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Factors Associated with Recovery from Anorexia Nervosa: A Population-Based Study
Abstract
To examine factors associated with the outcome of anorexia nervosa among women from the general population.
Women (N = 2,881) from the 1975-1979 birth cohorts of Finnish twins were screened for lifetime DSM-IV anorexia nervosa (N = 55 cases) using questionnaires and the SCID interview. Potential factors associated with the likelihood of recovery were addressed in the same assessment. Recovery was defined as restoration of weight, menstruation, and the absence of bingeing and purging for at least one year prior to assessment. Using two-tailed t tests and Pearson's chi-square tests, we contrasted recovered (N = 39) and unrecovered (N = 16) women. We then used logistic regression adjusted for duration of illness and Cox proportional hazard models to account for the variable lengths of illness on prognostic factors.
Unrecovered women were more likely to suffer from depressive symptoms prior to eating disorder onset (18.8% vs. 2.6%, p = 0.04), remain unemployed (18.8% vs. 2.6%, p = 0.04), report dissatisfaction with their current partner/spouse (p = 0.02), and report high perfectionism (p = 0.05) than were recovered women. When duration of illness was accounted for in the analyses, premorbid depression was the sole factor significantly associated with decreased likelihood of recovery (hazard ratio 0.17, 95% confidence interval: 0.03-0.89).
Predicting the course of anorexia remains fraught with difficulty, but premorbid depressive symptoms are associated with poor outcome of anorexia nervosa in the general population. © 2013 Wiley Periodicals, Inc. (Int J Eat Disord 2014; 47:117-123).
... Premorbid but not current depressive mood has been found to influence remission [20][21][22]. Keski-Rakhonen [22,23] emphasized that premorbid depression was the sole variable significantly associated with decreased likelihood of recovery from ED. Nevertheless, Zerwas et al. [7] found that trait anxiety was found to be negatively correlated with recovery from AN in their large international sample. ...
... Premorbid but not current depressive mood has been found to influence remission [20][21][22]. Keski-Rakhonen [22,23] emphasized that premorbid depression was the sole variable significantly associated with decreased likelihood of recovery from ED. Nevertheless, Zerwas et al. [7] found that trait anxiety was found to be negatively correlated with recovery from AN in their large international sample. ...
... Amongst the eating disorders' features it seems that selfinduced vomiting received the most consistent evidence as to its negative influence on remission [7,14]. In their recent study, Keski-Rakhonen et al. [22] do not point at any ED feature as significantly and consistently influencing the course of AN. They go on to state that low BMI at onset is commonly used as a proxy measure for severity of the illness but generally has not been linked to long-term outcomes, a conclusion that also was supported by Zerwas et al. [7]. ...
Objective To assess the potential role of selflessness in predicting remission from an eating disorder (ED) following discharge from an adolescent day-care unit.
Method Participants were 95 female patients (aged 13–19 years) with an ED diagnosis across the spectrum admitted to an adolescent day-care unit for EDs between 2008 and 2012. Forty-one of these participants completed the follow-up assessment, between 12 and 46 months following discharge. No significant differences were found in Time 1 variables between patients who participated in Time 2 and those who did not. At both time points, ED and psychiatric comorbidity diagnoses were made using standard structured interviews. Patients were also administered the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), The Eating Attitude Test (EAT-26), The Eating Disorder Inventory (EDI-2) and the Selflessness Scale (SS)*.
Results Only baseline Selflessness Scale was significant in predicting the continuous variable of ED symptomatology level in follow-up. When dividing EDI total score into its subscales at baseline, one of those, maturity fears, was found, together with the SS, significant in the prediction.
In predicting remission (this time as a dichotomized variable) in follow-up, only the SS, maturity fears, EDI total, and EAT-26, at baseline, predicted remission at follow-up,
but the strength of selflessness was the greatest.
Conclusions Psychological features are not the main target of the important search for predictors of remission from ED. The findings of the present study add the psychological feature of selflessness to this search. Psychotherapy can be enriched by identifying psychological features such as selflessness as one of its foci. The present findings might
also renew interest in maturity fears as an additional focus in psychotherapy. Level of evidence Level III, cohort study.
... Less is known, however, about whether major depressive disorder (MDD) and SUD persist following recovery from an ED, particularly in the long-term. Several studies have found that, compared to individuals with active EDs, those who had achieved recovery for greater than 12 months had fewer depressive symptoms [12,13] and were less likely to have major depressive disorder [14]. However, despite improvements in mood, evidence suggests that after ED recovery, levels of depression remain higher in those with ED histories than in healthy controls. ...
... Three additional studies also reported higher levels of depressive symptoms in those recovered from AN or bulimia nervosa (BN) for one year relative to those without ED histories [16][17][18][19]. Importantly, all [13][14][15][16][17][18][19] but one [12] of these studies were restricted to adolescent or young adult samples and most relied on self-report measures of depressive symptoms [15][16][17][18][19]. To our knowledge, no studies have examined the frequency of SUD following ED recovery. ...
... Consistent with prior studies [12][13][14], we found that individuals who had recovered from their EDs were less likely to be depressed than those who were actively ill with their ED. It is possible that the lower frequency of comorbid MDD observed in individuals who had recovered from their EDs could be a result of the disappearance of the negative consequences of eating disorders on mood. ...
Background:
Psychiatric comorbidity is common in eating disorders (EDs) and associated with poor outcomes, including increased risk for relapse and premature death. Yet little is known about comorbidity following ED recovery.
Methods:
We examined two common comorbidities, major depressive disorder (MDD) and substance use disorder (SUD), in adult women with intake diagnoses of anorexia nervosa and bulimia nervosa who participated in a 22-year longitudinal study. One hundred and seventy-six of 228 surviving participants (77.2%) were interviewed 22 years after study entry using the Eating Disorders Longitudinal Interval Follow-up Evaluation to assess ED recovery status. Sixty-four percent (n = 113) were recovered from their ED. The Structured Clinical Interview for DSM-IV was used to assess MDD and SUD at 22 years.
Results:
At 22-year follow-up, 28% (n = 49) met criteria for MDD, and 6% (n = 11) met criteria for SUD. Those who recovered from their ED were 2.17 times more likely not to have MDD at 22-year follow-up (95% CI [1.10, 4.26], p = .023) and 5.33 times more likely not to have a SUD at 22-year follow-up than those who had not recovered from their ED (95% CI [1.36, 20.90], p = .008).
Conclusion:
Compared to those who had not fully recovered from their ED, those who had recovered were twice as likely not to be diagnosed with MDD in the past year and five times as likely not to be diagnosed with SUDs in the past year. These findings provide evidence that long-term recovery from EDs is associated with recovery from or absence of these common major comorbidities. Because comorbidity in EDs can predict poor outcomes, including greater risk for relapse and premature death, our findings of reduced risk for psychiatric comorbidity following recovery at long-term follow-up is cause for optimism.
... Studies of AN have identified a number of predictors of recovery, including mood and anxiety symptoms, personality traits, body weight, and psychosocial difficulties (Keski-Rahkonen et al., 2013;Zerwas et al., 2013;Zipfel et al., 2000). Zipfel et al. (2000) examined predictors of outcome in AN (N = 84) and found that a long duration of illness prior to hospitalization, low BMI, inadequate weight gain during hospitalization, and severe psychological or social problems predicted poor outcome 21 years after hospitalization. ...
... Although the study was highly powered, it was limited by its retrospective and cross-sectional design with inherent potential for recall bias. A population-based study of 55 women with AN revealed in multivariate analyses that recovery was less likely when depressive symptoms were present prior to the onset of the eating disorder; however, other predictors (unemployment, marital dissatisfaction, perfectionism) were no longer significant once duration of eating disorder illness was controlled for in the analyses (Keski-Rahkonen et al., 2013). Steinhausen (2009) noted an association between positive family relationships and outcome in AN, finding that negative family ties were linked prospectively to the onset of binge eating and vomiting, suggesting that the relationship between vomiting and poorer outcome may be confounded by family-related and withinsubject emotional factors. ...
... Comorbidity may decrease the likelihood of recovery (e.g., Keski-Rahkonen et al., 2013). Eating disorders (EDs) have high rates of comorbidity, particularly with depression and substance abuse. ...
Objective
The objective of this study was to investigate predictors of long-term recovery from eating disorders 22 years after entry into a longitudinal study.
Method
One hundred and seventy-six of the 228 surviving participants (77.2%) were re-interviewed 20-25 years after study entry using the Longitudinal Interval Follow-up Evaluation to assess ED recovery. The sample consisted of 100 women diagnosed with anorexia nervosa (AN) and 76 with bulimia nervosa (BN) at study entry.
Results
A comorbid diagnosis of major depression at the start of the study strongly predicted having a diagnosis of AN-Restricting type at the 22-year assessment. A higher body mass index (BMI) at study intake decreased the odds of being diagnosed with AN-Binge Purge type, relative to being recovered, 22 years later. The only predictor that increased the likelihood of having a diagnosis of BN at the 22-year assessment was the length of time during the study when the diagnostic criteria for BN were met.
Conclusions
Together, these results indicate that the presence and persistence of binge eating and purging behaviors were poor prognostic indicators and that comorbidity with depression is particularly pernicious in AN. Treatment providers might pay particular attention to these issues in an effort to positively influence recovery over the long-term.
... Predictive modelling has highlighted the importance of persistent psychological difficulties, as having a co-morbid psychiatric disorder such as depression significantly predicts relapse of eating disorders (Sala et al., 2023). Anxiety and depression traits have been shown to predict ED symptoms as well as being a barrier to recovery (Keski-Rahkonen et al., 2014;Puccio et al., 2016;Di Lodovico et al., 2023). ...
... Interpersonal, work, and social impairments have been found to correlate to the severity of ED symptoms (Tchanturia et al., 2013;Cardi et al., 2018), such as calorie avoidance (Di Lodovico et al., 2023) and BMI (Pleplé et al., 2021). While unrecovered women with AN where more likely to report work and interpersonal issues than recovered women (Keski-Rahkonen et al., 2014). Autistic traits have been found to be correlated to psychological difficulties, including ED symptoms Leppanen et al., 2022). ...
... AT appears to be relatively rare among older women, with a population-based study reporting a 0.17% lifetime risk in women over 45 years old (11). It has not yet been established whether presentations of AT in older women represent a continuation of a lifelong illness or late onset of the disease: in the most comprehensive review to date (12), while AT was found to be more common than AN, comorbid depression was found in more than half of the older patients, which is in itself a risk factor for chronicity in AN (13). AT as a definition suffers from critical limits, as it lacks a consensus regarding age or duration of the illness, nor it differentiates de novo and recurrent cases. ...
... In Tozzi et al. (16) explored patients' perspectives on perceived causes of AN, and found that familial dysfunction (including emotional abuse), adverse experiences related to food (such as dieting, weight loss) and emotional duress (pressure, stress, frustration) were the most common perceived causes; a supportive relationship, personal growth (maturation) and therapy/counseling were the most frequently reported recovery factors. Bulik et al. (17) found that higher neuroticism raised the risk of developing AN; in Keski-Rahkonen et al. (13) found that pre-morbid depressive symptomatology predicted lower recovery rates in AN, and found that many unrecovered patients reported perfectionism and dissatisfaction with their partner. ...
Anorexia Nervosa (AN) is a severe eating disorder which typically develops in younger females. Many studies focus on this specific population, a majority of which will eventually partially or fully recover. A minority will become chronic despite extensive treatment. These patients are treatment-resistant and may not necessarily benefit from usual treatment. In this article we will reflect on possible mechanisms which may explain the maintenance of disease, and especially on the possible role of affective and anxiety disturbances. We will use, due to the lack of large-scale studies, data from risk and prognostic factors, treatment options and neurobiological correlates in chronic AN patients. Lastly, we will propose how these elements may advise further research and treatments.
... However, the authors highlight prominently that "depression had a negative influence on weight gain in four studies" (final sentence of the abstract, p. 605) and that "four well-designed studies found that depression is a negative factor for weight gain" (last bullet point in the highlights, p. 606), thus implying that although studies and findings were heterogeneous, there is at least some evidence that comorbid depression negatively affects weight gain during treatment of anorexia nervosa. In addition, the authors state that "overall, not taking level of evidence and bias into account, five studies found that depression was a negative predictor of weight gain (Berona et al., 2018;Keski-Rahkonen et al., 2014;Lock et al., 2006;Schlegl et al., 2014;Schlegl et al., 2016), whilst one study found that moderate depression (Schlegl et al., 2014) was a positive predictor" (p. 614) and that "overall, depression was the comorbid disorder that most clearly had a negative influence on weight gain, both in the short-term and long-term studies" (p. ...
... The study by Keski-Rahkonen et al. (2014) was not a treatment study but a naturalistic observational study with data from the general population. One of the findings was that women who were recovered from anorexia nervosa were less likely to have depressive symptoms prior to eating disorder onset than women who were not recovered. ...
In a recent review article, Eskild-Jensen et al. (2020) aimed to examine "comorbid depression as a negative predictor of weight gain during treatment of anorexia nervosa" (cf. title, p. 605) or more generally "the influence of psychiatric comorbidity on weight gain during treatment of anorexia nervosa" (cf. abstract, p. 605). Only few studies (15) were included in the review and the authors conclude that studies were heterogeneous in design, purpose, and outcome. This finding alone may lead readers to conclude that there is no consistent evidence that comorbid depression may negatively affect weight gain in anorexia nervosa. However, the authors highlight prominently that "depression had a negative influence on weight gain in four studies" (final sentence of the abstract, p. 605) and that "four well-designed studies found that depression is a negative factor for weight gain" (last bullet point in the highlights, p. 606), thus implying that although studies and findings were heterogeneous, there is at least some evidence that comorbid depression negatively affects weight gain during treatment of anorexia nervosa. In addition, the authors state that "overall, not taking level of evidence and bias into account, five studies found that depression was a negative predictor of weight gain (Berona et al., 2018; Keski-Rahkonen et al., 2014; Lock et al., 2006; Schlegl et al., 2014; Schlegl et al., 2016), whilst one study found that moderate depression (Schlegl et al., 2014) was a positive predictor" (p. 614) and that "overall, depression was the comorbid disorder that most clearly had a negative influence on weight gain, both in the short-term and long-term studies" (p. 614). In this commentary, we argue that these conclusions are unwarranted.
... However, the low prevalence of AN requires enormous population samples for that purpose [24][25][26]. Thus, it has been difficult to conduct conclusive prospective studies with a significant minimum number of diagnosable AN patients [24,27]. Moreover, there is some debate regarding the adequacy of establishing a PD diagnosis before adolescence, when AN often starts [28][29][30]. ...
... Recovered studies have produced mixed results regarding the presence of elevations in PDs or personality traits such as perfectionism, negative affectivity or obsessionality in recovered AN patients when compared to currently ill patients or healthy controls [7,[38][39][40]. This variability is probably due to the length of recovery, the criteria for defining recovery, variability in AN subtype compositions and age of onset, or differences in personality assessments [27,38,39,41,42]. ...
PurposeThe many studies examining the relationship between anorexia nervosa (AN) and personality abnormalities have observed high comorbidity. However, no definitive studies to date have established whether there is a causal connection or whether it is a complication. The current study aimed to explore the nature of the relationship between personality disorder (PD) traits, obsessionality and perfectionism, using a study design that allows the testing of some comorbidity models.Methods
Twenty-nine women were recruited from a group of former AN patients treated during their adolescence in a specialized unit around 20 years before the time of this study. They were divided into two groups according to the current presence of eating disorder (ED) symptoms (current-ED, n = 11; recovered, n = 18). Both groups were compared to a matched control group (n = 29) regarding current PD traits, obsessive beliefs and perfectionism.ResultsBorderline PD traits, most cluster C PD traits and overestimation of threat were more common in the current-ED group than in the control and recovered groups. Obsessive–compulsive PD traits, intolerance of uncertainty, and perfectionism were also significantly more prevalent in the current-ED group compared to controls but did not reach significance when compared to the recovered group. No significant differences were found between the recovered and control groups.Conclusion
Our results mostly support the personality abnormalities observed as a transient effect related to the presence of ED psychopathology in patients with adolescent-onset AN.Level of evidenceLevel III, case–control analytic studies.
... In a sample of adolescents, most with AN, those higher in perfectionism at intake took longer to reach 85% ideal body weight (Phillips et al., 2010). However, in a population-based study, perfectionism was not associated with likelihood of recovery from AN (Keski-Rahkonen et al., 2014). Vall and Wade (2017) found that higher maladaptive perfectionism (concern over mistakes) was associated with higher eating pathology at discharge and 3-month follow-up in their adolescent inpatient sample with AN; interestingly, adaptive perfectionism (personal standards) at baseline was not associated with eating pathology outcome, but increases in this perfectionism dimension between admission and discharge predicted readmission. ...
... Regarding depressive symptoms, a major depressive episode at baseline predicted higher odds of having a diagnosis of AN or BN compared to achieving recovery (defined as no eating disorder symptoms for the past 12 months) 22 years later (Franko et al., 2018). Furthermore, premorbid depressive symptoms were associated with decreased likelihood of recovery from AN, with recovery defined as weight restoration and absence of binge eating and purging for at least 1 year (Keski-Rahkonen et al., 2014). However, Calugi, El Ghoch, Conti, and Grave (2014) found no association between depressive symptoms at baseline and recovery from AN (assessed using EDE global scores) across a 1-year period. ...
Objective
Our goal was to examine potential predictors of a comprehensive operationalization of eating disorder recovery, characterized by physical, behavioral, and cognitive recovery, focusing on constructs related to self‐concept, personality, and negative affect.
Method
Participants were women with a history of an eating disorder who provided data via survey and interview at two time points separated by about 7–8 years and who met criteria for an eating disorder diagnosis at baseline (N = 36).
Results
Logistic regression models revealed that self‐esteem was a significant predictor of recovery status (OR = 1.12, p = .039) such that individuals with higher self‐esteem at baseline demonstrated significantly greater odds of being in full recovery at follow‐up. However, when self‐esteem was considered in a set along with baseline imposter phenomenon and anxiety, no single construct emerged as a significant unique predictor of recovery in logistic regression analyses.
Discussion
These results highlight the potential importance of self‐esteem in relation to recovery, with clinical implications related to bolstering self‐esteem as part of eating disorder treatment. Future research should continue to explore predictors using a comprehensive operationalization of eating disorder recovery in larger, more diverse samples to optimally identify factors associated with achieving recovery.
... Depression levels have been shown to decrease significantly following inpatient treatment and weight restoration [6][7][8][9], but appear to remain high even after long-term recovery [10]. In a population-based study of young women suffering 1 3 from AN, premorbid depression emerged as the strongest predictor of chronicity [11]. Moreover, a recent longitudinal study of women (outpatients at study entry) revealed that comorbidity with depression uniquely predicted persistence of AN at a 22-year follow-up assessment [12]. ...
... These results remained significant even when accounting for anti-depressant medication, and weight gain throughout the first month of hospitalization. Our findings are consistent with previous evidence of the predictive value of depression in AN outpatients [11,12,27]. Furthermore, they suggest a possible explanation for the lack of associations previously reported between depression and prognosis in studies of inpatients, which assessed depression at admission only. ...
Purpose:
The aim of this study was to investigate the predictive value of early changes in depression levels during inpatient treatment of adolescent anorexia nervosa (AN).
Methods:
Fifty-six adolescents (88% girls) aged 10-18 years (M = 15.35, SD = 2.23) diagnosed with AN were assessed at admission and 1 month following admission to an inpatient setting. Depression levels and eating disorder symptoms were reported at both assessments. Re-hospitalization within 12 months of discharge was documented using official national records.
Results:
Whereas depression levels at baseline were found equivalent between subsequently re-hospitalized and non-re-hospitalized patients, at 1 month after admission patients who were later re-hospitalized had higher levels of depression compared to those who were not re-hospitalized. These differences remained significant after controlling for weight gain and anti-depressant medication intake. We additionally found that the proportion of boys in the non-re-hospitalized group was substantially larger than their proportion in the re-hospitalized group.
Conclusions:
Our results suggest that depression at the point of hospital admission may not be a reliable predictor of treatment outcomes, and highlight the risk of relapse in AN patients whose depression levels do not alleviate after a month of inpatient treatment. Clinicians should consider providing more adjusted and intensive attention to such patients in their efforts to facilitate remission.
Level of evidence iii:
Well-designed cohort study.
... A comorbid major depressive disorder at intake predicted having AN-restricting subtype at follow-up, an older age at intake and greater severity of AN or BN symptoms at intake assessment predicted having AN-binge/purge subtype, and greater severity of BN symptoms at intake predicted having BN, suggesting the need to address these features to promote recovery. The depression finding is in line with work by Keski-Rahkonen and colleagues [105] who found that the strongest predictor of failure to recover was premorbid depression. ...
... With some exceptions-possibly premorbid depression [69,105]-the literature is lacking in replication of significant predictors. Lack of replication is likely due to the lack of consensus in defining and operationalizing recovery and differences in samples. ...
Purpose of review:
This review delineates issues in the conceptualization and operationalization of eating disorder recovery, highlights recent findings about recovery (since 2016), and proposes future directions.
Recent findings:
A longstanding problem in the field is that there are almost as many different definitions of recovery in eating disorders as there are studies on the topic. Yet, there has been a general shift to accepting that psychological/cognitive symptoms are important to recovery in addition to physical and behavioral indices. Further, several operationalizations of recovery have been proposed over the past two decades, and some efforts to validate operationalizations exist. However, this work has had limited impact and uptake, such that the field is suffering from "broken record syndrome," where calls are made for universal definitions time and time again. It is critical that proposed operationalizations be compared empirically to help arrive at a consensus definition and that institutional/organizational support help facilitate this. Themes in recent recovery research include identifying predictors, examining biological/neuropsychological factors, and considering severe and enduring anorexia nervosa. From qualitative research, those who have experienced eating disorders highlight recovery as a journey, as well as factors such as hope, self-acceptance, and benefiting from support from others as integral to the process of recovery. The field urgently needs to implement a universal definition of recovery that is backed by evidence, that can parsimoniously be implemented in clinical practice, and that will lead to greater harmonization of scientific findings.
... Research also shows that there is great heterogeneity in the course of EDs (Zerwas et al., 2013;Keski-Rahkonen et al., 2014). As some reviews indicate, approximately one-third of people with anorexia nervosa (AN) recover within 4 years of ED onset, whereas around 25% show a chronic course or continuous relapse (Berkman et al., 2007). ...
... Previous research indicates that there is great variability in the course of ED with some individuals displaying recovery and better QoL than others (Keski-Rahkonen et al., 2014). Thus, the identification of resilience factors associated with improvement of QoL and reduction of symptoms of ED is important to inform interventions. ...
Objective:
This study examined the longitudinal reciprocal associations between resilience factors, quality of life (QoL) domains, and symptoms of eating disorders (EDs). Hypotheses included predictive paths from resilience factors of "acceptance of self and life" and "personal competence" to increased QoL and predictive paths from previous levels of QoL to resilience.
Method:
A total of 184 patients with EDs (mean age = 29.55, SD = 9.17, 94.8% women) completed measures of resilience, QoL, and EDs symptoms over three waves spaced six month apart. Hypotheses were tested by path analysis.
Results:
Resilience factors predicted improvements in psychological health and social relationship domains of QoL and a reduction of ED symptoms over time. In addition, psychological health increased acceptance of self and life consistently over time, whereas physical health increased the competence component of resilience.
Discussion:
The relationships between resilience factors and QoL are reciprocal, with several mediational paths. A spiral of recursive influences between resilience factors and QoL can take place in people with EDs. This possibility offers new perspectives to understanding the process of recovery in patients with ED.
... Medical complications are typical during the acute phase of an eating disorder [7,8] and persist among those not successfully treated [9], leading to a wide range of physical and emotional disorders into early adulthood [10]. There is still considerable debate concerning the criteria for recovery [11,12] with quality of life remaining poor for many [13] and the costs of treatment being substantial [14]. The complex interplay between that have repeatedly been shown to predict both short-term and long-term outcomes. ...
... The current study has been limited to examining body weight as a measure of treatment effectiveness; however, it is important to acknowledge that there are other pertinent treatment variables that are relevant to a comprehensive assessment of treatment effectiveness. For example, symptom control related to binge eating, vomiting, impulsivity, anxiety and depression have been found to be related to outcome in AN [11,12,30,47]. It is obvious that treatment is ineffective if patients do not engage in the treatment process; therefore, patient retention rate is another important indicator of potential treatment effectiveness. ...
... Medical complications are typical during the acute phase of an eating disorder [7,8] and persist among those not successfully treated [9], leading to a wide range of physical and emotional disorders into early adulthood [10]. There is still considerable debate concerning the criteria for recovery [11,12] with quality of life remaining poor for many [13] and the costs of treatment being substantial [14]. The complex interplay between that have repeatedly been shown to predict both short-term and long-term outcomes. ...
... The current study has been limited to examining body weight as a measure of treatment effectiveness; however, it is important to acknowledge that there are other pertinent treatment variables that are relevant to a comprehensive assessment of treatment effectiveness. For example, symptom control related to binge eating, vomiting, impulsivity, anxiety and depression have been found to be related to outcome in AN [11,12,30,47]. It is obvious that treatment is ineffective if patients do not engage in the treatment process; therefore, patient retention rate is another important indicator of potential treatment effectiveness. ...
A major problem plaguing the discussion of insurance reimbursement for the treatment of anorexia nervosa is the apparent gap between research on variables associated with outcome and the formulas used for reimbursement.
... Even fewer studies examine, simultaneously, psychological, familial, and social factors among adolescent samples that have been systematically evaluated for the AN diagnosis. Considering limitations of current studies, predicting the course of AN remains a challenge [25]. Accordingly, the first objective of the present study was to examine the unique contribution of psychological, familial, and friendship factors in explaining AN symptom severity 1 year following the diagnosis among a sample of adolescent girls with presenting AN. ...
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.
... High rates of self-directedness, which is the ability to adapt behavior to achieve personal goals, and self-transcendence, which includes idealism, could predict worse treatment outcomes in this group of patients due to the aims and values of their sports practice and not with the disease. In ED, some predictors of bad outcome have been related to premorbid depression, obsessivecompulsive symptoms and long duration of disease [69][70][71]. Furthermore, different studies have suggested the importance of personality traits in treatment outcomes of ED. ...
Eating disorders (ED) have frequently been described among athletes. However, their specific features and therapy responses are lacking in the literature. The aims of this article were to compare clinical, psychopathological and personality traits between ED patients who were professional athletes (ED-A) with those who were not (ED-NA) and to explore differences in response to treatment. The sample comprised n = 104 patients with ED (n = 52 ED-A and n = 52 matched ED-NA) diagnosed according to DSM-5 criteria. Evaluation consisted of a semi-structured face-to-face clinical interview conducted by expert clinicians and a psychometric battery. Treatment outcome was evaluated when the treatment program ended. ED-A patients showed less body dissatisfaction and psychological distress. No differences were found in treatment outcome among the groups. Within the ED-A group, those participants who performed individual sport activities and aesthetic sports presented higher eating psychopathology, more general psychopathology, differential personality traits and poor therapy outcome. Individual and aesthetic sports presented more severity and worse prognosis. Although usual treatment for ED might be similarly effective in ED-A and ED-NA, it might be important to develop preventive and early detection programs involving sports physicians and psychologists, coaches and family throughout the entire athletic career and afterwards.
... There is evidence that individuals with eating disorders and comorbid depression or anxiety are more likely to have chronic eating disorder symptoms and poorer health than those without comorbidities. They also have poorer financial functioning and higher mortality rates than those without comorbid conditions (Keski-rahkonen et al., 2014). ...
Children and adolescents diagnosed with an eating disorder often meet the diagnosis of another mental health disorder. In addition to eating disorders, individuals with comorbid disorders have higher suicide rates and more severe and chronic eating disorder symptoms. The present research aimed to investigate the influence of comorbid conditions on the treatment outcomes of children and adolescents that attended a public community mental health service. It was hypothesised that the patients with comorbidities would have a more extended treatment duration, slower rates of weight restoration, more hospital admissions for medical compromise, and poorer functioning than those without comorbidities. Data from 78 past patients at the Eating Disorder Program in Queensland, Australia, were analysed. Patients with comorbidities demonstrated similar recovery rates to those without comorbidities. However, those with comorbid conditions had longer episodes of treatment. The study's results support using Family Based Treatment for patients with and without comorbidities. The implications of the findings for public mental health services and directions for future research are discussed.
... Even fewer studies examine, simultaneously, psychological, familial, and social factors among adolescent samples that have been systematically evaluated for the AN diagnosis. Considering limitations of current studies, predicting the course of AN remains a challenge [30] . Accordingly, the rst objective of the present study was to examine the unique contribution of psychological, familial, and friendship factors in explaining AN symptom severity one year following the diagnosis among a sample of adolescent girls presenting AN. ...
Objective: 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 one 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.
Method: 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 one year later (T2).
Results: 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.
Discussion: 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 one year following diagnosis.
... As noted by Broomfield, reports of age of onset may include when the parent first recalls their child's eating behavior changing, the point at which the family first noticed a change, or when the patient first received a diagnosis [6]. Other studies have attempted to apply systematic methods to determine age of onset, such as determining when weight loss began [14,15] or, using a structured diagnostic interview, when all criteria for a formal diagnosis were first met [16]. Few studies have attempted to systematically examine timing and sequence of the emergence of individual symptoms. ...
Purpose
Anorexia nervosa (AN) commonly begins in adolescence; however, detailed knowledge of symptom trajectories, including their temporal sequence, is less well elucidated. The purpose of the present study is to describe the onset and duration of disordered eating behaviors prior to a diagnosis of AN, examine concordance between child and parent report, and examine the relationships between timing of symptom onset and illness severity.
Methods
Seventy-one adolescents (ages 12–18 years) and their parents were interviewed about dieting, restriction, loss of control/binge eating, purging, excessive/compulsive exercise, weight history, and amenorrhea. Body mass index percentiles were calculated, and adolescents completed the Eating Disorder Examination-Questionnaire.
Results
Restriction, being underweight, dieting, and excessive exercise were reported by most of the sample; purging, loss-of-control eating, and having been overweight were reported by less than a third. Dieting typically emerged first, on average around age 14; the remainder of behaviors tended to emerge between ages 14 and 14½; and average age of formal diagnosis was slightly over 15 years. Dyads had good agreement regarding presence and timing of all behaviors except for dieting, for which children reported about 6 months earlier onset/longer duration, compared to parents. Although older age at interview was associated with lower body mass index percentile and higher EDE-Q score, neither age of onset nor duration was associated with severity when controlling for current age.
Discussion
Teens and parents describe a similar sequence of behavior changes leading up to a diagnosis of AN that typically begins with dieting and occurs over an approximate 1- to 1½-year period. Querying teens and parents about eating behavior changes may aid in identification and early intervention in AN; adolescents with normal weight who engage in persistent dieting or restrictive eating may warrant more frequent weight monitoring.
... Therefore, these data suggest an underlying anxious trait partially independent of nutrition. Also depression is known to be a key element in AN [17,18] and, similarly to what happens with anxiety, the onset of depression can precede AN [12,19] but the time-relationship with AN (e.g., predisposing factor versus consequence of AN-related severe malnutrition) is currently debated [20]. Importantly, anxious comorbidity negatively impacts on AN prognosis [21,22] and patients with AN and depression tend to be unresponsive to antidepressants [23], to gain less weight in treatment [24,25] and to report a mood relapse after recovery from the eating disorder [23]. ...
Purpose
Anorexia nervosa (AN) is a life-threatening condition in which temperament, anxiety, depression, and core AN body-related psychopathology (drive for thinness, DT, and body dissatisfaction, BD) are intertwined. This relationship has not been to date disentangled; therefore, we performed a multiple mediation analysis aiming to quantify the effect of each component.
Methods
An innovative multiple mediation statistical method has been applied to data from 184 inpatients with AN completing: Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire, Eating Disorders Inventory-2, State-Trait Anxiety Inventory, and Beck Depression Inventory.
Results
All affective temperaments but the hyperthymic one were involved in the relationship with DT and BD. Only the anxious temperament had a significant unmediated direct effect on DT after the strictest correction for multiple comparisons, while the depressive temperament had a significant direct effect on DT at a less strict significance level. State anxiety was the strongest mediator of the link between affective temperament and core AN body-related psychopathology. Depression showed intermediate results while trait anxiety was not a significant mediator at all.
Conclusion
Affective temperaments had a relevant impact on body-related core components of AN; however, a clear direct effect could be identified only for the anxious and depressive temperaments. Also, state anxiety was the strongest mediator thus entailing interesting implications in clinical practice.
Level of evidence
V, cross-sectional study.
... Identifying biomarkers to help predict AN risk and/or symptom severity would enable treatment to be directed at prodromal symptoms, before weight loss becomes too severe and protracted. Both comorbid diagnoses of and symptoms related to depression, anxiety, and obsessive-compulsive disorder (OCD) are associated with worsened illness, poorer treatment outcomes, and increased relapse in patients with AN (Keski-Rahkonen et al., 2014;Mischoulon et al., 2010;Thornton et al., 2011;Wild et al., 2016;Zerwas et al., 2013). AN often follows a pre-existing diagnosis of comorbid OCD, generalized anxiety disorder (GAD), and social phobia (Godart et al., 2000;Kaye et al., 2004;Meier et al., 2015;Strober et al., 2007), presenting potential targets for early intervention strategies. ...
Objective:
Identifying risk factors that contribute to the development of anorexia nervosa (AN) is critical for the implementation of early intervention strategies. Anxiety, obsessive-compulsive behavior, and immune dysfunction may be involved in the development of AN; however, their direct influence on susceptibility to the condition remains unclear. Here, we used the activity-based anorexia (ABA) model to examine whether activity, anxiety-like behavior, compulsive behavior, and circulating immune markers predict the subsequent development of pathological weight loss.
Method:
Female Sprague-Dawley rats (n = 44) underwent behavioral testing before exposure to ABA conditions after which they were separated into susceptible and resistant subpopulations. Blood was sampled before behavioral testing and after recovery from ABA to screen for proinflammatory cytokines.
Results:
Rats that were vulnerable to pathological weight loss differed significantly from resistant rats on all key ABA parameters. While the primary measures of anxiety-like or compulsive behavior were not shown to predict vulnerability to ABA, increased locomotion and anxiety-like behavior were both associated with the extent of weight loss in susceptible but not resistant animals. Moreover, the change in expression of proinflammatory markers IL-4 and IL-6 evoked by ABA was associated with discrete vulnerability factors. Intriguingly, behavior related to risk assessment was shown to predict vulnerability to ABA.
Discussion:
We did not find undisputable behavioral or immune predictors of susceptibility to pathological weight loss in the ABA rat model. Future research should examine the role of cognition in the development of ABA, dysfunction of which may represent an endophenotype linking anorectic, anxiety-like and compulsive behavior.
Public significance:
Anorexia nervosa (AN) has among the highest mortality rates of all psychiatric disorders and treatment options remain limited in their efficacy. Understanding what types of risk factors contribute to the development of AN is essential for implementing early intervention strategies. This study describes how some of the most common psychological features of AN could be used to predict susceptibility to pathological weight loss in a well-established animal model.
... In AN, concurrent anxiety or depressive symptoms, psychosocial difficulties [13], long duration of illness prior to hospitalisation, low BMI, and inadequate weight gain during hospitalisation are associated with poor outcome in general and 21 years after initial hospitalisation [14,15]. In BN, findings are mixed with a high frequency of compensatory behaviours [16] and comorbid psychiatric diagnoses associated with poor outcome [17][18][19], whereas perfectionism, obsessionality, anxiety, and genetic factors may increase the likelihood of developing a SEED [20]. ...
About 20% of individuals with anorexia nervosa (AN) remain chronically ill. Therefore, early identification of poor outcome could improve care. Genetic research has identified regions of the genome associated with AN. Patients with anorexia nervosa were identified via the Swedish eating disorder quality registers Stepwise and Riksät and invited to participate in the Anorexia Nervosa Genetics Initiative. First, we associated genetic information longitudinally with eating disorder severity indexed by scores on the Clinical Impairment Assessment (CIA) in 2843 patients with lifetime AN with or without diagnostic migration to other forms of eating disorders followed for up to 16 years (mean = 5.3 years). Second, we indexed the development of a severe and enduring eating disorder (SEED) by a high CIA score plus a follow-up time ≥5 years. We associated individual polygenic scores (PGSs) indexing polygenic liability for AN, schizophrenia, and body mass index (BMI) with severity and SEED. After multiple testing correction, only the BMI PGS when calculated with traditional clumping and p value thresholding was robustly associated with disorder severity (βPGS = 1.30; 95% CI: 0.72, 1.88; p = 1.2 × 10–5) across all p value thresholds at which we generated the PGS. However, using the alternative PGS calculation method PRS-CS yielded inconsistent results for all PGS. The positive association stands in contrast to the negative genetic correlation between BMI and AN. Larger discovery GWASs to calculate PGS will increase power, and it is essential to increase sample sizes of the AN GWASs to generate clinically meaningful PGS as adjunct risk prediction variables. Nevertheless, this study provides the first evidence of potential clinical utility of PGSs for eating disorders.
... In AN, concurrent anxiety or depressive symptoms, psychosocial di culties, 13 long duration of illness prior to hospitalization, low BMI, and inadequate weight gain during hospitalization are associated with poor outcome in general and 21 years after initial hospitalization. 14,15 In BN, ndings are mixed with a high frequency of compensatory behaviours 16 and comorbid psychiatric diagnoses associated with poor outcome, [17][18][19] whereas perfectionism, obsessionality, anxiety, and genetic factors may increase the likelihood of developing a SEED. ...
About 20% of individuals with anorexia nervosa (AN) remain chronically ill. Therefore, early identification of poor outcome could improve care. Genetic research has identified regions of the genome associated with AN. Patients with anorexia nervosa were identified via the Swedish eating disorder quality registers Stepwise and Riksät and invited to participate in the Anorexia Nervosa Genetics Initiative. First, we associated genetic information longitudinally with eating disorder severity indexed by scores on the Clinical Impairment Assessment (CIA) in 2,843 patients with lifetime AN with or without diagnostic migration to other forms of eating disorders followed for up to 16 years (mean = 5.3 yrs). Second, we indexed development of a severe and enduring eating disorder (SEED) by a high CIA score plus a follow-up time ≥5 years. We associated individual polygenic scores (PGSs) indexing polygenic liability for AN, schizophrenia, and body mass index (BMI) with severity and SEED. After multiple testing correction, only the BMI PGS when calculated with traditional clumping and p value thresholding was robustly associated with disorder severity (βPGS = 1.30; 95% CI: 0.72, 1.88; p = 1.2 x 10-5) across all p value thresholds at which we generated the PGS. However, using the alternative PGS calculation method PRS-CS yielded inconsistent results for all PGS. The positive association stands in contrast to the negative genetic correlation between BMI and AN. Larger discovery GWASs to calculate PGS will increase power, and it is essential to increase sample sizes of the AN GWASs to generate clinically meaningful PGS as adjunct risk prediction variables. Nevertheless, this study provides the first evidence of potential clinical utility of PGSs for eating disorders.
... More in detail, anxiety has been found to mediate the relationship between perfectionism and eating symptoms (Egan et al., 2013) and, as stated before, perfectionism is considered as a transdiagnostic factor across EDs, anxiety, and depression (Drieberg et al., 2019). Still, anxiety and depression are frequently comorbid with AN (Abbate Daga et al., 2011;Ulfvebrand et al., 2015) and overall relevant since often precede the onset of EDs (Keski-Rahkonen et al., 2014;Klump et al., 2004). Therefore, it could be relevant to take anxiety and depression into account when investigating perfectionism in AN. ...
Perfectionism is a risk and maintaining factor for anorexia nervosa (AN) but studies on its classification are lacking. This study aimed to classify patients with AN and healthy controls (HCs) according to their perfectionism; to evaluate the association between perfectionism clusters and severity of general and eating psychopathology for both groups; to investigate the relationship between baseline perfectionism and hospitalization outcome for patients. A sample of 207 inpatients with AN and 292 HCs completed: Eating Disorders Inventory-2, Frost Multidimensional Perfectionism Scale, Beck Depression Inventory, and State- Trait Anxiety Inventory. Cluster analyses were run to classify participants according to their perfectionism scores. Three clusters (i.e., high, medium, low perfectionism) emerged for both patients with AN and HCs. The high perfectionism cluster was over-represented among patients. Both groups reported significant differences across clusters in eating-related difficulties. In AN, anxiety and depression severity varied across clusters according to perfectionism, but patients' baseline perfectionism was unrelated to hospitalization outcome. Inpatients with AN and HCs could be grouped in clusters of high, medium, and low perfectionism which also mirrored their eating psychopathology severity. Finally, hospitalization outcome was unrelated to inpatients' baseline perfectionism.
... For example, a study by Sutandar-Pinnock, Woodside, Carter, Olmsted, and Kaplan (2003) found that among a group of inpatients with AN, lower perfectionism scores at admission predicted better response to treatment and better outcome at followup. A more recent study likewise found that individuals recovered from AN had lower perfectionism scores than individuals who were not recovered from AN (Keski-Rahkonen et al., 2013). Similarly, data from a longitudinal study of adolescents with AN suggest that the relationship between perfectionism and duration of illness is inverse, such that those individuals with higher perfectionism are more likely to have a longer duration of illness (Nilsson, Sundbom, & H€ aggl€ of, 2008). ...
Anorexia nervosa (AN) is a serious illness that challenges mental health professionals globally. While family-based treatment is well established for adolescents with parents able to collaborate, little data are available to inform treatment choice for chronic or adult patients. This review proposes that the current high attrition, poor compliance, and suboptimal efficacy of outpatient interventions may reflect inadequate consideration of individual difference variables. Data on certain variables demonstrated to have relevance for AN are briefly summarized, and novel psychotherapeutic interventions that have taken these variables into account are reviewed. These data suggest that identifying subgroups of individuals with AN on the basis of relevant personality or neurocognitive variables may be one way to improve treatment acceptability and effectiveness for this challenging population.
... These are factors known to predict poor outcome and might explain the low recovery rate (Löwe et al., 2001;Wild et al., 2016). Comorbidity negatively affects remission (Kaye, Bulik, Thornton, Barbarich, & Masters, 2004;Keski-Rahkonen et al., 2014;Pollice, Kaye, Greeno, & Weltzin, 1997;Puccio, Fuller-Tyszkiewicz, Ong, & Krug, 2016), and in the present sample both anxiety disorders and affective disorders were significantly more prevalent among non-recovered patients. In total, more than 70% of the patients were diagnosed with a comorbid disorder at both the 5-and the 17-year follow-ups, a larger proportion than in comparable longitudinal studies (Dobrescu et al., 2020;Löwe et al., 2001;Quadflieg & Fichter, 2019). ...
Objective
Although studies with short and intermediate observation time suggest favorable outcomes in regard to eating disorders (ED), there is limited knowledge on long‐term outcomes. The present study aimed to investigate the 5‐ and 17‐year outcome of adult patients with longstanding ED who were previously admitted to an inpatient ED unit. ED diagnoses and recovery, comorbid and general psychopathology, along with psychosocial functioning and quality of life were evaluated.
Method
Sixty‐two of the 80 living patients (78% response rate) with anorexia nervosa (n = 23), bulimia nervosa (n = 25), or other specified feeding or eating disorders (n = 14) at admission were evaluated. The mean age at the 17‐year follow‐up point was 46.2 (SD 7.5). The Eating Disorder Examination (EDE) was used to assess recovery. The Mini International Neuropsychiatric Interview (M.I.N.I.) and self‐report instruments provided additional information.
Results
There was a significant reduction in patients fulfilling criteria for an ED from the 5‐year to the 17‐year follow‐up, meanwhile recovery rates were stable. A total of 29% of the patients were fully recovered and 21% were partially recovered while the remaining 50% had not recovered. No significant changes were found in any self‐report measures and more than 70% had a comorbid disorder at both assessments.
Discussion
The findings illustrate the protracted nature of ED for adults with longstanding ED. A long illness duration prior to treatment is unfortunate and early detection and treatment is advisable.
... More recently, the first paragraph opening a report describing factors associated to AN recovery from a Finnish populationbased study Keski-Rahkonen et al. (180) reads: "A substantial proportion [of AN patients] attains complete recovery, even without formal treatment, but about one in five suffers from a chronic disorder that carries a high risk of mortality" (p. 117). ...
To the extent that severe and lasting anorexia nervosa (SE-AN) is defined in terms of refractoriness to the best treatments available, it is mandatory to scrutinize the proven effectiveness of the treatments offered to patients. The array of so-called current evidence-based treatments for anorexia nervosa (AN) encompasses the entire spectrum of treatments ranging from specialized brand-type treatments to new treatments adapted to the specific characteristics of people suffering from AN. However, after several randomized control trials, parity in efficacy is the characteristic among these treatments. To further complicate the landscape of effective treatments, this “tie score” extends to the treatment originally conceived as control conditions, or treatment as usual conditions. In retrospection, one can understand that treatments considered to be the best treatments available in the past were unaware of their possible iatrogenic effects. Obviously, the same can be said of the theoretical assumptions underpinning such treatments. In either case, if the definition of chronicity mentioned above is applied, it is clear that the responsibility for the chronicity of the disorder says more about the flagrant inefficacy of the treatments and the defective assumptions underpinning them, than the nature of the disorder itself. A historical analysis traces the emergence of the current concept of “typical” AN and Hilde Bruch's contribution to it. It is concluded that today's diagnostic criteria resulting from a long process of acculturation distort rather than capture the essence of the disorder, as well as marginalizing and invalidating patients' perspectives.
... More in detail, the percentage of MDD in our sample of patients with AN was in line with previous literature (Keski-Rahkonen et al., 2014) and no differences emerged between AN subtypes. Data concerning the prevalence of MDD among AN subtypes is scarce, with some studies suggesting a major prevalence of MDD in (Fernandez-Aranda et al., 2007;Lipson and Sonneville, 2020). ...
Anorexia Nervosa (AN) and Major Depressive Disorder (MDD) are frequent comorbid conditions. It is unclear how MDD affects intensive emergency treatment and outcome. Eighty-seven AN inpatients were analyzed, twenty-two suffered also from MDD. Individuals with AN and MDD at admission had no remarkable differences in psychopathology, but a full diagnosis of MDD – and not just the presence of depressive symptoms - was associated with longer length of stay and worse clinical outcome (weight restoration, increase of caloric intake). Health care policies might consider that MDD comorbidity, regardless of AN clinical severity, affects the efficacy and timing of acute treatments.
... The sequence of mood followed by weight improvements observed in the present study suggests that treating depressive symptoms in SE-AN may be an important step in the progression towards recovery. Depression early in the course of AN or before onset is associated with poor outcomes (Franko et al., 2018;Keski-Rahkonen et al., 2014), and addressing depressive symptoms has been highlighted as an important treatment strategy for SE-AN (Hay et al., 2012). Given that response to antidepressant medication in AN is low (Zipfel, Giel, Bulik, Hay, & Schmidt, 2015) and the effectiveness of rTMS as an anti-depressive treatment (McClintock et al., 2018), rTMS may provide an alternative treatment option for people with SE-AN. ...
Objective
This study assessed longer‐term outcomes from a randomised controlled feasibility trial of 20 sessions of real versus sham high‐frequency repetitive transcranial magnetic stimulation (rTMS) to the left dorsolateral prefrontal cortex in adults with severe, enduring anorexia nervosa (SE‐AN).
Methods
Thirty participants who completed the original study protocol were invited to take part in an open follow‐up (18‐months post‐randomisation), assessing body mass index (BMI), eating disorder (ED) symptoms and other psychopathology.
Results
Twenty‐four participants (12 each originally allocated to real/sham) completed the 18‐month follow‐up. Ten of 12 participants who originally received sham treatment had real rTMS at some stage during the follow‐up. A medium between‐group effect size was seen for BMI change from baseline to 18‐months, favouring those originally allocated to real rTMS. In this group at 18‐months, five participants were weight recovered (BMI ≥18.5 kg/m²), compared with one participant in the original sham group. Both groups showed further improvement in ED symptoms during the follow‐up. Effects on mood were largely maintained at follow‐up, with catch‐up effects in the original sham group.
Conclusions
Findings suggest that rTMS treatment effects on mood are durable and that BMI and ED symptom improvements need time to emerge. Large‐scale trials are needed.
Highlights
• At 18‐months post‐randomisation, mood improvements seen in the real rTMS group at 4‐months post‐randomisation remained broadly stable.
• In relation to body mass index (BMI) change, whilst there were further improvements in both groups up to the 18‐month follow‐up, change in the original real rTMS group was larger.
• Participants in both the real rTMS and sham rTMS groups showed further improvements in eating disorder symptoms and associated psychosocial impairment during the follow‐up with small between‐group differences at 18‐months.
... The symptom profile differs somewhat from that of unipolar depression in that somatic features such as loss of energy and reduced activation are less pronounced, whereas cognitive features such as negative views of the self are higher [88]. Indeed, the chance of recovery is reduced in people who developed AN after they had experienced depression [89]. In addition, the long-term outcomes of patients with AN complicated with mood comorbidity were reduced [90]. ...
The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.
... The relevance of a depressive trait in AN is grounded on literature showing depression as a key element in AN (Monteleone et al., 2019;Solmi et al., 2019). Also, the onset of depression tend to precede AN (Deep et al., 1995) and unrecovered women report more often to have suffered from major depression before developing AN, even after controlling for duration of illness (Keski-Rahkonen et al., 2014). Consistently, major depression in AN has been reported not to be responsive to antidepressant treatments (Mischoulon et al., 2011) and full recovery from ED was associated with greater likelihood of depression relapse (Mischoulon et al., 2011). ...
Background:
Anorexia nervosa (AN) is a severe mental illness. Personality traits and comorbidity with affective and anxiety disorders are key-aspects of its pathogenesis but little attention has been paid so far to affective temperaments in AN. Also, childhood anxiety is proposed to impact on AN clinical severity. Therefore, we aimed to investigate if affective temperaments could be related to AN eating psychopathology also clarifying if those with low versus high scores on depressive and anxious temperaments could differ in AN clinical current and lifetime severity.
Methods:
One-hundred and forty-seven inpatients with AN were consecutively recruited. All participants completed: Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire, Eating Disorder Examination Questionnaire, State Trait Anxiety Inventory, Beck Depression Inventory. Clinical data were collected upon admission.
Results:
Regression models showed that all affective temperaments were associated with eating psychopathology (eating restraint and eating, shape, and weight concerns); however, when controlling for confounders, only the anxious temperament remained significant. Also, those patients with higher scores on depressive and anxious temperaments reported higher current and lowest lifetime body mass index (BMI).
Limitations:
Only inpatients were recruited; self-report assessments were used and follow-up data are lacking.
Conclusions:
Results from this study support the association between affective (anxious in particular) temperament traits and the presence of altered eating psychopathology in AN. Also, higher traits of depressive and anxious temperaments reported higher current and lowest lifetime BMI. Should these findings be confirmed, the assessment of the anxious temperament could fruitfully inform prevention and treatment interventions for AN.
... Recovery is often determined based on BMI, self-report and questionnaires 38,39 . It is striking that (recovery of) BID is mainly assessed with self-report measures such as questionnaires measuring cognition and affect regarding the body and its size e.g. ...
Body image disturbances (BID) are a key feature of eating disorders (ED). Clinical experience shows that BID exists in patients who Completed their Eating Disorder Treatment (CEDT), however studies concerning BID in CEDT patients are often limited to cognition and affect, measured by interviews and questionnaires. The current study is the first systematic study investigating the full scope of the mental body representation, including bodily attitudes, visual perception of body size, tactile perception, and affordance perception in CEDT patients. ED patients (N = 22), CEDT patients (N = 39) and healthy controls (HC; N = 30) were compared on BID tasks including the Body Attitude Test (BAT), Visual Size Estimation (VSE), Tactile Estimation Task (TET), and Hoop Task (HT). Results on the BAT show higher scores for ED patients compared to CEDT patients and HC but no difference between CEDT patients and HC. Both ED and CEDT patients show larger overestimations on the VSE and HT compared to HC, where ED patients show the largest overestimations. No group differences were found on the TET. The results indicate the existence of disturbances in visual perception and affordance perception in CEDT patients. Research focussing on more effective treatments for ED addressing multiple (sensory) modalities is advised.
... The tipping point of change is one conceptualization evolving from limited primary research into factors that motivate or encourage recovery in individuals with AN (Dawson, Mullan, and Sainsbury 2015;Hay and Cho 2013;Hillen et al. 2015). This study presents one possible antecedent account of the tipping point of change; however, other conceptualizations exist about recovery in AN and understanding the factors that are related to 'recovery' (Dawson, Mullan, and Sainsbury 2015;Hay and Cho 2013;Hillen et al. 2015;Keski-Rahkonen et al. 2014). ...
Objective: The aim of this study was to understand factors related to treatment and/or recovery from self-reported Anorexia Nervosa, including ‘the tipping point of change’.
Method: An online questionnaire was developed and administered from December 2014 to December 2015 to individuals ≥18 years of age with Anorexia Nervosa in the past or currently who were recruited through eating disorder organizations in Australia and the United Kingdom. Responses to a specific qualitative question on ‘the tipping point of change’ were analyzed using conventional content analysis.
Results: One hundred sixty-one participants completed some or all of the questionnaire; only 67 women (41.61%) answered Question 6 on ‘the tipping point of change’, and analyses were restricted to data from these women. The themes identified were: 1) realizing the loss of something valuable, 2) the risk of losing something valuable, and 3) something to live for/stay well for.
Conclusion: These results are important for healthcare providers as they work with patients to identify life experiences, including ‘loss/potential loss’ and ‘the need for preservation’, that have personal significance. Some patients may realize that ‘enough is enough’; something needs to change. These intrinsic motivating factors may also be the impetus for eventual recovery for some individuals.
... There are numerous publications and several reviews on the topic, yet those studies and reviews have presented conflicting results, likely due in part to methodological differences across studies. For example, studies have utilized different samples, such as clinical samples (Herzog et al., 1999), health registers (Papadopoulos, Ekbom, Brandt, & Ekselius, 2009), community samples (Holland, Bodell, & Keel, 2013), and twin cohort registers ( Keski-Rahkonen et al., 2014;Mustelin et al., 2015). ...
Objective:
Assessment of the long-term outcome of anorexia nervosa (AN) in a very large sample of inpatients (N = 1,693) and identification of predictors for poor outcome.
Method:
Over 25 years (mean 10 years), consecutively admitted inpatients of a specialized hospital were followed. A subsample of 112 patients with 20-year follow-up was defined. Bivariate comparisons and logistic regression analysis identified risk factors of poor outcome.
Results:
Body mass index (BMI) increased during the follow-up period. Eating behavior as well as general psychopathology improved but did not reach the level of healthy controls. Remission was found in 30% (total sample) and in 40% (20-year follow-up subsample). Crossover from AN to binge-eating disorder or obesity was rare. The predictors of a negative course of illness included lower BMI at admission; a higher score on the Eating Disorder Inventory Maturity Fears subscale at admission; fewer follow-up years; and higher age at admission. The main diagnostic crossover occurred from AN to eating disorder not otherwise specified. Motherhood was related to better outcome.
Discussion:
Many patients with very severe AN recover from their illness but AN also shows considerable long-term negative consequences. Over long time periods, survivors show improvement but better treatments for severe cases are still needed. Predictors of outcome included symptom severity, chronicity, and length of follow-up but not psychiatric comorbidity.
... Experiential avoidance, perfectionism, and lack of flexibility-all widespread in patients with AN [35][36][37]-are described as factors involved in the maintenance of AN [38] and even associated with poor outcome [39]. Qigong addresses these issues by inviting participants to participate in a non-competitive, non-Cartesian activity and to experiment with different internal experiences. ...
Background
Qigong is a mind-body intervention focusing on interoceptive awareness that appears to be a promising approach in anorexia nervosa (AN). In 2008, as part of our multidimensional treatment program for adolescent inpatients with AN, we began a weekly qigong workshop that turned out to be popular among our adolescent patients. Moreover psychiatrists perceived clinical benefits that deserved further exploration.
Methods and findings
A qualitative study therefore sought to obtain a deeper understanding of how young patients with severe AN experience qigong and to determine the incentives and barriers to adherence to qigong, to understanding its meaning, and to applying it in other contexts. Data were collected through 16 individual semi-structured face-to-face interviews and analyzed with the interpretative phenomenological analysis method. Eleven themes emerged from the analysis, categorized in 3 superordinate themes describing the incentives and barriers related to the patients themselves (individual dimension), to others (relational dimension), and to the setting (organizational dimension). Individual dimensions associated with AN (such as excessive exercise and mind-body cleavage) may curb adherence, whereas relational and organizational dimensions appear to provide incentives to join the activity in the first place but may also limit its post-discharge continuation. Once barriers are overcome, patients reported positive effects: satisfaction associated with relaxation and with the experience of mind-body integration.
Conclusions
Qigong appears to be an interesting therapeutic tool that may potentiate psychotherapy and contribute to the recovery process of patients with AN. Further analysis of the best time window for initiating qigong and of its place in overall management might help to overcome some of the barriers, limit the risks, and maximize its benefits.
... The information about potential factors predicting the out- come of an ED is also inconsistent and conflicting (Berkman et al. 2007;Hilbert et al. 2014). Nevertheless, the most frequently reported outcome predictors in AN are age of onset, low weight, severity of core ED-related preoccupations and behaviours, emer- gence of binge/purge (B/P) behaviours in restrictive AN (AN-R) patients, the presence of psychiatric comorbidities, relationships with significant others, social capabilities, duration of illness and follow-up, and treatment-related considerations (Strober et al. 1997;Steinhausen 2002;Bachner-Melman et al. 2006;Couturier & Lock 2006;Fichter et al. 2006;Berkman et al. 2007;YackobovitchGavan et al. 2009;Zerwas et al. 2013;Keski-Rahkonen et al. 2014 ). In BN, outcome predictors relate to individual and family history of obesity, presence of psychiatric comorbidities, problematic fam- ily environment, poor social adjustment, low motivation, and treatment-related considerations (Fichter & Quadglieg 2004;Berkman et al. 2007;Carter et al. 2012;Hilbert et al. 2014). ...
Objective: Research in eating disorders (EDs) suggests that outcome variables other than that of the ED per se, such as the presence of comorbid disorders and overall functioning at follow-up, may influence the ED condition at that time. We sought to assess the factors potentially predicting these different outcome variables.
Methods: Eighty-eight female adolescent in-patients with an ED were assessed on admission, discharge, and around one-year post-discharge using clinical interviews and self-rating questionnaires assessing ED and other relevant symptoms.
Results: The mean body mass index (BMI) of patients with anorexia nervosa increased from admission to discharge and was maintained at follow-up. Twenty-eight patients were remitted at follow-up, whereas 48 and 12 patients had intermediate and poor ED-related outcome, respectively. Follow-up BMI was correlated with baseline BMI. Good ED-related outcome at follow-up according to accepted criteria was associated with more lifetime suicide attempts and more severe baseline ED symptomatology. Elevated psychiatric comorbidity at follow-up was associated with elevated baseline anxiety and with re-hospitalisation during the post-discharge follow-up period. Better academic/occupational functioning and social functioning at follow-up were associated with less lifetime suicide attempts, less re-hospitalisation and lower baseline anxiety.
Conclusions: In EDs, diverse factors may predict different outcome variables.
... Such findings have led to perfectionism being proposed as a risk factor for AN and a target for interventions in AN (Egan et al., 2011). In addition, perfectionism has been found to impact treatment outcome, being predictive of poorer treatment prognosis and higher treatment attrition rate (Bizeul et al., 2001;Keski-Rahkonen et al., 2014;Sutandar-Pinnock et al., 2003). ...
This study aimed to explore the experiences of adults with anorexia nervosa who took part in a perfectionism group intervention in an inpatient setting. Thematic analysis was used to explore patient feedback collected in focus groups. Patient feedback was generally positive and centred around three main themes: perceived benefits of the group, the content of the group and suggested improvements. The findings suggest that a brief perfectionism group intervention is an acceptable treatment with a range of perceived benefits for patients with severe anorexia nervosa. Understanding patients' experiences of the intervention can provide further important information to maximise therapeutic impact of the group in inpatient settings.
... [33][34][35] The BMI range of patients at medium term (5-10 years) follow-ups is shifted to the left (lower BMI); in recovered patients overweight occurs with a substantially lower probability than in the general population. 36,37 Here we performed three cross-trait analyses involving AN risk and BMI variation in two GWAMAs. First, we performed a crosstrait analysis of the 1000 SNPs with the lowest P-values from the largest GWAMA for AN (GCAN 10 ) for evidence of association in the largest published GWAMA for BMI variation (GIANT 13 ). ...
... [33][34][35] The BMI range of patients at medium term (5-10 years) follow-ups is shifted to the left (lower BMI); in recovered patients overweight occurs with a substantially lower probability than in the general population. 36,37 Here we performed three cross-trait analyses involving AN risk and BMI variation in two GWAMAs. First, we performed a crosstrait analysis of the 1000 SNPs with the lowest P-values from the largest GWAMA for AN (GCAN 10 ) for evidence of association in the largest published GWAMA for BMI variation (GIANT 13 ). ...
The maintenance of normal body weight is disrupted in patients with anorexia nervosa (AN) for prolonged periods of time. Prior to the onset of AN, premorbid body mass index (BMI) spans the entire range from underweight to obese. After recovery, patients have reduced rates of overweight and obesity. As such, loci involved in body weight regulation may also be relevant for AN and vice versa. Our primary analysis comprised a cross-trait analysis of the 1000 single-nucleotide polymorphisms (SNPs) with the lowest P-values in a genome-wide association meta-analysis (GWAMA) of AN (GCAN) for evidence of association in the largest published GWAMA for BMI (GIANT). Subsequently we performed sex-stratified analyses for these 1000 SNPs. Functional ex vivo studies on four genes ensued. Lastly, a look-up of GWAMA-derived BMI-related loci was performed in the AN GWAMA. We detected significant associations (P-values <5 × 10(-5), Bonferroni-corrected P<0.05) for nine SNP alleles at three independent loci. Interestingly, all AN susceptibility alleles were consistently associated with increased BMI. None of the genes (chr. 10: CTBP2, chr. 19: CCNE1, chr. 2: CARF and NBEAL1; the latter is a region with high linkage disequilibrium) nearest to these SNPs has previously been associated with AN or obesity. Sex-stratified analyses revealed that the strongest BMI signal originated predominantly from females (chr. 10 rs1561589; Poverall: 2.47 × 10(-06)/Pfemales: 3.45 × 10(-07)/Pmales: 0.043). Functional ex vivo studies in mice revealed reduced hypothalamic expression of Ctbp2 and Nbeal1 after fasting. Hypothalamic expression of Ctbp2 was increased in diet-induced obese (DIO) mice as compared with age-matched lean controls. We observed no evidence for associations for the look-up of BMI-related loci in the AN GWAMA. A cross-trait analysis of AN and BMI loci revealed variants at three chromosomal loci with potential joint impact. The chromosome 10 locus is particularly promising given that the association with obesity was primarily driven by females. In addition, the detected altered hypothalamic expression patterns of Ctbp2 and Nbeal1 as a result of fasting and DIO implicate these genes in weight regulation.Molecular Psychiatry advance online publication, 17 May 2016; doi:10.1038/mp.2016.71.
... Even after recovery, almost 40 % of them report significant levels of sexual discord with their current partners [16]. Moreover, dissatisfaction with their current partners/spouses is more severe in unrecovered AN patients when compared to recovered women [50] Although the family of adolescent AN patients has received a lot of research attention which lead to a substantial number of evidence-based interventions on supporting or even treating the family, the partner of an adult AN patient has not received the same kind of attention so far. Of the extremely few studies regarding the partners of ED patients, most have been conducted during the past 5 years or so. ...
Little empirical evidence exists concerning sexual functioning and sexuality in women suffering from anorexia nervosa (AN). The current review of the literature since 2000 on AN and sexual functioning produced only a small number of studies on the subject. Most of the research was conducted with small numbers of individuals and utilized different measurements and methodological approaches. Almost all studies showed that AN was related with lower sexual functionality. The factors that influence this reduction in sexual functionality are various and may differ according to the subtype of AN. There is an almost unanimous view based on the research findings that the biological effect of starvation on the human body is the main reason why AN patients report loss of interest in sex and sparse sexual activities. AN symptomatology itself and, more specifically, body image distortion and body dissatisfaction, seem to increase the feeling of shame associated with nudity and hinder the ability of the sufferers to enjoy unobstructed having sex with their partners. On the other hand, personality traits, and especially obsessionality and emotional restraint, seem to have a negative influence both on the ability of the AN patients to create meaningful romantic relationships and to enjoy their sexual life. It is still unclear whether comorbidity with depression and/or anxiety disorders can further deteriorate AN patients’ sexual function. Due to the small number of publications, no definite conclusions can be drawn yet, with the exception that AN can be related with lower sexual function.
A comprehensive handbook covering current, controversial, and debated topics in psychiatric practice, aligned to the EPA Scientific Sections. All chapters been written by international experts active within their respective fields and they follow a structured template, covering updates relevant to clinical practice and research, current challenges, and future perspectives. This essential book features a wide range of topics in psychiatric research from child and adolescent psychiatry, epidemiology and social psychiatry to forensic psychiatry and neurodevelopmental disorders. It provides a unique global overview on different themes, from the recent dissemination in ordinary clinical practice of the ICD-11 to the innovations in addiction and consultation-liaison psychiatry. In addition, the book offers a multidisciplinary perspective on emerging hot topics including emergency psychiatry, ADHD in adulthood, and innovation in telemental health. An invaluable source of evidence-based information for trainees in psychiatry, psychiatrists, and mental health professionals.
Eating disorders, especially anorexia nervosa, are complex and devastating illnesses. Although eating disorders have a high mortality rate and are relatively common, there are many barriers for those seeking treatment. Provider training and education, weight bias among health care providers, geographical and language barriers, and a lack of options because of insurance restrictions prevent many families from receiving appropriate care, especially in smaller or rural communities. In those areas, providers are left to piece together treatment using a small number of other providers from different disciplines who have a willingness to work with this population. Outpatient family based treatment is an evidenced-based treatment of anorexia nervosa and relies on a multidisciplinary approach to care. Community-based care teams can be an effective way to treat those with eating disorders seeking family based treatment. There are several strategies for building collaborative teams that can provide comprehensive and accessible care to those with few options. [ Pediatr Ann . 2024;53(1):e22–e27.]
The main triggers of functional hypothalamic amenorrhoea are stress, weight loss, or excessive exercise, but the pathogenesis is not always immediately clear. This chapter highlights what is known about the pathophysiology of this form of menstrual dysfunction, as well as the steps for diagnostic evaluation, with a particular focus on less defined clinical situations as borderline energy deficiency, amenorrhoea that persists after weight recovery, and overlap of hypothalamic amenorrhoea with polycystic ovary syndrome.KeywordsFunctional hypothalamic amenorrhoeaLow energy availabilityBody compositionAmenorrhoea after weight recovery
Background:
Anorexia nervosa (AN) is a serious mental illness with high rates of relapse and mortality. Psychiatric comorbidities are common but their impact on the prognosis is largely unknown.
Objective:
The aim was to investigate the influence of psychiatric comorbidity on weight gain during treatment of AN.
Methods:
A systematic search was performed in PubMed/MEDLINE, EMBASE and PsycINFO. Studies evaluating psychiatric comorbidity as a predictor for treatment outcome (weight gain) were included, however, comorbid alcohol/drug addiction was excluded from this review.
Results:
Four thousand five hundred and twenty six publications were identified from which 15 were included. The majority of the included studies had a prospective open naturalistic study design, a short-term follow-up period, and were based on small populations of primarily adolescent and adult women. Four studies indicate depression, and two obsessiveness as negative prognostic factors, whilst one study indicated moderate depression and yet another, neuroticism, as positive predictors for weight gain.
Discussion:
The systematic scoping review found a large number of publications whereof only a few directly described the influence of psychiatric comorbidity on weight gain in AN. Overall, studies were heterogeneous in design, purpose and outcome making comparisons difficult. Findings were divergent but depression had a negative influence on weight gain in four studies.
Background
The DSM-5 introduced purging disorder (PD) as an other specified feeding or eating disorder characterized by recurrent purging in the absence of binge eating. The current study sought to describe the long-term outcome of PD and to examine predictors of outcome.
Methods
Women ( N = 84) who met research criteria for PD completed a comprehensive battery of baseline interview and questionnaire assessments. At an average of 10.24 (3.81) years follow-up, available records indicated all women were living, and over 95% were successfully located ( n = 80) while over two-thirds ( n = 58) completed follow-up assessments. Eating disorder status, full recovery status, and level of eating pathology were examined as outcomes. Severity and comorbidity indicators were tested as predictors of outcome.
Results
Although women experienced a clinically significant reduction in global eating pathology, 58% continued to meet criteria for a DSM-5 eating disorder at follow-up. Only 30% met established criteria for a full recovery. Women reported significant decreases in purging frequency, weight and shape concerns, and cognitive restraint, but did not report significant decreases in depressive and anxiety symptoms. Quality of life was impaired in the physical, psychological, and social domains. More severe weight and shape concerns at baseline predicted meeting criteria for an eating disorder at follow-up. Other baseline severity indicators and comorbidity did not predict the outcome.
Conclusions
Results highlight the severity and chronicity of PD as a clinically significant eating disorder. Future work should examine maintenance factors to better adapt treatments for PD.
La dieta occidentale ha modificato le ancestrali attitudini alimentari dell’uomo dell’era paleolitica? R. Nardi, P. Gnerre Alimentazione e longevità A. Mazza, G. Torin Rischio cardiovascolare e alimentazione: punto della situazione E. Filippini, G. Di Pasquale Ripensare gli obiettivi terapeutici: abbassare il colesterolo LDL o ridurre l’insulino-resistenza e lo stato pro-infiammatorio? L. Briatore La dieta DASH nelle malattie cardiovascolari e dismetaboliche A. Bosio, G. Pinna I falsi miti: quello che il medico deve dire al suo paziente per evitare i preconcetti ai fini di una buona educazione alimentare M. Malta Focus su alcool e salute M. Visconti Il paradosso francese; vantaggi e svantaggi presunti o certi del consumo quotidiano di vino S. Maccariello, G. Ballardini Olio e salute: le diverse tipologie in commercio, miti, preconcetti, metodi di cottura, svantaggi e alimentazione sana C. Parodi, E. Ottaviano La nutrizione nell’anziano fragile R. Risicato, M. Rondana Anoressia: lo stato dell’arte G. Tenconi Obesità sarcopenica F. Macchi, P. Brandimarte, A. Babbanini, G. Amadio, A. Martini, A. Zanotelli, G. Zoso, A.P. Rossi FODMAP e gluten sensitivity: quali evidenze e quale dieta? C. Tieri Dieta priva di glutine: quali rischi (in assenza di celiachia)? F. Tangianu Cibi crudi o cotti, quali tutele per i consumatori? E. Guberti Integratori alimentari: uso e abuso C. Parodi, F. Pivari Ruolo della nutraceutica in Medicina Interna: indicazioni e limiti A.F.G. Cicero, F. Fogacci Dieta chetogenica: pro e contro A. Casola, L. Bianchi, S. Detrenis, M. del Mar Jordana-Sanchez, S. Pioli, M. Meschi
Background
Network analysis of psychiatric symptoms describes reciprocal relationships of individual symptoms, beyond categorical diagnoses. Those with eating disorders (EDs) frequently have complex patterns of comorbid symptoms and the transdiagnostic theory includes shared common core features across diagnoses. We aim to test whether general psychiatric symptoms comprise components of these transdiagnostic features.
Methods
Network analysis was applied on 2068 patients with EDs (955 anorexia nervosa [AN], 813 bulimia nervosa [BN], and 300 binge‐eating disorder [BED]). All patients underwent clinical interviews and some self‐reported questionnaires, such as the Symptom Check‐List 90 (SCL‐90) to measure psychiatric symptoms, the Eating Disorder Inventory (EDI) to measure ED‐specific symptoms, and the Tridimensional Personality Questionnaire (TPQ) for personality traits.
Results
Across EDs and within each ED, SCL‐90 scores of depression, anxiety and interpersonal sensitivity, EDI ineffectiveness, interoceptive awareness, interpersonal distrust, and drive for thinness had high centrality. Notably, body mass index (BMI) and EDI bulimia played a central role when considering the whole group, whereas they did not in individual EDs.
Discussion
The shared centrality of identified nodes in both individual and merged groups supported the transdiagnostic theory of EDs (diagnoses share core ED features), with a central role of BMI. Moreover, the most central nodes were general psychiatric symptoms, interpersonal domain, and self‐efficacy. These findings suggest that—in addition to ED‐core symptoms and BMI—depressive and anxiety symptoms, interpersonal sensitivity and ineffectiveness may be important targets to provide effective treatments across AN, BN, and BED.
Les médecines complémentaires sont nombreuses et variées, leur recours est largement répandu et en hausse. Selon les pratiques, les données d’évaluation sont plus ou moins riches, mais il y a peu de conclusions consensuelles quant à leur efficacité, même en cas de littérature abondante. Nous commencerons par un état des lieux de l’adéquation des méthodes conventionnelles utilisées pour l’évaluation du médicament, à savoir de l’essai contrôlé randomisé (ECR) et des méta-analyses, pour l’évaluation des médecines complémentaires.A travers trois applications pratiques, nous réfléchirons ensuite à l’apport d’autres méthodes, moins reconnues à ce jour dans le champ de l’evidence based medecine mais pouvant apporter d’autres éclairages. En particulier, nous discuterons de l’intérêt des méthodes mixtes, des études qualitatives et de l’exploitation des grandes bases de données médico-administratives. Nous réaliserons une revue mixte sur l’évaluation de l’hypnose pour le travail et l’accouchement, une étude qualitative sur l’expérience du qi gong par des patientes hospitalisées pour anorexie mentale sévère, et nous étudierons le potentiel d’exploitation du Système National d'Information Inter Régimes de l'Assurance Maladie (SNIIRAM) pour évaluer les médecines complémentaires. Les deux premiers axes nous amèneront à questionner le choix des critères de jugement et des instruments de mesure utilisés dans les ECR et nous inciteront à accorder davantage de place et de légitimité à la perspective du patient. Plus largement, cela nous invitera à remettre en cause la suprématie traditionnellement accordée aux études quantitatives pour la remplacer par une vision non hiérarchique mais synergique des approches qualitatives et quantitatives. Le troisième axe nous permettra d’identifier les limites actuelles à l’exploitation du SNIIRAM pour l’évaluation des médecines complémentaires, à la fois sur le plan technique et sur le plan de la représentativité. Nous proposerons des mesures concrètes pour rendre possible et pertinente son exploitation dans le champ de l'évaluation des médecines complémentaires.Enfin, dans la discussion générale, nous tiendrons compte du fait que l’évaluation des médecines complémentaires n’a pas pour but d’autoriser ou non une mise sur le marché. Ainsi, contrairement à l'évaluation des médicaments, l'évaluation des médecines complémentaires ne s'inscrit pas toujours dans une visée de prise de décision. Nous soulignerons l’importance de tenir compte de la visée (visée de connaissance ou visée de décision) dans l’élaboration d’une stratégie de recherche et nous proposerons deux stratégies différentes en nous appuyant sur la littérature et les résultats issus de nos trois exemples d'application. Concernant la stratégie de recherche à visée de prise de décision, nous montrerons l’importance des étapes de définition de l’intervention, d’identification des critères de jugement pertinents, et d’optimisation de l’intervention, avant la réalisation d’essais pragmatiques visant à évaluer l’efficacité en vie réelle. Nous verrons comment la volonté d’évaluer ces pratiques nous renvoie à des défis en terme de réglementation et nous soulignerons par ailleurs la nécessité d’évaluer la sécurité de ces pratiques en développant des systèmes de surveillance adaptés.
Purpose of review:
The purpose of this review is to discuss the diagnosis, medical complications, and treatment of eating disorders as defined by the newly released Diagnostic and Statistical Manual, 5th edition.
Recent findings:
With the introduction of the Diagnostic and Statistical Manual, 5th edition, the diagnostic criteria for anorexia nervosa and bulimia nervosa have been revised to better capture the varied presentations of patients with eating disorders. In addition, new eating disorder diagnoses including binge-eating disorder, characterized by recurrent bingeing without associated compensatory behaviors, and avoidant/restrictive food intake disorder, characterized by a restrictive eating pattern without associated body dysmorphism, allow for increased recognition, diagnosis, and treatment of disordered eating patterns. In addition to a high mortality rate, eating disorders are associated with serious medical sequelae secondary to malnutrition and disordered behaviors, including disturbances of the cardiovascular, neurologic, gastrointestinal, reproductive, and skeletal systems. Early diagnosis and family-based treatment are associated with improved outcomes in children and adolescents.
Summary:
Eating disorders are illnesses with biological, psychological, and social implications that commonly present in childhood and adolescence. Gynecologists are on the front line for the screening and diagnosis of eating disorders in adolescent women.
Une comorbidité dépressive est souvent retrouvée au cours de l’anorexie mentale (AM), et la prescription d’antidépresseurs est fréquente, mais n’est étayée sur aucune donnée probante dans la littérature. D’une part, des symptômes dépressifs isolés sont fréquents, liés à la symptomatologie de l’AM, à la dénutrition ou à une phase évolutive de la maladie. D’autre part, un épisode dépressif majeur (EDM) est également fréquent et impacte l’évolution de l’AM, mais est difficile à différencier cliniquement des symptômes isolés. Les essais cliniques concernant l’utilisation d’antidépresseurs (AD) au cours de l’AM sont défavorables à cette prescription. Selon les recommandations internationales, elle n’est pas recommandée en première intention et n’est à envisager qu’après renutrition, et uniquement en présence d’une comorbidité dépressive caractérisée. Différentes faiblesses méthodologiques peuvent expliquer l’absence de preuve de l’efficacité des antidépresseurs dans l’AM. Le diagnostic d’EDM au cours de l’AM doit s’appuyer sur des éléments spécifiques : antécédents familiaux de trouble de l’humeur, chronologie d’apparition des signes dépressifs, existence de symptômes prédictifs d’un épisode dépressif majeur. Nous proposons un arbre décisionnel pour la prescription d’AD au cours de l’AM. Les inhibiteurs sélectifs de la recapture de la sérotonine, mieux tolérés, sont à privilégier et le terrain somatique fragile des patients doit être évalué avant la prescription, puis surveillé.
Anorexia nervosa (AN) is a serious illness that challenges mental health professionals globally. While family-based treatment is well established for adolescents with parents able to collaborate, little data are available to inform treatment choice for chronic or adult patients. This review proposes that the current high attrition, poor compliance, and suboptimal efficacy of outpatient interventions may reflect inadequate consideration of individual difference variables. Data on certain variables demonstrated to have relevance for AN are briefly summarized, and novel psychotherapeutic interventions that have taken these variables into account are reviewed. These data suggest that identifying subgroups of individuals with AN on the basis of relevant personality or neurocognitive variables may be one way to improve treatment acceptability and effectiveness for this challenging population.
The EDI-2 manual is currently out of print but the attached file provides the table of contents for the EDI-3 which includes all of the EDI-2 items as well as the updated scale structure and scoring system for the EDI-3
Anorexia nervosa, a psychiatric disorder characterized by self-induced starvation, is associated with endocrine dysfunction and comorbid anxiety and depression. Animal data suggest that oxytocin may have anxiolytic and antidepressant effects. We have reported increased postprandial oxytocin levels in women with active anorexia nervosa and decreased levels in weight-recovered women with anorexia nervosa compared to healthy controls. A meal may represent a significant source of stress in patients with disordered eating. We therefore investigated the association between postprandial oxytocin secretion and symptoms of anxiety and depression in anorexia nervosa.
We performed a cross-sectional study of 35 women (13 women with active anorexia nervosa, 9 with weight-recovered anorexia nervosa, and 13 healthy controls). Anorexia nervosa was diagnosed according to DSM-IV-TR criteria. Serum oxytocin and cortisol and plasma leptin levels were measured fasting and 30, 60, and 120 minutes after a standardized mixed meal. The area under the curve (AUC) and, for oxytocin, postprandial nadir and peak levels were determined. Anxiety and depressive symptoms were assessed using the Spielberger State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory II (BDI-II). The study was conducted from January 2009 to March 2011.
In women with anorexia nervosa, oxytocin AUC and postprandial nadir and peak levels were positively associated with STAI trait and STAI premeal and postmeal state scores. Oxytocin AUC and nadir levels were positively associated with BDI-II scores. After controlling for cortisol AUC, all of the relationships remained significant. After controlling for leptin AUC, most of the relationships remained significant. Oxytocin secretion explained up to 51% of the variance in STAI trait and 24% of the variance in BDI-II scores.
Abnormal postprandial oxytocin secretion in women with anorexia nervosa is associated with increased symptoms of anxiety and depression. This link may represent an adaptive response of oxytocin secretion to food-related symptoms of anxiety and depression.
Morbidity and mortality rates in patients with eating disorders are thought to be high, but exact rates remain to be clarified.
To systematically compile and analyze the mortality rates in individuals with anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS).
A systematic literature search, appraisal, and meta-analysis were conducted of the MEDLINE/PubMed, PsycINFO, and Embase databases and 4 full-text collections (ie, ScienceDirect, Ingenta Select, Ovid, and Wiley-Blackwell Interscience).
English-language, peer-reviewed articles published between January 1, 1966, and September 30, 2010, that reported mortality rates in patients with eating disorders.
Primary data were extracted as raw numbers or confidence intervals and corrected for years of observation and sample size (ie, person-years of observation). Weighted proportion meta-analysis was used to adjust for study size using the DerSimonian-Laird model to allow for heterogeneity inclusion in the analysis.
From 143 potentially relevant articles, we found 36 quantitative studies with sufficient data for extraction. The studies reported outcomes of AN during 166 642 person-years, BN during 32 798 person-years, and EDNOS during 22 644 person-years. The weighted mortality rates (ie, deaths per 1000 person-years) were 5.1 for AN, 1.7 for BN, and 3.3 for EDNOS. The standardized mortality ratios were 5.86 for AN, 1.93 for BN, and 1.92 for EDNOS. One in 5 individuals with AN who died had committed suicide.
Individuals with eating disorders have significantly elevated mortality rates, with the highest rates occurring in those with AN. The mortality rates for BN and EDNOS are similar. The study found age at assessment to be a significant predictor of mortality for patients with AN. Further research is needed to identify predictors of mortality in patients with BN and EDNOS.
The objective of this study was to examine whether there is an association between individual and family eating patterns during childhood and early adolescence and the likelihood of developing a subsequent eating disorder (ED). A total of 1664 participants took part in the study. The ED cases (n 879) were referred for assessment and treatment to specialized ED units in five different European countries and were compared to a control group of healthy individuals (n 785). Participants completed the Early Eating Environmental Subscale of the Cross-Cultural (Environmental) Questionnaire, a retrospective measure, which has been developed as part of a European multicentre trial in order to detect dimensions associated with ED in different countries. In the control group, also the General Health Questionnaire-28 (GHQ-28), the semi-structured clinical interview (SCID-I) and the Eating Attitudes Test (EAT-26) were used. Five individually Categorical Principal Components Analysis (CatPCA) procedures were adjusted, one for each theoretically expected factor. Logistic regression analyses indicated that the domains with the strongest effects from the CatPCA scores in the total sample were: food used as individualization, and control and rules about food. On the other hand, healthy eating was negatively related to a subsequent ED. When differences between countries were assessed, results indicated that the pattern of associated ED factors did vary between countries. There was very little difference in early eating behaviour on the subtypes of ED. These findings suggest that the fragmentation of meals within the family and an excessive importance given to food by the individual and the family are linked to the later development of an ED.
An investigation was carried out in 1986 of 41 patients, 39 female and 2 male, who had been treated for anorexia nervosa in a psychiatric ward at a general hospital between 1958 and 1980. A follow-up analysis was carried out, in which 30 subjects participated. Using the scores on the 40-item version of the EAT as outcome criteria, validated by the Morgan-Hayward outcome scales, the outcome distribution and rate of mortality was in agreement with previous findings. Further data concerning weight, menstruation, and nutritional, social and psychiatric status were based on a semistructured interview as well as on the scores on the EAT, the GHQ, and the MMPI. Prognostic variables were analysed, indicating that duration of illness, poor motivation for treatment, social withdrawal, and poor family relations were significant as predictors of poor outcome.
Clinicians are under increasing pressure to transfer inpatients with anorexia nervosa to less intensive treatment early in their hospital course. This study identifies prognostic factors clinicians can use in determining the earliest time to transfer an inpatient with anorexia to a day hospital program.
The authors reviewed the charts of 59 female patients with anorexia nervosa who were transferred from 24-hour inpatient care to an eating disorder day hospital program. They evaluated the prognostic significance of a variety of anthropometric, demographic, illness history, and psychometric measures in this retrospective chart review.
Greater risk of day hospital program treatment failure and inpatient readmission was associated with longer duration of illness (for patients who had been ill for more than 6 years, risk ratio = 2.7), amenorrhea (for patients who had this symptom for more than 2.5 years, risk ratio = 5.7), or lower body mass index at the time of inpatient admission (for patients with a body mass index of 16.5 or less, risk ratio = 9.6; for those with a body mass index 75% or less than normal, risk ratio = 7.2) or at the time of transition to the day hospital program (for patients with a body mass index of 19 or less, risk ratio = 3.9; for those with a body mass index 90% or less than normal, risk ratio = 11.7).
Inpatients with anorexia nervosa who have the poor prognostic indicators found in this study are in need of continued inpatient care to avoid immediate relapse and higher cost and longer duration of treatment.
The authors sought to derive heritability estimates for anorexia nervosa and to explore the etiology of the comorbid relationship between anorexia nervosa and major depression.
They applied bivariate structural equation modeling to a broad definition of anorexia nervosa and lifetime major depression as assessed in a population-based sample of 2,163 female twins.
Anorexia nervosa was estimated to have a heritability of 58% (95% confidence interval=33%-84%). The authors were unable to completely rule out a contribution of shared environment. The comorbidity between anorexia nervosa and major depression is likely due to genetic factors that influence the risk for both disorders.
Although the study was limited by the small number of affected twins, the results suggest that genetic factors significantly influence the risk for anorexia nervosa and substantially contribute to the observed comorbidity between anorexia nervosa and major depression.
The present review addresses the outcome of anorexia nervosa and whether it changed over the second half of the 20th century.
A total of 119 study series covering 5,590 patients suffering from anorexia nervosa that were published in the English and German literature were analyzed with regard to mortality, global outcome, and other psychiatric disorders at follow-up.
There were large variations in the outcome parameters across studies. Mortality estimated on the basis of both crude and standardized rates was significantly high. Among the surviving patients, less than one-half recovered on average, whereas one-third improved, and 20% remained chronically ill. The normalization of the core symptoms, involving weight, menstruation, and eating behaviors, was slightly better when each symptom was analyzed in isolation. The presence of other psychiatric disorders at follow-up was very common. Longer duration of follow-up and, less strongly, younger age at onset of illness were associated with better outcome. There was no convincing evidence that the outcome of anorexia nervosa improved over the second half of the last century. Several prognostic features were isolated, but there is conflicting evidence. Most clearly, vomiting, bulimia, and purgative abuse, chronicity of illness, and obsessive-compulsive personality symptoms are unfavorable prognostic features.
Anorexia nervosa did not lose its relatively poor prognosis in the 20th century. Advances in etiology and treatment may improve the course of patients with anorexia nervosa in the future.
Family, twin and adoption studies have provided evidence for familial and genetic influences on individual differences in disease risk and in human behavior. Attempts to identify individual genes accounting for these differences have not been outstandingly successful to date, and at best, known genes account for only a fraction of the familiality of most traits or diseases. More detailed knowledge of the dynamics of gene action and of specific environmental conditions are needed. Twin and twin-family studies with multiple measurements of risk factors and morbidity over time can permit a much more detailed assessment of the developmental dynamics of disease risk and the unfolding of behavioral risk factors.
Body mass index (BMI), a simple anthropometric measure, is the most frequently used measure of adiposity and has been instrumental in documenting the worldwide increase in the prevalence of obesity witnessed during the last decades. Although this increase in overweight and obesity is thought to be mainly due to environmental changes, i.e., sedentary lifestyles and high caloric diets, consistent evidence from twin studies demonstrates high heritability and the importance of genetic differences for normal variation in BMI. We analysed self-reported data on BMI from approximately 37,000 complete twin pairs (including opposite sex pairs) aged 20-29 and 30-39 from eight different twin registries participating in the GenomEUtwin project. Quantitative genetic analyses were conducted and sex differences were explored. Variation in BMI was greater for women than for men, and in both sexes was primarily explained by additive genetic variance in all countries. Sex differences in the variance components were consistently significant. Results from analyses of opposite sex pairs also showed evidence of sex-specific genetic effects suggesting there may be some differences between men and women in the genetic factors that influence variation in BMI. These results encourage the continued search for genes of importance to the body composition and the development of obesity. Furthermore, they suggest that strategies to identify predisposing genes may benefit from taking into account potential sex specific effects.
Little population-based data exist on the prevalence or correlates of eating disorders.
Prevalence and correlates of eating disorders from the National Comorbidity Replication, a nationally representative face-to-face household survey (n = 9282), conducted in 2001-2003, were assessed using the WHO Composite International Diagnostic Interview.
Lifetime prevalence estimates of DSM-IV anorexia nervosa, bulimia nervosa, and binge eating disorder are .9%, 1.5%, and 3.5% among women, and .3% .5%, and 2.0% among men. Survival analysis based on retrospective age-of-onset reports suggests that risk of bulimia nervosa and binge eating disorder increased with successive birth cohorts. All 3 disorders are significantly comorbid with many other DSM-IV disorders. Lifetime anorexia nervosa is significantly associated with low current weight (body-mass index <18.5), whereas lifetime binge eating disorder is associated with current severe obesity (body-mass index > or =40). Although most respondents with 12-month bulimia nervosa and binge eating disorder report some role impairment (data unavailable for anorexia nervosa since no respondents met criteria for 12-month prevalence), only a minority of cases ever sought treatment.
Eating disorders, although relatively uncommon, represent a public health concern because they are frequently associated with other psychopathology and role impairment, and are frequently under-treated.
Most previous studies of the prevalence, incidence, and outcome of anorexia nervosa have been limited to cases detected through the health care system, which may bias our understanding of the disorder's incidence and natural course. The authors sought to describe the onset and outcomes of anorexia nervosa in the general population.
Lifetime prevalences, incidence rates, and 5-year recovery rates of anorexia nervosa were calculated on the basis of data from 2,881 women from the 1975-1979 birth cohorts of Finnish twins. Women who screened positive for eating disorder symptoms (N=292), their screen-negative female co-twins (N=134), and 210 randomly selected screen-negative women were assessed for lifetime eating disorders by telephone by experienced clinicians. To assess outcomes after clinical recovery and to detect residua of illness, women who had recovered were compared with their unaffected co-twins and healthy unrelated women on multiple outcome measures.
The lifetime prevalence of DSM-IV anorexia nervosa was 2.2%, and half of the cases had not been detected in the health care system. The incidence of anorexia nervosa in women between 15 and 19 years of age was 270 per 100,000 person-years. The 5-year clinical recovery rate was 66.8%. Outcomes did not differ between detected and undetected cases. After clinical recovery, the residua of illness steadily receded. By 5 years after clinical recovery, most probands had reached complete or nearly complete psychological recovery and closely resembled their unaffected co-twins and healthy women in weight and most psychological and social measures.
The authors found a substantially higher lifetime prevalence and incidence of anorexia nervosa than reported in previous studies, most of which were based on treated cases. Most women recovered clinically within 5 years, and thereafter usually progressed toward full recovery.
About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress towards the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.
• Clinical surveys of "selected" convenient patient samples (hospital or clinic) can lead to spurious conclusions unless the relationship of selected patients to the source population is carefully controlled. The possibility of biased conclusions from uneven selection rates of patients is called Berkson fallacy.
Studies of cerebral palsy and low birth weight provide clear examples of Berkson fallacy. A fictitious clinical survey of cerebral palsy and low birth weight is presented to illustrate how Berkson fallacy may lead to interesting but spurious conclusions from patient surveys.
(Am J Dis Child 130:56-60, 1976)
• There are several diseases, including schizophrenia, alcoholism, and opiate addiction, for which the long-term prognosis is subject to disagreement between clinicians and researchers and also among researchers. Part of this disagreement may be attributable to a difference in the populations they sample. The clinician samples the population currently suffering from the disease (a "prevalence" or census sample), while research samples tend to more nearly represent the population ever contracting the disease (an "incidence" sample). The clinician's sample is biased toward cases of long duration, since the probability that a case will appear in a prevalence sample is proportional to its duration, hence "the clinician's illusion." The statistical mechanism of this bias is illustrated and its consequences detailed. Other sources of sampling bias in clinical and research samples are briefly described and partial remedies are suggested.
Background:
This study investigated the epidemiology of eating disorders in a population-based sample of young adults.
Method:
A mental health questionnaire was sent to a nationally representative two-stage cluster sample of 1863 Finns aged 20-35 years. All screen-positives and a random sample of screen-negatives were invited to participate in a Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) interview. Case records from all lifetime mental health treatments were also obtained and were used to complement the diagnostic assessment.
Results:
The lifetime prevalence of anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified and any eating disorder among women were 2.1%, 2.3%, 2.0% and 6.0%, respectively, while there was only one man with an eating disorder. Unlike other mental disorders, they are associated with high education. Of women diagnosed with lifetime eating disorder, 67.9% had at least one comorbid Axis I psychiatric disorder, most commonly depressive disorder. While 79.3% of women with lifetime eating disorder had had a treatment contact, only one third of persons with current eating disorder had a current treatment contact. Women whose eating disorder had remitted still experienced more psychological distress and had lower psychosocial functioning that women without lifetime Axis I disorders.
Conclusion:
Eating disorders are the fourth largest group of mental disorders among young women. They tend to be comorbid, often remain untreated and are associated with residual symptoms after the remission of eating disorder symptoms.
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.
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.
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.
The strength of the bodies of literature was moderate for factors associated with AN and BN outcomes and weak for BED. © 2007 by Wiley Periodicals, Inc. Int J Eat Disord 2007
We examined the course of major depressive disorder (MDD) and predictors of MDD recovery and relapse in a longitudinal sample of women with eating disorders (ED).
246 Boston-area women with DSM-IV anorexia nervosa-restricting (ANR; n=51), AN-binge/purge (ANBP; n=85), and bulimia nervosa (BN; n=110) were recruited between 1987 and 1991 and interviewed using the Eating Disorders Longitudinal Interval Follow-up Evaluation (LIFE-EAT-II) every 6-12 months for up to 12 years. 100 participants had MDD at study intake and 45 developed MDD during the study. Psychological functioning and treatment were assessed.
Times to MDD onset (1 week-4.3 years), recovery (8 weeks-8.7 years), and relapse (1 week-5.2 years) varied. 70% recovered from MDD, but 65% subsequently relapsed. ANR patients were significantly less likely to recover from MDD than ANBP patients (p=0.029). Better psychological functioning and history of MDD were associated with higher chance of MDD recovery. Higher baseline depressive severity and full recovery from ED were associated with greater likelihood of MDD relapse; increased weight loss was somewhat protective. Adequate antidepressant treatment was given to 72% of patients with MDD and generally continued after MDD recovery. Time on antidepressants did not predict MDD recovery (p=0.27) or relapse (p=0.26).
Small ED diagnostic subgroups; lack of non-ED control group.
The course of MDD in EDs is protracted; MDD recovery may depend on ED type. Antidepressants did not impact likelihood of MDD recovery, nor protect against relapse, which may impact on treatment strategies for comorbid MDD and EDs.
To review recent studies describing eating disorder course and outcome.
Electronic and manual searches were conducted to identify relevant articles published since 2004.
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.
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.
The purpose of this study is to analyze the developmental relationships of adolescent-onset Axis I mental disorders and eating disorders (EDs).
One thousand three hundred eighteen adolescent twins born from 1983 to 1987 completed a professionally administered semistructured psychiatric interview at the age of 14 years and a questionnaire follow-up at the age of 17.5 years.
Eating disorders at the age of 17.5 years were significantly predicted by major depressive disorder (odds ratio, 5.9; 95% confidence interval, 2.6-15.3) and generalized anxiety disorder (GAD) (odds ratio, 4.7; 95% confidence interval, 1.8-15.6) at the age of 14 years, when baseline EDs were excluded. Early-onset major depressive disorder in combination with GAD increased the likelihood of developing EDs compared with either mood or anxiety disorders alone. Similar risks and trends were evident in within-family analyses of twin pairs discordant for baseline predictors and ED outcome.
Depressive disorder and GAD that manifest at that age of 14 years predict future EDs. Analysis of discordant twins suggested that early-onset depressive disorder and GAD prospectively relate to EDs in adolescence, even after familial factors are taken into account.
This is a prognostic study on 41 patients with anorexia nervosa (including three males) who satisfied defined diagnostic criteria. The patients had all been admitted to a metabolic unit where the mainstay of treatment was nursing care aimed at rapid restoration of body weight. A follow-up was conducted after a minimum lapse of four years after each patient's discharge from hospital. The outcome of the patient's illness was expressed in terms of an 'average outcome score' and a 'general outcome'. The series included a relatively high proportion of patients with a long illness who had received previous psychiatric treatment. Their families tended to come from higher social classes; a disturbed relationship with the patient was frequent. Premorbid disturbances in personality development were also common. The immediate response to treatment was excellent, with the majority of the patients returning to a normal weight, but relapses after discharge were common and readmissions were necessary in half the patients. At follow-up, the patients fell into the following defined categories: 'good' (39%), 'intermediate' (27%), 'poor' (29%), died (5%). Most of the patients who failed to recover continued to display the clinical features characteristic of anorexia nervosa. Among predictors of an unfavourable outcome were found a relatively late age of onset, a longer duration of illness, previous admissions to psychiatric hospitals, a disturbed relationship between the patient and other members of the family, and premorbid personality difficulties. It is suggested according to the severity of their illness, rather than on the method of treatment itself. The illness may last several years before eventual improvement or recovery, and a follow-up study must be extended over at least four years to be meaningful. An accurate prediction of eventual outcome is almost impossible, but late recoveries justify an optimistic outlook and continued therapeutic endeavour.
Clinical surveys of "selected" convenient patient samples (hospital or clinic) can lead to spurious conclusions unless the relationship of selected patients to the source population is carefully controlled. The possibility of biased conclusions from uneven selection rates of patients is called Berkson fallacy. Studies of cerebral palsy and low birth weight provide clear examples of Berkson fallacy. A fictitious clinical survey of cerebral palsy and low birth weight is presented to illustrate how Berkson fallacy may lead to interesting but spurious conclusions from patient surveys.
There are several diseases, including schizophrenia, alcoholism, and opiate addiction, for which the long-term prognosis is subject to disagreement between clinicians and researchers and also among researchers. Part of this disagreement may be attributable to a difference in the populations they sample. The clinician samples the population currently suffering from the disease (a "prevalence" or census sample), while research samples tend to more nearly represent the population ever contracting the disease (an "incidence" sample). The clinician's sample is biased toward cases of long duration, since the probability that a case will appear in a prevalence sample is proportional to its duration, hence "the clinician's illusion." The statistical mechanism of this bias is illustrated and its consequences detailed. Other sources of sampling bias in clinical and research samples are briefly described and partial remedies are suggested.
Empirical definitions of remission and recovery from eating disorders are needed to understand outcome data and compare results across studies.
106 treatment-seeking women with bulimia nervosa, who had abstained from binging and purging for at least 4 weeks, were followed prospectively. Relapse was defined as at least 4 consecutive weeks of either binging and purging weekly or binging two or more times per week, regardless of purging. Recovery was differentiated from remission based on the probability of relapse. The minimum number of weeks after which the risk of relapse leveled off was used as the cut-off to distinguish between the two outcomes. Kaplan-Meier methods were used to estimate the weekly probability of relapse.
When defining remission as at least 4 weeks of being asymptomatic, a quarter of the women relapsed within 11 weeks. By 37 weeks, only 49% of the women remained asymptomatic (95% CI, 41-61). The probability of relapse was substantial for approximately a year after a woman ceased to binge and purge.
Bulimia nervosa is an episodic disorder. As a conservative approach, periods of being asymptomatic that last less than 1 year should be labeled as remissions, not recoveries.
This study investigates psychiatric comorbidity associated with eating disorder symptomatology among adolescents in the community.
Four hundred three adolescents in the community were administered structured clinical interviews to assess mood, anxiety, eating, substance use, and personality disorders.
Adolescents with dysthymia, panic and major depressive disorder were significantly more likely than those without these disorders to have an eating disorder. After controlling for the effects of other Axis I disorders and personality disorders, only dysthymia independently predicted the presence of an eating disorder. Several personality disorders were also associated with eating disorder symptoms. However, only obsessive-compulsive personality disorder predicted eating disorder symptoms after controlling for other personality disorders.
Although previous research on adults has focused on the association between major depressive disorder and eating disorders, dysthymia may be more strongly associated with eating disorders among adolescents in the community. This association is not accounted for by psychiatric comorbidity.
This overview presents selected recent developments in twin studies of adult psychiatric disorders. Subjects examined include the generalizability of heritability estimates, the impact of sex on patterns of familial transmission, gene-environment interaction, twin studies of anxiety and eating disorders, the so-called family environment, special issues raised by twin studies of drug use and abuse, and gene-environment correlation. The studies reviewed suggest that (1) the heritability of many behavioral traits may be greater in permissive than in restrictive environments and, (2) for psychiatric and drug abuse disorders, genes probably work through both traditional within-the-skin physiological pathways and outside-the-skin behavioral pathways. In the latter, genes affect aspects of the social environment, such as exposure to stressful life events and levels of social support, which in turn feed back on risk of illness. Twin studies remain a vibrant part of the field of psychiatric genetics and an important complement to and context for current efforts to localize individual susceptibility genes.
We explored anorexic patients' subjective accounts of the causes of their anorexia and of the factors that fostered recovery. Subjective accounts could assist in understanding this complicated and often intractable disorder.
All female new referrals to an eating disorders service underwent extensive interviews including open-ended questions about their beliefs concerning the causes of their anorexia nervosa and factors that led to recovery. Responses were categorized by two independent raters.
The most commonly mentioned perceived causes were dysfunctional families, weight loss and dieting, and stressful experiences and perceived pressure. The three most commonly cited factors contributing to recovery were supportive nonfamilial relationships, therapy, and maturation.
Individuals with anorexia nervosa perceive both external (family environment) and personal factors (dieting and stress) as contributory to their disorders. The results underscore the importance of interpersonal factors in recovery from anorexia nervosa and suggest that attention to this area in treatment may be beneficial.
To review the literature on the incidence and prevalence of eating disorders.
We searched Medline using several key terms relating to epidemiology and eating disorders and we checked the reference lists of the articles that we found. Special attention has been paid to methodologic problems affecting the selection of populations under study and the identification of cases.
An average prevalence rate for anorexia nervosa of 0.3% was found for young females. The prevalence rates for bulimia nervosa were 1% and 0.1% for young women and young men, respectively. The estimated prevalence of binge eating disorder is at least 1%. The incidence of anorexia nervosa is 8 cases per 100,000 population per year and the incidence of bulimia nervosa is 12 cases per 100,000 population per year. The incidence of anorexia nervosa increased over the past century, until the 1970s.
Only a minority of people who meet stringent diagnostic criteria for eating disorders are seen in mental health care.
This exploratory Internet-based study attempts to understand what eating disorder sufferers suggest when they mention the word recovery. All messages (N = 685) posted in a Finnish-language eating disorders discussion group during a 3-month period were analyzed for the contexts of the word recovery using text analysis software and qualitative methods. The discussion group participants' views of recovery changed according to their current stage of change. Mentioning recovery was least likely during precontemplation and relapse. Internet discussion group was seen as helpful in the early stages of change, but as impeding recovery in the last stages. Willpower and ceasing to identify with eating disorders were viewed as essential to recovery. The value of professional help in recovery was viewed as conditional on the eating disorders sufferer's own willingness to change. Internet-based support groups have many potential therapeutic applications. Motivational aspects need to be taken into account in promoting recovery.
The objective of this study was to assess whether short self-report eating disorder screening questions are useful population screening methods.
We screened the female participants (N = 2881) from the 1975-1079 birth cohorts of Finnish twins for eating disorders, using several short screening questions and three Eating Disorder Inventory (EDI) subscales. Comparing these measures with clinician-conducted semi-structured diagnostic interviews (N = 549) of Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) anorexia and bulimia, we calculated their sensitivities and specificities and drew receiver operating characteristic curves to further compare these items.
For current and lifetime bulimia, best tradeoffs between sensitivity and specificity were reached by addressing purging behaviors. For current and lifetime anorexia, the questions "Have you ever had anorexia" and "Has anybody ever suspected that you might have an eating disorder?" optimized tradeoffs between sensitivity and specificity. These questions generally outperformed EDI subscales.
Simple screening questions, although less than ideal, are at least as good as other available instruments for community screenings.
Depression is a chronic illness in children and adolescents that often leads to long-term difficulties with recurrent episodes of depression. Standard treatment must continue beyond acute symptom reduction to a chronic disease management model, such as those used in pediatric asthma and diabetes. Within the chronic disease management model, treatment interventions are directed not only at the urgent or acute concern but also at the prevention of future problems. Lack of consistent efficacy in acute treatment studies has limited long-term prevention treatment research in pediatric depression. The impact of long-term treatments, both psychosocial and pharmacologic, is currently unknown.
A substantial number of patients treated in specialized eating disorder programs fail to meet criteria for anorexia nervosa or bulimia nervosa, the 2 eating disorders with specified criteria in DSM-IV, and are diagnosed with eating disorder not otherwise specified (NOS). In a general psychiatric setting, where the severity of eating pathology is likely to be milder than in specialty programs, we predicted that most patients with disordered eating would fail to meet the full criteria for one of the DSM-IV eating disorders and instead would be diagnosed with eating disorder NOS.
Two thousand five hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) upon presentation for treatment. The findings presented in this report were derived from patients interviewed from December 1995 to August 2006.
Thirteen percent (N = 330) of the patients were diagnosed with a lifetime history of an eating disorder, 307 of whom received 1 diagnosis and 23 of whom were diagnosed with 2 disorders. Almost half (N = 164) of the disorders were present at the time of presentation, approximately one sixth (N = 60) were considered to be in partial remission, and slightly more than one third (N = 129) were past diagnoses. When binge-eating disorder was combined with the other forms of eating disorder NOS, as it is in DSM-IV, 90.2% (148/164) of the patients with a current eating disorder were diagnosed with eating disorder NOS.
The preponderance of eating-disordered patients in a general psychiatric setting were diagnosed with eating disorder NOS. This finding suggests that there is a problem with the clinical applicability of the diagnostic criteria in the DSM-IV eating disorder category.
Eating disorder inventory 2, professional manual
- D M Garner
Garner DM. Eating disorder inventory 2, professional manual. Odessa, FL:
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Twin studies of psychiatric illness: an update
- Kendler
Kendler KS. Twin studies of psychiatric illness: an update. Arch Gen Psychiatry 2001;58:1005-1014.