Patterns and predictors of recovery in anorexia nervosa and bulimia nervosa

OBJECTIVE: The purpose of this study was to assess the course and outcome of anorexia nervosa and bulimia nervosa at 1 year in a large cohort of women with eating disorders. METHOD: A prospective, naturalistic, longitudinal design was used to map the course of 225 women with anorexia nervosa, bulimia nervosa, and mixed anorexia and bulimia nervosa. Structured interviews were conducted quarterly. Follow-up data are presented in terms of patterns of recovery, clinical features predictive of time to recovery, and the role of comorbid disorders as fixed predictors. RESULTS: The recovery rate of bulimics was significantly better than that of anorexic or mixed subjects, yet nearly half the anorexic and mixed subjects no longer met full DSM-III-R criteria for at least 8 consecutive weeks during the first year of follow-up. Percent ideal body weight and type of eating disorder were significantly associated with outcome. CONCLUSIONS: Our findings suggest that the diagnosis of anorexia nervosa has severe implications.     

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 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.     

Binge eating disorder: treatment outcome over a 6-year course

Little is known about the long-term course of binge eating disorder (BED). The aim of the study was to assess the 3- and 6-year course and outcome of 68 consecutively treated females with BED. Their mean age was 29.3 years and they were assessed longitudinally at four timepoints: (1) beginning of therapy; (2) end of therapy; (3) 3-year follow-up; and (4) 6-year follow-up. Self rating as well as expert ratings were used for assessment. Symptoms of specific eating disorder as well as general psychopathology were measured. The general pattern of results over time was as follows: substantial improvement during therapy; slight (in most cases nonsignificant) decline during the first 3 years after the end of treatment, and further improvement and stabilization in years 4, 5, and 6 after the end of treatment. At the 6-year follow-up, the majority showed no major DSM-IV eating disorder, 5.9% had BED, 7.4% had shifted to bulimia nervosa (purging type) (DSM-IV), 7.4% were classified as ED-NOS, and one patient died. Based on an operationalized global outcome score for the complete sample, 57.4% had good outcome, 35.3% intermediate outcome, 5.9% poor outcome, and one person (1.4%) died. BED and BNP patients showed very similar intermediate and long-term course in self ratings as well as expert ratings.     

Regulatory effects of soluble growth factors on choriocapillaris endothelial growth and survival

The purpose of the following study was a multidimensional assessment of the course of anorexia nervosa. In our follow-up-study we were able to examine 41 out of 51 patients meeting DMS-111 R criteria for anorexia nervosa in our department at a mean follow-up of 5.3 years. At the first evaluation the patients were characterized by an early age of onset (mean 14.2 years), no or very little previous psychiatric treatment, and restrictive eating habits (72.5%); the mean age was 15.2 years. At the time of follow-up, the physical outcome was unfavourable for 50% of the patients; one patient had died. The psychosocial outcome was less favourable for 60%. Against the background of a neurotic structure, social and sexual disturbances were found although the patient's weight was often normal. Depressive symptoms and a "slimness ideal" were found among a large number of patients, just as much as the fear of gaining weight--which prove to be a reliable indicator for the continuation of an eating disorder. A multidimensional evaluation facilitates an assessment of the determinants of prognosis. Previous psychiatric treatment and low body weight were associated with an unfavourable, mention of problems/disturbances in the family environment with a good somatic outcome. Outpatient treatment indicates a favourable psychosocial outcome.     

Cognitive behavioral guided self-help for the treatment of recurrent binge eating.

Objective: Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy–effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU). Method: In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses. Results: At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change. Conclusions: CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relative sedimentation of hematopoietic progenitors in human cord blood, peripheral blood, and bone marrow as determined by counterflow centrifugal elutriation

OBJECTIVE: Although there have been many studies of the outcome of anorexia nervosa, methodological weaknesses limit their interpretation. The authors used a case-control design to try to improve knowledge about the outcome of anorexia nervosa. METHOD: All new female patients referred to an eating disorders service between Jan. 1, 1981, and Dec. 31, 1984, who had probable or definite anorexia nervosa were eligible for inclusion. Of these women, 86.4% (N = 70) were located and agreed to participate. The comparison group (N = 98) was a random community sample. All subjects were interviewed with a structured diagnostic instrument. RESULTS: A minority of the patients (10%) continued to meet the criteria for anorexia nervosa a mean of 12 years after initial referral. Even among those who no longer met these criteria, relatively low body weight and cognitive features characteristic of anorexia nervosa (perfectionism and cognitive restraint) persisted. The rates of lifetime comorbid major depression, alcohol dependence, and a number of anxiety disorders were very high. CONCLUSIONS: In the managed care/brief treatment era, therapeutic approaches with an excessive focus on weight gain that neglect the detection and treatment of associated psychological features and comorbidity may be inappropriate. Anorexia nervosa is a serious psychiatric disorder with substantial morbidity.     

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.     

First recovery in anorexia nervosa patients in the long-term course: A discrete-time survival analysis.

The results of a 12-year follow-up study of occurrence and timing of first recovery in 69 hospitalized patients with severe anorexia nervosa (AN) are presented. For the first time discrete-time survival analysis methods were used to determine the likelihood of recovery in AN patients. Furthermore, predictors gleaned from pretreatment-posttreatment studies of long-term outcome in AN could be evaluated as to their effect on a change in the time course structure of the likelihood of first recovery. Results show that AN condition did not improve until after 6 years after the first inpatient treatment in 50% of patients. However, a restricter-type AN and low serum creatinine levels were predictors for earlier recovery. One specific effect was that AN patients who show purging behavior in combination with additional social disturbances have a lower chance of recovering. The use of discrete-time survival analysis methodology in further prospective studies will contribute to the development of more tailored treatment of AN, which also takes the individual phase of illness and specific aspects of the symptomatology into account. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Interview for the Diagnosis of Eating Disorders—IV: Application to DSM–IV diagnostic criteria.

The authors describe the psychometric development of the fourth revision of the Interview for Diagnosis of Eating Disorders (IDED–IV). The IDED–IV was tested for the purpose of differential diagnosis of eating disorders, that is, anorexia nervosa, bulimia nervosa, and binge eating disorder. Evidence for internal consistency was found for symptom ratings relevant to anorexia nervosa, bulimia nervosa, and binge eating disorder. Support was found for the content validity as well as the concurrent and discriminant validity of the IDED–IV. Finally, tests of the interrater agreement for differential diagnosis of eating disorders found the IDED–IV to yield very reliable data. The authors conclude that the IDED–IV yields sufficiently reliable and valid data to be used for determining diagnoses in research studies and clinics specializing in the treatment of eating disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

Eating disorders: A bibliography of recent clinical and research reports.

Lists 47 references on eating disorders, including binge eating, bulimia, bulimarexia (binge eating and purging), and compulsive eating. This bibliography was compiled from a systematic review of selected journals and books about the assessment and treatment of obesity, anorexia nervosa, and eating disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Distinguishing recovery from remission in a cohort of bulimic women: how should asymptomatic periods be described?

BACKGROUND: Empirical definitions of remission and recovery from eating disorders are needed to understand outcome data and compare results across studies. METHOD: 106 treatment-seeking women with bulimia nervosa, who had abstained from binging and purging for at least 4 weeks, were followed prospectively. Relapse was defined as at least 4 consecutive weeks of either binging and purging weekly or binging two or more times per week, regardless of purging. Recovery was differentiated from remission based on the probability of relapse. The minimum number of weeks after which the risk of relapse leveled off was used as the cut-off to distinguish between the two outcomes. Kaplan-Meier methods were used to estimate the weekly probability of relapse. RESULTS: When defining remission as at least 4 weeks of being asymptomatic, a quarter of the women relapsed within 11 weeks. By 37 weeks, only 49% of the women remained asymptomatic (95% CI, 41-61). The probability of relapse was substantial for approximately a year after a woman ceased to binge and purge. CONCLUSION: Bulimia nervosa is an episodic disorder. As a conservative approach, periods of being asymptomatic that last less than 1 year should be labeled as remissions, not recoveries.     

Self-monitoring in the assessment of eating disorders.

Self-monitoring is a key feature of cognitive behavioral therapy (CBT) for eating disorders. It provides a detailed measure of eating problems and the circumstances under which they occur, but it does not yield precise estimates of amount of caloric intake. It indexes the progress of treatment and helps guide the focus of each therapy session. Adherence to self-monitoring is good provided that therapists implement it skillfully within a collaborative therapeutic alliance. Anorexia nervosa patients may pose a particular challenge in this respect. Self-monitoring may play an important role in the rapid effects of CBT for bulimia nervosa. Preliminary data indicate that self-monitoring of binge eating and purging may provide a valid measure of treatment outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pharmacologic approaches in the treatment of eating disorders

Important advances in the treatment of eating disorders, particularly bulimia nervosa, have been made during the past decade. Controlled trials for bulimia nervosa have demonstrated significant benefit from short-term pharmacotherapy with antidepressant medications and from short-term individual and group psychotherapies. Despite these advances, treatment of a patient often involves complex clinical decisions around such issues as choice of initial treatment modality, incomplete resolution of symptoms, and the role of long-term maintenance treatment. To address these questions, this review focuses primarily on summarizing results of published controlled trials of pharmacotherapy in patients with bulimia nervosa. In addition, it outlines the more limited literature on controlled pharmacotherapy trials for anorexia nervosa and for the provisionally identified syndrome of binge eating disorder.     

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.     

Effect of the chaperone-like alpha-crystallin on the refolding of lysozyme and ribonuclease A

This article is a critical review of the evolution of diagnostic criteria for anorexia nervosa, bulimia nervosa, and binge eating disorder. The shortcomings of the current diagnostic criteria for all three disorders are addressed, as are the primary nosological challenges facing the field.     

Is decision making really impaired in eating disorders?

Objective: Decision making has been reported to be reduced in eating disorders. However, studies are sparse and have been carried out in various selected populations. In the current study we arranged to confirm previous observations and to assess the relationship between decision making and dimensions relevant to eating disorders. Method: Patients suffering from anorexia nervosa (n = 49), bulimia nervosa (n = 38), and healthy controls (n = 83) were assessed using the Iowa Gambling Task (IGT). All patients were euthymic and free of psychotropic medication. Self-questionnaires (Eating Disorder Inventory–2; Gardner, 1991; and Eating Attitude Test; Garner & Garfinkel, 1979) were used to assess clinical dimensions relevant to eating disorders. Results: No significant differences in IGT performance were observed between patients and healthy controls or between restrictive and purging types of anorexia nervosa. No correlations were found between IGT performance and eating disorder questionnaires. Conclusion: These results do not support reduced decision making in patients with eating disorders, and suggest that previously reported alterations could be related to other clinical characteristics. This should stimulate new topic-related studies designed to reach a firm conclusion. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Eating disorders revisited. II: Bulimia nervosa and related syndromes

Bulimia nervosa and related syndromes are common, and occur in up to 5% of women who attend general practitioners. Young women in First World countries, particularly those who "diet", are at increased risk. Behaviours, such as binge eating and induced vomiting, are typically kept well hidden. Only a minority of those with these disorders present for treatment. General practitioners play a key role in primary and secondary prevention. Effective treatments include psychotherapies that focus on the patient's attitudes and relationships, not just the binge eating behaviour. About 50% of patients make a complete recovery, but the long term outcome is unknown.