Intensive Treatments in Adolescent Anorexia Nervosa

Approximately one-fifth to one-third of patients with adolescent anorexia nervosa (AN) need intensive care in the course of their illness. This article provides an update and discussion on different levels of intensive care (inpatient treatment (IP), day patient treatment (DP) and home treatment (HoT)) in different health care systems based on recently published literature. Important issues discussed in this article are new recommendations for the refeeding process and the definition of target weight as well as principles of medical stabilization and psychotherapeutic approaches. The pros and cons of longer or shorter hospitalization times are discussed, and the advantages of stepped care and day patient treatment are described. A new promising intensive treatment method involving the patient, their caregivers and the direct home environment is introduced. Parents and caregivers should be included in treatment research to foster collaborative work with the attending clinicians. There is an urgent need to evaluate the mid- to long-term outcomes of various intensive treatment programs to compare their effectiveness and costs across different health care systems. This could help policy makers and other stakeholders, such as public and private insurances, to enhance the quality of eating disorder care.

Anorexia nervosa in males: excess mortality and psychiatric co-morbidity in 609 Swedish in-patients

BACKGROUND

Anorexia nervosa (AN) is a psychiatric disorder with high mortality.

METHOD

A retrospective register study of 609 males who received hospitalized care for AN in Sweden between 1973 and 2010 was performed. The standardized mortality ratios (SMRs) and Cox regression-derived hazard ratios (HRs) were calculated as measures of mortality. The incidence rate ratios (IRRs) were calculated to compare the mortality rates in patients with AN and controls both with and without psychiatric diagnoses.

RESULTS

The SMR for all causes of death was 4.1 [95% confidence interval (CI) 3.1-5.3]. For those patients with psychiatric co-morbidities, the SMR for all causes of death was 9.1 (95% CI 6.6-12.2), and for those without psychiatric co-morbidity, the SMR was 1.6 (95% CI 0.9-2.7). For the group of patients with alcohol use disorder, the SMR for natural causes of death was 11.5 (95% CI 5.0-22.7), and that for unnatural causes was 35.5 (95% CI 17.7-63.5). The HRs confirmed the increased mortality for AN patients with psychiatric co-morbidities, even after adjusting for confounders. The IRRs revealed no significant difference in mortality patterns between the AN patients with psychiatric co-morbidity and the controls with psychiatric diagnoses, with the exceptions of alcohol use disorder and neurotic, stress-related and somatoform disorders, which seemed to confer a negative synergistic effect on mortality.

CONCLUSION

Mortality in male AN patients was significantly elevated compared with the general population among only the patients with psychiatric co-morbidities. Specifically, the presence of alcohol and other substance use disorders was associated with more profound excess mortality.

Funen Anorexia Nervosa Study - a follow-up study on outcome, mortality, quality of life and body composition

Eating disorders (EDs) comprise a wide range of symptoms, with severe psychological and physical implications for the patient. EDs include anorexia nervosa (AN), bulimia nervosa (BN) and until 2013 eating disorder not otherwise specified (EDNOS), if criteria for AN or BN were not met. Patients suffering from an ED have poor prognosis, with more than half of AN patients not obtaining complete remission. One-fifth develops a chronic disease. EDs have an increased risk of premature death and patients with EDs report poorer quality of life (QoL) compared to both the general population and other psychiatric/somatic diseases. Patients who, apparently, obtain complete remission will still be affected in QoL when compared to a healthy reference group. Treatment is complicated by high drop-out rates, hence making large retrospective follow-up studies difficult to conduct. The multiple endocrine disturbances as a result of the severe malnourishment in AN often result in amenorrhea and a weight goal for remenorrhea has been ambiguous. This thesis encompasses results from four studies examining the abovementioned challenges and is based on a large retrospective cohort of ED patients referred to a highly specialized ED treatment unit. Study 1: QoL in EDs was reported for a large retrospective Danish cohort. Furthermore, meta-analysis on existing published literature was performed to determine potential differences between the diagnostic groups. QoL in EDs was significantly decreased compared to the general population and no difference between the diagnostic groups was established. Study 2: ED pathology (measured by the Eating Disorder Inventory - 2 (EDI-2)) and outcome (measured by the Morgan Russell Outcome Schedule (MROS)) was reported for a large retrospective Danish cohort. The correlation between the patient-reported measurements (SF-36 & EDI-2) and clinician-assessed characteristics (BMI and remission status) was investigated in a group of ED patients (n=383). A high association between EDI scores and BMI was observed in AN and EDNOS, despite remission status, representing an increase in symptomatology with increasing BMI. This was not present in BN. We found no association between HRQoL and BMI in any of the diagnostic groups. Study 3:  Mortality rates were calculated in a large group of ED patients (n=998) including AN, BN and EDNOS with a long follow-up time. We found a SMR of 2.9 for AN, which was considerably lower than previous published results. We compared the results to data from the same catchment area published prior to the establishment of a multidisciplinary ED center. Patients with EDs had a significantly increased risk of premature death compared to the general population; however the mortality rates had decreased since the formation of the ED unit. Study 4: The association between body composition measures and amenorrhea was studied in a cohort of adult patients with a history of AN (n=113) and predicted probabilities for the resumption of menses was determined. We found a high association between DXA scans and BMI in predicting the resumption of menses. Half of the patients were predicted to resume their menstrual status at BMI 19/fat percentage 23, however at BMI 14/fat percentage 11 still 25% of patients were predicted to resume their menses.

Safe refeeding management of anorexia nervosa inpatients: an evidence-based protocol

OBJECTIVE

Anorexia nervosa is associated with several serious medical complications related to malnutrition, severe weight loss, and low levels of micronutrients. The refeeding phase of these high-risk patients bears a further threat to health and potentially fatal complications. The objective of this study was to examine complications due to refeeding of patients with anorexia nervosa, as well as their mortality rate after the implementation of guidelines from the European Society of Clinical Nutrition and Metabolism.

METHODS

We analyzed retrospective, observational data of a consecutive, unselected anorexia nervosa cohort during a 5-y period. The sample consisted of 65 inpatients, 14 were admitted more than once within the study period, resulting in 86 analyzed cases.

RESULTS

Minor complications associated with refeeding during the first 10 d (replenishing phase) were recorded in nine cases (10.5%), four with transient pretibial edemas and three with organ dysfunction. In two cases, a severe hypokalemia occurred. During the observational phase of 30 d, 16 minor complications occurred in 14 cases (16.3%). Six infectious and 10 non-infectious complications occurred. None of the patients with anorexia nervosa died within a follow-up period of 3 mo.

CONCLUSIONS

Our data demonstrate that the seriousness and rate of complications during the replenishment phase in this high-risk population can be kept to a minimum. The findings indicate that evidence-based refeeding regimens, such as our guidelines are able to reduce complications and prevent mortality. Despite anorexia nervosa, our sample were affected by serious comorbidities, no case met the full diagnostic criteria for refeeding syndrome.

Dying to be thin. Your guide to today's mental health issues

With increased awareness of under 12s, as well as older children, developing serious eating disorders there is an urgent need for early recognition and treatment, as Dr Agnes Ayton explains.

Deaths by suicide among individuals with anorexia as arbiters between competing explanations of the anorexia-suicide link

BACKGROUND

Suicide is a leading cause of death among individuals with anorexia nervosa (AN). In this paper, we examined competing explanations of the high rate of death by suicide among individuals with anorexia nervosa (AN).

METHODS

Nine case reports of individuals with AN who died by suicide were evaluated to determine whether death by suicide occurred a) because physical health was so compromised that what would be a non-lethal suicide attempt in a healthy adult became a fatal suicide attempt, or b) because highly lethal suicide attempts that would have killed any adult, healthy or medically compromised, were made.

RESULTS

The findings converged with the latter hypothesis, as predicted by Joiner's [Joiner, T., 2006. Why People Die By Suicide. Harvard University Press, Cambridge, MA] theory of suicide, which suggests individuals with AN may habituate to the experience of pain during the course of their illness and accordingly die by suicide using methods that are highly lethal.

LIMITATIONS

This study utilized case reports instead of an experimental design, which impedes its ability to comment on whether there is a causal relationship between Joiner's theory and death by suicide among individuals with AN.

CONCLUSIONS

Clinicians are encouraged to carefully assess suicidality in AN patients, paying particular attention to issues related to lethality.

Switching to the bingeing/purging subtype of anorexia nervosa is frequently associated with suicidal attempts

OBJECTIVE

Anorexia nervosa has the highest suicide mortality ratio of psychiatric disorders, suicide being associated with many factors. We assessed the first lifetime occurrence of these factors taking into account their possible overlap.

METHOD

Three hundred and four in- and out-patients with anorexia nervosa (DSM-IV) were systematically recruited in three hospitals of Paris suburbs, between December 1999 and January 2003. Patients were assessed by a face-to-face interview (DIGS). Current eating disorder dimensions were measured, and patients interviewed by a trained clinician to assess minimal BMI and, retrospectively, the age at which anorexia nervosa, major depressive disorder, anxiety disorders and switch to bingeing/purging type occurred for the first time, if applicable.

RESULTS

Major depressive disorder (p<0.001) and subtype switch from the restrictive to the bingeing/purging type (p<0.001) were the two factors significantly more frequently occurring before suicidal attempts, and remained involved when a multivariate analysis is performed, whether syndromic or dimensional measures are being used. Taking into account lifetime occurrence with a survival analysis, the switch to bingeing/purging type of anorexia appears as a major predictive factor, with a large increase of the frequency of suicidal attempts (OR=15) when compared to patients with neither major depressive disorder nor bingeing/purging type.

CONCLUSIONS

Bingeing/purging type of anorexia nervosa is largely associated with suicidal attempts, and may deserve specific attention. If confirmed on a prospectively designed study, these results would argue for early detection and/or more intensive and specific therapeutic intervention on this aspect of bingeing and purging behaviors.

Zwangsbehandlung bei Anorexia nervosa

Anorexia nervosa is a psychiatric disorder with a very high mortality rate. If the eating disorder reaches life-threatening severity, for example through a body mass index lower than 13 kg/m (2), the possibility of compulsory treatment has to be considered. However, civil commitment of patients and forced feeding against their will may reduce self confidence and self esteem. This impedes the important goal of motivating patients to undergo psychotherapy. Furthermore, compulsory treatment is regarded as a contravention of the patient's physical inviolability as enshrined in the German Constitution. Up to now only a few studies about the use of guardianship legislation for anorexia nervosa have been published. The present paper reviews psychiatric literature and significant judgements of German courts on this topic. It finishes by examining clinical issues on forced feeding and possible consequences for psychotherapy.

Outcome and prognostic factors for adolescent female in-patients with anorexia nervosa: 9- to 14-year follow-up

BACKGROUND

Earlier studies have indicated poor long-term outcomes for patients with anorexia nervosa.

AIMS

To study health and social outcomes of adolescent in-patients with anorexia nervosa in relation to prognostic factors.

METHOD

A register study based on based on socio-economic and health data was conducted for a national cohort of female residents in Sweden born between 1968 and 1977, including 748 in-patients with anorexia nervosa.

RESULTS

At follow-up 9-14 years after hospital admission, 8.7% of patients with anorexia nervosa had persistent psychiatric health problems demanding hospital care and 21.4% were dependent on society for their main income; the stratified relative risks were 5.8 (95% CI 4.7-7.6) and 2.6 (2.3-3.0) respectively, compared with the general female population. The mortality rate for patients with anorexia nervosa was 1.2% and the stratified risk ratio for maternity was 0.6 (95% CI 0.5-0.7). Long duration of hospital care and psychiatric comorbidity were predictors of persistent psychiatric problems and financial dependency on society.

CONCLUSIONS

The outcome in this cohort of adolescent in-patients with anorexia nervosa was considerably better than that reported in previous studies.

[Suicidal behaviour in a clinical population of 12- to 17-year-old patients with eating disorders]

INTRODUCTION

The aim of this study was to determine the prevalence of suicidal behavior and comorbidity among patients 12-17 years of age with eating disorders. Previous studies showed an increased rate of suicidal behavior in young people with eating disorders.

MATERIALS AND METHODS

Data were collected as part of a European study concerning eating disorders. 37 patients (12-17 years, mean age 15 years) from the Center for Eating Disorders, Odense University Hospital, participated in the study. The frequency of suicidal behavior was tested individually by BAB-T interview (''Grading of Anorexia and Bulimia, Teen-ager''), which is a semi-structured interview with the patient, and by YSR (''Youth Self Report'') a questionnaire filled in by the patient herself.

RESULTS

Suicidal behavior was shown by 40% of the patients, and 29% had self-injurious behavior. There was a tendency for suicidal behavior and comorbidity to be more prominent in the youngest patients.

CONCLUSION

The risk of suicidal behavior is greater in patients with eating disorders than in the background population. In the youngest patients there is an increased tendency to suicidal behavior and comorbidity, but this requires further documentation. The clinician must be aware of self-injurious behavior in patients with eating disorders, including those between 12 and 17 years of age.

Cardiovascular complications of eating disorders

Eating disorders (anorexia nervosa and bulimia) are associated with the highest mortality rate of any psychiatric disorder. Much of this mortality and morbidity stem from cardiovascular complications such as arrhythmia related to a prolonged QTc interval and/or electrolyte disorders, hypotension, and bradycardia. Structurally, the heart in patients with eating disorders is atrophic, which may relate to longstanding hypovolemia. These patients have low cardiac output and demonstrate increased peripheral vascular resistance despite the presence of hypotension. The treatment of eating disorders is incremental caloric feeding, which can have its own intrinsic cardiovascular risk (refeeding syndrome) manifested by arrhythmia, tachycardia, congestive heart failure, and sudden cardiac death. Patients will require close monitoring and slower refeedings to minimize the risk of these complications.

Long-term mortality in anorexia nervosa: a report after an 8-year follow-up and a review of the most recent literature

OBJECTIVE

To evaluate long-term mortality rate of anorexia nervosa (AN) patients in a southern Italy population compared to the most recent literature.

DESIGN

Retrospective and review setting.

PATIENTS AND INTERVENTIONS

One hundred and forty-seven female AN patients, consecutively admitted from 1994 to 1997 to the Outpatient Unit, were re-examined between June and November 2003. Our data are compared with 10 other studies published since 1988.

RESULTS

One hundred and twenty-three deaths in 2240 patients, amounting to a total mortality rate of 5.25% were reported in the literature. Deaths due to suicide, AN-related and AN-unrelated diseases were 1.20, 3.07 and 0.98%, respectively. After correcting for unrelated deaths, mortality rate was 4.27%. In our 8-year follow-up, we found a mortality rate of 2.72% (1.82% after correcting for unrelated deaths). Standardized mortality ratio was 9.7.

CONCLUSION

We interpret our favourable findings as a consequence of an integrated, clinical-nutritional and psychiatric approach. Finally, considering AN demographic characteristics, that is young female subjects in Westernized societies, mortality rate is confirmed to be dramatically high.

Improved survival in adolescent patients with anorexia nervosa: a comparison of two Swedish national cohorts of female inpatients

OBJECTIVE

The authors examined two cohorts of female inpatients with anorexia nervosa a decade apart to determine whether there had been any changes in terms of survival.

METHOD

The Swedish National Registers, which contain information about hospital discharges and deaths for the entire population, were used to investigate differences in mortality. Subjects born between 1958 and 1967 and hospitalized due to anorexia nervosa between 1977 and 1981 (N=564) were compared with subjects born between 1968 and 1977 and hospitalized due to anorexia nervosa between 1987 and 1991 (N=554). The cohorts were followed from first hospital admission until 1992 and 2002, respectively.

RESULTS

Twenty-five deaths (4.4%) were recorded within the cohort hospitalized between 1977 and 1981, and seven deaths (1.3%) occurred in the cohort hospitalized between 1987 and 1991. The hazard ratio of death for the 1977-1981 cohort relative to the 1987-1991 cohort was 3.7.

CONCLUSIONS

Mortality among female patients with anorexia nervosa in hospital care in Sweden has decreased dramatically, which is probably related to the introduction of specialized care units.

Medical complications of anorexia nervosa and bulimia nervosa

PURPOSE OF REVIEW

This review focuses on recent publications concerning medical complications in patients with eating disorders, including anorexia nervosa and bulimia nervosa.

RECENT FINDINGS

Recent literature continues to reflect that multiple organ systems are frequently affected by eating disorders. The literature underscores the frequently cited risk of premature death in those with anorexia nervosa. A plethora of dermatologic changes have been described, some signaling serious underlying pathophysiology, such as purpura, which indicates a bleeding diathesis. Much of the literature continues to delineate the fact that diabetic patients with eating disorders are at high risk of developing diabetic complications. Gastrointestinal complications can be serious, including gastric dilatation and severe liver dysfunction. Acrocyanosis is common, and patients with anorexia nervosa are at risk of various arrhythmias. Low-weight patients are at high risk for osteopenia/osteoporosis. Nutritional abnormalities are also common, including sodium depletion and hypovolemia, hypophosphatemia and hypomagnesemia. Resting energy expenditure, although very low in low-weight patients, increases dramatically early in refeeding.

SUMMARY

Medical complications are common and often serious in patients with eating disorders, particularly those with anorexia nervosa.

Incidence, prevalence and mortality of anorexia nervosa and other eating disorders

PURPOSE OF REVIEW

The purpose of this review is to evaluate the recent literature on the incidence and prevalence of and mortality associated with eating disorders.

RECENT FINDINGS

General-practice studies show that the overall incidence rates of anorexia nervosa remained stable during the 1990s, compared with the 1980s. Some evidence suggests that the occurrence of bulimia nervosa is decreasing. Anorexia nervosa is a common disorder among young white females, but is extremely rare among black females. Recent studies confirm previous findings of the high mortality rate within the anorexia nervosa population.

SUMMARY

The incidence of anorexia nervosa is around eight per 100,000 persons per year. An upward trend has been observed in the incidence of anorexia nervosa in the past century till the 1970s. The most substantial increase was among females aged 15-24 years, for whom a significant increase was observed from 1935 to 1999. The average prevalence rates for anorexia nervosa and bulimia nervosa among young females are 0.3 and 1%, respectively. Only a minority of people with eating disorders, especially with bulimia nervosa, are treated in mental healthcare.

Twelve-year course and outcome predictors of anorexia nervosa

OBJECTIVE

The current study presents the long-term course of anorexia nervosa (AN) over 12 years in a large sample of 103 patients diagnosed according to criteria in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

METHOD

Assessments were made at the beginning of therapy, at the end of therapy, at the 2-year follow-up, at the 6-year follow-up, and at the 12-year follow-up. Self-rating and an expert-rating interview data were obtained.

RESULTS

The participation rate at the 12-year follow-up was 88% of those alive. There was substantial improvement during therapy, a moderate (in many instances nonsignificant) decline during the first 2 years posttreatment, and further improvement from 3 to 12 years posttreatment. Based on a global 12-year outcome score, 27.5% had a good outcome, 25.3% an intermediate outcome, 39.6% had a poor outcome, and 7 (7.7%) were deceased. At the 12-year follow-up 19.0% had AN, 9.5% had bulimia nervosa-purging type (BN-P), 19.0% were classified as eating disorder not otherwise specified (EDNOS). A total of 52.4% showed no major DSM-IV eating disorder and 0% had binge eating disorder (BED). Systematic-strictly empirically based-model building resulted in a parsimonious model including four predictors of unfavorable 12-year outcome explaining 45% of the variance, that is, sexual problems, impulsivity, long duration of inpatient treatment, and long duration of an eating disorder.

CONCLUSION

Mortality was high and symptomatic recovery protracted. Impulsivity, symptom severity, and chronicity were the important factors for predicting the 12-year outcome.

Diminution de la mortalité et stabilité du taux de guérison dans le suivi de l’anorexie mentale

OBJECTIVES

Anorexia nervosa is an eating disorder that combines malnutrition, amenorrhea, and distorted body image. To learn more about the course of this disease we undertook a retrospective study of girls diagnosed with anorexia nervosa in the Saint Etienne Endocrinology Department between 1979 and 2004.

METHODS

Patients were diagnosed according to DSMIV criteria. Data collected to complete the Morgan-Russell outcome assessment schedule included chronology of illness, patients' morphological features, anorexia type, treatment choice, patient's gynecological history, and social status.

RESULTS

The study included 206 cases. The average follow-up period was 8.3 +/- 5.3 years. Defining recovery as stable BMI>17.5 kg/m2 for at least one year and recovery of normal menstruation, full recovery was observed in 55.8% and partial recovery in 25.7%, while 18.5% remained chronically ill. Early onset (i.e., during adolescence) was associated with good prognosis, and advanced emaciation and delayed or insufficient medical care with poor prognosis.

CONCLUSIONS

The seriousness of this disease is due more to the incidence of cases that become chronic than to the mortality rate. Prediction of severity would be improved by taking into account underlying personality traits, such as addictive tendencies and depression.

The mortality rate from anorexia nervosa

OBJECTIVE

We determined the standardized mortality ratio (SMR) in our anorexia nervosa (AN) patient population.

METHOD

We used a cross-sectional design to study an inception cohort (1981-2000) drawn from the provincial tertiary care eating disorders program at St. Paul's Hospital (British Columbia, Canada). All patients who completed their initial assessment for an eating disorder were included in the study. Vital status, date and cause of death from British Columbia Vital Statistics Agency, date of assessment, date of birth, and diagnosis at the time of assessment were collected for each patient.

RESULTS

Of 954 patients, 326 diagnosed with AN completed an assessment over the 20 years. The SMR was 10.5 (95% confidence interval [CI] = 5.5-15.5) for AN.

DISCUSSION

Some studies in the literature report that AN has the highest mortality rate of any psychiatric disorder in young females. However, others dispute this fact and report an SMR lower than the normal population mortality (SMR = 0.71). Contrary to some reports in the literature, our study confirms a high mortality rate within the AN population.

Anorexia nervosa mortality in Northeast Scotland, 1965-1999

OBJECTIVE

Most previous studies of mortality in anorexia nervosa patients have shown an increased risk of premature death but have been limited by methodological constraints. This study aimed to overcome some of these constraints by having a large original sample size, diagnosis confirmed by case note review, a long duration of follow-up, and a clear base population.

METHOD

The authors identified 524 anorexia nervosa cases seen in specialist services in Northeast Scotland; anorexia nervosa diagnosis was confirmed by scrutinizing case notes. Those who had died were identified from the National Health Service register or register of deaths. The death rates and causes of death were analyzed.

RESULTS

Twenty-three patients died, giving a crude death rate of 4.4% and a standardized mortality rate of 3.3 (95% CI=2.2-4.9). In only one-third of the cases was anorexia nervosa on the death certificate, but an eating disorder or other psychiatric pathology probably contributed to several of the other deaths. Older age at the time the patient was seen at the specialist service was the only identifiable risk factor in the group of patients who died. The median length of time between diagnosis and death was 11 years.

CONCLUSIONS

Anorexia nervosa is associated with increased risk of premature death. It is possible that death rates could be reduced by early diagnosis and by long-term specialist care.

Characteristics of anorexia nervosa-related deaths in Norway (1992-2000): data from the National Patient Register and the Causes of Death Register

OBJECTIVE

This study investigated demographic and diagnostic characteristics of individuals whose medical record or death certificate indicated the presence of anorexia nervosa at the time of death.

METHOD

Two national registers, the National Patient Register (NPR) and the Causes of Death Register (CODR), were examined in Norway for anorexia nervosa-related deaths occurring across a 9-year period (1992-2000).

RESULTS

The medical record or death certificate listed anorexia nervosa as a diagnosis or cause of death for 66 individuals. Rates of death were 6.46 and 9.93 per 100,000 deaths for the NPR and the CODR, respectively. A substantial percentage of deaths (43.9%) in both registers occurred at or above the age of 65 years. For the NPR, the mean age at the time of death was 61 years and 31% of deaths occurred among men. For the CODR, the mean age at the time of death was 49 years and 18% of deaths occurred among men.

DISCUSSION

Potential merits and shortcomings of assessing mortality rates using register-based data without linkage to a previously identified clinical sample are discussed.

[Involuntary hospitalization of patients with anorexia nervosa: clinical issues and empirical findings]

Avoidance and refusal of treatment by patients with anorexia nervosa are eminent features of the disorder. A subgroup of severely ill patients are affected by involuntary hospitalizations. Based on empirical studies, this review analyzes whether patients with involuntary hospitalization differ from patients with voluntary treatment with regard to clinical characteristics and treatment outcomes. Furthermore, reasons for treatment refusal and diminished treatment motivation are outlined based on a selective review of the literature. Patients who where admitted involuntarily had significantly more previous hospitalizations and a longer duration of illness. Other predisposing factors for an involuntary admission were a history of childhood abuse and self-mutilative behavior, whereas a history of comorbid substance abuse or clinical depression was not predictive. Empirical findings suggest that weight restoration was similarly effective for both patient groups. Because catamnestic studies of patient groups with involuntary admissions are insufficient, it is presently difficult to assess the treatment response and the risk of mortality in the long-term. Future research is mandatory to identify risk factors in this special group of patients in order to establish specific interventions.

An audit of a British sample of death certificates in which anorexia nervosa is listed as a cause of death

OBJECTIVE

Anorexia nervosa is associated with an increased mortality rate. National mortality statistics based on statutory death certification are potentially an important source of information. However, there are reasons to believe that these statistics may be subject to significant errors. An audit of the quality of information and diagnosis was conducted on death certificates in which anorexia nervosa was mentioned.

METHOD

The current study examined data from death certificates of people who died in England and Wales between 1993 and 1999.

RESULTS

There were 230 such deaths, but only 128--just over one half--were rated as likely to be deaths associated with true anorexia nervosa.

DISCUSSION

National mortality statistics derived from death certificates are a flawed source of information on deaths from anorexia nervosa when taken at face value. There may be both underreporting and overreporting. Detailed examination may improve their usefulness by reducing the overerreporting. It seems likely that the association of deaths with anorexia nervosa is systematically underreported.

Essst�rungen im Kindes- und Jugendalter

The most important eating disorders are anorexia and bulimia, which most frequently occur for the first time during adolescence and continue into adulthood. Medical complications and accompanying psychological disturbances cause a significant mortality rate of up to 6% in anorexia and up to 3% in bulimia. The pathogenesis of eating disorders is still unclear. Current etiological concepts are multidimensional including biological, individual, familial, and sociocultural factors. In spite of a great variety of therapeutic possibilities, the prognosis for eating disorders is quite poor. In the long term, only about 50% of the persons affected overcome their illness. Preventive measures are therefore indispensable.

Anorexia nervosa: a 63-year population-based survival study

As eating disorders attract increasing publicity, more affected individuals will seek medical attention. Many will have needs for life insurance. Due to selection bias, most of the literature on anorexia nervosa (AN) presents an unfavorable prognosis. Therefore, the impairment is considered an adverse life insurance risk. This review is from an unselected, community population. The demographics of the study population and its expected mortality are similar to a population purchasing life insurance products. Comparative experience over 63 years of follow-up reveals mortality ratios and excess death rates similar to those expected for the population. High-risk comorbid diagnoses of depression and alcoholism are discussed.

Current challenges in recognizing and treating eating disorders

Anorexia nervosa and bulimia nervosa are serious, life-threatening illnesses that often require several years of treatment. Although classified as mental health diagnoses, they are associated with significant medical consequences and have the highest rate of premature death of any mental health diagnosis. They also are associated with the highest rate of short- and long-term physiological complications. Eating disorders disproportionately affect young women. With early intervention and aggressive treatment, affected adolescents and young adults can recover and be free of the disorder. This article reviews the difficulties in recognizing that a patient has an eating disorder and the signs and symptoms providers should look for. It also discusses our current understanding of the causes of eating disorders as well as current treatment methods, which involve a multidisciplinary approach.

Long-term survival of patients with anorexia nervosa: a population-based study in Rochester, Minn

OBJECTIVE

To estimate long-term survival of unselected patients with anorexia nervosa from Rochester, Minn.

PATIENTS AND METHODS

In this population-based retrospective cohort study, all 208 Rochester residents who presented with anorexia nervosa (193 women and 15 men) for the first time from 1935 through 1989 were monitored for up to 63 years. Subsequent survival was compared with that expected for Minnesota white residents of similar age and sex, and standardized mortality ratios were determined on the basis of age- and sex-specific death rates for the US population in 1987.

RESULTS

Survival was not worse than expected in this cohort (P = .16). The estimated survival 30 years after the initial diagnosis of anorexia nervosa was 93% (95% confidence interval, 88%-97%) compared with an expected 94%. During 5646 person-years of follow-up (median, 22 years per patient), 17 deaths occurred (14 women and 3 men) compared with an expected 23.7 deaths (standardized mortality ratio, 0.71; 95% confidence interval, 0.42-1.09). One woman died of complications of anorexia nervosa, 2 women committed suicide, and 6 patients (5 women and 1 man) died of complications of alcoholism. Other causes of death were not increased.

CONCLUSIONS

Long-term survival of Rochester patients with anorexia nervosa did not differ from that expected. This finding suggests that overall mortality was not increased among the spectrum of cases representative of the community.

Predictors of mortality in eating disorders

BACKGROUND

Anorexia nervosa, but not bulimia nervosa, has one of the highest mortality rates among psychiatric disorders. However, potential predictors of mortality, such as comorbid psychiatric illnesses, remain unclear. We sought to determine mortality ratios and predictors of fatal outcome in women diagnosed as having anorexia or bulimia nervosa.

METHODS

Women (N = 246) diagnosed as having either DSM-IV anorexia nervosa (n = 136) or bulimia nervosa (n = 110) between January 1, 1987, and December 31, 1991, participated in a prospective longitudinal study. Vital status was determined by ongoing contact and a National Death Index search as of December 1998 (overall ascertainment, 99.8%) and telephone contact as of October 2000 (ascertainment, 95.0%).

RESULTS

Eleven women died. Standardized mortality ratios were elevated for all causes of mortality (11.6; 95% confidence interval, 5.5-21.3) and suicide (56.9; 95% confidence interval, 15.3-145.7) in anorexia nervosa but not for death (1.3; 95% confidence interval, 0.0-7.2) in bulimia nervosa. Predictors of mortality in anorexia nervosa included severity of alcohol use disorder during follow-up (P<.001). Hospitalization for an affective disorder before baseline assessment seemed to protect women from a fatal outcome (P<.001).

CONCLUSIONS

Physicians treating patients with anorexia nervosa should carefully assess patterns of alcohol use during the course of care because one third of women who had alcoholism and died had no history of alcohol use disorder at intake.

[Children in the drive for thinness. How early anorexia nervosa modifies development]

In adolescents and young women, the prevalence of anorexia nervosa is 0.5-1%. Approximately 5% of all anorectics are younger than 12 years of age. Frequent psychiatric concomitant conditions that develop during the long-term course are depression or dysthymia (in our own patient material approximately 14%) and anxiety (some 28%). In our own studies, healing success was achieved in 54% of the cases; 18% achieved partial remission with remnant symptoms of an unspecific eating disorder, and 28% continued to exhibit anorectic and/or bulimic symptoms. Of prognostic importance were eating disorders in the child's first year and the duration of the catamnesis. The prognosis of anorexia nervosa with onset in childhood does not appear to differ significantly from that of anorexia with onset in adolescence or adulthood.

Mortality in concurrent type 1 diabetes and anorexia nervosa

OBJECTIVE

Previous studies in this field report early occurrence of diabetic complications, but excess mortality, though expectable, has not been reported. We combined information from earlier studies to estimate the mortality for this group of patients.

RESEARCH DESIGN AND METHODS

The observed mortality is analyzed using crude mortality rate (a percentage), standardized mortality ratio (SMR), incidence rate ratio, risk difference, and survival analysis.

RESULTS

After approximately 10 years of follow-up, 13 of 510 females with type 1 diabetes, 43 of 658 females with anorexia nervosa (AN), and 8 of 23 concurrent case subjects had died. Mortality rate was 2.2 (per 1,000 person-years) for type 1 diabetes, 7.3 for AN cases, and 34.6 for concurrent cases. Crude mortality rates were 2.5, 6.5, and 34.8%, respectively. SMR was 4.06 in type 1 diabetes, 8.86 in AN, and 14.5 in concurrent cases. Survival analysis indicated between-group differences in mortality.

CONCLUSIONS

Concurrent type 1 diabetes and AN is a rare but serious condition in females. All indexes of mortality evidence excess mortality in this preliminary study. Vigorous and well-directed treatment efforts seem vital for this subpopulation. Collaboration between diabetologists and eating disorder specialists is warranted. The implications of other eating disorders and subclinical eating disorders in diabetic populations need to be analyzed, especially because these conditions are more frequent than clinical eating disorders.

Anorexia nervosa: manifestations and management for the gastroenterologist

Anorexia nervosa is a complex psychiatric disorder with significant morbidity and mortality. It is important for gastroenterologists to be aware of the physiological effects and potential complications of anorexia nervosa, as they are frequently involved in treating patients with this disorder. We review the classic, GI, and neuroendocrinological features of anorexia nervosa. We also discuss gender differences and treatment options in anorexia nervosa. Further studies of GI physiology and pharmacology are needed to determine whether any disturbances may be amenable to therapeutic intervention. Future treatments directed at improving GI sensorimotor function and neurohormonal abnormalities in patients with anorexia nervosa may impact their nutritional rehabilitation and may have important health economic implications as patients avoid hospitalization and are restored to full activities in society. The current team approach, which incorporates psychiatrists, psychologists, nutritionists, pediatricians, internists, and gastroenterologists in the treatment of patients with anorexia nervosa, will continue to be essential.

[A study of patients with anorexia nervosa in Gavleborg. More boys than girls required intensive care]

In the early 1970's British doctors (Beaumont et al) published clinical findings and concluded that anorexia nervosa is a disease occurring in both sexes. Until then it had been considered a female disease only. A number of studies have reported a rather poor outcome for boys and men. In a Danish study infertility was noted in affected men. The aim of this study is to describe typical arrays of clinical data in order to assess attitudes and values concerning the effect of treatment on 28 teenagers out of a total of 48 children and adolescents. A sociometric questionnaire was used to assess the youngsters' knowledge of their disease, their opinions concerning the competence of staff, their feelings concerning treatment, including parental involvement in therapy and medications used, as well as their opinions concerning the results of treatment. All boys are alive (in 1999), 19 years after falling ill. The boys were much more reluctant to accept inpatient care than were the girls, who seem to show greater autonomy. Participants' final appraisal of treatment is slightly positive, whereas in the hypothetical situation that a friend might fall ill with an eating disorder, a sizeable majority would recommend contact with child psychiatry.

Outcome of severe anorexia nervosa patients receiving inpatient treatment in Japan: an 8-year follow-up study

Sixty-one subjects with anorexia nervosa (AN) were followed for a minimum of 4 years after discharge (mean 8.3 years). They were evaluated using the Morgan-Russell Outcome Assessment Scale. Thirty-one (51%) were categorized as having good outcome, eight (13%) as intermediate, 15 (25%) as poor, and seven (11%) had died. As predictors of outcome, later onset (after 20 years of age) and low minimum body mass index were associated with poor prognosis. The outcome of AN in Japan is relatively similar to those in Western countries, irrespective of different sociocultural backgrounds and health systems.

Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study

BACKGROUND

Given our poor understanding of the very long-term course of anorexia nervosa. many questions remain regarding the potential for recovery and relapse. The purpose of the present study was to investigate long-term outcome and prognosis in an anorexic sample 21 years after the initial treatment.

METHOD

A multidimensional and prospective design was used to assess outcome in 84 patients 9 years after a previous follow-up and 21 years after admission. Among the 70 living patients, the follow-up rate was 90%. Causes of death for the deceased patients were obtained through the attending physician. Predictors of a poor outcome at the 21-year follow-up were selected based on the results of a previous 12-year follow-up of these patients.

RESULTS

Fifty-one per cent of the patients were found to be fully recovered at follow-up, 21% were partially recovered and 10% still met full diagnostic criteria for anorexia nervosa. Sixteen per cent were deceased, due to causes related to anorexia nervosa. The standardized mortality rate was 9.8. The three groups also showed significant differences in psychosocial outcome. A low body mass index and a greater severity of social and psychological problems were identified as predictors of a poor outcome.

CONCLUSIONS

Recovery is still possible for anorexic patients after a period of 21 years. On the other hand, patients can relapse, becoming symptomatic again despite previously achieving recovery status. Only a few patients classified as having a poor outcome were found to seek any form of treatment, therefore, it is recommended that these patients should be monitored regularly and offered treatment whenever possible.

[Mortality and causes of death in patients with eating disorders in Denmark, 1970-1993]

INTRODUCTION

The aim of this study was to describe standardised mortality rates and causes of death in patients with eating disorders, who were admitted to Danish psychiatric and somatic hospitals during the period, 1970 to 1993.

METHODS

By means of record-linkage, the study covered all patients admitted for and diagnosed as suffering from an eating disorder, according to the ICD-8 classification system, at any Danish psychiatric (since 1970) or somatic department (since 1977) during the period 1970-1993. The study comprised 2763 patients 237 of whom were males. The maximum follow-up time was 23 years and the mean follow-up time 10.3 years.

RESULTS

The crude mortality at follow-up was 8.4%. A significant excessive mortality was demonstrated, as the standardised mortality ratio (SMR) of the total patient population was 6.69 (CI 5.68-7.83) and the highest rate ratio (RR) of 14.92 (CI 9.66-22.03) related to women aged 25-29.

CONCLUSION

With its 2763 patients, this is the largest study of a population with eating disorders ever published. The study documents a significant excessive mortality among such patients in all age groups.

Death from anorexia nervosa: age span and sex differences

The purpose of this study was to assess characteristics of individuals who died from anorexia nervosa by assessing the frequency with which anorexia nervosa is listed as a causal factor related to the death of individuals in the USA. Data from over 10 million death records (all National Center for Health Statistic registered deaths in the USA for 1986-90) were examined for mention of anorexia nervosa as a primary or contributing cause of death. Only 724 were found, which equals an average of 145 annual deaths, and a rate of 6.73 per 100,000 deaths. The age and sex distribution suggests two fatal forms of anorexia nervosa, an early-onset form comprising 89% women and a later form comprising 24% men. The findings suggest that the mortality risk from current anorexia nervosa may be lower than formerly supposed and that it is not confined to young adults and adolescents.

Hospital admission and mortality rates in anorexia nervosa: experience from an integrated medical-psychiatric outpatient treatment

OBJECTIVES

To evaluate the effectiveness of an integrated medical-psychiatric treatment of major eating disorders.

DESIGN

Historical cohort study.

SETTING

Outpatient Unit for Protein Energy Malnutrition of the Department of Clinical and Experimental Medicine, "Federico II" University of Naples, time of study: January 1994 to December 1997 PARTICIPANTS: 147 female patients with restrictive or bulimic anorexia nervosa (mean age 19.8 +/- 13.7, BMI 14.7 +/- 2.1 Kg/m2) consecutively attending the outpatient unit between January 1994 and December 1997.

MAIN OUTCOME MEASURES

Hospitalization and mortality rates were evaluated up to Jan 1999 with a minimum follow-up of 18 months.

RESULTS

There were 23 admissions to the Clinical Nutrition ward for 19 patients (i.e. 12.9%) mostly due to severe protein energy malnutrition, and 2 deaths, only 1 strictly related to anorexia (mortality rate 0.7%).

CONCLUSIONS

Integrated outpatient medical-psychiatric treatment for major eating disorders is an effective and inexpensive procedure that reduces mortality and admissions due to medical complications in the medium term.

Evaluation of treatment and intermediate and long-term outcome of adolescent eating disorders

BACKGROUND

A cohort of 60 adolescent eating-disordered patients that was consecutively admitted between 1979 and 1988 to a child and adolescent psychiatric university department in Berlin, Germany was followed up at a mean of 5-0 years and for a second time at a mean of 11.5 years.

METHODS

Each patient was personally interviewed and findings dealing with eating disorder symptoms and psychosocial functioning were rated on four-point scales. In addition, the duration of both in-patient and out-patient treatment and the Body Mass Index (BMI) were recorded.

RESULTS

Patients were in treatment for a mean of 33 % of the initial 5-year follow-up period, but this has dropped to a mean of 17% of the entire 11-year follow-up period. No predictors of treatment duration were found. The mortality rate was 8.3% at the second follow-up. The distribution of abnormal BMIs ( < 17.5) reflected a trend of improvement with increasing duration of follow-up. In comparison to the 5-year follow-up, fewer patients suffered from symptoms of the full clinical picture of an eating disorder at the 11-year follow-up. Among the surviving patients 80% recovered during the long-term course. There were few specific predictors of three different outcome criteria.

CONCLUSION

This outcome study of adolescent eating disorders provides further evidence that the long-term course of the disorders in terms of the eating pathology is better than can be expected after a few years. Very little can be said with regard to individual prognosis.

Mortality in eating disorders: a descriptive study

OBJECTIVE

We report rates and causes of death for a cohort of 246 eating-disordered women and provide descriptive information on their eating disorder and comorbid diagnoses.

METHOD

Data on mortality were collected as part of a longitudinal study of anorexia nervosa and bulimia nervosa, now in its 11th year. Other data sources included death certificates, autopsy reports, relative interviews, and a National Death Index search.

RESULTS

Seven deaths have occurred during the study, all among anorexic subjects with a history of binging and purging and with comorbid Axis I disorders. The crude mortality rate was 5.1%. The standardized mortality ratios for death (9.6) and suicide (58.1) were significantly elevated (p <. 001).

CONCLUSIONS

Anorexia nervosa is associated with a substantial risk of death and suicide. Features correlated with fatal outcome are longer duration of illness, binging and purging, comorbid substance abuse, and comorbid affective disorders.

Six-year course and outcome of anorexia nervosa

OBJECTIVE

Since there are discrepant findings in the literature, we studied the longer-term course in a large sample of 103 DSM-IV anorexia nervosa (AN) patients.

METHOD

Assessments were made at four points of time: beginning of therapy, end of therapy, 2-year follow-up, and 6-year follow-up. Self-rating scales as well as expert-rating interview data were used. Eating disorder-specific and general psychopathology were assessed. These data were also compared with data on the 6-year course of patients with bulimia nervosa and binge eating disorder, respectively, who were treated at the same institution at about the same time.

RESULTS

The participation rate at the two follow-ups was high (97.9% of those alive). The general pattern of results over time of those alive at 6-year follow-up was as follows: substantial improvement during therapy, moderate (in many instances nonsignificant) decline during the first 2 years posttreatment, and further improvement from 3 to 6 years posttreatment. At the time of the 6-year follow-up, 26.8% had AN, 9. 9% had bulimia nervosa-purging type (BN-P), 2.0% were classified as eating disorder not otherwise specified (ED-NOS), all diagnosed according to DSM-IV criteria; more than one half (55.4%) showed no major DSM-IV eating disorder. Based on an operationalized global outcome score at 6-year follow-up, 34.7% had a good outcome, 38.6% an intermediate outcome, 20.8% a poor outcome, and 6 of 101 persons (5.9%) were deceased. Body mass index was 17.9 +/- 2.8 at the 6-year follow-up; amenorrhea was still found in 23.9%.

DISCUSSION

In comparison to samples with bulimia nervosa or binge eating disorder, the 6-year course of anorexia nervosa was less favorable. Mortality was rather high and symptomatic recovery protracted; predictors of unfavorable 6-year course were the presence of binges during 4 weeks before index treatment, psychiatric comorbidity, and low body weight at discharge from index treatment.