A systematic review of dropout from treatment in outpatients with anorexia nervosa

OBJECTIVE:

Dropout from treatment has serious implications for patients, clinicians, and researchers. The aim of this study was to examine rates of dropout from outpatient treatment for anorexia nervosa (AN) and critically examine the various definitions of dropout used.

METHOD:

A systematic review was conducted, including pharmacological and psychological interventions. All articles in PubMed, Web of Science, and the Cochrane Library were considered, and screened against a priori inclusion/exclusion criteria. Relationships between treatment outcome and dropout rate were examined across studies.

RESULTS:

Nineteen relevant studies were identified, with dropout rates ranging from 4.8% (family therapy) to 100% (dietary advice). In most cases, dropout was in the range of 20–40%. Definitions of dropout used varied widely. A significant negative correlation was found between rate of dropout and body mass index (BMI) at 1 year, but this did not remain significant when differences in BMI at baseline were taken into account.

DISCUSSION:

High rates of dropout from treatment for AN have serious implications for recovery, research, and the development of new treatments. A suggested reporting structure is proposed, with the aim of increasing the consistency of dropout reporting and facilitating greater understanding of this phenomenon. © 2011 by Wiley Periodicals, Inc. (Int J Eat Disord 2011)     

Coronary atherosclerosis in anorexia nervosa

BACKGROUND: Chest pain is a common complaint in patients with anorexia nervosa (AN). Of those who experience chest pain, about 20% meet the diagnostic criteria for typical or atypical angina. METHODS: We compared the intima-medial thickness (IMT) of the carotid artery measured by ultrasound in AN with controls and found no difference. RESULTS AND DISCUSSION: Although clinically relevant atherosclerosis can occur in patients with a normal IMT, there is a strong correlation between carotid IMT and coronary atherosclerosis. This suggests that an atherosclerotic origin of chest pain in AN patients is unlikely.     

The clinical presentation of Japanese women with anorexia nervosa and bulimia nervosa: a study of the Eating Disorders Inventory-2

OBJECTIVE: The current study described the clinical presentation of anorexia nervosa (AN) and bulimia nervosa (BN) in Japan utilizing the Eating Disorders Inventory-2 (EDI-2) and assessed whether the clinical profile of eating disorder cases in Japan differs significantly from North American data. METHOD: Statistical comparisons of Japanese AN, BN, and non-eating-disordered (NonED) EDI-2 data were conducted across diagnostic groups and with the North American standardization sample. RESULTS: The Japanese diagnostic groups reported significant between-group differences on all eight EDI-2 subscales. Compared with the standardization sample, all the Japanese groups reported significantly greater maturity fears, the Japanese AN-restricting subtype group (AN-R) reported lower levels of drive for thinness and perfectionism, the Japanese BN group reported lower levels of drive for thinness, and the Japanese NonED Group reported lower levels of drive for thinness and perfectionism but higher rates of ineffectiveness. DISCUSSION: Differences between the Japanese and North American groups suggest that certain cultural differences exist in eating disorder profiles.     

Severe and enduring anorexia nervosa: Update and observations about the current clinical reality

Several objectives underlie the current article. First, to review historical diagnostic issues and clinical strategies for treating SE-AN. Second, to provide an overview of recent evidence informed strategies and clinical innovations for the treatment of SE-AN. Third, based on the authors' collective clinical and research experience, we offer eight observations that we believe capture the current clinical experience of patients with SE-AN. Some of these observations represent empirically testable hypotheses, but all are designed to generate a meaningful discussion about the treatment of this group of individuals with eating disorders. Finally, we hope to call clinicians, scientists, professional organizations, advocates, and policy makers to action to attend to critical issues related to the care of individuals with SE-AN. We believe that an international discussion could clarify areas of need for these patients and identify opportunities for clinical innovation that would enhance the lives of individuals with SE-AN and their families.     

Amphetamine induced dopamine release increases anxiety in individuals recovered from anorexia nervosa

Objective:

Genetic, pharmacologic, and physiological data suggest that individuals with anorexia nervosa (AN) have altered striatal dopamine (DA) function.

Method:

We used an amphetamine challenge and positron emission tomography [¹¹C]raclopride paradigm to explore DA striatal transmission in 10 recovered (REC) AN compared with 9 control women (CW).

Results:

REC AN and CW were similar for baseline, postamphetamine [¹¹C]raclopride binding potential (BP_ND) and change (Δ) in BP_ND for all regions. In CW, ventral striatum Δ BP_ND was associated with euphoria (r = ?0.76; p = 0.03), which was not found for REC AN. Instead, REC AN showed a significant relationship between anxiety and Δ BP_ND in the precommissural dorsal caudate (r = ?0.62, p = 0.05).

Discussion:

REC AN have a positive association between endogenous DA release and anxiety in the dorsal caudate. This finding could explain why food‐related DA release produces anxiety in AN, whereas feeding is pleasurable in healthy participants. © 2011 by Wiley Periodicals, Inc. (Int J Eat Disord 2012)

     

Severe and enduring anorexia nervosa: No easy solutions

There is currently no evidence-based definition of severe and enduring anorexia nervosa (SE-AN) with which to reliably inform clinical practice and research. Indeed, data on the effect of AN severity and duration on treatment outcome are inconsistent. A large group of patients with SE-AN are repeatedly unsuccessfully managed with the available eating disorders treatments and have no access to adequate treatment for their illness. Cognitive behavioral therapy (CBT) adapted for SE-AN has been designed to enhance quality of life and reduce harm rather than promoting weight gain in such patients, and has had some success. However, a percentage of patients with SE-AN achieves remission, or at least returns to a normal weight range, with available evidence-based treatments for eating disorders, such as enhanced CBT (CBT-E). It would therefore be worth conducting a large-scale randomized controlled trial comparing CBT adapted for SE-AN with CBT-E to assess their relative acceptability; efficacy, including their effect on quality of life and medical stability; cost-effectiveness; and the treatment response moderators that might allow better matching of patients with SE-AN to a treatment oriented either to harm reduction or to change.     

Anxiolytic effects of acute tryptophan depletion in anorexia nervosa

OBJECTIVE: Recent studies have raised the question as to whether a dysregulation of the neurotransmitter serotonin may contribute to the alterations in mood seen in anorexia nervosa (AN). People with AN tend to be anxious, obsessional, perfectionistic, and harm avoidant. These traits are premorbid and persist after recovery. It has been suggested that increased activity of brain serotonin systems could contribute to this pathologic condition. Dieting in AN, which serves to reduce plasma levels of tryptophan (TRP), may serve to reduce symptoms of dysphoric mood. METHOD: Fourteen women currently symptomatic with AN (ILL AN), 14 women recovered from AN (REC AN), and 15 healthy control women (CW) underwent acute tryptophan depletion (ATD). Measures of psychological state were self-assessed at baseline and hourly after ATD to determine whether ATD would reduce negative mood. RESULTS: ILL AN and REC AN had significantly higher mean baseline TRP/LNAA (tryptophan/large neutral amino acids) ratios compared with CW. In contrast to placebo, the ATD challenge demonstrated a significantly greater reduction in the TRP/LNAA ratio for ILL AN (-95%) and REC AN (-84%) compared with CW (-70 %). Both the ILL AN and REC AN had a significant reduction in anxiety on the ATD day compared with the placebo day. DISCUSSION: These data demonstrate that a dietary-induced reduction of TRP, the precursor of serotonin, is associated with decreased anxiety in people with AN. Restricting dietary intake may represent a mechanism through which individuals with AN modulate a dysphoric mood.