Treatment of chronic anorexia nervosa: a 4-year follow-up of adult patients treated in an acute inpatient setting

Despite evidence from a number of long-term follow-up studies of anorexia nervosa that nearly 50% of patients eventually make a full recovery, controlled trials of psychotherapy for anorexia nervosa are lacking. Those with severe and enduring problems represent a considerable therapeutic challenge. Thirty-four consecutive adult referrals to the inpatient treatment unit who fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria for anorexia nervosa were examined pre-admission, post-discharge and 4 years after admission. Characteristics of remitted and non-remitted patients were examined. Secondary analyses considered the differences between patients with anorexia nervosa, restricting type and anorexia nervosa binging/purging type. The findings highlight a number of differences between patients with anorexia nervosa (restricting type) versus anorexia nervosa (binging/purging type) as well as remitted versus non-remitted patients. The use of a comprehensive battery of assessments found that resolution of eating disorder symptomatology was paralleled by improvements in emotional and psychological distress and improvement in body image perception and coping skills. Better results were obtained for those who had continuity of care on an outpatient basis. This pattern is particularly significant given the more 'chronic' nature of the sample that were older, with a higher incidence of binge-eating and purging than previous samples. Results provide some encouragement for the treatment of those adults with anorexia nervosa who typically have less favourable outcomes.     

Personality characteristics of women before and after recovery from an eating disorder

BACKGROUND: Previous studies of personality characteristics in women with eating disorders primarily have focused on women who are acutely ill. This study compares personality characteristics among women who are ill with eating disorders, recovered from eating disorders, and those without eating or other Axis I disorder pathology. METHOD: Female participants were assessed for personality characteristics using the Temperament and Character Inventory (TCI): 122 with anorexia nervosa (AN; 77 ill, 45 recovered), 279 with bulimia nervosa (BN; 194 ill, 85 recovered), 267 with lifetime histories of both anorexia and bulimia nervosa (AN + BN; 194 ill, 73 recovered), 63 with eating disorder not otherwise specified (EDNOS; 31 ill, 32 recovered), and 507 without eating or Axis I disorder pathology. RESULTS: Women ill with all types of eating disorders exhibited several TCI score differences from control women, particularly in the areas of novelty-seeking, harm avoidance, self-directedness, and cooperativeness. Interestingly, women recovered from eating disorders reported higher levels of harm avoidance and lower self-directedness and cooperativeness scores than did normal control women. CONCLUSIONS: Women with eating disorders in both the ill and recovered state show higher levels of harm avoidance and lower self-directedness and cooperativeness scores than normal control women. Although findings suggest that disturbances may be trait-related and contribute to the disorders' pathogenesis, additional research with more representative community controls, rather than our pre-screened, normal controls, is needed to confirm these impressions.     

Individual-specific risk factors for anorexia nervosa: a pilot study using a discordant sister-pair design

BACKGROUND: The aim of this pilot study was to examine which unique factors (genetic and environmental) increase the risk for developing anorexia nervosa by using a case-control design of discordant sister pairs. METHODS: Forty-five sister-pairs, one of whom had anorexia nervosa and the other did not, were recruited. Both sisters completed the Oxford Risk Factor Interview for Eating Disorders and measures for eating disorder traits, and sib-pair differences. Blood or cheek cell samples were taken for genetic analysis. Statistical power of the genetic analysis of discordant same-sex siblings was calculated using a specially written program, DISCORD. RESULTS: The sisters with anorexia nervosa differed from their healthy sisters in terms of personal vulnerability traits and exposure to high parental expectations and sexual abuse. Factors within the dieting risk domain did not differ. However, there was evidence of poor feeding in childhood. No difference in the distribution of genotypes or alleles of the DRD4, COMT, the 5HT2A and 5HT2C receptor genes was detected. These results are preliminary because our calculations indicate that there is insufficient power to detect the expected effect on risk with this sample size. CONCLUSIONS: A combination of intrinsic and extrinsic factors increases the risk of developing anorexia nervosa. It would, therefore, be informative to undertake a larger study to examine in more detail the unique genetic and environmental factors that are associated with various forms of eating disorders.     

Screening for Axis II personality disorders in women with bulimic eating disorders

The Personality Diagnostic Questionnaire (PDQ) was completed by 628 eating-disordered women: 300 with normal-weight bulimia, 15 with anorexia nervosa with bulimic features, and 313 with subdiagnostic eating disorders. Three-quarters (75%) of subjects with normal-weight bulimia had personality disorder diagnoses, compared with 50% of those with subdiagnostic eating disorders. The average number of separate PDQ diagnoses was 2.7 for the normal-weight bulimia group, 2.5 for the group with anorexia nervosa with bulimic traits, and 1.5 for the subdiagnostic group. The most common PDQ diagnoses were schizotypal, histrionic, and borderline disorders, but avoidant and dependent personality features also occurred. Personality disturbances may be common in patients with eating disorders.     

Osteoporosis in women with anorexia nervosa

Because estrogen deficiency predisposes to osteoporosis, we assessed the skeletal mass of women with anorexia nervosa, using direct photon absorptiometry to measure radial bone density in 18 anorectic women and 28 normal controls. The patients with anorexia had significantly reduced mean bone density as compared with the controls (0.64 +/- 0.06 vs. 0.72 +/- 0.04 g per square centimeter, P less than 0.001). Vertebral compression fractures developed in two patients, and bone biopsy in one of them demonstrated osteoporosis. Bone density in the patients was not related to the estradiol level (r = 0.02). Levels of parathyroid hormone, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D were normal despite low calcium intakes. The patients with anorexia who reported a high physical activity level had a greater bone density than the patients who were less active (P less than 0.001); this difference could not be accounted for by differences in age, relative weight, duration of illness, or serum estradiol levels. The bone density of physically active patients did not differ from that of active or sedentary controls. We conclude that women with anorexia nervosa have a reduced bone mass due to osteoporosis, but that a high level of physical activity may protect their skeletons.     

Personality of recovered patients with bipolar affective disorder

Personality traits of 45 patients with bipolar affective disorder who were fully recovered were compared with those of 78 patients with unipolar affective disorder (also fully recovered) and with those of 1172 never mentally ill first-degree relatives. The most striking finding is the similarity in personality between the recovered bipolar and unipolar patients, who both differed substantially from the never-ill group on measures of emotional strength. Bipolar men had normal levels of extraversion, whereas bipolar women, like unipolar women, were introverted.     

Childhood eating and weight in eating disorders: a multi-centre European study of affected women and their unaffected sisters

BACKGROUND: Previous studies have suggested that childhood eating and weight problems may be risk factors for eating disorders. Robust evidence is still lacking. AIMS: To investigate whether childhood eating and weight problems increase the risk of eating disorders in affected women compared to their unaffected sisters. METHODS: Women (150) with anorexia (AN) or bulimia nervosa (BN) recruited from clinical and community samples were compared to their unaffected sister closest in age on maternal reports of childhood eating and weight. RESULTS: Women with BN were significantly more overweight at the ages of 5 and 10 (both OR = 2.8, p < 0.01), ate a lot (OR = 1.3, p < 0.01), were less picky (OR = 0.6, p < 0.05) and ate quickly (OR = 2.3, p < 0.05) between the ages of 6 and 10 compared to their healthy sisters. Significantly more women with AN were described as having a higher weight at 6 months (OR = 0.8, p < 0.01) and 1 year (OR = 0.6, p < 0.01) compared to their healthy sisters. Childhood eating was comparable in the women with AN and their unaffected sisters. CONCLUSIONS: Traits of childhood overeating were more common in bulimic women compared to their unaffected siblings. Subjects with AN did not differ from their sisters on eating variables. The increased risk of BN due to childhood overweight suggests that prevention strategies for childhood obesity and overweight may therefore be applicable in BN.     

Psychoendocrine interaction in anorexia nervosa,and the retreat from puberty: A study of attitudes to adolescent conflict,and luteinizing hormone response to luteinizing hormone releasing factor,in refed anorexia nervosa subjects

Seventeen young women suffering from anorexia nervosa underwent LHRF infusion, and repertory grid psychometric measures, soon after they had regained ideal body weight. Those who had regained normal LH responsiveness showed repertory grid evidence of increased adolescent conflict compared to those who failed to respond to LHRF. Certain other clinical variables which might account for this finding were excluded, and the hypothesis that amenorrhoea in anorexia nervosa is partly explicable as a psychobiological defence against adolescent conflict is supported.     

神经性厌食患者的人格特征及焦虑抑郁症状

目的:探讨神经性厌食患者的人格特征及焦虑抑郁症状,为临床治疗和疾病预防提供参考依据。方法:选取94例同时符合中国精神障碍分类与诊断标准第3版(CCMD-3)和美国精神障碍诊断与统计手册第4版(DSM-Ⅳ)诊断标准的神经性厌食患者,其中限食型41例,暴食/清除型53例;选取72例某精神专科医院实习护士为对照组。两组均采用明尼苏达多项人格(MMPI)、汉密顿抑郁量表(HAMD)、汉密顿焦虑量表(HAMA)进行测查。结果:病例组抑郁症状(85.1%vs.8.3%)和焦虑症状(75.5%vs.2.8%)的检出率高于对照组(均P0.05)。病例组M M PI测试结果除男子-女子气、说谎量表、诈病量表、校正量表的T分与对照组无统计学差异外(均P0.05),精神病态、抑郁、癔病、疑病、偏执、精神衰弱、精神分裂症、轻躁狂及社会内向的T分均高于对照组(均P0.05);T分最高的量表分为精神病态(Pd)(63.8±11.2),其次是抑郁(D)(61.0±12.8),两点编码呈现24/42编码。暴食/清除型患者的疑病(Hs)的T分高于限食型[(53.3±9.9)vs.(58.7±9.3),P0.05]。结论:神经性厌食患者有其特定的人格特征,尤其是精神病态和抑郁更为突出。     

Axes I and II comorbidity and treatment experiences in eating disorder subjects

BACKGROUND: The present study determined the psychiatric comorbidity of Axes I and II in a sample of subjects with eating disorders (EDs). The objective was to investigate associations between comorbidity and current and past treatment. METHODS: In a sample of 248 women (77 anorexia nervosa, 137 bulimia nervosa, 34 eating disorders not otherwise specified), psychiatric comorbidity of Axes I and II was determined with the Structured Clinical Interview of DSM-IV. Current and past treatment since ED onset were also assessed. RESULTS: High levels of psychiatric comorbidity were found in the total sample (71% Axis I and 68% Axis II). Only 17% of cases had no psychiatric comorbidity. Anxiety (52%) and affective disorders (50%) were the most common Axis I diagnoses. Personality disorders of Clusters C (52%) and B (23%) were most common for Axis II. Twenty-one percent of participants who were not in treatment at the time had a history of inpatient treatment, and an additional 59% had a history of outpatient treatment. Thirty-eight percent of participants currently in outpatient treatment had a history of inpatient treatment. Participants with multiple comorbidity (Axes I and II) had the highest proportion of cases who had been treated by health professionals. Higher levels of comorbidity were associated with experiences in more intense treatment settings (ranging from no treatment to inpatient treatment). CONCLUSIONS: ED subjects with greater comorbidity require more treatment encounters and more intense treatment settings. The association between comorbidity and treatment experiences may represent a bias in the assessment of comorbidity when samples with heterogeneous treatment history are recruited.     

What predicts suicide attempts in women with eating disorders?

BACKGROUND: Suicide is a common cause of death in anorexia nervosa and suicide attempts occur often in both anorexia nervosa and bulimia nervosa. No studies have examined predictors of suicide attempts in a longitudinal study of eating disorders with frequent follow-up intervals. The objective of this study was to determine predictors of serious suicide attempts in women with eating disorders. METHOD: In a prospective longitudinal study, women diagnosed with either DSM-IV anorexia nervosa (n = 136) or bulimia nervosa (n = 110) were interviewed and assessed for suicide attempts and suicidal intent every 6-12 months over 8.6 years. RESULTS: Fifteen percent of subjects reported at least one prospective suicide attempt over the course of the study. Significantly more anorexic (22.1%) than bulimic subjects (10.9%) made a suicide attempt. Multivariate analyses indicated that the unique predictors of suicide attempts for anorexia nervosa included the severity of both depressive symptoms and drug use over the course of the study. For bulimia nervosa, a history of drug use disorder at intake and the use of laxatives during the study significantly predicted suicide attempts. CONCLUSIONS: Women with anorexia nervosa or bulimia nervosa are at considerable risk to attempt suicide. Clinicians should be aware of this risk, particularly in anorexic patients with substantial co-morbidity.     

Long-term follow-up of anorexia nervosa

This study compared the long-term outcome of restricting and bulimic anorexic women using standardized psychometric instruments in addition to global clinical ratings. Results indicated that, in general, restricting and bulimic anorexic subtypes did not differ in their long-term outcome according to clinical ratings and standardized assessments of anorexic symptoms, psychiatric diagnoses, and psychosocial functioning. The only exception to this pattern was that the bulimic group had a higher incidence of substance use disorders during the last year compared with the restricting group. Findings also indicated that relative to a matched comparison group of women of average weight, a significant percentage of anorexics from both subtypes met DSM-III criteria for an affective or anxiety disorder at some point in their lives as well as at long-term follow-up. Results are discussed in terms of theoretical and methodologic issues involved in the long-term follow-up of anorexia nervosa.     

Symptomatology, psychosexual development and gender identity in 42 anorexic males

Forty-two male patients with an anorexic syndrome were assessed. Twenty-nine of them had a primary anorexia nervosa (most of them also had bulimic symptoms). They were compared with a series of 23 female anorexia nervosa patients. The males scored more highly than female patients on a number of symptoms, but generally more similarities than differences in symptomatology were apparent. Male patients with primary anorexia nervosa also showed several signs of a disturbed psychosexual and gender identity development. The data support the hypothesis that males with atypical gender role behaviour have an increased risk for developing anorexia nervosa or bulimia in adolescence.     

Eating disorders

Eating disorders are common among adolescent girls and young women and are associated with potentially serious medical complications, yet they often go undetected and untreated. All patients with eating disorders should be evaluated and treated for medical complications of the disease at the same time that psychotherapy and nutritional counseling are undertaken. Pharmacologic agents are often useful as adjuncts to psychotherapy for bulimia nervosa or binge-eating disorder; in the case of anorexia nervosa, psychotropic medication is generally reserved for patients with a concurrent psychiatric illness or those who have recovered some weight.     

Delay of gratification in bulimic and restricting anorexia nervosa patients

This investigation posited that impairment in the delay of gratification is an etiological factor in anorexia nervosa that differentiates between bulimic anorexic and restricting anorexic subgroups. Forty-eight women aged 18-32 served as subjects. Among subjects aged 18-29, restricting anorexics scored significantly higher than bulimic anorexics on delay. Treatment implications indicate that restricting anorexics would benefit from intervention designed to decrease impulse control, while bulimic anorexics would benefit from intervention designed to increase delaying capacity.     

Pregnancy and perinatal complications associated with risks for common psychiatric disorders in a population-based sample of female twins.

The association between pregnancy and perinatal complications (PPCs) and risks for adult psychiatric disorders other than psychoses has received relatively limited attention. In this study, we aim to characterize the associations between PPCs and risks for anxiety, affective, substance use, and eating disorders in a population-based sample of twins. Personal interviews were conducted with 1,806 female twin subjects to assess their lifetime history of alcoholism, anorexia nervosa, bulimia nervosa, generalized anxiety disorder, major depression, panic disorder, simple phobias, and social phobias. PPCs were retrospectively assessed at personal interview with the subject's parents. The associations between PPCs and risks for psychiatric disorders are characterized using logistic regression. In this sample of twins, gestational age is associated with a significantly increased risk for anorexia nervosa and pregnancy complications are associated with a significantly increased risk for both anorexia nervosa and bulimia nervosa. Pregnancy and perinatal complications may be associated with an increased risk for eating disorders in women.     

Single nucleotide polymorphisms in the leptin receptor gene: studies in anorexia nervosa

Anorexia nervosa is an eating disorder of unknown aetiology. There is significant evidence for a genetic component in the pathogenesis of this disorder. A region on chromosome 1 has been identified as a susceptibility locus. The leptin receptor has been mapped to a similar region, further upstream of this susceptibility locus. Leptin and its receptor are known to be important factors in the control and regulation of body weight. Single nucleotide polymorphisms (SNPs) in the leptin receptor are associated with measures of body weight. In the present study, SNPs in the coding region of the leptin receptor were analysed and their possible association with anorexia nervosa was investigated. Two cohorts of young women, 176 Caucasian anorexia nervosa patients and 152 normal Caucasian females, were genotyped for three SNPs in the leptin receptor. There was no significant difference in allele or genotype frequency, for any SNP, between the normal controls and the cohort of anorexia subjects. There were no significant associations with any genotype and body mass index in either the control or anorexic cohorts. When the anorexic cohort was subdivided into restricting and bingeing/purging behaviours, we found no significant association with any genotype. Analysis of haplotypes showed no significant evidence of association with anorexia. In summary, leptin receptor SNPs do not appear to be important factors in the regulation of body weight in young, pre-menopausal women or have any significant association with anorexia nervosa.     

The childhood and family background of women with clinical eating disorders: a comparison with women with major depression and women without psychiatric disorder

BACKGROUND: Childhood antecedents are often put forward as being of possible aetiological significance for both anorexia nervosa and bulimia nervosa. METHOD: Comparisons were made of groups of women with eating disorders with groups of women with major depression or without current psychiatric disorder, using the Childhood Experience of Care and Abuse interview (CECA). RESULTS: Women with bulimia nervosa (or mixed bulimia and anorexia nervosa) tended to report more troubled childhood experiences than did women from the non-morbid comparison group. In this respect, they resembled those with major depression. In contrast, those with anorexia nervosa resembled the non-morbid women rather than the other psychiatric groups. CONCLUSIONS: Adversity in childhood as measured by the CECA may play a part in the causation of bulimia nervosa but not of anorexia nervosa. It remains possible that more specific or subtle family influences may be relevant.     

Pregnancy and perinatal complications associated with risks for common psychiatric disorders in a population‐based sample of female twins

The association between pregnancy and perinatal complications (PPCs) and risks for adult psychiatric disorders other than psychoses has received relatively limited attention. In this study, we aim to characterize the associations between PPCs and risks for anxiety, affective, substance use, and eating disorders in a population‐based sample of twins. Personal interviews were conducted with 1,806 female twin subjects to assess their lifetime history of alcoholism, anorexia nervosa, bulimia nervosa, generalized anxiety disorder, major depression, panic disorder, simple phobias, and social phobias. PPCs were retrospectively assessed at personal interview with the subject's parents. The associations between PPCs and risks for psychiatric disorders are characterized using logistic regression. In this sample of twins, gestational age is associated with a significantly increased risk for anorexia nervosa and pregnancy complications are associated with a significantly increased risk for both anorexia nervosa and bulimia nervosa. Pregnancy and perinatal complications may be associated with an increased risk for eating disorders in women. © 2001 Wiley‐Liss, Inc.     

Do illness characteristics and familial risk differ between women with anorexia nervosa grouped on the basis of personality pathology?

BACKGROUND: In view of the potential utility of personality-based groupings in eating disorders (EDs), and the lack of studies using this approach in large samples of individuals with anorexia nervosa (AN), this study set out to examine (i) the nature of personality-based clusters of women with lifetime AN and (ii) if these clusters are associated with either clinical symptoms or aetiological variables. METHOD: The self-report Dimensional Assessment of Personality Pathology (DAPP) was completed by 153 women with a lifetime diagnosis of DSM-IV AN. A cluster analysis was used to identify personality-based subgroups. Clusters were then compared on clinical and aetiological variables. RESULTS: Three personality-based clusters were identified, defined by broad, avoidant and compulsive types of personality pathology. Dimensions of low dissocial behaviour, high inhibition and high compulsivity were common to all clusters, while dimensions related to emotional dysregulation appeared more heterogeneous. Clinical symptoms were not related to personality profile with the exception of a trend towards more fasting behaviour in the broad group. The compulsive cluster with the narrowest range of extreme personality traits reported the highest familial risk of eating pathology. CONCLUSIONS: The three clusters identified in our AN sample were similar to those previously identified in broader eating disordered samples. Personality-based clusters did not correspond overall to clinical symptoms but aetiological differences supported their validity. Broader personality pathology indicative of emotional dysregulation, problems with identity and relationships, in addition to core traits, may increase vulnerability to AN in those with less familial risk.