. Oestrogen (in high doses) has been shown to exert antidepressant effects and positively impact on MD symptoms as a treatment in its own right, or in combination with antidepressants, in women of menopausal age. It is proposed that a combination of SSRIs and oestrogen therapy may facilitate physiological normalization in MD in women of non-menopausal age and in AN. Preliminary evidence suggests oestrogen treatment alone is of some benefit to patients and it is proposed that a combination of SSRI and oestrogen will precipitate and potentially accelerate symptomatic remission. Should this approach be successful, it offers the capacity for improvement over traditional antidepressant use in women diagnosed with MD and a novel strategy for the treatment of AN, a serious clinical illness associated with the highest mortality of any psychiatric condition.
    The International Journal of Neuropsychopharmacology 05/2011; 14(4):553-66. DOI:10.1017/S1461145710000982 · 5.26 Impact Factor
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    • "The first, proposed by the Eating Disorders DSM-5 Work Group (, is conservative and suggests relaxing the diagnostic criteria for AN (e.g., dropping the amenorrhea criterion) and BN (e.g., lowering from twice to once a week the minimum frequency of binge eating and inappropriate compensatory behaviors), and to separate BED from EDNOS category. The rationale of removing amenorrhea from the diagnosis of AN stems from the observation that individuals who meet all DSM-IV criteria for AN except amenorrhea have similar psychopathology and treatment outcomes of those with full AN [16]. In addition, the amenorrhea criterion cannot be applied to pre-menarchal females, to females taking oral contraceptives, to post-menopausal females, or to males. "
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    ABSTRACT: Eating disorders are common health problems afflicting mainly female adolescents and young women. They are associated with important physical health and psychosocial morbidity, and carry increased risk of death. Their cause is not yet completely understood and their management is complex, with some patients resisting all available treatments. AIMS OF THIS REVIEW: To provide the readers with an update regarding our knowledge and understanding of eating disorders. Medline database has been used for searching articles on eating disorders published since 1980. The key words used were eating disorders, anorexia nervosa, bulimia nervosa, bulimia, and binge eating. Professional books published during this period has been also reviewed. In the last 30 years a substantial improvement has been achieved both in the understanding and management of eating disorders, but many problems still need to be resolved. Three principal priorities should be addressed. First, the actual classification of eating disorders should be revised, since about half the cases seen in clinical practice receive a diagnosis of eating disorder not otherwise specified, and it is common to observe a migration between eating disorder diagnoses. Second, the research on pathogenesis should better clarify the exact role of genetic and environmental risk factors, and how they interact and vary across the development and maintenance of eating disorders. Third, there is an urgent need both to disseminate the few evidence-based treatments available, and to develop more potent treatments for all the eating disorder diagnostic categories.
    European Journal of Internal Medicine 04/2011; 22(2):153-60. DOI:10.1016/j.ejim.2010.12.010 · 2.30 Impact Factor
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    • ") and inconsistent in those not meeting criterion A (Santonastaso et al., 2009; Thomas et al., 2009) or criterion D (Dalle Grave et al., 2008; Gendall et al., 2006), compared with women with threshold AN. "
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    ABSTRACT: Practical limitations and sample size considerations often lead to broadening of diagnostic criteria for anorexia nervosa (AN) in research. The current study sought to elucidate the effects of this practice on resultant sample characteristics in terms of eating disorder behaviors, psychiatric comorbidities, temperament and personality characteristics, and heritability point estimates. Three definitions of AN were created: meeting all Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for AN (AN-DSM-IV), meeting all DSM-IV criteria except criterion D, amenorrhea, (AN-noD), and broadening DSM-IV AN criteria by allowing a higher body mass index value, eliminating criterion D, and allowing less stringent body weight concerns (AN-Broad). Using data from the Swedish Twin Registry, 473 women fit one of the three definitions of AN. Women with AN-DSM-IV reported significantly more eating disorder behaviors than women with AN-Broad. Women with AN-noD reported more comorbid psychiatric disorders than women with AN-DSM-IV and AN-Broad. Temperament and personality characteristics did not differ across the three groups. Heritability point estimates decreased as AN definition broadened. Broadening the diagnostic criteria for AN results in an increased number of individuals available for participation in research studies. However, broader criteria for AN yield a more heterogeneous sample with regard to eating disorder symptoms and psychiatric comorbidity than a sample defined by narrower criteria.
    Journal of Psychiatric Research 10/2010; 45(5):691-8. DOI:10.1016/j.jpsychires.2010.10.003 · 4.09 Impact Factor
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