Outcome predictors in the short-term treatment of anorexia nervosa: an integrated medical-psychiatric approach

Therapeutic outcome and long-term naturalistic follow-up of female adolescent outpatients with AN: clinical, personality and psychopathology evolution, process indicators and outcome predictors

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness of growing prevalence in childhood and adolescence. Despite its severity, there are still no completely satisfactory evidence-based treatments. Follow-up studies represent the most effective attempt to enlighten treatment effectiveness, outcome predictors and process indicators.

METHODS

Seventy-three female participants affected with AN were assessed at intake (T0) and at 6 (T1) and 12 (T2) months of an outpatient multimodal treatment program. Nineteen participants were assessed 15 years after discharge (T3). Changes in diagnostic criteria were compared with the chi-square test. Clinical, personality and psychopathology evolution were tested with ANOVA for repeated measures, using the t-test or Wilcoxon test as post-hoc. T0 features among dropout, stable and healed participants were compared. Healed and unhealed groups at long-term follow-up were compared using Mann-Whitney U test. Treatment changes were correlated to each other and with intake features using multivariate regression.

RESULTS

The rate of complete remission was 64.4% at T2, and 73.7% at T3. 22% of participants maintained a full diagnosis at T2, and only 15.8% at T3. BMI significantly increased at each time-point. A significant decrease of persistence and increase in self-directedness were evidenced between T0 and T2. Interoceptive awareness, drive to thinness, impulsivity, parent-rated, and adolescent-rated general psychopathology significantly decreased after treatment. Lower reward dependence and lower cooperativeness characterized the dropout group. The healed group displayed lower adolescent-rated aggressive and externalizing symptoms, and lower parent-rated delinquent behaviors. BMI, personality and psychopathology changes were related with each other and with BMI, personality and psychopathology at intake.

CONCLUSION

A 12-months outpatient multimodal treatment encompassing psychiatric, nutritional and psychological approaches is an effective approach for the treatment of mild to moderate AN in adolescence. Treatment was associated not only with increased BMI but also with positive personality development, and changes in both eating and general psychopathology. Lower relational abilities may be an obstacle to healing. Approaches to treatment resistance should be personalized according to these finding.

Comorbid depression as a negative predictor of weight gain during treatment of anorexia nervosa: A systematic scoping review

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness with high rates of relapse and mortality. Psychiatric comorbidities are common but their impact on the prognosis is largely unknown.

OBJECTIVE

The aim was to investigate the influence of psychiatric comorbidity on weight gain during treatment of AN.

METHODS

A systematic search was performed in PubMed/MEDLINE, EMBASE and PsycINFO. Studies evaluating psychiatric comorbidity as a predictor for treatment outcome (weight gain) were included, however, comorbid alcohol/drug addiction was excluded from this review.

RESULTS

Four thousand five hundred and twenty six publications were identified from which 15 were included. The majority of the included studies had a prospective open naturalistic study design, a short-term follow-up period, and were based on small populations of primarily adolescent and adult women. Four studies indicate depression, and two obsessiveness as negative prognostic factors, whilst one study indicated moderate depression and yet another, neuroticism, as positive predictors for weight gain.

DISCUSSION

The systematic scoping review found a large number of publications whereof only a few directly described the influence of psychiatric comorbidity on weight gain in AN. Overall, studies were heterogeneous in design, purpose and outcome making comparisons difficult. Findings were divergent but depression had a negative influence on weight gain in four studies.

Naturalistic follow-up of subjects affected with anorexia nervosa 8 years after multimodal treatment: Personality and psychopathology changes and predictors of outcome

Background:

Eating disorders (EDs) are serious mental illnesses of growing clinical and social impact. Despite their severity, there is still no satisfactory evidence-based treatment. Follow-up investigations are the most reliable studies to enlighten long-term outcome predictors and modifiers.

Methods:

In total, 59 subjects affected with anorexia nervosa were assessed 8 years after their admission into an outpatient multimodal treatment program for eating disorders. The follow-up changes in diagnostic criteria were compared with Chi-square test. Improved and not-improved subjects were compared. Clinical, personality and psychopathology features between T0 and T1 were compared with t-test for repeated measures. Correlation between T0 features and changes at T1 in personality and psychopathology features were assessed.

Results:

The rate of complete remission was 42%, an overall rate of 67.8% improved, a rate of 18.6% worsened. Concerning personality, a significant decrease of harm avoidance and increase in self-directedness were evidenced. Interoceptive awareness, drive for thinness, bulimia were significantly reduced at follow-up. Many T0 personality facets were related to personality and psychopathology improvement at follow-up.

Conclusion:

Multimodal treatment encompassing psychiatric, nutritional and psychological approaches is at the moment the most reliable approach for the treatment of moderate to severe anorexia nervosa with a discrete rate of improvement. Some personality and psychopathology characteristics may represent specific factors which favor resistance and impair improvement. Future approaches should consider the personalization of therapeutic approach according to these features.

Resistance to treatment and change in anorexia nervosa [corrected]: a clinical overview

BACKGROUND

Current literature on Eating Disorders (EDs) is devoid of evidence-based findings providing support to effective treatments, mostly for anorexia nervosa (AN). This lack of successful guidelines may play a role in making these disorders even more resistant. In fact, many individuals do not respond to the available treatments and develop an enduring and disabling illness. With this overview we aimed to highlight and discuss treatment resistance in AN--with an in-depth investigation of resistance-related psychological factors.A literature search was conducted on PubMed and PsychINFO; English-language articles published between 1990 and 2013 investigating the phenomenon of resistance to treatment in AN have been considered.

DISCUSSION

The selected papers have been then grouped into four main thematic areas: denial of illness; motivation to change; maintaining factors and treatment outcome; and therapeutic relationship. Eating symptomatology was found to only partially explain resistance to treatment. The role of duration of illness has been questioned whilst some maintaining factors seemed promising in providing a useful framework for this phenomenon. Emotive and relational aspects have been investigated on their role in resistance as well as therapists' countertransference.

SUMMARY

Remarkably there has been little research done on resistance to treatment in the ED field, in spite of its clinical relevance. Motivation, insight and subjective meaning of the illness can be useful tools to manage the resistance phenomenon when coupled with a wider approach. The latter enables the therapists to be aware of their role in the therapeutic alliance through countertransference aspects and to consider the EDs as disorders of the development of both personality and self, entailing severe impairments as regards identity and relationships.

Prevalence and treatment of narcissistic personality disorder in the community: a systematic review

BACKGROUND

Few studies have examined the prevalence and treatment of narcissistic personality disorder (NPD).

METHOD

We systematically reviewed studies of NPD that used suitable diagnostic methods in adult nonclinical samples and evaluated their strengths and weaknesses. Searches were conducted of MEDLINE (using both MeSH category and free-word search terms), PsycINFO, and PsycLIT for articles in English from January 1980 to August 2008 using the terms Narcissis* and prevalence, of unpublished work identified via contacts with experts in the field, of books on personality disorders, and of reference lists from relevant articles and books. We evaluated articles using a 6-point epidemiologic quality tool that we developed. To determine the most efficacious treatments for NPD without other comorbidities, we performed searches using Narcissis*, pharmacology, clinical pharmacology, therapeutics, and psychotherapy for reports of controlled trials from January 1980 to August 2008.

RESULTS

We identified 7 prevalence studies that had used a structured or semistructured interview, 5 of which scored 5/6 using the epidemiologic quality tool. Mean prevalence was 1.06%, and the range was 0% to 6.2%. We found no studies of treatment meeting our inclusion criteria.

CONCLUSIONS

There was an overall finding of a low prevalence of NPD in adult nonclinical samples. Changes in the classification system might promote further empirical investigations.

Symptoms of psychosis in anorexia and bulimia nervosa

Despite evidence from case series, the comorbidity of eating disorders with psychosis is less investigated than their comorbidity with anxiety and mood disorders. We investigated the occurrence of symptoms of psychosis in 112 female patients diagnosed with DSM-IV eating disorders (anorexia nervosa=61, bulimia nervosa=51) and 631 high school girls in the same health district as the patients: the items of the SCL-90R symptom dimensions "paranoid ideation" and "psychoticism" were specifically examined. No case of co-morbid schizophrenia was observed among patients. Compared with controls, the patients with anorexia nervosa were more likely to endorse the item "Never feeling close to another person"; the patients with bulimia nervosa were more likely to endorse the item "Feeling others are to blame for your troubles". Both groups of patients were more likely than controls to endorse the item "Idea that something is wrong with your mind". The students who were identified by the EAT and the BITE as being "at risk" for eating disorders were more likely to assign their body a causative role in their problems. Symptoms of psychosis can be observed in patients with eating disorders, but these could be better explained within the psychopathology of the disorders rather than by assuming a link with schizophrenia.

Relationship between pretreatment laboratory-measured episodes of reactive hypoglycemia and short-term weight restoration in anorexia nervosa: a preliminary study

Refeeding outcome is difficult to predict in anorexia nervosa (AN). Because reactive hypoglycemia (RH) during an oral glucose tolerance test (OGTT) correlates with rapid increases of energy intake just before the OGTT in AN patients, this study investigated whether pretreatment laboratory-measured RH episodes might be associated with refeeding progress in this disorder. Forty-six female patients with AN (25 restrictors and 21 binge/purgers) and 11 controls underwent an OGTT before treatment. The patients were divided into groups according to the presence of RH. Thereafter, AN patients underwent nutritional rehabilitation, and weight gain and daily energy intake were evaluated. In both AN subtypes, the RH groups showed more daily energy intake and gained more weight compared with the non-RH groups. The present study found a close relationship between pretreatment laboratory-measured RH episodes and refeeding progress, suggesting that pretreatment laboratory-measured RH episodes may be an important predictor of short-term refeeding outcome in AN.

Glucose tolerance predicts short-term refeeding outcome in females with anorexia nervosa

OBJECTIVE

Little is known about biologic predictors of refeeding outcome in anorexia nervosa (AN). Because nutritional status mirrors glucose metabolism during an oral glucose tolerance test (OGTT) in AN, this study investigated whether pretreatment glucose response patterns during the OGTT might be associated with refeeding progress in patients with AN.

METHODS

Sixty-four female patients with anorexia (33 restrictors and 31 binge/purgers) and 13 healthy control subjects underwent an OGTT before nutritional rehabilitation, including desensitization to fear of energy intake of 1000 to 1600 kcal/day. Patients were divided into flat-type responders, impaired glucose tolerance (IGT)-type responders, and normal-type glucose responders. Daily energy intake, weekly weight gain, and the duration of desensitization period were evaluated until the 12th week.

RESULTS

The patients with anorexia consisted of 20 flat-type, 21 IGT-type, and 23 normal- type responders. Normal-type responders required a shorter time to complete the desensitization period than other responders (p = .003 for restrictors, p < .001 for binge/purgers). In terms of refeeding progress, significant group effects for daily energy intake and weekly weight gain were evident in restrictors (p = .006, p = .028, respectively) and binge/purgers (p < .001, p = .003, respectively); normal-type responders showed good refeeding progress compared with other responders in both AN subtypes.

CONCLUSIONS

The present study found a close relationship between pretreatment glucose responses, therapeutic progress of desensitization to fear of energy intake, and refeeding progress in both AN subtypes. Our findings suggest that glucose tolerance may be a useful predictor of short-term refeeding outcome in this disorder.