Severe and enduring anorexia nervosa: Can risk of persisting illness be identified, and prevented, in young patients?

Predictors for and duration of hospitalization among children and adolescents with eating disorders

OBJECTIVE

The objective of this study was to investigate the predictive value of sex, age, body mass index (BMI), Eating Disorder Examination (EDE) score, social risk factors, and psychiatric comorbidities for hospitalization and hospitalization duration among children and adolescents suffering from eating disorders.

METHOD

This prospective cohort study involved 522 consecutive patients who had been referred to a specialized eating disorder unit between January 1, 2009 and December 31, 2015; participants were followed up until August 1, 2016 by medical records. We used regression analyses to evaluate the prognostic value of sex, age, BMI, EDE, eating disorder diagnoses, social risk factors, and psychiatric comorbidities concerning inpatient hospitalization and hospitalization duration.

RESULTS

We found that younger age, higher EDE global score, lower BMI percentile, anorexia nervosa, a higher number of social risk factors, and the presence of diagnosed self-harm increased the odds of being hospitalized, while being female and having a comorbid autism spectrum condition increased the duration of hospitalization. No other psychiatric comorbidity was found to significantly predict hospitalization or duration of hospitalization.

DISCUSSION

The odds of being hospitalized were predicted by the severity of anorexia nervosa and indicators of social risk factors in the family, whereas the duration of hospitalization was predicted by having a comorbid autism spectrum condition, indicating a difference between the factors affecting the risk of hospitalization and the factors affecting the duration of hospitalization. This calls for further exploration of tailored treatments for eating disorders.

PUBLIC SIGNIFICANCE STATEMENT

This study finds that hospitalization for an eating disorder is predicted by the severity of the illness, self-harm, and social risk factors. Duration of hospitalization is predicted by having a comorbid autism spectrum condition. These findings indicate that the treatment of eating disorders may require different treatment approaches depending on the presentation of the individual patient to reduce both the need for hospitalization and the length of inpatient stay.

Differences in Telomere Length between Adolescent Females with Anorexia Nervosa Restricting Type and Anorexia Nervosa Binge-Purge Type

Physiological and psychological distress may accelerate cellular aging, manifested by shortening of telomere length (TL). The present study focused on TL shortening in anorexia nervosa (AN), an illness combining physiological and psychological distress. For that purpose, we measured TL in 44 female adolescents with AN at admission to inpatient treatment, in a subset of 18 patients also at discharge, and in 22 controls. No differences in TL were found between patients with AN and controls. At admission, patients with AN-binge/purge type (AN-B/P; n = 18) showed shorter TL compared with patients with AN-restricting type (AN-R; n = 26). No change in TL was found from admission to discharge, despite an improvement in body mass index standard deviation score (BMI-SDS) following inpatient treatment. Older age was the only parameter assessed to be correlated with greater TL shortening. Several methodological changes have to be undertaken to better understand the putative association of shorter TL with B/P behaviors, including increasing the sample size and the assessment of the relevant pathological eating disorder (ED) and non-ED psychological correlates in the two AN subtypes.

Novel ketamine and zinc treatment for anorexia nervosa and the potential beneficial interactions with the gut microbiome

Anorexia nervosa (AN) is a severe illness with diverse aetiological and maintaining contributors including neurobiological, metabolic, psychological, and social determining factors. In addition to nutritional recovery, multiple psychological and pharmacological therapies and brain-based stimulations have been explored; however, existing treatments have limited efficacy. This paper outlines a neurobiological model of glutamatergic and γ-aminobutyric acid (GABA)-ergic dysfunction, exacerbated by chronic gut microbiome dysbiosis and zinc depletion at a brain and gut level. The gut microbiome is established early in development, and early exposure to stress and adversity contribute to gut microbial disturbance in AN, early dysregulation to glutamatergic and GABAergic networks, interoceptive impairment, and inhibited caloric harvest from food (e.g., zinc malabsorption, competition for zinc ions between gut bacteria and host). Zinc is a key part of glutamatergic and GABAergic networks, and also affects leptin and gut microbial function; systems dysregulated in AN. Low doses of ketamine in conjunction with zinc, could provide an efficacious combination to act on NMDA receptors and normalise glutamatergic, GABAergic and gut function in AN.

Adolescent eating disorder treatment outcomes of an in-person partial hospital program versus a virtual intensive outpatient program

OBJECTIVE

Though virtual outpatient psychotherapy for eating disorders is likely effective, less is known about virtual higher levels of care. The current study examined the clinical outcomes of a family-based virtual intensive outpatient program (vIOP) for youth with eating disorders which was developed in response to the COVID-19 pandemic, compared to the same institution's in-person partial hospital program (PHP).

METHODS

Treatment outcomes were assessed via chart review in 102 patients between the ages of 9-23 (M = 15.2, SD = 2.5) who were predominantly cisgender female (84.3%) and primarily diagnosed with anorexia nervosa (64.7%) or atypical anorexia (23.5%). Participants were either treated in the in-person PHP before the pandemic (n = 49) or the vIOP during the pandemic (n = 53). Percent expected body weight (%EBW) was examined at baseline, end of treatment, 3-months post-treatment, and 6-months post-treatment, as well as the frequency of medical, psychiatric, and residential admissions before, during, and after vIOP or PHP participation.

RESULTS

Linear mixed models demonstrated no effect of treatment modality (in-person versus virtual) on %EBW over time. The duration of the vIOP was, on average, 12 calendar days longer, though the amount billed for the vIOP was lower. Survival analyses and Cox regression models did not suggest differences in the frequency of hospital and residential treatment admissions during treatment (vIOP: 9.4%, PHP: 10.0%) or post-treatment (vIOP: 15.0%, PHP: 10.2%).

DISCUSSION

Findings support virtual family-based programs as suitable alternatives to in-person treatment and underscore the potential cost-effectiveness of a family-based IOP versus PHP.

PUBLIC SIGNIFICANCE

This study demonstrates that a virtual, family-based, intensive outpatient program for youth with eating disorders had similar treatment outcomes to an in-person partial hospitalization program. Specifically, the virtual and in-person programs had similar weight restoration outcomes and rates of medical, psychiatric, or residential treatment admissions during or after treatment initiation. Findings support the use of virtual treatment, even for youth requiring a high level of intervention.

A Delphi study to explore clinician and lived experience perspectives on setting priorities in eating disorder services

Background

Due to scarce resources and high demand, priority setting in mental health services is necessary and inevitable. To date, no study has examined priority setting in eating disorder (ED) services specifically. Here, we evaluate the level of consensus and perceived relative importance of factors used to determine patient prioritisation in ED services, amongst clinicians and individuals with lived experience (LE) of an ED.

Methods

A three round Delphi study and a ranking task were used to determine the level of consensus and importance. Consensus was defined as > 80% agreement or disagreement. Items that reached consensus for agreement were ranked in order of importance from most to least important. Participants were 50 ED clinicians and 60 LE individuals. Participant retention across rounds 2, 3, and 4 were 92%, 85%, and 79%, respectively.

Results

Over three iterative rounds, a total of 87 statements about patient prioritisation were rated on a 5-point Likert-scale of agreement. Twenty-three items reached consensus in the clinician panel and 20 items reached consensus in the LE panel. The pattern of responding was broadly similar across the panels. The three most important items in both panels were medical risk, overall severity, and physical health deteriorating quickly. Clinicians tended to place greater emphasis on physical risk and early intervention whereas the LE panel focused more on mental health and quality of life.

Conclusions

Eating disorder services tend to prioritise patients based upon medical risk and severity, and then by the order in which patients are referred. Our findings align in some respects with what is observed in services, but diverge in others (e.g., prioritising on quality of life), providing important novel insights into clinician and LE opinions on waiting list prioritisation in EDs. More research is warranted to validate these findings using multi-criterion decision techniques and observational methods. We hope these findings provide a foundation for future research and encourage evidence-based conversations around priority setting in ED services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08170-4.

Inpatients with severe-enduring anorexia nervosa: Understanding the "enduringness" specifier

BACKGROUND

Despite the need for a common definition of severe and enduring anorexia nervosa (SE-AN) with the overarching goal to optimize treatments, this definition still is being debated. Therefore, in this study we conducted an in-depth investigation of the history of AN and its clinical outcomes on inpatients with AN to ascertain the eventual "profiles" for individuals with varying durations of the illness (DOI).

METHODS

We recruited 169 inpatients with AN, grouping them according to DOI: <3 years (short duration, SD-AN); 3-6.99 years (medium duration, MD-AN); and ≥7 years (long duration, LD-AN). We then performed a self-report and interview-based investigation of AN history, clinical data, eating, and general psychopathology, including personality, premorbid traits, stage of change, and quality of life. We measured the clinical outcomes for hospitalization as well.

RESULTS

The majority of the measures did not differ across groups. Those with LD-AN were older and diagnosed mostly with the binge-purging AN subtype, failed more previous AN-related treatments, reported a lower lifetime body mass index, and trended toward a younger age at onset when compared to the other groups. All patients responded equally well to hospitalization, but patients with SD-AN improved less in drive for thinness and body-related concerns.

CONCLUSIONS

We did not find the "enduringness" of AN to be a specifier of severity. Hospitalization was effective for those with LD-AN and MD-AN, while interventions for the core cognitive aspects of over-evaluation of body shape should be offered to patients with SD-AN.

A Perspective on Chronic and Long-Lasting Anorexia Nervosa

Anorexia Nervosa (AN) is a severe eating disorder which typically develops in younger females. Many studies focus on this specific population, a majority of which will eventually partially or fully recover. A minority will become chronic despite extensive treatment. These patients are treatment-resistant and may not necessarily benefit from usual treatment. In this article we will reflect on possible mechanisms which may explain the maintenance of disease, and especially on the possible role of affective and anxiety disturbances. We will use, due to the lack of large-scale studies, data from risk and prognostic factors, treatment options and neurobiological correlates in chronic AN patients. Lastly, we will propose how these elements may advise further research and treatments.

Gut Feelings: How Microbiota Might Impact the Development and Course of Anorexia Nervosa

Anorexia nervosa (AN) can probably be regarded as a "model" for studying the interaction of nutrition with the gut-brain axis, which has drawn increased attention from researchers and clinicians alike. The gut microbiota influences somatic effects, such as energy extraction from food and body weight gain, as well as appetite, gut permeability, inflammation and complex psychological behaviors, such as depression or anxiety, all of which play important roles in AN. As nutrition is one of the main factors that influence the gut microbiota, nutritional restriction and selective eating in AN are likely influencing factors; however, nutritional rehabilitation therapy is surprisingly understudied. Here, we review the general mechanisms of the interactions between nutrition, the gut microbiota and the host that may be relevant to AN, paying special attention to the gut-brain axis, and we present the first specific findings in patients with AN and corresponding animal models. In particular, nutritional interventions, including food selection, supplements, and pre-, pro- and synbiotics that have the potential to influence the gut microbiota, are important research targets to potentially support future AN therapy.

Serious and enduring anorexia nervosa from a developmental point of view: How to detect potential risks at an early stage and prevent chronic illness?

This commentary on serious and enduring anorexia nervosa adopts the position of a developmental psychiatrist. It argues that this perspective illuminates the etiology and course of severe and enduring anorexia nervosa (SE-AN) and could thus help to develop treatments targeting typical early characteristics of patients with SE-AN. Based on a detailed knowledge of contributing factors, a risk score for SE-AN should be designed by which the probability of chronicity could be calculated at an early stage and preventive measures be taken. As the formation of habits seems to play an important role in establishing a chronic course of AN, psychotherapeutic techniques that include "habit reversal" should be considered during the early stage. Another recommended step in preventing SE-AN is the identification of resilience factors that are associated with a late favorable outcome.

Physical and psychological aspects of anorexia nervosa based on duration of illness: a cross-sectional study

Background

We evaluated physical and psychological features of patients with anorexia nervosa (AN) who differed by duration of illness.

Methods

Data were obtained from 204 female patients with AN, divided into two groups based on illness duration: short-term illness duration (less than 5 years; n = 118); and long-term duration (5 years or more; n = 86). Physical parameters were measured using blood serum testing and psychological aspects were assessed using various instruments.

Results

A significantly higher proportion of restricting type AN was observed in the short-term group while the proportion of binge eating/purging type AN was higher in the long-term group. There was no difference in body mass index (BMI) between the groups. Serum total protein, albumin, potassium, chloride, and calcium in the long-term group were significantly lower than in the short-term group. Overall scores on the Eating Disorder Inventory as well as most of the subscales, except maturity fears, were higher in the long-term group than in the short-term group. The care subscale of the Parental Bonding Instrument (PBI) was lower in the long-term group than in the short-term group, while the overprotection subscale of the PBI was higher in the long-term group than in the short-term group. Results of a multiple regression analysis indicated that the overprotection subscale of the PBI was the only significant predictor of duration of illness.

Conclusions

Duration of illness may be associated with physical and psychological features of AN; thus, adapting therapeutic approaches to illness duration might be necessary.

Clinical Characteristics of Inpatients with Childhood vs. Adolescent Anorexia Nervosa

We aimed to compare the clinical data at first presentation to inpatient treatment of children (<14 years) vs. adolescents (≥14 years) with anorexia nervosa (AN), focusing on duration of illness before hospital admission and body mass index (BMI) at admission and discharge, proven predictors of the outcomes of adolescent AN. Clinical data at first admission and at discharge in 289 inpatients with AN (children: n = 72; adolescents: n = 217) from a German multicenter, web-based registry for consecutively enrolled patients with childhood and adolescent AN were analyzed. Inclusion criteria were a maximum age of 18 years, first inpatient treatment due to AN, and a BMI <10th BMI percentile at admission. Compared to adolescents, children with AN had a shorter duration of illness before admission (median: 6.0 months vs. 8.0 months, p = 0.004) and higher BMI percentiles at admission (median: 0.7 vs. 0.2, p = 0.004) as well as at discharge (median: 19.3 vs. 15.1, p = 0.011). Thus, in our study, children with AN exhibited clinical characteristics that have been associated with better outcomes, including higher admission and discharge BMI percentile. Future studies should examine whether these factors are actually associated with positive long-term outcomes in children.

Introduction to a special issue on child and adolescent feeding and eating disorders and avoidant/restrictive food intake disorder

OBJECTIVE

We are very pleased to introduce a special issue of the International Journal of Eating Disorders on child and adolescent feeding and eating disorders and avoidant/restrictive food intake disorder (ARFID).

METHOD

Contributions focused on five main themes: (1) the definition and assessment of ARFID; (2) the clinical phenomenology of ARFID; (3) similarities and differences between ARFID and anorexia nervosa (AN); (4) novel treatments for ARFID; and (5) new ideas for improving treatment outcomes in AN.

RESULTS

These papers highlight the importance of clear operationalization and measurement of the ARFID diagnostic criteria. ARFID phenotypes bear both similarities and important differences in clinical profile, course, and outcome from AN. Findings suggest the utility of adapting existing treatments for restrictive eating disorders to apply to ARFID and engender clinical creativity to move beyond existing treatments and develop novel interventions that address the heterogeneity of ARFID. Furthermore, burgeoning understanding of ARFID offers the potential that novel treatments for ARFID may also be applied to improve outcomes for AN.

DISCUSSION

This collection of papers features child and adolescent feeding and eating disorder patient groups that have been understudied and we hope that this catalyzes clinical research in these important presentations.