Body Weight as a Prognostic Factor for Day Hospital Success in Adolescents With Anorexia Nervosa

For female adolescents with anorexia nervosa, body weight at admission as a predictor of treatment outcome in the day hospital setting was examined. A retrospective review of patient charts was completed to determine success or failure in the day hospital program based on weight above or below 85% of ideal body weight. There was not a greater risk of failure in the day hospital program for patients with ideal body weight below 85% compared to those patients with an ideal body weight of ≥ to 85%. Body weight did not predict day hospital success in adolescents with anorexia nervosa in this study.     

Manualized family-based treatment for anorexia nervosa: a case series

OBJECTIVE: The purpose of this study was to describe a case series of children and adolescents (mean age = 14.5 years, SD = 2.3; range 9-18) with anorexia nervosa who received manualized family-based treatment for their eating disorder. METHOD: Forty-five patients with anorexia nervosa were compared pre- and post-treatment on weight and menstrual status. RESULTS: After an average of 17 treatment sessions, patients were significantly improved on primary measures of outcome (body mass index and percentage of ideal body weight). Defining outcome categorically (Morgan-Russell outcome criteria), 56% (n = 25) had a good outcome (>85% ideal body weight and menses), 33% (n = 15) an intermediate outcome (>85% IBW and menses intermittent), and 11% (n = 5) responded poorly (<85% ideal body weight and no menses). CONCLUSIONS: Findings provide preliminary support for the feasibility of an outpatient approach with active parental involvement in the treatment of children and adolescents with anorexia nervosa. However, randomized, controlled studies are needed to establish the relative efficacy of this family-based treatment approach.     

A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa

OBJECTIVE: To compare the effectiveness of behavioral family systems therapy (BFST) with that of ego-oriented individual therapy (EOIT) as treatments for adolescents with anorexia nervosa. METHOD: Thirty-seven adolescents meeting DSM-III-R criteria for anorexia nervosa were randomly assigned to receive BFST or EOIT, in addition to a common medical and dietary regimen. In BFST, the family was seen conjointly, the parents were placed in control of the adolescent's eating, distorted beliefs were targeted through cognitive restructuring, and strategic/behavioral interventions were used to change family interactions. In EOIT, the adolescent was seen individually, with an emphasis on building ego strength and uncovering the dynamics blocking eating; parents were seen collaterally. Measures administered before, after, and at 1-year follow-up tapped body mass index, menstruation, eating attitudes, ego functioning, depression, and family interactions. RESULTS: BFST produced greater weight gain and higher rates of resumption of menstruation than EOIT. Both treatments produced comparably large improvements in eating attitudes, depression, and eating-related family conflict, but very few changes occurred on ego functioning. CONCLUSIONS: BFST and EOIT proved to be effective treatments for adolescents with anorexia nervosa, but BFST produced a faster return to health.     

Anorexia nervosa in Chinese adolescents-does culture make a difference?

The clinical and psychosocial characteristics of 16 Chinese adolescents from Hong Kong with anorexia nervosa are reported. In contrast to previous local reports of adult patients, over 80 per cent of these younger patients reported a fear of fatness. It appears that, against the background of increasing Westernization, the illness is taking on a Western pattern, in line with the suggestion that significant concern about weight in anorexia nervosa is a pathoplastic effect of Westernization. There was also a marked increase in the referral rate of patients in the younger age group, reflecting both an increase in the incidence and general awareness of the illness.     

Bone mineral density in adolescent girls with anorexia nervosa--a cross-sectional study

The total body and lumbar spine bone mineral density (BMD) were measured in order to determine the prevalence and possible risk factors of decreased BMD in anorexia nervosa (AN). Subjects Sixty-one in-patient girls with DSM III-R AN: age 14.7±2.16 years; duration of AN 12.9±15.1 months; percentage of ideal body weight 70±8.7 %; body mass index score −1.62±0.79. Method Total body (in 61 patients) and lumbar spine BMD (in 43 patients), content of lean and fat tissue mass were measured by DXA during the first month of treatment. Results Low total body BMD was found in 23.7 % and low lumbar spine BMD in 36.6 % of patients. There was a negative correlation between BMD and age, age of menarche, degree of undernourishment, duration of AN and amenorrhea. A step-wise linear regression analysis revealed that age of menarche was the most important factor related to BMD in this group. Accepted: 14 September 2001     

Anorexia nervosa and depression. On the relation of body weight and depressive symptoms

To investigate the relationship between weight deficit and depressive symptoms, 48 adolescent patients (41 females, 7 males) fulfilling DSM III R criteria for anorexia nervosa were also assessed for DSM III diagnosis of major depressive disorder (MDD). Patients who met diagnostic criteria for MDD had a significantly lower body weight than those without a current episode of MDD. In turn patients with high weight loss had higher mean depression scores (HAMD, SDS) than patients with less weight deficit. With increase of body weight we found a highly significant decrease of depressive symptoms. The authors hypothesize that the DSM III criteria for MDD may not specifically distinguish between starvation-related psychopathology in anorexia nervosa and primary affective disorder.     

Clinical and personality characteristics of adolescents with anorexia nervosa with or without non-suicidal self-injurious behavior

PurposeAbout one-fifth of patients with anorexia nervosa (AN) engage in non-suicidal self-injury (NSSI). This study examined clinical and temperament profile of female adolescents with both disorders (AN+NSSI) as compared with peers with AN only.MethodsA consecutive sample of 73 female adolescents with AN (mean age: 13.77 years), who had been admitted to inpatient or day-hospital services, received clinical, cognitive, and temperament/character evaluations. Of them, 32 met DSM-5 criteria also for NSSI. Assessments included demographics, standard nutrition parameters, Youth Self-Report (YSR), Wechsler Intelligence Scale for Children IV (WISC-IV), Temperament and Character Inventory (TCI), and Global Assessment of Functioning (GAF).ResultsNo differences were detected between AN+NSSI and AN in demographics, body mass index, or age at onset of AN. AN+NSSI had higher rate of binging and purging, higher YSR scores for both internalizing and externalizing psychopathology, lower total IQ, and lower Self-directedness and Cooperativeness scores.ConclusionsThese data suggest that adolescents with AN+NSSI have psychopathological, cognitive and overall character features that differ from patients with AN only. These characteristics may have implications for treatment and outcome.     

Hypothalamic-pituitary-adrenal-cortical activity in anorexia nervosa and bulimia

We studied hypothalamic-pituitary-adrenal-cortical (HPA) activity in nine underweight women with anorexia nervosa, 12 women of normal body weight with bulimia, and nine control subjects. The measures of HPA activity were the pattern of plasma cortisol secretion over 24 hr and the responses of plasma cortisol to dexamethasone suppression and to low dose ACTH stimulation. The patients with anorexia nervosa had significantly elevated 24 hr concentrations of plasma cortisol compared to the controls and showed significantly less cortisol suppression following dexamethasone. There was no difference between patients with anorexia nervosa and controls in the rise in plasma cortisol following ACTH. On most measures of HPA activity, the normal weight patients with bulimia were indistinguishable from the controls. These results suggest that HPA activity is normal in most patients of normal body weight with bulimia and that the psychological and behavioral disturbances common to both anorexia nervosa and bulimia are, in the absence of significant weight loss, insufficient to produce major alterations in HPA activity.     

Étude du lien parental dans l’enfance chez les enfants et adolescents avec anorexie mentale

IntroductionAnorexia nervosa constitutes a severe and complex eating disorder occurring principally in adolescence. It is one of the most deadly psychiatric disorders. Considering the multifactorial nature of anorexia nervosa, the important place of the family and the growing interest in the theory of attachment in eating disorders, parental bonding is questioned in anorexia nervosa. The main study goal is to analyze parental bonding in a population of children and adolescents with anorexia nervosa. The secondary objective is to study differences according to the age group.MethodWe realized an observational pilot study in Bordeaux over a period from June 2015 to April 2017. Twenty five young girls with anorexia nervosa, aged 10 to 17 years, hospitalized in the department of child and adolescent psychiatry and department of eating disorders have been included and divided into two groups: peripubertal for children under 14 and pubertal for children aged 14 to 17 years. We met them individually to complete a series of questionnaires including the Parental Bonding Instrument (for assessing attachment), the Mini International Neuropsychiatry Interview for Children and Adolescent (for detecting the presence of comorbidity) and a structured questionnaire for collecting general information on anorexia nervosa.ResultsResults revealed high parental care, high maternal and paternal overprotection with predominantly “optimal” parenting style followed by “affectionate constraint” style. Significant differences were observed in anorexia nervosa patients with maternal (P = 0.011) and paternal (P = 0.085) overprotection in pubes compared to peripubertal. In correlation analysis, there was a positive correlation between maternal protection and age of diagnosis and a negative correlation between parental care and duration of illness. Furthermore, the maternal overprotection tended to be correlated significantly and positively with the age of the diagnosis and the paternal overprotection with the body mass index.ConclusionOur study shows a rating by the parents of warm and understanding parents, an over-protective mother and a father encouraging autonomy. There is maternal and paternal overprotection in pubertal anorexia nervosa compared with peripubertals. Our results suggest the importance of analyzing parenting style in addition to Parental Bonding Instruments results and of supporting the importance of the development of family therapy in the anorexia nervosa.     

Blindness and anorexia nervosa

Two cases of anorexia nervosa in blind patients are reported. They demonstrate that blind children experience many developmental problems which are thought to be important in the etiology of anorexia nervosa. Similarly, blind children are unusually susceptible to misperceive their body size and weight. The apparent absence of a strong association between congenital blindness and anorexia nervosa challenges the presumed aetiological link between disturbed body image and identity diffusion, and anorexia nervosa.     

Metabolic state and value-based decision-making in acute and recovered female patients with anorexia nervosa

BackgroundPatients with anorexia nervosa forgo eating despite emaciation and severe health consequences. Such dysfunctional decision-making might be explained by an excessive level of self-control, alterations in homeostatic and hedonic regulation, or an interplay between these processes. We aimed to understand value-based decision-making in anorexia nervosa and its association with the gut hormone ghrelin. Besides its homeostatic function, ghrelin has been implicated in the hedonic regulation of appetite and reward via the modulation of phasic dopamine signalling.MethodsIn a cross-sectional design, we studied acutely underweight (n = 94) and recovered (n = 37) patients with anorexia nervosa of the restrictive subtype, as well as healthy control participants (n = 119). We assessed plasma concentrations of desacyl ghrelin and parameters of delay discounting, probability discounting for gains and losses, and loss aversion.ResultsRecovered patients displayed higher risk aversion for gains, but we observed no group differences for the remaining decision-making parameters. Desacyl ghrelin was higher in acutely underweight and recovered participants with anorexia nervosa relative to healthy controls. Moreover, we found a significant group × desacyl ghrelin interaction in delay discounting, indicating that in contrast to healthy controls, acutely underweight patients with anorexia nervosa who had high desacyl ghrelin concentrations preferably chose the delayed reward option.LimitationsWe probed decision-making using monetary rewards, but patients with anorexia nervosa may react differently to disorder-relevant stimuli. Furthermore, in contrast to acyl ghrelin, the functions of desacyl ghrelin are unclear. Therefore, the interpretation of the results is preliminary.ConclusionThe propensity for risk aversion as found in recovered patients with anorexia nervosa could help them successfully complete therapy, or it could reflect sequelae of the disorder. Conversely, ghrelin findings might be related to a mechanism contributing to disease maintenance; that is, in acutely underweight anorexia nervosa, a hungry state may facilitate the ability to forgo an immediate reward to achieve a (dysfunctional) long-term goal.     

Eating disorders in males

Eating disorders are one of the rare psychiatric disorders with a large preponderance of female patients. The other articles in this issue review eating disorders in children and adolescents and focus primarily on female patients. This article reviews the eating disorders that occur in male children and teenagers, including anorexia nervosa, bulimia nervosa, binge eating disorder, a subtype of body dysmorphic disorder named muscle dysmorphobia, and obesity. This article reviews subgroups of boys who are at higher risk for developing eating disorders. The article commences with the difference in male perceptions of body image and dieting behaviors.     

Troubles bipolaires et anorexie mentale : une étude clinique

PurposeAnorexia nervosa is often accompanied by comorbid mood disorders, in particular depression, but individual or family history of bipolar disorders has not frequently been explored in anorexia nervosa. The objectives of the present study were: (1) to assess the frequency of bipolar disorders in patients with anorexia nervosa hospitalized in adolescence and in their parents, (2) to determine whether the patients with a personal or family history of bipolar disorders present particular characteristics in the way in which anorexia nervosa manifests itself, in their medical history, in the secondary diagnoses established, and in the treatments prescribed.MethodOverall, 97 female patients aged 13 to 20 hospitalized for anorexia nervosa and their parents were assessed. The diagnoses of anorexia nervosa and bipolar disorders were established on the basis of DSM-IV-TR criteria.ResultsA high frequency of type II and type V bipolar disorders was observed. The patients with anorexia nervosa and presenting personal or family histories of bipolar disorder had an earlier onset of anorexia nervosa, more numerous hospitalizations, a longer time-lapse between anorexia nervosa onset and hospitalization, more suicide attempts and more psychiatric comorbidities.ConclusionThe occurrence of anorexia nervosa–bipolar disorders comorbidity appears to be considerable and linked to the severity of anorexia nervosa, raising the issue of the relationship between anorexia nervosa and bipolar disorders.     

Predictors of Weight Restoration in a Day-Treatment Program that Supports Family-Based Treatment for Adolescents with Anorexia Nervosa

Family-Based Treatment (FBT) is considered a first-line treatment for adolescents with eating disorders. The traditional outpatient model of FBT may not, however, be appropriate for adolescents requiring more intensive treatment due to severe medical complications or insufficient progress in traditional outpatient FBT. In response, efforts have been made to incorporate FBT into higher levels of care, such as day-treatment programs (DTPs), for families who need additional support. Little is known about the factors that predict weight restoration for DTPs intended to support FBT. The current study examined the ability of specific adolescent and caregiver variables to predict weight restoration at discharge for adolescents with anorexia nervosa (AN) enrolled in a skills-based DTP that supports FBT. Participants were 87 adolescents diagnosed with AN and their caregivers (N = 74). Body Mass Index (BMI) at baseline, percentage of Expected Body Weight (%EBW) gain within the first 4 weeks, and caregiver empowerment level at baseline were found to significantly predict weight restoration. Higher BMI at baseline and higher %EBW gained in the first 4 weeks of treatment were predictive of weight restoration, whereas lower caregiver empowerment at baseline was predictive of weight restoration. Additionally, the rate of weight gain is reported for this DTP grounded in FBT philosophy.     

Psychiatrists' attitudes towards autonomy, best interests and compulsory treatment in anorexia nervosa: a questionnaire survey

Background

The compulsory treatment of anorexia nervosa is a contentious issue. Research suggests that psychiatrists have a range of attitudes towards patients suffering from anorexia nervosa, and towards the use of compulsory treatment for the disorder.

Methods

A postal self-completed attitudinal questionnaire was sent to senior psychiatrists in the United Kingdom who were mostly general adult psychiatrists, child and adolescent psychiatrists, or psychiatrists with an interest in eating disorders.

Results

Respondents generally supported a role for compulsory measures under mental health legislation in the treatment of patients with anorexia nervosa. Compared to 'mild' anorexia nervosa, respondents generally were less likely to feel that patients with 'severe' anorexia nervosa were intentionally engaging in weight loss behaviours, were able to control their behaviours, wanted to get better, or were able to reason properly. However, eating disorder specialists were less likely than other psychiatrists to think that patients with 'mild' anorexia nervosa were choosing to engage in their behaviours or able to control their behaviours. Child and adolescent psychiatrists were more likely to have a positive view of the use of parental consent and compulsory treatment for an adolescent with anorexia nervosa. Three factors emerged from factor analysis of the responses named: 'Support for the powers of the Mental Health Act to protect from harm'; 'Primacy of best interests'; and 'Autonomy viewed as being preserved in anorexia nervosa'. Different scores on these factor scales were given in terms of type of specialist and gender.

Conclusion

In general, senior psychiatrists tend to support the use of compulsory treatment to protect the health of patients at risk and also to protect the welfare of patients in their best interests. In particular, eating disorder specialists tend to support the compulsory treatment of patients with anorexia nervosa independently of views about their decision-making capacity, while child and adolescent psychiatrists tend to support the treatment of patients with anorexia nervosa in their best interests where decision-making is impaired.     

A placebo-controlled crossover study of oral clonidine in acute anorexia nervosa

The alpha 2-adrenergic agonist clonidine has been reported to increase feeding in several species. This study evaluated the effects of clonidine (500-700 micrograms/day), administered per os, to four treatment-resistant anorexia nervosa patients in a long-term placebo-controlled crossover trial. All patients increased their body weight significantly. Clonidine administration, however, did not influence the rate of weight gain, nor did clonidine affect hunger or satiety sensations. Similarly, 24-hour urinary 3-methoxy-4-hydroxyphenylglycol levels and levels of anxiety and depression were unchanged by clonidine. By contrast, clonidine showed significant hemodynamic effects; clonidine lowered systolic and diastolic blood pressure, reduced pulse rate, and produced sedation. Discontinuation of clonidine was associated with a small but significant weight loss compared to a small weight increase during the initiation of clonidine treatment. The results suggest that clonidine may not be indicated in the treatment of anorexia nervosa.     

A randomized controlled study of cognitive behavior therapy and behavioral family therapy for anorexia nervosa patients

Very few studies have examined the role of cognitive behavior therapy (CBT) in the outpatient treatment of anorexia nervosa. This study used a randomized, controlled design to evaluate a 12-month, manual based program of CBT, with behavioral family therapy as the comparison group. Twenty-five adolescents and young adults with anorexia nervosa, currently living with their families, were recruited into the study with both treatment groups receiving 21-25 sessions of therapy. Outcome measures included nutritional status, eating behaviors, mood, self-esteem, and family communication. Sixty percent of the total sample and 72% of treatment completers had “good” outcome (defined as maintaining weight within 10% of average body weight and regular menstrual cycles) at post-treatment and at six months follow-up. No significant differences between treatment groups were found and the majority of patients did not reach symptomatic recovery. While limited by the small sample size, the findings compliment and extend previous research.     

Effectiveness of individualized,integrative outpatient treatment for females with anorexia nervosa and bulimia nervosa

ABSTRACT

The effectiveness of an individualized outpatient program was investigated in the treatment of bulimia nervosa (BN) and anorexia nervosa (AN). Participants included 151 females who received outpatient eating disorder treatment in the partial hospitalization program, the intensive outpatient program, or a combination of the two programs. Outcome measures included the Eating Disorder Inventory (EDI-2), Beck Depression Inventory (BDI-II), frequency of binge eating and purging, and mean body weight. Findings included significant increases in weight for the AN group, reductions in binge eating frequency for the BN group, and reductions in EDI-2 and BDI-II scores and purging frequency for both groups. This study provides preliminary support for the efficacy of a multimodal program for the treatment of both anorexia nervosa and bulimia nervosa.     

Abnormal functional global and local brain connectivity in female patients with anorexia nervosa

BackgroundPrevious resting-state functional connectivity studies in patients with anorexia nervosa used independent component analysis or seed-based connectivity analysis to probe specific brain networks. Instead, modelling the entire brain as a complex network allows determination of graph-theoretical metrics, which describe global and local properties of how brain networks are organized and how they interact.MethodsTo determine differences in network properties between female patients with acute anorexia nervosa and pairwise matched healthy controls, we used resting-state fMRI and computed well-established global and local graph metrics across a range of network densities.ResultsOur analyses included 35 patients and 35 controls. We found that the global functional network structure in patients with anorexia nervosa is characterized by increases in both characteristic path length (longer average routes between nodes) and assortativity (more nodes with a similar connectedness link together). Accordingly, we found locally decreased connectivity strength and increased path length in the posterior insula and thalamus.LimitationsThe present results may be limited to the methods applied during preprocessing and network construction.ConclusionWe demonstrated anorexia nervosa–related changes in the network configuration for, to our knowledge, the first time using resting-state fMRI and graph-theoretical measures. Our findings revealed an altered global brain network architecture accompanied by local degradations indicating wide-scale disturbance in information flow across brain networks in patients with acute anorexia nervosa. Reduced local network efficiency in the thalamus and posterior insula may reflect a mechanism that helps explain the impaired integration of visuospatial and homeostatic signals in patients with this disorder, which is thought to be linked to abnormal representations of body size and hunger.