Convalescent resting tachycardia predicts unfavorable outcome of anorexia nervosa

Background: In patients with anorexia nervosa (AN) who have tachycardia during the clinical course, difficulty in treatment has been observed. The purpose of the present study was to evaluate the association between heart rate (HR) in the weight loss and weight recovery periods, and outcome. Methods: The subjects consisted of 40 girls with AN (age at onset, 8–16 years). The outcome 1–5 years after the initiation of treatment was regarded as favorable for both bodyweight within 15% of the standard weight and regular menstruation during the last 6 months, and unfavorable for bodyweight <85% of the standard weight and absent or nearly always absent menstruation. HR during the weight loss period was obtained at the outpatient clinic on the first visit. For HR during the weight recovery period, we used the resting and peak HR obtained in exercise tolerance test, which was performed when the bodyweight successfully increased along with improvement in physical complications. The association between each HR and outcome was evaluated. Results: Favorable outcomes were observed in 19 of the 40 patients after the 1 year follow up but in 32 after the 5 year follow up. Resting HR during the weight recovery period was higher throughout the 5 years in the unfavorable than in the favorable outcome group, with significant differences after the 2, 4, and 5 year follow ups. Conclusion: In AN, resting t achycardia during the convalescent period is associated with unfavorable outcome.     

A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up

BACKGROUND: There is growing evidence that family therapy is an effective treatment for adolescent anorexia nervosa. This study aimed to ascertain the long-term impact of two forms of outpatient family intervention previously evaluated in a randomised controlled trial (RCT). METHOD: A five-year follow-up was conducted on a cohort of 40 patients who had received either 'conjoint family therapy' (CFT) or 'separated family therapy' (SFT). All patients were traced and 38 agreed to be reassessed (29 interviewed in person, 3 completed telephone interviews, 6 completed questionnaires and/or agreed for parents/GP to be interviewed). RESULTS: Overall there was little to distinguish the two treatments at 5 years, with more than 75% of subjects having no eating disorder symptoms. There were no deaths in the cohort and only 8% of those who had achieved a healthy weight by the end of treatment reported any kind of relapse. Three patients developed bulimic symptoms but only one to a degree warranting a diagnosis of bulimia nervosa. The one difference between the treatments was in patients from families with raised levels of maternal criticism. This group of patients had done less well at the end of treatment if they had been offered conjoint family meetings. At follow-up this difference was still evident, as shown in the relative lack of weight gain since the end of outpatient treatment. CONCLUSIONS: This study confirms the efficacy of family therapy for adolescent anorexia nervosa, showing that those who respond well to outpatient family intervention generally stay well. The study provides further support for avoiding the use of conjoint family meetings at least early on in treatment when raised levels of parental criticism are evident.     

Iron status and haematological changes in adolescent female inpatients with anorexia nervosa

OBJECTIVES: (i) To investigate the incidence of iron deficiency (both latent iron deficiency and iron deficiency anaemia) in post menarchal female adolescent patients hospitalized with anorexia nervosa. (ii) To observe changes in iron status during refeeding. METHODS: During the study period all post menarchal female patients admitted to the adolescent unit with anorexia nervosa were invited to participate. Ferritin, serum iron, transferrin and transferrin saturation were measured on admission and discharge. Haemoglobin, haematocrit, weight, and body mass index were monitored weekly. RESULTS: All 12 eligible patients participated in the study. Four patients had elevated ferritin levels on admission. Ten of the 12 showed a statistically significant fall in serum ferritin at time of discharge compared with admission (P = 0.004). One of 12 patients had a low serum iron at presentation. All 12 had normal serum iron levels at discharge. Nine of the 12 subjects had a higher serum iron at discharge which was statistically significant (P = 0.046). There was no significant change in haemoglobin levels when comparing admission and discharge levels. Nine of the 12 patients however, transiently developed anaemia, at some stage during treatment. CONCLUSIONS: Iron deficiency is uncommon at both presentation and after nutritional rehabilitation in post menarchal adolescent females with anorexia nervosa. This is most likely due to increased iron storage secondary to the contraction of the circulating blood volume and reduced iron losses from (secondary) amenorrhoea. The fall in ferritin observed during treatment is due to haemopoiesis necessary to fill the increased blood volume associated with weight gain. This also results in normalization of the haemoglobin and haematocrit.     

Prospective 10-year follow-up in adolescent anorexia nervosa--course, outcome, psychiatric comorbidity, and psychosocial adaptation

The aim of the present study was to follow up the long-term course of adolescent-onset anorexia nervosa by repeated assessment, to analyze the association between the course of the eating disorder and psychiatric comorbidity, and to evaluate psychosocial outcome. The sample consisted of 39 inpatients who were reinvestigated 3, 7, and 10 years after discharge. The patients and 39 controls matched for age, gender, and occupational status were assessed with structured interviews on DSM-III-R eating disorders, additional axis I and axis II psychiatric disorders, and psychosocial functioning. Results showed that 69 % of the original subjects met the criteria for full recovery at the 10-year follow-up. One patient (3%) still exhibited the full syndrome of restrictive anorexia nervosa, two patients (5%) the full syndrome of bulimia nervosa. None of the patients had died. Of the subjects, 51% currently had an axis I psychiatric disorder and 23% met the full criteria for a personality disorder. Apart from the eating disorder, anxiety disorders and avoidant-dependent and obsessive-compulsive personality disorders were the most common psychiatric diagnoses. There was a significant association between psychiatric comorbidity and the outcome of the eating disorder and between outcome and psychosocial adaptation. With regard to psychiatric morbidity and psychosocial functioning, long-term recovered patients did not differ significantly from normal controls. It is concluded that in most patients adolescent anorexia nervosa takes a prolonged course, although it seems to be more favorable than in adult-onset forms. Those who achieve complete recovery from the eating disorder have a good chance of overcoming other psychiatric disorders and to adapt to social requirements.     

Bone mineral density in children and adolescent girls with anorexia nervosa in Japan

BACKGROUND: The correlation between reduced bone mineral density (BMD) and the disease anorexia nervosa (AN) has long been established. The aim of the present study was to examine the relationship in more detail, particularly focusing on the increasing incidence of the disease occurring in adolescent patients. METHOD: Twenty-four girls diagnosed with AN were enrolled in the study. All subjects ranged in age from 11.1 to 15.5 years, with an average age of 13.5 years. The BMD of lumbar spines and femoral necks were measured. All the values for BMD at admission were expressed as means +/- SD and patients with and without menarche were separately investigated. RESULTS: The average BMD of lumbar spines at the time of admission was -0.51 SD in total. However, the average BMD of patients without menarche was -1.28 SD, which was significantly lower than the -0.16 SD on average in patients with menarche. As a whole the BMD of femoral necks at admission tended to be lower than that of lumbar spines. Similarly, it was lower in patients without menarche (-1.7 SD on average) than in those with menarche (-0.77 SD on average). CONCLUSIONS: BMD was lower in children and adolescent AN patients without menarche, and such a tendency was more significant at the femoral neck region. In child AN cases without menarche, the BMD, especially at the femoral neck, needs to be measured, and later recovery should be monitored closely over a long period.     

An innovative treatment programme for anorexia nervosa

We present the case of an Australian girl with severe anorexia nervosa who had previously been resistant to treatment, and who was subsequently treated successfully by an innovative programme at the Karolinska Institute in Stockholm. The programme is based on a distinctive concept of causation of eating disorders in which it is postulated that they develop as a consequence of starvation rather than a primary mental disorder. The treatment focuses on relearning how to eat and perceive satiety using a unique feed-back system, together with provision of warmth, limitation of exercise and facilitating social adaptation.     

Contingent negative variation in children with anorexia nervosa

BACKGROUND: Central catecholamines, particularly dopaminergic and noradrenergic systems, have affected the appetitive behavior in patients with anorexia nervosa (AN). The purpose of this study is to distinguish the characteristics of contingent negative variation (CNV) and postimperative negative variation (PINV), which may reflect the level of catecholamine in children with AN. METHODS: Eight children with AN aged 10 to 15 years and 23 age-matched healthy children were recruited. Contingent negative variation was recorded from the frontal midline (Fz), central midline (Cz) and parietal midline (Pz) referenced to linked earlobes during 30 trials consisting of a warning stimulus and an imperative stimulus with an interstimulus interval of 2 s and an intertrial interval of 10 s. The imperative stimulus of each trial required a button press. RESULTS: Children with AN had a diminished amplitude of the CNV. They had a significantly more attenuated early CNV and late CNV amplitude at Cz than normal children. No significant differences were observed between AN children and normal children in the amplitude of PINV at all three electrode sites. No difference could be found between the two groups in the frequencies of normal and abnormal duration of PINV. CONCLUSION: These findings suggest that early CNV may be diminished by norepinephrine deficiency and late CNV may be attenuated by dopaminergic deficiency in children with AN. Reduced CNV may represent impaired cognitive processes which reflect impaired appetitive behavior in AN children.     

Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions

This paper reports the results of a randomised treatment trial of two forms of outpatient family intervention for anorexia nervosa. Forty adolescent patients with anorexia nervosa were randomly assigned to "conjoint family therapy" (CFT) or to "separated family therapy" (SFT) using a stratified design controlling for levels of critical comments using the Expressed Emotion index. The design required therapists to undertake both forms of treatment and the distinctiveness of the two therapies was ensured by separate supervisors conducting live supervision of the treatments. Measures were undertaken on admission to the study, at 3 months, at 6 months and at the end of treatment. Considerable improvement in nutritional and psychological state occurred across both treatment groups. On global measure of outcome, the two forms of therapy were associated with equivalent end of treatment results. However, for those patients with high levels of maternal criticism towards the patient, the SFT was shown to be superior to the CFT. When individual status measures were explored, there were further differences between the treatments. Symptomatic change was more marked in the SFT whereas there was considerably more psychological change in the CFT group. There were significant changes in family measures of Expressed Emotion. Critical comments between parents and patient were significantly reduced and that between parents was also diminished. Warmth between parents increased.     

儿童厌食和睡眠障碍共病的初步探讨

目的 了解儿童厌食和睡眠障碍的相关影响因素,为早期干预提供依据.方法 以兰州市二城区三所幼儿园和三所小学2～12岁儿童为调查对象,向家长发放调查问卷,内容包括母亲孕期、出生、喂养和睡眠情况及父母一般情况等,共发放问卷1 800份,收回有效问卷1 560份,回收率86.7%.结果 调查儿童中厌食375人,发生率为23.9%,其中48%同时合并睡眠障碍;睡眠障碍儿童330人,其中54.5%合并有厌食;厌食合并睡眠障碍儿童180人,发生率为11.5%.两者的发生主要与母亲孕期的睡眠、心情、饮食、生产情况,辅食的添加时间,饮食习惯等有密切关系.结论 厌食和睡眠障碍的发生密切相关,儿童期的厌食和睡眠障碍与母亲孕期、围生期因素及早期的喂养有关,提示早期干预的必要性.     

Monitoring nutritional status accurately and reliably in adolescents with anorexia nervosa

Aim:   Accurate assessment of nutritional status is a vital aspect of caring for individuals with anorexia nervosa (AN) and body mass index (BMI) is considered an appropriate and easy to use tool. Because of the intense fear of weight gain, some individuals may attempt to mislead the physician. Mid-upper arm circumference (MUAC) is a simple, objective method of assessing nutritional status. The setting is an eating disorders clinic in a tertiary paediatric hospital in Western Australia. The aim of this study is to evaluate how well MUAC correlates with BMI in adolescents with AN.
Methods:   Prospective observational study to evaluate nutritional status in adolescents with AN.
Results:   Fifty-five adolescents aged 12–17 years with AN were assessed between January 1, 2004 and January 1, 2006. MUAC was highly correlated with BMI ( r  = 0.79, P  < 0.001) and individuals with MUAC ≥20 cm rarely required hospitalisation (negative predictive value 93%).
Conclusions:   MUAC reflects nutritional status as defined by BMI in adolescents with AN. Lack of consistency between longitudinal measurements of BMI and MUAC should be viewed suspiciously and prompt a more detailed nutritional assessment.     

Magnetic resonance imaging of clival marow in patients with anorexia nervosa

Hematological abnormalities, commonly associated with anorexia nervosa (AN) patients, are thought to be the results of serous atrophy in the bone marrow. Magnetic resonance imaging (MRI) has been utilized to ascertain T1 and T2 prolongation of marrow intensity in the lumbar spine, pelvis and proximal femora. The results correlate well with the severity of hematological abnormalities and body mass index. More importantly, the propensity for peripheral marrow involvement of T2 prolongation contrasts with the axial involvement in other marrow disorders. MRI undertaken in patients with AN to exclude hypothalamic tumor showed that the clival marrow was equivalent to the peripheral marrow. The signal pattern of clival marrow on sagittal T1 weighted MR images was evaluated in four teenage female patients with AN complicated by hematological abnormalities. Although the clival marrow intensity should be uniformly high in teenagers, three patients, two with pancytopenia and one with leukopenia and anemia, exhibited homogenous low intensity. One patient who had leukopenia only and the highest body mass index, showed inhomogeneous low intensity. The signal changes returned to normal in all patients but one, who died before examination after 6–11 months, at which time the others had almost recovered their original weight and normal hemogram. T1 prolongation in the clival marrow represents bone marrow dysfunction and the inhomogeneity of the signal change may imply relative preservation of hematopoiesis and body fat composition. Lack of knowledge of this phenomenon may lead to diagnostic confusion with other marrow disorders on cranial MRI.     

Readiness to recover in adolescent anorexia nervosa: prediction of hospital admission

OBJECTIVES: To determine if motivation to change in anorexia nervosa during treatment is a predictor of hospitalisation in adolescent patients. METHOD: The Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ), the Eating Disorders Inventory-2 (EDI-2) and the Beck Depression Inventory (BDI) were administered to a group of 70 anorexia nervosa patients (mean age 15.6 years). They were all receiving treatment at a specialised Eating Disorder Unit and were at different points in the treatment programme. Admission during 6-9 month follow-up was recorded in 63 of these patients who had been admitted to the Unit. The other 7 patients were contacted by phone to determine if they had been hospitalised in another unit during the follow-up period. RESULTS: Patients who needed hospital admission during follow-up had higher mean scores at first evaluation on some of the EDI-2 scales and on the BDI, lower ANSOCQ scores and were more likely to have been outpatients at first evaluation. In the logistic regression analysis a low ANSOCQ score and being an outpatient at first evaluation were shown to be independent predictors of hospitalisation during follow-up. CONCLUSIONS: Low motivation to change, depressive symptomatology and some EDI-2 scales are related to the necessity of hospital admission in adolescent patients with anorexia nervosa.     

Bone marrow hypoplasia in anorexia nervosa

Within a 2-year period, from March 1974 until May 1976 10 patients with anorexia nervosa were seen at the children's university hospitals of München (2 patients) and Gießen (8 patients). The patients were 10–16 years old, with one exception all girls, and had the typical cachexia, hypothermia, bradycardia, gray, hairy skin, and amenorrhea in those who had reached menarche.The blood counts at diagnosis revealed a leukopenia (below 5000/mm³) in 6 patients and a thrombocytopenia (below 150000/mm³) in 4 patients. The bone marrow was examined in 7 patients and showed marked hypocellularity with only few megakaryocytes present and abundant vacuolated hyaline material. Bone marrow erythroblasts were decreased (below 20%) in 5 patients, although peripheral blood hemoglobin and hematocrit were normal or even elevated in all 10 patients. In 7 patients blood urea nitrogen was elevated above 30 mg%, the highest value being 145 mg%.Blood and bone marrow alterations as well as the renal abnormalities disappeared within days to a few weeks after a regimen of strict fluid and caloric intake was initiated and a gain in body weight of up to 10 kg was achieved. intake was initiated and a gain in body weight of up to 10 kg was achieved.

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Zusammenfassung In etwas über 2 Jahren, vom März 1974 bis Mai 1976, sahen wir an den Universitäts-Kinderkliniken von München (2 Patienten) und Gießen (8 Patienten) insgesamt 10 Patienten mit Pubertätsmagersucht. Die Patienten waren 10–16 Jahre alt, mit einer Ausnahme alle Mädchen, und zeigten die typische Magerkeit, Hypothermie, bradycardie, graue, schuppige, haarige Haut und Amenorrhoe bei vorangegangener Menarche.Bei Diagnose hatten 6 Patienten eine Leukozytopenie (unter 5000/mm³) und 4 eine Thrombozytopenie (unter 150000/mm³) im peripheren Blut. Das bei 7 Patienten untersuchte Knochenmark war zellarm mit nur wenig, ausreifungsgehemmten Megakaryozyten und wies fädig-gelatinöse, schwach rosa gefärbte, mit Vakuolen durchsetzte Massen auf. Die Erythrobalasten im Knochenmark waren in 5 Fällen vermindert (unter 20%), obwohl die peripheren Hämoglobinoder Hämatokritwerte bei allen 10 Patienten normal oder sogar erhöht waren. Bei 7 Patienten waren die Serum-Harnstoffwerte erhöht (über 30 mg%); höchster Wert 145 mg%.Die Blut- und Knochenmark veränderungen sowie die erhöhten Harnstoff-werte verschwanden innerhalb von Tagen bis wenigen Wochen durch intensive Flüssigkeits- und Kalorienzufuhr mit entsprechendem Gewichtsanstieg.

     

Normal gastric antral myoelectrical activity in early onset anorexia nervosa

Anorexia, epigastric discomfort, nausea, and vomiting may result from disordered gastric motility and emptying. These features have been found in many adults with anorexia nervosa, but have never been investigated in early onset anorexia nervosa. In 14 patients with early onset anorexia nervosa (eight of whom had upper gastrointestinal tract symptoms), six children with other eating disorders, four children with non-ulcer dyspepsia, and 10 controls matched for age and sex, the non-invasive technique of surface electrogastrography was used to measure fasting and postprandial gastric antral electrical control activity, which underlies antral motility. The electrical signal was recorded by four bipolar silver/silver chloride electrodes attached to the upper abdomen, amplified and low pass filtered at 0.33 Hz before being displayed on a polygraph, digitised at 1 Hz, and stored on the hard disk of a personal computer for later offline analysis. Patients with non-ulcer dyspepsia had gastric antral dysrhythmias. No significant difference was found in the mean (SD) dominant frequency of the antral electrical control activity between patients with early onset anorexia nervosa (2.86 (0.35) cycles/minute (cpm)), patients with other eating disorders (3.14 (0.65) cpm), and controls (3.00 (0.46) cpm). The amplitude of electrical control activity increased postprandially in all but one subject and the fasting/postprandial amplitude ratio did not significantly differ between patients with early onset anorexia nervosa and controls, though patients with longer established disease had a smaller increase in amplitude. Gastric antral electrical dysrhythmias are not a feature of early onset anorexia nervosa and therefore do not induce or perpetuate food refusal in this disorder.     

Stability, correlates, and outcome of adolescent suicidal risk

BACKGROUND: The goal of this study was to investigate the stability and correlates of adolescent suicidal risk across adolescence. METHODS: Suicidal risk was studied longitudinally in N = 593 subjects in 1994, 1997, and 2001 at mean ages of 13, 16, and 20 years. Three partly overlapping suicidal risk groups were compared to three control groups matched by age and gender regarding behavioural and emotional problems, number and impact of life events, coping capacities, self-related cognitions, and the size and efficiency of the social network. Psychiatric diagnoses were obtained in young adulthood. RESULTS: The group stability of suicidal risk was 43% from time 1 to time 2 and 18% from time 1 to time 3. Intra-individual stability of suicidal risks across adolescence was significantly higher than expected. At all three times of assessment, there was a clear excess of abnormal psychosocial findings in the suicidal risk groups as compared to the matched controls. Substance abuse disorders, depressive disorders, phobias and any psychiatric disorders in young adulthood were predicted by suicidal risk in preadolescence irrespective of behavioural and emotional disorders. CONCLUSIONS: Suicidal risk individuals are remarkably stable across adolescence and show a very consistent pattern of associated behavioural and emotional problems and psychosocial variables across time from preadolescence to young adulthood. They also display an increased risk for some mental disorders in young adulthood.