Comparison between continued inpatient treatment versus day patient treatment after short inpatient care in early onset anorexia nervosa (COTIDEA trial): a study protocol for a non-inferiority randomised controlled trial

BACKGROUND

In children with early-onset anorexia nervosa (first symptoms before 13 years old, EO-AN), experts recommend initial outpatient treatment but in-patient treatment (IP) is frequently indicated due to acute medical instability or for those who have not improved with outpatient treatment. This IP can target either a partial weight restauration or a total weight normalization (return to the previous BMI growth trajectory). There are no evidence in the literature on which is the better therapeutic option in EOAN. But as long length of stay induce social isolation, with elevated costs, we wonder if a stepped-care model of daypatient treatment (DP) after short IP stabilisation may be a treatment option as effective as full-time IP to target weight normalization. We designed a two-arm randomised controlled trial testing the non-inferiority of a stepped-care model of DP after short IP stabilisation versus full-time IP.

METHODS

Eighty-eight children aged 8 to 13 years suffering from EOAN with initial severe undernutrition will be randomly allocated to either IP treatment as usual or a stepped care DP model both targeting weight normalization. Assessments will be conducted at inclusion, somatic stabilization, weight normalization, 6 months and 12 months post randomisation. The primary outcome will be BMI at 12 months post-randomisation. Secondaries outcomes will included clinical (tanner stage), biological (prealbumin, leptin, total ghrelin and IGF1) and radiological (bone mineralization and maturation) outcomes, eating symptomatology and psychiatric assessments, motivation to change, treatment acceptability and quality of life assessments, cost-utility and cost-effectiveness analyses.

DISCUSSION

COTIDEA will provide rigorous evaluation of treatment alternative to full-time inpatient treatment to allow a reduction of social iatrogenic link to hospital length of stay and associated costs.

TRIAL REGISTRATION

Trial is registered on ClinicalTrials.gov (NCT04479683).

Inpatient target discharge weight for early-onset anorexia nervosa: Restoring premorbid BMI percentile to improve height prognosis

OBJECTIVE

Early-onset anorexia nervosa (EO-AN) is characterized by restricted food intake leading to low body weight, emerging before 14 years old. Most patients reaching a target body mass index (BMI) around the 25th percentile at hospitalization discharge display an incomplete prospective height catch-up. A better understanding of height prognosis determinants is required.

METHODS

In 74 children with an EO-AN, we collected height and weight premorbidly, at hospitalization, and at discharge, 6 months, 12 months, and at longer-term follow-up of 36 months. We defined a height prognosis parameter (HPP) as the difference between the height percentile at follow-up times and the premorbid height percentile. We explored the relationship between weight parameters and height catch-up at follow-up with linear regression analyses.

RESULTS

A higher weight suppression (WS) - i.e., difference between premorbid and current BMI - at admission and discharge was associated with lower HPP - i.e., a greater loss of height - at 12 months and 36 months follow-up. Similarly, a higher premorbid BMI percentile was associated with a lower HPP at 12 and 36 months.

CONCLUSION

Target discharge weight for EO-AN patients should be tailored and based on premorbid BMI trajectory to improve height prognosis.

[Suicide attempts with a violent method: Experience of a transdisciplinary psychiatric ward combining psychiatric and somatic care]

INTRODUCTION

Suicide is the second leading cause of death in young adults. Suicide attempts by violent methods predict later completed suicide and premature mortality. Suicide prevention is a major public health issue in this specific population. The French Student Health Foundation (FSEF) developed a psychiatric ward that includes psychiatric and somatic approaches. This transdisciplinary unit provides mixed psychiatric and rehabilitation treatments for those persons who have attempted suicide and have severe somatic injuries.

METHODS

We conducted a retrospective study including all subjects admitted into the transdisciplinary unit from 1st January 2011 to 31 December 2017, after a suicide attempt by jumping from a height, in front of a moving object, or by crashing of a motor vehicle. Data was obtained from the medical and administrative records of the clinic.

RESULTS

In total, 215 persons were admitted into the transdisciplinary unit after a suicide attempt by a violent mean. Among them, 91.6% had jumped from a height, 7.4% had jumped in front of a train or a metro and 0.9% had crashed a motor vehicle. They were on average 25.5years old and 50.2% were men. 45.1% had a diagnosis of schizophrenic disorders and 34.4% of mood disorders. A total of 35.6% presented at least one previous suicide attempt, and among them 40.3% had previously attempted suicide with a violent mean. Substance abuse, mostly alcohol and/or cannabis, featured in 40.8% of subject history. The subjects hospitalised in the transdisciplinary unit had multiple, severe injuries: 78.1% had spine fractures, 69.8% had lower limb fractures, 47.9% had pelvic fractures and 43.3% had upper limb fractures. Moreover, 25.5% of them had sacral root damages. The length of stay averaged 184days and varied in a large range (less than a month to more than two years). The Activities of Daily Living scores were higher than 3 (out of a maximum score of 4) reflecting an important need of assistance. These scores decreased significantly during the hospitalisation for dressing, feeding, continence and locomotion but remained high for comportment and communication. At discharge, the physical sequelae were still important: 61% of people hospitalised had pain that required step 2 or 3 analgesics, 44% had analgesics for neuropathic pain, 80% had lower limb impairments, most often with walking limitation, and 26% had continence disorders. The psychotropic treatments at discharge were related to the psychiatric disorders observed and included 42% antidepressants, 63% neuroleptics and 16% mood stabilizers.

CONCLUSION

This study highlights the severity of the somatic and psychiatric disorders affecting people who are admitted into this transdisciplinary unit. These subjects who have attempted suicide require particular care with multidisciplinary management in order to promote their rehabilitation, reintegration and prevent a suicide reattempt.

Bipolar disorders in severe anorexia nervosa: prevalence and relationships

BACKGROUND

The comorbidity between anorexia nervosa (AN) and bipolar disorders (BD) among subjects with AN is a matter of some debate, regarding its existence, its impact on the clinical manifestations of AN and the nature of the relationship between these disorders. Our aims were: (1) to evaluate the prevalence of BD among patients with severe AN; and (2) to determine whether people with a history of BD present particular clinical AN characteristics in comparison to people with a comorbid major depressive disorder or with any mood disorder comorbidity.

METHODS

177 AN subjects were surveyed to assess their nutritional state, dietary symptomatology, psychiatric comorbidities, treatments received and associated response. The diagnosis of BD relied on DSM-5 criteria, using the short-CIDI. The discriminant features of patients with AN and suspected BD were identified, comparing them to the characteristics of AN patients without any mood disorder and AN patients suffering from major depressive disorder.

RESULTS

Among AN subjects, 11.3% were suspected to have BD. In comparison with the two other groups, these patients had more severe clinical profiles in terms of duration of AN (6.7 years, p = 0.020), nutritional state (p max  =  0.031), levels of anxious, depressive and dietary symptoms, lifetime comorbidity with anxious disorders, quality-of-life (p =  0.001) and treatment (antidepressant and mood stabilizers, (p  =  0.029)).

LIMITATIONS

The participants were hospitalized in a tertiary center with severe AN. The diagnosis of BD requires evaluation using a more precise diagnostic instrument CONCLUSION: These results underline the importance of systematic early detection of BD and mood disorders among individuals with severe AN, to provide optimum treatment.

LEVEL OF EVIDENCE

III: Evidence obtained from a cross-sectional study.

[Diversity of hospital care for anorexia nervosa in psychiatry in France]

BACKGROUND

Hospitalization is rare in anorexia nervosa (AN) and local application of indications is heterogeneous. However, no study has evaluated the effect of these different treatment modalities on the mean length of stay. Our objective was to describe the context and modalities of a wide range of hospital care programs offered to patients with anorexia nervosa in eleven specialized French psychiatric centers for patients from childhood to adulthood. This work was carried out within the framework of the EVHAN (Evaluation of Hospitalization for AN, Eudract number: 2007-A01110-53, registered in Clinical trials) research program. The EVHAN program comprises five main lines: weight objectives at discharge, the practice or not of a separation period, the use of clear nutritional dietary objectives (cognitive/behavioral), the intensity of family involvement in treatment, and the existence or absence of a stabilization phase before ending inpatient treatment. These main lines will make it possible to study the impact of treatment modalities on the future of patients in the short and medium term (at discharge and at 1-year follow-up).

METHODS

The eleven centers are located in France (Bordeaux, Nantes, Paris and Ile-de-France, Rouen and Saint-Étienne). Various staff members (psychiatrists, somatic doctors, nurses, dieticians, psychologists) from each center were interviewed using a semi-structured questionnaire. Data on operating modalities and context of care were collected and analyzed.

RESULTS

Four of the eleven centers were exclusively child/adolescent centers, and seven of 11 were adolescent (from 11, 13 or 16 years) and young adult centers. All centers offered a graduated approach from outpatient to full hospitalization. The majority had a number of beds allocated for patients with eating disorders. The criteria for hospitalization were homogeneous with respect to somatic and/or psychic severity prefiguring the consensus criteria defined by the French Health Authority (HAS) in 2010. Child/adolescent units used the weight curve to set weight objectives at discharge (between the 10th and 50th percentiles). Most adult units used weight objectives at discharge corresponding to a body mass index between 17 and 20kg/m². Nine centers used a written or oral care contract. One unit did not separate the patient from her/his usual environment, the others had a practice gradient of partial separation and total separation times. These were either short, lasting a maximum of 3 weeks, or long, lasting more than 3 weeks. Conversely, patients were not isolated within the unit, and benefited from a rich social life, depending on her/his physical condition. The patient's family was in contact with the team and fully supported. The longest periods of separation involved adolescents and adults. Nutritional support varied from a group approach (meals in the dining room, standardized meals of the care center) to very individualized approaches within a specific framework. All the units reported meeting with families at least once during the hospitalization; with the patient's parents for child/adolescent patients and/or unmarried patients and with the husband/wife for married patients. The majority of the centers requested a phase of weight stabilization, whatever the age before hospital discharge.

CONCLUSION

There is international and national consensus regarding the indications for hospitalization, and the main lines of multidisciplinary care to be developed within this framework. However, local application of these indications was heterogeneous resulting in diverse modalities of hospital care for anorexia nervosa in France. Specialized teams have developed management strategies arising from their "team culture". The complexity of the anorexic pathology, due to the psyche-soma intrication and the diversity of age groups, highlights the complexity of care available. The impact of this diversity of hospital care on patient outcomes will be studied as a result of this work.

Absence of relationships between depression and anxiety and bone mineral density in patients hospitalized for severe anorexia nervosa

INTRODUCTION

Low BMD is frequent in anorexia nervosa (AN), depression, and during SSRI treatment but relation between these elements in AN is not established. The aims of this study were to assess the relationships between depression and anxiety, SSRI prescription, and (1) low BMD during inpatient treatment and (2) BMD change 1 year after hospital discharge.

METHODS

From 2009 to 2011, 212 women with severe AN have been included in the EVHAN study (EValuation of Hospitalisation for AN). Depression, anxiety and obsessive-compulsive symptoms and comorbidity were evaluated using psychometric scales and CIDI-SF. BMD was measured by dual-energy X-ray absorptiometry.

RESULTS

According to the CIDI-SF, 56% of participants (n = 70) had a lifetime major depressive disorder, 27.2% (n = 34) had a lifetime obsessive-compulsive disorder, 32.8% (n = 41) had a lifetime generalized anxiety disorder and 25.6% (n = 32) had a lifetime social phobia disorder. Half of the sample (50.7%; n = 72) had a low BMD (Z score ≤ - 2). In multivariate analysis, lifetime lowest BMI was the only determinant significantly associated with low BMD (OR = 0.56, p = 0.0008) during hospitalization. A long duration of AN (OR = 1.40 (0.003-3.92), p = 0.03), the AN-R subtype (OR = 4.95 (1.11-26.82), p = 0.04), an increase of BMI between the admission and 1 year (OR = 1.69 (1.21-2.60), p = 0.005) and a gain of BMD 1 year after the discharge explained BMD change.

CONCLUSION

We did not find any association between depression and anxiety or SSRI treatment and a low BMD or variation of BMD.

LEVEL OF EVIDENCE

Level III, cohort study.

[What factors explain the length of hospitalization for anorexia nervosa: A systematic review]

OBJECTIVES

The cost of hospital treatment for anorexia nervosa (AN) is very high given its duration. Identifying factors related to length of hospital stay (LOS) would make it possible to consider targeted therapeutic strategies that, by optimizing care, would reduce their duration and costs. The objective of this work is to identify the factors related (predictive and associated) to LOS for AN.

METHODS

Systematic review of existing literature up to October 2020, based on Pubmed, according to PRISMA recommendations (Preferred Reported Items for Systematic reviews and Meta-Analysis). Factors related to LOS have been described in two categories: factors related to clinical aspects ; and factors related to therapeutic aspects and management modalities. We distinguished predictive factors (identified as pre-hospitalization or contemporaneous with hospital admission) and associated factors (observed during hospitalization) for each category.

RESULTS

Thirteen articles were selected. Samples from the selected studies ranged from 35 to 381 subjects, mostly women with restrictive type AN (R-AN), but some samples included all types of AN, or focused on purging-type forms. The mean age at admission ranged from 13.6 years (Standard Deviation-SD:±1.6) to 30.3 years (SD :±13.9), corresponding to adolescent, adult or mixed samples. Mean body mass indices at admission ranged from 12.3 (SD±1.4) to 16.6 (SD:±2.1). The duration of disease progression ranged from 11.7 months±2.2 to 9.7 years. Mean LOS are short for studies conducted in pediatrics or in medical services (ranging from 13.0 days [SD±7.3] to 22.1 days [SD±9.4]); they are more variable for studies conducted in psychiatry: from 15.6 days (SD±1.0) to 150.2 days (SD±80.8). Among the factors related to an increase in LOS, clinical predictors included: older age at onset or admission; longer duration of the disorder; low minimum body weight during AN; low BMI at admission; purgative form of anorexia nervosa; and high levels of dietary symptoms (asceticism and ineffectiveness dimensions on Eating Disorder Inventory-2). Therapeutic and management modality predictive factors were: a higher number of hospitalizations for AN; the use of enteral nutrition (nasogastric or percutaneous gastric tube) on admission or during hospitalization; the use of intravenous renutrition coupled with oral renutrition; hospitalization far from the patient's home; absence of hospital care in psychiatry after medical stabilization in a somatic unit; compulsory hospitalization. Associated factors were: the presence of psychiatric comorbidities; greater weight gain during hospitalization. Among the factors related to a decrease in LOS, the clinical predictive factor were: greater self-confidence at admission (measured by the Eating Disorder Recovery Self-Efficacy Questionnaire). Therapeutic and management modality predictors included: increased caloric intake of oral renutrition on admission; intake of oral nutritional supplements on admission; and hospitalization in urban areas. The associated factor was: compliance with the weight contract in the adolescent population.

DISCUSSION

Factors related to an increase in LOS are explained by: higher resistance to treatment, higher severity of the disease, the time required for weight gain in services using cognitive-behavioural therapy, complications associated with renutrition modalities such as parenteral renutrition, difficulties in organising outpatient follow-up which require better consolidation of inpatient treatment and the lack of multidisciplinary care in medical services. Factors related to a decrease in LOS are due to: faster weight gain, the presence of a greater number of outpatient follow-up structures close to the hospital and better adherence to treatment to complete the weight contract.

CONCLUSIONS

Taking these factors into account during hospitalization for AN would help optimize care, duration and costs. This situation therefore requires the development of therapeutic trials targeting the identified factors in order to reduce LOS in the treatment of AN.

Impact of bipolar disorder on eating disorders severity in real-life settings

BACKGROUND

Comorbidity of bipolar disorder (BD) and eating disorders (ED) is common and increases the course and severity of BD. However, the impact of comorbid BD on the clinical profile of ED patients remains unclear. Most studies have focused on patients primarily assessed for BD and data on patients with a primary diagnosis of ED are sparse. We investigated the association between a dual diagnosis and severity in terms of clinical, neuropsychological dimensions and daily functioning.

METHOD

Two hundred and sixty-one patients with ED were consecutively recruited. BD was screened with the MINI and further confirmed in the French expert centre network. The severity of ED symptoms was assessed with the EDE-Q and EDI-2, daily functioning with the FAST. The neurocognitive assessment targeted attention, set-shifting and decision-making.

RESULTS

Forty-nine patients screened positive for BD, but diagnosis was confirmed in only thirty patients (11.5% of the cohort). After multiple adjustments, comorbidity was associated with greater severity on the total score and three subscales of the EDE-Q and on four of the ten dimensions of the EDI-2. Comorbid BD was associated with lower daily functioning but not with lower neuropsychological performance.

LIMITATIONS

Sample referred to specialist clinics not large enough to authorize an analysis by subtype and cross-sectional evaluation.

CONCLUSION

The association between ED and BD increases ED severity for most of these core features. It negatively impacts daily functioning. The results also highlight issues about the validity of screening tools to detect BD in patients with ED.

[Bipolar disorders and anorexia nervosa: A clinical study]

PURPOSE

Anorexia nervosa is often accompanied by comorbid mood disorders, in particular depression, but individual or family history of bipolar disorders has not frequently been explored in anorexia nervosa. The objectives of the present study were: (1) to assess the frequency of bipolar disorders in patients with anorexia nervosa hospitalized in adolescence and in their parents, (2) to determine whether the patients with a personal or family history of bipolar disorders present particular characteristics in the way in which anorexia nervosa manifests itself, in their medical history, in the secondary diagnoses established, and in the treatments prescribed.

METHOD

Overall, 97 female patients aged 13 to 20 hospitalized for anorexia nervosa and their parents were assessed. The diagnoses of anorexia nervosa and bipolar disorders were established on the basis of DSM-IV-TR criteria.

RESULTS

A high frequency of type II and type V bipolar disorders was observed. The patients with anorexia nervosa and presenting personal or family histories of bipolar disorder had an earlier onset of anorexia nervosa, more numerous hospitalizations, a longer time-lapse between anorexia nervosa onset and hospitalization, more suicide attempts and more psychiatric comorbidities.

CONCLUSION

The occurrence of anorexia nervosa-bipolar disorders comorbidity appears to be considerable and linked to the severity of anorexia nervosa, raising the issue of the relationship between anorexia nervosa and bipolar disorders.

[Guidelines for the prescription of mood stabilizers for adolescents: A literature review]

INTRODUCTION

Adolescence is a unique phase of the human developmental process. In adolescents, psychotropic medications may have different efficacy and tolerance profiles compared to those at other stages of the lifespan. Mood stabilizers are a complex pharmacological category including lithium, some anticonvulsants, and some second generation antipsychotics. Focusing on this class of pharmacological agents, we aim to answer the following questions: in which indications and according to which modalities should mood stabilizers be prescribed during adolescence?

METHODS

Information was sought from the websites of the French Haute Autorité de santé (HAS) and Agence nationale de sécurité du médicament et des produits de santé (ANSM), the American Food and Drug Administration (FDA) and the British National Institute for Health and Clinical Excellence (NICE). Guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP) were also reviewed. Additional articles were found using PubMed and Google Scholar. We assumed that guidelines published by a national institute were the most relevant, second information from medical academies, then literature reviews, and finally single studies. Practical prescription data were also sought from the French Vidal Drug Dictionary.

RESULTS

For bipolar disorder in adolescents, lithium has been the first drug licensed in France (from the age of 16) and in the USA (from the age of 12), with indications for acute mania and preventive treatment. Benefits for impulsive and self-aggressive behaviour disorders (especially relevant in case of borderline personality disorder) have also been documented, although lithium has not been licensed in any country for those indications. Extended-release tablets are usually used, at doses targeting for a lithiemia between 0.8 and 1.2mEq/L 12hours after last intake. Because of a narrow therapeutic window and potential side effects (especially nephrotoxicity), lithium prescription requires regular blood tests and good treatment compliance. None of the anticonvulsants has been licensed by a national drug administration as a mood stabilizer in adolescents. However, the AACAP recommends valproate as a first line treatment for mania, even though the NICE and the ANSM caution that valproate should not be used by women of child bearing age. Besides its teratogenic and endocrine side effects, valproate exposes one to the risk of hepatic toxicity. That is why regular liver function tests should be prescribed when valproate is chosen. According to the AACAP, carbamazepine (which is licensed for the treatment of mania in adults) is not a first line treatment for adolescents. Indeed, no clinical study has demonstrated its efficacy on manic episodes in adolescents. Moreover, carbamazepine exposes one to the risk of agranulocytosis. Lamotrigine has not been approved for adolescents, but some studies suggest its efficacy for bipolar depression (often a treatment-resistant phase) in this age group. Major side effects are the risk of Lyell or Stevens-Johnsons syndrome (which usually occur within the first eight weeks of treatment). There is no need for biological tests, just clinical monitoring. Pharmacological interactions between lamotrigine and oral contraceptives require caution. Finally, the use of some second generation antipsychotics for bipolar disorder in adolescents has been approved by national drug administrations. In France, only aripiprazole is licensed for acute mania (from the age of 13). In the USA, aripiprazole is licensed from the age of 10 for acute mania and preventive treatment, while risperidone and quetiapine are licensed from the age of 10 for acute mania, and olanzapine is licensed from the age of 13 for acute mania. The AACAP recommends second generation antipsychotics as a first line treatment for bipolar disorder. Moreover, the AACAP and the NICE recommend second generation antipsychotics for behavioural disorders in adolescents. Recommended doses are usually lower and titration slower than for adults. As in adults, adverse effects are metabolic, motor and cognitive disorders. Moreover, hyperprolactinemia, sedation and weight gain are more frequent than in adults.

DISCUSSION

Epidemiologic data for prescription of mood stabilizers in adolescents only partially concord with recommendations from drug administrations and scientific societies. On the one hand, there is a trend toward preferential prescription of second generation antipsychotics, on the other hand lithium is hardly prescribed to adolescents, less often than anticonvulsants. Thus, without approval from any drug administration, the anticonvulsants are often preferred to lithium (because of lithium's potential risks due to noncompliance or voluntary poisoning) and to second generation antipsychotics (because of their tolerance profile). Nevertheless, for prescribers it is a complex matter to compare side effects: the frequency and intensity of adverse effects is quite variable from one mood stabilizer to another, and such a thing as an expected value is therefore hard to define. Regardless of the medication chosen, compliance and therapeutic alliance are major issues. Compliance is especially low during adolescence (less than 40% according to a study on bipolar disorder). This lack of compliance has multiple determinants: poor acceptance or misunderstanding of the psychiatric disorder, indirect effects of bad relationships with parents and more generally adults, but also reckless behaviour or death wishes. Improving therapeutic alliance appears as a major challenge for health practitioners dealing with youth. One interesting path of research could be the therapeutic education programs using humanistic communication techniques (addressing both adolescents and their parents) which have already produced encouraging results.

[Depressive symptoms during anorexia nervosa: State of the art and consequences for an appropriate use of antidepressants]

OBJECTIVE

Depressive comorbidity is often associated with anorexia nervosa (AN), and antidepressant medication is widely used although it does not rely on any convincing data in the scientific literature. Our objectives were: to summarize the epidemiological, physiological, psychopathological literature about the relation between AN and manifestations of depression, and to focus on the clinical trial data assessing the use of antidepressant medication in AN in order to clarify the strategy for the use of antidepressant in AN during adolescence.

METHOD

A manual computerised search (Medline) was performed for relevant published studies assessing the association between depressive signs or Major Depressive Disorder (MDD) and AN. Another manual computerised search (Medline) listed clinical trials assessing antidepressant in AN.

RESULTS

On the one hand, depressive symptoms are common during the course of AN and could have different meaning. Indeed, firstly, we can distinguish symptoms that are inherent to AN and which can be mistaken for depressive signs (for instance: low self-esteem, reduced social contacts). Secondly, long-term undernourishment can be held responsible for numerous psychological distortions, including anxiety and depression symptoms such as insomnia, impaired concentration, or social isolation. Thirdly, the natural course of AN can also lead to "depressive moments", in particular when switching to a "purging type" AN, or when recovery mobilizes control and narcissistic issues. On the other hand, MDD is also highly prevalent among AN patients and is a negative prognosis factor. Thus, it is complex to differentiate MDD from isolated depressive symptoms that could be inherent of the AN symptomatology which raises the question of the role of antidepressant medication in treatment of depression in AN. No significant benefit of antidepressant medication in AN has been shown in clinical trials, and according to international guidelines it should be prescribed only as a second-line treatment, after appropriate refeeding, and in case of an authentic depressive disorder. Those data appear to be in contradiction with the frequent use of those drugs in clinical practice.

DISCUSSION

Nevertheless, clinical trials assessing antidepressant treatment in AN suffer from methodological weakness concerning the size of the sample, the choice of the population or the evaluation criterion. This lack of proof must raise our vigilance concerning antidepressant medication in AN but should not categorically prevent the clinician from using it when necessary. We do believe that there are some indications for prescribing antidepressant in patients with AN. The clinical challenge lies in the differentiation of the depressive symptoms that are transitory and likely to improve without medication from those that signal the presence of an MDD. Three criterion could be indicative of MDD: familial history of mood disorder, as it is a major risk factor for MDD among relatives; the chronology of appearance of both disorders, when MDD pre-exists AN; a few specific symptoms cannot be attributed to undernourishment or reactive depressive signs, such as morning insomnia, daily variation of depressive symptoms, suicidal attempts or ideation and guilt ideation. Thus, in integrating the data from the literature review, we propose a pragmatic therapeutic strategy for the use of an antidepressant in AN during adolescence that lies in 3 main categories for depressive manifestations in AN: therapeutic emergencies: when an obvious and severe MDD is comorbid to AN, immediate antidepressant would be required; isolated and non-specific depressive sign: no medication would be relevant as they are supposed to improve with refeeding and psychotherapeutic support; intermediary patterns which is probably the most frequent situation. In the last case, it would be relevant to abstain from prescribing medication in first line, but an antidepressant medication should be quickly considered in the presence of one (or several) criterion listed above and its persistence despite refeeding. The general medical state of this fragile population of patients should be evaluated (standard blood test, ECG) before and during treatment.

Épidémiologie, dépistage et organisation des soins

Nous aborderons les données récentes de la littérature concernant la prévalence, l’incidence, le sex-ratio, l’âge de début, la mortalité, la morbidité, les facteurs prédictifs et pronostics de l’anorexie mentale, de la boulimie et de l’hyperphagie boulimique. Nous appuyant sur la littérature internationale nous décrirons les problèmes posés par chacun de ces troubles depuis la question du dépistage en population générale à l’organisation optimale des soins autour de chacune de ces affections. Enfin, discuterons de comment optimiser les prises en charges de ces affections dans le système de soins français.

Mood disorders in eating disorder patients: Prevalence and chronology of ONSET

OBJECTIVES

In a clinical population, we estimated the frequency of mood disorders among 271 patients suffering from Anorexia Nervosa (AN) and Bulimia Nervosa (BN) in comparison to a control group matched for age and gender.

METHOD

The frequency of mood disorders was measured using the Mini International Neuropsychiatric Interview (MINI), DSM-IV version.

RESULTS

Mood disorders were more frequent among eating disorder (ED) patients than among controls, with a global prevalence of the order of 80% for each ED group. The majority of the mood disorders comorbid with ED were depressive disorders (MDD and dysthymia). The relative chronology of onset of these disorders was equivocal, because mood disorders in some cases preceded and in others followed the onset of the eating disorders.

LIMITATIONS

Our sample was characterized by patients with severe ED and high comorbidities, and thus do not represent the entire population of AN or BN. This also may have resulted in an overestimation of prevalence.

CONCLUSION

Mood disorders appear significantly more frequently in patients seeking care for ED than in controls. These results have implications for the assessment and treatment of ED patients, and for the aetio-pathogenesis of these disorders.

[Epidemiology of anorexia nervosa: a review]

A critical review of the literature was conducted to provide answers to three questions: firstly, are we facing a national and/or international epidemic of anorexia nervosa (AN) as claimed in the media by certain professionals? Secondly, is AN simply an ordinary crisis of adolescence? Thirdly, is it a pathology that solely affects the higher socio-professional categories?

METHOD

A Medline search was conducted and backed up by a manual search to find all the studies or literature reviews published on prevalence, incidence rates, outcomes, morbidity and mortality in AN and its links with social class, covering the period 2000-2011.

RESULTS

The differing methodologies of the studies on these themes have a considerable impact on the interpretation of results. For each indicator retained, the results observed in the different studies are detailed and commented in the light of these differences. The prevalence of AN in women aged 11 to 65 in non-clinical population ranges from 0 to 2.2 %. It varies in particular with the age of the studied subjects, the measurements used, and the definition criteria for AN. Among men, the lifetime prevalence is around 0.3%. The marked disparities in incidence rates observed are related to the nature of the samples considered: subjects consulting in hospital, whether in a specialised department or in any department, those consulting general practitioners (GPs), or subjects from general population samples recruited in different surveys (girls in schools for example). The incidence of female cases is low in general medicine or specialised consultation in town (whatever the speciality): from 4.2 and 8.3/100,000 individuals per year. It is much higher in the general population, ranging from 109 to 270/100,000 individuals per year. In fact, the studies reporting variations in the incidence of AN were conducted on samples from clinical populations in certain countries (United States and United Kingdom). They are probably more a reflection of variations in detection rates and use of healthcare, than of variations in the incidence in the general population. The mean duration of AN appears shorter in the general population than in clinical populations. On average, 47% of the individuals treated for AN recovered, 34% improved, 21% had a chronic eating disorder, and 5% died. The outcome is better for subjects treated during adolescence. Mortality is frequently expressed in crude mortality rate (CMR), which is not very informative on account of the heterogeneous natures of the cohorts followed; only the studies reporting standardised mortality rate (SMR) are informative. AN appears as having one of the highest mortality rates among psychiatric pathologies. Mortality varies according to the population considered. Rates observed are 6.2 to 10.6 times greater than that observed in the general population for a follow-up duration ranging respectively from 13 to 10 years. It is lower for longer follow-up periods, only 3.7 times more frequent than in the general population for follow-up periods of 20 to 40 years. It appears lower for subjects treated before the age of 20. The main causes of death are eating disorder complications, suicide and cancer. One review of the literature concluded in the absence of any significant link between this pathology and social class.

DISCUSSION

There is nothing in the incidence and prevalence data to back up the notion of a recent "epidemic" of AN. AN is not simply a crisis of adolescence: morbidity and mortality are considerable in this pathology. The relationship between AN and social class is not established.

Can birth weight predict later body composition in anorexia nervosa?

BACKGROUND/OBJECTIVES

The relationship between birth weight and body composition at later stages in life was not studied previously in anorexia nervosa (AN). The aim of the following brief report is to present results concerning the relationship between birth weight and later body composition specifically in AN, and to check if the programming of body composition from birth weight is still detected in severely emaciated AN patients.

SUBJECTS/METHODS

One hundred and fifty-one female AN patients aged between 13 and 44 were recruited from 11 inpatient treatment facilities in France. Birth weight, body weight and height were obtained. Body composition was measured using bioelectrical impedance. Birth weight was significantly correlated to lifetime maximum body mass index (BMI; r=0.211, P=0.009) and significantly correlated to fat-free mass index (r=0.190, P=0.027) but not to fat mass index (FMI).

RESULTS

This report confirms that even in AN when patients are severely emaciated and where fat-free mass (FFM) and fat mass (FM) are low, a link between birth weight and FFM and BMI can still be identified, independently from age.

CONCLUSION

Further studies are needed on larger samples exploring other factors, such as gender, puberty and ethnicity.

Factors predictive of ten-year mortality in severe anorexia nervosa patients

OBJECTIVE

Little is known concerning mortality and predictive factors for anorexia nervosa in-patients. This study aimed to establish mortality rates and identify predictors in a large sample of adults through a 10-year post in-patient treatment follow-up.

METHOD

Vital status was established for 601 anorexia nervosa (DSM-IV) consecutive in-patients with initial evaluation at admission. Standardized mortality ratio (SMR) was calculated. Cox analyses for hypothesized predictors of mortality were performed.

RESULTS

Forty deaths were recorded. SMR was 10.6 [CI 95% (7.6-14.4)]. Six factors at admission were associated with death: older age, longer eating disorder duration, history of suicide attempt, diuretic use, intensity of eating disorder symptoms, and desired body mass index at admission.

CONCLUSION

Anorexia nervosa in-patients are at high risk of death. This risk can be predicted by both chronicity and seriousness of illness at hospitalization. These elements should be considered as warnings to adapt care provision and could be targeted by treatment.

First Report of Plasmodiophora brassicae on Rapeseed in the Grand Duchy of Luxembourg

Rapeseed (Brassica napus L.) is the third most important crop after wheat and barley in the Grand Duchy of Luxembourg. Since 2005, clubroot symptoms in this crop have been reported by farmers in the Gutland Region. In February 2009, plants of the hybrid rapeseed cv. Exocet, with stunted growth, yellow leaves, and club-shaped roots, were sampled from a field in Oberkorn village near Differdange. Microscopic observations of the rapeseed root fragments revealed the presence of the three life stages characteristic of Plasmodiophora brassicae Woronin. Plasmodia and zoosporangia were observed in the root hairs and resting spores were present in root galls. Individual spores were 2 to 3 μm in diameter. Total DNA was extracted from the root galls with a FAST DNA Kit (MP Biomedicals, Irvine, CA). The internal transcribed spacer region (ITS) and 5.8S gene of the rDNA region were amplified with ITS5 and ITS4 primers as described by White et al. (2) and part of this region was sequenced. A BLASTn search in GenBank revealed that the sequence closely resembled (98% identity) sequences of P. brassicae (Genbank Accession No. EF195335) from an isolate of the pathogen from Switzerland. To confirm the presence of the pathogen, seeds of the susceptible ecotype cvi-0 of Arabidopsis thaliana were grown in a soil sample (1 liter) collected near the infected rapeseed plants. After 55 days of growth in a glasshouse at 15 to 20°C, the roots of 11 plants were analyzed. Two showed clear clubroot symptoms and four others exhibited small swellings. The remaining five plants were symptomless, but plasmodia and zoosporangia were found in root hair cells. Clubroot caused by P. brassicae has previously been described on B. napus and other crucifers (1). To our knowledge, this is the first report of clubroot disease caused by P. brassicae in Luxembourg. Because its presence has since been observed in new fields in the Gutland Region and because of the ability of the pathogen to survive for a long period in the soil, this disease could represent a severe threat for cropping of Brassicaceae in Luxembourg and neighboring countries. References: (1) I. R. Crute et al. Plant Breed. Abstr. 50:91, 1980. (2) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic press: San Diego, 1990.

Family history of anxiety and mood disorders in anorexia nervosa: review of the literature

OBJECTIVE

To provide a critical review of the research on mood and anxiety disorders in relatives of individuals with anorexia nervosa (AN). In the first section, we explore methodological issues with these studies. In the second section, we present results.

METHOD

A Medline search identified studies published on family history of mood and anxiety disorders in AN, and was complemented by a manual search. Only studies from 1980 to 2006 using strict diagnostic criteria for the disorders were included [Feighner and Halmi criteria for AN, Reasearch Diagnostic Criteria (RDC), Diagnostic and Statistical Manual of Mental Disorders - Third Edition - Revised (DSM-III-R) or DSM - Fourth Edition (DSM-IV) for anorexia and other disorders].

RESULTS

A review of the research methods used in the studies revealed a number of methodological problems. Therefore, we provide only a description of the prevalence of mood and anxiety disorders in relatives of individuals with AN.

CONCLUSIONS

In the light of the methodological issues uncovered, the value of the results of these studies and their implications for further study are considered.

Resolving a disagreement in a clinical team: overcoming conflicting views about the role of family therapy in an outpatient treatment programme for anorexia nervosa

In the Adolescent Psychiatry Department at the Institut Mutualiste Montsouris, Paris, as is also observed in the literature, the outcome for anorexic patients can sometimes be catastrophic, regardless of treatments proposed. This disturbing finding led us to reassess our therapeutic treatment strategies, in an effort to improve patient outcome. The multidimensional treatment program implemented in the Department includes parent counselling, but not the whole family in a family therapy procedure. It has been demonstrated better outcome for patients who underwent family therapy in comparison to patients who underwent individual therapy. This raised the question of whether family therapy could improve our outpatient programme. This paper describes here how a research programme was developed to resolve a disagreement in our clinical team as to whether family therapy should be added to the existing care programme. The paper describes the difficulties encountered by our team, and the experimental design chosen to resolve the debate. Data will not be set out here.

Étude des relations entre alexithymie et anhédonie chez des femmes présentant des troubles du comportement alimentaire et chez des témoins

INTRODUCTION

Alexithymia and anhedonia both refer to a deficit in emotion regulation. Although these 2 concepts have been conceptualized to be closely linked, very few studies aimed at examining carefully their interrelations.

OBJECTIVES

Therefore, the purpose of the present study was to investigate the relationships between scores on alexithymia and anhedonia self-reports, and to assess whether the results were influenced by the presence of an emotional disorder.

LITERATURE FINDINGS

The 20-item Toronto Alexithymia Scale is the self-report most frequently used to assess alexithymia. Nevertheless, the results of recent studies comparing the psychometric properties of the TAS-20 and another alexithymia self-report - the Bermond-Vorst Alexithymia Questionnaire (BVAQ) - have recommended the BVAQ over the TAS-20.

DESIGN

Thus, both questionnaires were included in the present study. In addition, since depression and anxiety may influence the correlations between alexithymia and anhedonia scores, we also measured depression and anxiety and these scores were used to control for their potential confounding effect in the analyses. Two groups of participants were included in this study: 46 eating disordered female patients (ED) and 198 female control subjects. All the participants filled up the Bermond-Vorst Alexithymia Questionnaire-form B (BVAQ-B), the 20-item Toronto Alexithymia Scale (TAS-20), the Chapman and Chapman Social Anhedonia Scale (SAS) and Physical Anhedonia Scale (PAS), the 13-item Beck Depression Inventory (BDI) and the Spielberger State and Trait Anxiety Inventory (STAI-Y). The analyses consisted, first, in establishing the matrix of correlations between these self-reports total scores, using Pearson's coefficients of correlation. Then, TAS-20, BVAQ-B, SAS and PAS scores were correlated, adjusting for BDI and STAI scores, using partial correlation analyses. Mean scores comparisons according to the group of participants, and to the presence/absence of alexithymia, as well as to the presence/absence of anhedonia were performed using ANCOVAs or Mann-Whitney tests.

RESULTS

As predicted, BDI and STAI scores were found significantly and positively correlated with alexithymia and anhedonia scores in both participant groups. After controlling for depression and anxiety scores, TAS-20 and PAS scores remained significantly correlated, but not TAS-20 and SAS scores. BVAQ-B scores remained significantly correlated with PAS and SAS scores in the control group, but only with the PAS scores in the ED group. ED patients had higher alexithymia and anhedonia scores than the controls. In total, among the alexithymic individuals, 8.9% were social anhedonics, and 31.1% had a physical anhedonia. Conversely, among the participants with a physical anhedonia, two third were alexithymics. The same proportion of participants with a social anhedonia was alexithymic (66.7%).

CONCLUSION

The results of the present study are informed about the relationships between alexithymia and anhedonia. They also stress the need to rely on several alexithymia measurements, and they further demonstrate the necessity to compare the associations between different affect regulation dimensions in normal and psychopathological disorders.

Le contrat de poids lors d'une hospitalisation pour anorexie mentale

The weight contract is a traditional practice of the classical modalities of hospitalization of anorexics subjects. However, it is usually practised using different methods according to hospitals. It was explained on the theoretical side by our team but never exposed in its practical side. We propose to explain here in detail our practice of the weight contract. The information reported in this article is the result of articles review published by the professor Jeammet's team and of information resulting from meetings with experts of this team. First of all, we will expose the current context of care in the institut mutualiste Montsouris as well as the negotiation of the weight contract. Then, we will expose the method of care regarding somatic aspects, renutrition, body care, chemotherapy and family preoccupation. Lastly, we will explain in which situations the contract is sometimes renegotiated. In conclusion, we will summarize the utility of such a tool.

Validité du questionnaire d’alexithymie de Bermond et Vorst : étude chez des sujets présentant des troubles du comportement alimentaire et chez des témoins

Alexithymia core features are the difficulties in identifying and describing feelings; the difficulties in distinguishing feelings from the bodily sensations of emotional arousal; an impaired symbolization, as evidenced by a paucity of fantasies and other imaginative activity; and a tendency to focus on external events rather than inner experience. Several measures of alexithymia have been developed, including interviewer-rated questionnaires and self-report questionnaires. Among the self-report questionnaires, the 20-item Toronto Alexithymia scale (TAS-20) is the most commonly used, but it fails to measure all the core features of alexithymia. A recently developed instrument, the Bermond-Vorst Alexithymia Questionnaire (BVAQ), allows the measurement of the alexithymia core features, as well as an additional one. It appeared to present good psychometric properties, notably the abbreviated BVAQ-form B. The results of recent studies comparing the psychometric properties of the TAS-20 and the BVAQ have recommended the BVAQ over the TAS-20. However, this questionnaire needed further validation.

OBJECTIVES

Thus, the aim of the present study was to determine the convergent, discriminant and concurrent validity of the Bermond-Vorst Alexithymia Questionnaire -- form B (BVAQ-B) in a clinical sample of 59 eating disorder patients, as well as in 191 controls. The TAS-20 constituted the gold standard for the assessment of the BVAQ-B' convergent validity. To compare the concurrent validity of the BVAQ-B and the TAS-20, participants also completed several self-reports investigating different dimensions of emotion regulation capacities: the 13-item Beck Depression Inventory (BDI), the Spielberger State and Trait Anxiety Inventory (STAI-form Y), as well as the Chapman and Chapman Physical and Social Anhedonia Scales (PAS and SAS). One way analyses of variance were used for mean scores comparisons. Convergent validity was determined using Pearson coefficients of correlation.

RESULTS

Results of the analyses suggested the BVAQ-B has a satisfying convergent and discriminant validity. This was observed in both the clinical and control samples. Moreover, the comparison of the convergent validity of the BVAQ-B and the TAS-20 revealed several differences between these two alexithymia self-report questionnaires. The BVAQ-B appeared less sensitive to the subjective emotional state of the participants than the TAS-20. Whereas it was argued the TAS-20 overlaps with other emotional state scores, the BVAQ-B would allow to measure alexithymia more specifically. In addition, the present results allowed to further determine the relations between alexithymia and other dimensions of emotion regulation capacities. The analyses confirmed that alexithymia is linked to other emotion regulation dimensions such as depression and anxiety. Moreover, alexithymia was associated with physical and social anhedonia, two dimensions that received less interest in the alexithymia literature to date. This study also showed that control and clinical sample have different emotion regulation capacities. Eating disorder patients were not only more alexithymic and more depressed, but also more anxious and more anhedonic than the controls. Finally, this study revealed that alexithymia differs whether the alexithymic individuals are patients or controls. Healthy alexithymic individuals (ie, individuals categorized as alexithymic in the control group) seemed characterised by a selective deficit of emotional cognition, with sparing of emotional experience (Bermond's type II alexithymia). Alexithymics individuals of the eating -disorder group seemed particularly unabled to experience affect. This pattern could correspond to Bermond's type I alexithymia, which is characterised by the absence of emotional experience and, consequently, by the absence of the cognition accompanying the emotion. In summary, results of the present study add to the literature debating on whether alexithymia is similar in different types of population.

Treatment of adolescent patients with eating disorders: description of a psychodynamic approach in clinical practice

Anorexia nervosa (AN) is now usually considered to be a multifactorial disorder, and there is a consensus among clinicians that its treatment should be aimed at restoring weight, altering anorexic attitudes, treating any medical complications, supporting and treating the family, enhancing autonomy, facilitating identity formation, and increasing self-esteem by means of psychotherapy. The practical aspects of such treatments not only vary from country to country, but sometimes also from one treatment team to another. International meetings dedicate considerable discussion to the subject but, as it seems to be relatively ignored in the published literature, we here describe the main elements of our own method.

Obsessive compulsive disorders in eating disorders

OBJECTIVE

The aim of this study is to explore current and lifetime prevalence of obsessive compulsive disorders (OCD) in eating disorder (ED) subgroups and subtypes defined by the DSM-IV and to study the chronology of appearance of these disorders taking into account the role played by denutrition.

METHOD

Current and lifetime prevalence were investigated using the Mini International Neuropsychiatric Interview (MINI) and the Yale-Brown Obsessive Compulsive Scale in a sample of 89 DSM-IV ED patients (58 AN and 31 BN) and 89 matched controls.

RESULTS

Current and lifetime prevalence of OCD in ED was significantly higher than in general population (15.7% and 19% vs. 0% and 1.1%, P<.05). Anorexic patients presented a slightly higher current and lifetime comorbidity than bulimic patients (19% and 22.4% vs. 9.7% and 12.9%, n.s.). Purging anorexia was the diagnostic subtype, which presented the higher prevalences (29% and 43%), followed by restrictive anorexia (16%) and purging bulimia (13%). In the great majority of cases (65%), OCD diagnosis preceded ED diagnosis. Finally, OCD current prevalence and Y-BOCS scores of underweight patients were not significantly higher than normal-weight patients, suggesting that there were only limited links between denutrition and obsessionality.

[Current and lifetime prevalence of obsessive compulsive disorders in eating disorders]

A significant proportion of patients suffering from Eating Disorders (ED) present a comorbidity with anxiety disorders. Among the anxiety disorders, Obsessive Compulsive Disorders (OCD) are the third most frequently diagnosis observed in ED. However, prevalence rates from the literature are contradictory depending on the diagnostic criteria and evaluation tools used. Studies concerning the chronology of appearance of OCD and ED and the role played by denutrition are even rarer and equally contradictory.

OBJECTIVE

The aim of this study is to bring new empirical data to the study of the correlations between OCD and ED by exploring, in a significant clinical sample, the current and lifetime OCD comorbidity in the diagnostic sub-groups and sub-types of ED as defined by the DSM IV and to study the chronology of appearance of these disorders taking into account the role played by denutrition. We make the assumption that there should be a difference in the prevalence of obsessive compulsive disorders in the various ED sub-groups and sub-types and that purging anorexics should, at equivalent levels of denutrition, exhibit higher OCD prevalence rates than the other sub-types as a result of their more severe general psychopathology.

METHODS

Current and lifetime prevalence were investigated using the Mini International Neuropsychiatric Interview (MINI) and the Yale-Brown Obsessive Compulsive Scale in a sample of 89 DSM IV eating disorders in and out-patients aged between 15 and 30 (58 AN and 31 BN) and 89 matched controls. In order to increase the validity of the current diagnosis of OCD only patients presenting an OCD diagnosis on the MINI (excluding obsessions and compulsions related to food and body image) and a score of 16 or more on the Y-BOCS were included in the study.

RESULTS

Current and lifetime prevalence of OCD in ED is significantly higher than in general population (15.7% and 19% vs 0% and 1.1%, p < 0.05). Anorexic and bulimic patients do not show any difference in the current and lifetime comorbidity (19% and 22.4% vs 9.7% and 12.9%, ns). Concerning the diagnostic sub-types, following our assumption purging anorexics present the higher current and lifetime prevalences (29% and 43%), followed by restrictive anorexia (16%) and purging bulimia (13%). The only significant difference is found in the lifetime prevalence of OCD between purging and non purging anorexics. In the great majority of cases (65%) OCD diagnosis precedes ED diagnosis and OCD current prevalence and Y-BOCS scores of underweight patients are not significantly higher than normal weight patients, suggesting that there are only limited links between denutrition and obsessionality.

LIMITS

Some methodological limitations must be considered. First of all, the small sample size of the diagnostic sub-types of ED do not enable us to draw definitive conclusions concerning the prevalence of OCD in the clinical forms of ED. Some of the diagnostic sub-types of ED, as BN-NP, appear at different ages: in order to better investigate the prevalence of OCD in all the diagnostic sub-types, larger age ranges should be considered. Secondly, our sample of anorexics is almost made of hospitalized inpatients recrutated in a specialized university unit, whereas bulimics are all consulting outpatients. It is possible that the higher than normal rates of OCD in anorexics could be related to the severity of this sample. Comparisons with samples of consulting anorexics should be performed. Lastly, it is necessary to evoke the limitation represented by the choice of a healthy control group. OCD are rare in the general population and the differences found between the clinical and the control groups do not offer strong arguments to support the specificity of the association between OCD and ED, which would be better explored by using a pathological control group.

CONCLUSIONS

So far, none of the various models proposed to explain the comorbidity observed between ED and OCD appears completely satisfactory. ED and OCD would share a genetic vulnerability to a dysregulation of serotoninergic functioning which would predispose these subjects, depending on specific clinical and biological conditions, to develop an obsessional and compulsive symptomatology more or less focused on food and body image. The knowledge of the clinical and biological specificities of the ED diagnostic sub-types presenting an OCD comorbidity could point the way towards specific therapeutic interventions in these patients. Our study of the comorbidity of OCD in ED makes a further contribution to the identification of specific links between the OCD and the various clinical forms of ED. More clinical and biological studies are needed to further explore these relationships.