Course and outcome in adolescent anorexia nervosa

OBJECTIVE: To investigate course, outcome, and psychiatric comorbidity in adolescent anorexia nervosa by repeated follow-up assessment. METHOD: Thirty-four subjects (88%) of an original sample of 39 inpatients were followed up personally 3 and 7 years after discharge and classified according to DSM-III-R eating disorder categories. Standardized psychometric instruments were used to assess specific eating disorder symptoms, concomitant general psychopathology, and comorbid psychiatric diagnoses. RESULTS: After 7 years, 1 patient (3%) had anorexia nervosa, 4 patients (12%) bulimia nervosa, and 10 patients (29%) eating disorder not otherwise specified (EDNOS). Anxiety disorders (41%) and affective disorders (18%) were the most prevalent comorbid psychiatric disorders. Concomitant general psychopathology was significantly related to the outcome of the eating disorder. CONCLUSIONS: According to our results, the majority of former adolescent anorexic inpatients had shown substantial improvement in their eating disorders symptomatology after 7 years. Patients with persisting eating disorders mostly suffered from restrictive symptoms. The prevalence and distribution of psychiatric comorbidity were similar to those of adult-onset anorexia nervosa. Subjects with a worse outcome of the eating disorder also displayed higher levels of general psychopathology.     

A comparison of ever-married and never-married women with anorexia nervosa or bulimia nervosa

OBJECTIVE: The results of the scant research on anorexia nervosa and marriage suggest that married anorexics may exhibit more severely disordered eating. However, past research has not controlled for the greater age of married versus unmarried anorexics, and very little research has been conducted on marriage and women with bulimia nervosa. We investigated differences in disordered eating and clinical traits between ever-married and never-married women with anorexia nervosa or bulimia nervosa and statistically controlled for age. METHOD: Adult women ages 20-45, who were assessed in an outpatient eating disorders clinic and diagnosed with anorexia nervosa (n = 91) or bulimia nervosa (n = 223), completed several measures of disordered eating and related traits at the point of initial evaluation. RESULTS: In simple comparisons, ever-married women differed from their never-married peers with regard to several indices of symptom history and severity. However, after controlling for age, ever-married women differed only with regard to an earlier onset of menarche and, for women with bulimia nervosa, an earlier onset of sexual intercourse. DISCUSSION: Results are discussed with regard to possible explanation and directions for future research.     

Anorexia nervosa and bulimia nervosa: I. Diagnosis and treatment

Disturbed eating behaviour and disturbed body experience are important features for the differential diagnosis of eating disorders from other disorders. Eating disorders occur mainly in young females. The one-year prevalence of anorexia nervosa is 0.4% and that of bulimia nervosa 1.5% among young females. To motivate patients for treatment it is important to discuss physical problems and the high risk of severe complications with them. It is difficult to motivate patients for treatment, because anorexia nervosa patients deny their illness and bulimia nervosa patients are ashamed and hide their disturbed eating behaviour. The treatment of anorexia nervosa consists of two partly overlapping phases: normalizing the eating pattern to improve weight restoration and psychotherapeutic treatment for underlying emotional problems. Family therapy is effective for patients younger than 18 years with a short duration of illness. Cognitive behaviour therapy is the most important form of treatment for bulimia nervosa.     

Annual treatment rates and estimated incidence of eating disorders in Austria

BACKGROUND: At present, the prevalence and incidence of eating disorders in Austria is unknown; not even rough estimates of countrywide annual treatment rates are available. AIMS: To assess the number of patients in Austria with eating disorders currently under treatment and to compare this rate with the estimated prevalence and incidence of eating disorders, thus providing an estimate of unrecorded cases and the appropriateness of health care for these disorders. METHODS: The number of patients being treated in major out-patient and in-patient facilities was assessed by questionnaires. Prevalence and incidence rates in Austria were estimated by extrapolation of epidemiological data from comparable Western countries to Austrian figures from the most recent population census in 1991. RESULTS: Altogether 1075 patients were being treated in 1994 at 26 institutions, including all specialized centres, pediatric and psychiatric university hospitals. Surprisingly, the annual treatment rates for anorexia and bulimia nervosa were equal. There is a considerable discrepancy between these treatment figures and prevalence/incidence estimates (in absolute numbers): the estimated anorexia nervosa point prevalence is about 2500 girls aged 15-20 years, whilst a minimum of 4400 girls suffer from subclinical eating disorders, and there are about 6500 bulimia nervosa cases in young women aged 20-30 years. The incidence might be about 600 new onset cases per year for anorexia, and about 870 for bulimia nervosa. The size of the problem (lifetime prevalence) may comprise at least 36,000 women with bulimia nervosa. CONCLUSIONS: Eating disorders pose a major public health problem for women in Austria. It is unlikely that the vast majority of unrecorded cases was treated in private practice or in hospitals which failed to respond to our questionnaire. The discrepancy between annual treatment rates and prevalence/incidence estimates points to a lack of specialized eating disorder units in Austria.     

Multifactorial assessment of bulimia nervosa.

Investigated a multifactorial approach to the assessment of bulimia nervosa by means of hierarchical factor analysis. 245 bulimia nervosa patients and 68 patients with either anorexia nervosa or eating disorders not otherwise specified were administered a self-report battery that was organized into 21 dimensions relevant to eating disorder patients. When dimensions from this battery were subjected to hierarchical factor analysis, support for bulimia nervosa as a unique diagnostic category was obtained. However, the emergence of 3 secondary factors and 6 primary factors suggests that bulimia nervosa can also be described more complexly. The emergence of a multifactorial model of bulimia nervosa that incorporates several existing unidimensional models suggests the potential for both divergent and complicated clinical presentation in bulimia nervosa patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A study of personality in eating disorders

Some evidence suggests that temperament and personality traits could influence the development and severity of eating disorders. This study was designed to study these aspects. METHODS: 72 patients with DSM-IV eating disorders including 25 anorexia nervosa restricting type, 17 with anorexia nervosa binge eating-purging type and 30 with bulimia nervosa were studied and compared with thirty healthy controls. Personality disorders and temperament were studied with the Eysenck's EPQ, Cloninger's TCI and SCID-II. Impulsive and clinical features were studied with specific rating scales. RESULTS: 61.8% of patients had at least one personality disorder. Avoidant personality disorder was the most commonly diagnosed in anorexia restricting type (25%). Borderline personality disorder was the most frequent in bulimia nervosa and in the binge eating-purging type of anorexia nervosa. Dimensionally, the group of eating disorders presented high scores in neuroticism and low scores in self-directedness. Higher harm avoidance was found in bulimic patients and higher persistence was associated with anorectic patients. Bulimic patients were significantly more impulsive than anorectic and controls. CONCLUSIONS: Temperament and personality traits differ in anorectic and bulimic patients. Bulimic symptoms are linked to impulsive temperament traits and to impulsive personality features. Anorectic symptoms are linked to persistent temperament traits and anxious personality features.     

Bias and bulimia nervosa: how typical are clinic cases?

OBJECTIVE: Since patients being treated for bulimia nervosa constitute only a minority of persons with the disorder, the cases seen in clinics may be subject to sampling bias. The aim of this study was to investigate sampling bias as it affects secondary referrals for bulimia nervosa. METHOD: The personal and family characteristics of a consecutive series of 60 women with secondary referrals for bulimia nervosa (clinic subjects) were compare with those of 83 subjects with bulimia who were recruited directly from the community. Most of the data were collected by interview. RESULTS: The demographic characteristics of the two groups were similar. The clinic subjects had a more severe eating disorder and much greater impairment of social functioning. There was no difference between the groups in duration of the eating disorder or level of general psychiatric disturbance. The community subjects were heavier and had stronger family histories of obesity. CONCLUSIONS: There is sampling bias among secondary referrals for bulimia nervosa. The relative absence of persons prone to obesity among secondary subjects is important, since there is evidence that vulnerability to obesity is a poor prognostic feature as well as being a risk factor for the development of bulimia nervosa. The greater social impairment among the clinic subjects is suggestive of greater personality disturbance in this group. Caution is warranted when generalizing from clinic cases to the disorder as a whole.     

The demand for eating disorder care. An epidemiological study using the general practice research database

BACKGROUND: An epidemiological study of anorexia nervosa and bulimia nervosa in primary care was performed using the General Practice Research Database (GPRD). METHOD: The GPRD was screened between 1988 and 1994 for newly diagnosed cases of anorexia nervosa and bulimia nervosa. The validity of the computer diagnosis was established by obtaining clinical details from a random sample of the general practitioners (GPs). RESULTS: Incidence rates for detection of cases by GPs in 1993 was 4.2 per 100,000 population for anorexia nervosa, and 12.2 per 100,000 for bulimia nervosa. The relative risks of females to males was 40:1 for anorexia nervosa and 47:1 for bulimia nervosa. A threefold increase in the recording of bulimia nervosa was found from 1988 to 1993. Eighty per cent of anorexia nervosa cases and 60% of bulimia nervosa cases were referred to secondary care. CONCLUSION: There is a continuing expansion of service need for bulimia nervosa. The majority of cases of eating disorders are referred to secondary services. There is scope for more effective management of bulimia nervosa in primary care.     

An application of expectancy theory to eating disorders: Development and validation of measures of eating and dieting expectancies.

Instruments for measuring learned expectations for reinforcement from eating and from dieting and thinness were constructed and validated. Five eating reinforcement expectancies and 1 dieting-thinness reinforcement expectancy were identified and their factor structure replicated on an independent sample. The expectancy that dieting and thinness lead to overgeneralized self-improvement characterized bulimia nervosa and anorexia nervosa patients and correlated with dieting behavior in a general sample. Expectancies for negative reinforcement from eating (e.g., eating helps manage negative affect) characterized bulimic but not anorexic individuals and were correlated with indexes of restraint plus disinhibition in a general sample. Positive reinforcement expectancies (e.g., eating is pleasurable and rewarding) were unrelated to disinhibited eating, but anorexic patients expected significantly less positive reinforcement from eating than did bulimic patients or controls. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Biological aspects of anorexia nervosa and bulimia nervosa.

In this article, we review biological factors relevant to the understanding of anorexia nervosa and bulimia nervosa. We consider the physical presentation of these disorders; the medical complications of starvation, binging, and purging; and the cognitive and behavioral effects of starvation. We also review neurophysiological and neurochemical aspects of these illnesses and their biological treatments. These biological variables are most prominent in the perpetuation of the eating disorders. Effective treatment approaches must consider psychosocial as well as biological variables to be optimally effective. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The "presyrinx" state: a reversible myelopathic condition that may precede syringomyelia

The purpose of this investigation was to develop a brief self-report inventory which could be used to evaluate treatment outcome for anorexia and bulimia nervosa. The Multifactorial Assessment of Eating Disorders Symptoms (MAEDS) was constructed to measure six symptom clusters which have been found to be central to the eating disorders: depression, binge eating, purgative behavior, fear of fatness, restrictive eating, and avoidance of forbidden foods. The factor structure of the MAEDS was found to be stable and it was found to have satisfactory reliability and validity. Normative data were collected so that raw scores could be converted to standardized scores. While still in the experimental stages, the MAEDS shows promise as a valid and economical measure of treatment interventions for anorexia and bulimia nervosa.     

Serum leptin and body weight in females with anorexia and bulimia nervosa

In this study we hypothesized that there is a correlation between serum leptin levels and body mass indices within patients with anorexia nervosa or bulimia nervosa during a twelve weeks' course of in-patient treatment. We evaluated leptin levels weekly in female in-patients with anorexia (n = 17) or bulimia nervosa (n = 18). Only patients with anorexia nervosa were therapeutically encouraged to gain weight throughout the treatment episode. For the whole cohort, body mass indices and serum leptin levels were highly correlated upon admission (r = 0.89, p < 0.001). The median intra-individual correlation in the anorexia group was higher than in the bulimia group (0.63 and 0.39, respectively). The intra-individual correlations were higher in those anorexia nervosa patients who showed increments of their body mass index within the observation span. This dynamic aspect is important specifically in patients with anorexia nervosa during therapeutically induced weight gain.     

Comparison of cognitive style in bulimia nervosa and depression

This study investigated the global and specific cognitive style associated with bulimia nervosa. Three groups of women (women with bulimia nervosa, women with major depression, and controls) completed measures of eating disorder severity, depression, dysfunctional cognitions and irrational beliefs. The control group was found to report significantly lower levels of cognitive distortions and irrational beliefs overall than both women with bulimia nervosa and women with depression. However, no difference was found between the latter two groups. Furthermore, the pattern of individual cognitions and beliefs was exactly the same. When depression was statistically controlled, cognitive style no longer differentiated between the control group and two clinical groups. These results have implications for improving the effectiveness of cognitive behaviour therapy for bulimia nervosa.     

Equivalence of body image disturbances in anorexia and bulimia nervosa.

A silhouette method, the Body Image Assessment, was used to measure self-evaluation of current and ideal body size in 3 groups: Ss with anorexia nervosa (n?=?37), Ss with bulimia nervosa (n?=?59), and normal control Ss (n?=?95). Current and ideal body size measures were contrasted across the 3 groups using body mass index as a covariate to control for the Ss' actual body size. Both eating disorder groups judged current body size to be larger and ideal body size to be thinner relative to control Ss. When actual body size was not statistically controlled, Ss with anorexia nervosa judged current body size to be thinner than did control Ss and Ss with bulimia nervosa. Data illustrate the importance of controlling for actual body size when investigating the self-evaluation of body size. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Colonic and anorectal function in constipated patients with anorexia nervosa

OBJECTIVES: Many patients with eating disorders complain of severe constipation. Previous studies have suggested that constipation in patients with anorexia nervosa may be associated with slow colonic transit. However, it is unclear whether a refeeding program will alter colonic transit in these patients. The aim of this study was to investigate colorectal function by measuring colonic transit and anorectal function in anorexic patients with constipation during treatment with a refeeding program. METHODS: We prospectively studied 13 female patients with anorexia nervosa who were admitted to an inpatient treatment unit and compared them to 20 previously studied, age-matched, healthy female control subjects. Patients underwent colonic transit studies using a radiopaque marker technique and anorectal manometry measuring anal sphincter function, rectal sensation, expulsion dynamics, and rectal compliance. Patients were studied both early (< 3 wk) and late (> 3 wk) in their admission. We restudied two patients who had slow colonic transit. All patients also underwent structured interviews. RESULTS: Four of six patients studied within the first 3 wk of their admission had slow colonic transit, defined as > 70 h (108.0 +/- 17.0 h, mean +/- SEM), on initial evaluation. In contrast, none of the seven patients studied later than 3 wk into their admission had slow colonic transit. Two of the four patients with slow transit were restudied later in their admission and were found to have normal transit times. Rectal sensation, internal anal sphincter relaxation threshold, rectal compliance, sphincter pressures, and expulsion pattern were normal in all subjects. CONCLUSIONS: Despite complaints of severe constipation, colonic transit is normal or returns to normal in the majority of patients with anorexia nervosa once they are consuming a balanced weight gain or weight maintenance diet for at least 3 wk.     

The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study

OBJECTIVE: To assess the long-term course of recovery and relapse and predictors of outcome in anorexia nervosa. METHOD: A naturalistic, longitudinal prospective design was used to assess recovery and relapse in patients ascertained through a university-based specialty treatment program. Patients were assessed semiannually for 5 years and annually thereafter over 10-15 years from the time of their index admission. Recovery was defined in terms of varying levels of symptom remission maintained for no fewer than 8 consecutive weeks. RESULTS: Nearly 30% of patients had relapses following hospital discharge, prior to clinical recovery. However, most patients were weight recovered and menstruating regularly by the end of follow-up, with nearly 76% of the cohort meeting criteria for full recovery. Relapse after recovery was relatively uncommon. Of note, time to recovery was protracted, ranging from 57-79 months depending on definition of recovery. Among restrictors at intake, nearly 30% developed binge eating, occurring within 5 years of intake. A variety of predictors of chronic outcome and binge eating were identified. There were no deaths in the cohort. CONCLUSION: The course of anorexia nervosa is protracted. Predictors of outcome are surprisingly few, but those identified are in keeping with previous accounts. The intensive treatment received by these patients may account for the lower levels of morbidity and mortality when considered in relation to other reports in the follow-up literature.     

Distinguishing the role of eating disturbance from depression in the sex role self-perceptions of anorexic and bulimic inpatients.

Previous research has linked specific sex role self-perceptions to two major eating disorders: anorexia nervosa and bulimia. To date, however, sex role self-perceptions and ideals unique to eating disturbance have not been distinguished from those related to depression and other concomitant psychopathology. The Bem Sex-Role Inventory was administered twice (self-ratings and ideal self-ratings) to 83 women: 37 eating disorder inpatients, 12 depressed inpatients, and 34 high school and college students. Results indicate that both patient groups scored significantly lower (p?p?     

Assessment and treatment of bulimia nervosa

Bulimia nervosa is characterized by binge eating and inappropriate compensatory behaviors, such as vomiting, fasting, excessive exercise and the misuse of diuretics, laxatives or enemas. Although the etiology of this disorder is unknown, genetic and neurochemical factors have been implicated. Bulimia nervosa is 10 times more common in females than in males and affects up to 3 percent of young women. The condition usually becomes symptomatic between the ages of 13 and 20 years, and it has a chronic, sometimes episodic course. The long-term outcome has not been clarified. Other psychiatric conditions, including substance abuse, are frequently associated with bulimia nervosa and may compromise its diagnosis and treatment. Serious medical complications of bulimia nervosa are uncommon, but patients may suffer from dental erosion, swollen salivary glands, oral and hand trauma, gastrointestinal irritation and electrolyte imbalances (especially of potassium, calcium, sodium and hydrogen chloride). Treatment strategies are based on medication, psychotherapy or a combination of these modalities.