Can psychopathology at age 7 be predicted from clinical observation at one year? Evidence from the ALSPAC cohort.

One of the challenges of developmental psychopathology is to determine whether identifiable pathways to developmental disorders exist in the first months or years of life. Early identification of such disorders poses a similar challenge for clinical services. Using data from a large contemporary birth cohort, we examined whether psychopathology at age seven can be predicted from clinician observation at one year. Two groups of clinical raters observed videos of caregiver-infant interaction. Neither group of raters could reliably identify any precursors of later development of psychopathology in the one-year-old infants in this setting.

The sociocommunicative deficit subgroup in anorexia nervosa: autism spectrum disorders and neurocognition in a community-based, longitudinal study.

BACKGROUND: A subgroup of persons with anorexia nervosa (AN) have been proposed to have sociocommunicative problems corresponding to autism spectrum disorders [ASDs, i.e. DSM-IV pervasive developmental disorders (PDDs): autistic disorder, Asperger's disorder, PDD not otherwise specified (NOS)]. Here, clinical problems, personality traits, cognitive test results and outcome are compared across 16 subjects (32%) with teenage-onset AN who meet or have met ASD criteria (AN+ASD), 34 ASD-negative AN subjects and matched controls from a longitudinal Swedish study including four waves of independent assessments from the teens to the early thirties. METHOD: The fourth wave included the Structured Clinical Interview for DSM-IV (SCID)-I and the SCID-II (cluster C, i.e. 'anxious' PDs) interviews, the Asperger Syndrome Diagnostic Interview, self-assessments by the Autism Spectrum Quotient and the Temperament and Character Inventory, neurocognitive tests by subscales from the Wechsler scales, continuous performance tests, Tower of London, and Happé's cartoons. RESULTS: The ASD assessments had substantial inter-rater reliability over time (Cohen's κ between 0.70 and 0.80 with previous assessments), even if only six subjects had been assigned a diagnosis of an ASD in all four waves of the study, including retrospective assessments of pre-AN neurodevelopmental problems. The AN+ASD group had the highest prevalence of personality disorders and the lowest Morgan-Russell scores. The non-ASD AN group also differed significantly from controls on personality traits related to poor interpersonal functioning and on neurocognitive tests. CONCLUSIONS: A subgroup of subjects with AN meet criteria for ASDs. They may represent the extreme of neurocognitive and personality problems to be found more generally in AN.

Abnormal melatonin synthesis in autism spectrum disorders.

Melatonin is produced in the dark by the pineal gland and is a key regulator of circadian and seasonal rhythms. A low melatonin level has been reported in individuals with autism spectrum disorders (ASD), but the underlying cause of this deficit was unknown. The ASMT gene, encoding the last enzyme of melatonin synthesis, is located on the pseudo-autosomal region 1 of the sex chromosomes, deleted in several individuals with ASD. In this study, we sequenced all ASMT exons and promoters in individuals with ASD (n=250) and compared the allelic frequencies with controls (n=255). Non-conservative variations of ASMT were identified, including a splicing mutation present in two families with ASD, but not in controls. Two polymorphisms located in the promoter (rs4446909 and rs5989681) were more frequent in ASD compared to controls (P=0.0006) and were associated with a dramatic decrease in ASMT transcripts in blood cell lines (P=2 x 10(-10)). Biochemical analyses performed on blood platelets and/or cultured cells revealed a highly significant decrease in ASMT activity (P=2 x 10(-12)) and melatonin level (P=3 x 10(-11)) in individuals with ASD. These results indicate that a low melatonin level, caused by a primary deficit in ASMT activity, is a risk factor for ASD. They also support ASMT as a susceptibility gene for ASD and highlight the crucial role of melatonin in human cognition and behavior.

Ten-year follow-up of adolescent-onset anorexia nervosa: psychiatric disorders and overall functioning scales.

The aim of this study was to assess prospectively the long-term outcome in a representative sample of teenage-onset anorexia nervosa (AN) in respect of psychiatric disorders and overall outcome. Fifty-one AN cases, recruited by community screening, with a mean age of onset of 14 years, was contrasted with 51 matched comparison cases at a mean age of 24 years (10 years after AN onset). All 102 cases had been examined at ages 16 and 21 years. At 24 years all probands were interviewed regarding psychiatric disorders (SCID-I) and overall outcome (Morgan-Russell assessment schedule, the GAF). There were no deaths at 10-year follow-up. One in four in the AN group had a persisting eating disorder (ED), including three who still had anorexia nervosa. Lifetime diagnoses of affective disorders and obsessive-compulsive disorder were over-represented in the AN group. Outcome according to Morgan-Russell was poor in 27%, intermediate in 29%, and good in 43%. According to the GAF, half the AN group had a poor psychosocial functioning. These were subjects with either a persisting ED or lifelong problems with social interaction or obsessive-compulsive behaviour. Ten-year outcome of teenage-onset AN is favourable in the majority of cases; most individuals have recovered from their ED and have no other axis I disorder. However, half the AN group reported poor psychosocial outcome, in most cases explained by a persisting ED or chronic obsessive-compulsive behaviour/social interaction problems.

Regional cerebral blood flow in weight-restored anorexia nervosa: a preliminary study.

Twenty-one individuals (19 females, two males) with teenage-onset anorexia nervosa (AN), 19 of whom were weight restored, were assessed using single-photon emission computed tomography (SPECT) 7 years after onset of AN, at a mean age of 22 years. For comparison we recruited a younger group without neuropsychiatric disorder (mean age 9:8 years; five females, four males) who underwent SPECT at follow-up after an operation for coarctation of the aorta or because of lymphatic leukaemia. Ethical considerations precluded the study of regional cerebral blood flow (rCBF) in participants with completely normal development. The group with AN showed marked hypoperfusion of temporal, parietal, occipital, and orbitofrontal lobes compared to the contrast group. rCBF was not correlated to body mass index in any of the groups. Results suggest that, even long after re-feeding has occurred, AN may be associated with moderate to severe cerebral blood flow hypoperfusion in the temporoparietal (or temporoparietooccipital) region and in the orbitofrontal region. A limitation of the study is that the young contrast group in this study could be expected to have a higher global rCBF than the group with AN. However, this should not significantly affect the relative values used in this study.

Depressive disorders in teenage-onset anorexia nervosa: a controlled longitudinal, partly community-based study.

The study objective was to examine the prevalence and course of depressive disorders (DDs) in teenage-onset anorexia nervosa (AN) over a period of 10 years. Fifty-one adolescents with AN and a sex- and age-matched control group (n = 51) were assessed at ages 16, 21, and 24 years. Probands and controls were examined in depth using semistructured and structured interviews. Their parents were interviewed on the occasion of the first examination. DDs were assessed using DSM-III-R criteria. Subjects with AN had a greatly increased rate of DDs (85%) of all kinds and at all ages as compared with control subjects. The risk of DD during the follow-up period from 21 up to and including 24 years could be predicted by diagnostic group status and the presence of DD during the period from 16 to 21 years, while the risk of DD during the follow-up period from 16 up to and including 21 years was solely predicted by the presence of AN at age 16 years. Long-term resolution of the eating disorder (ED) was associated with the absence of mood disorder or vice versa. Bipolar disorder (BP) occurred at roughly the expected rate (11%) among subjects (probands and controls) with major depression (MDD). In conclusion, depression is a very common comorbid problem in AN: more than four of five individuals with teenage-onset AN had at least one episode of DSM-III-R depression (MD or dysthymia [DT]) within 10 years after onset of the ED. AN appears to trigger the first episode of depression, but once it is manifest, depression predicts further depressive episodes.

Ten-year follow-up of adolescent-onset anorexia nervosa: physical health and neurodevelopment.

To study the development of physical health and some neuromotor functions in anorexia nervosa (AN) 51 individuals (48 females, three males) with a mean AN onset of 14 years, recruited after community screening, were followed prospectively together with 51 age-, sex-, and school-matched individuals without AN (controls). About 10 years after AN onset, all individuals were examined in respect of physical health and neurodevelopment. There were no deaths. Weight and height had normalised, except in three participants with persistent AN. Significantly more participants with AN had a physical complaint/disorder, including hirsutism. This might be a long-term complication in weight restored AN. Dysdiadochokinesis occurred almost exclusively among individuals with former AN in accordance with our previous studies.

Ten-year follow-up of adolescent-onset anorexia nervosa: personality disorders.

OBJECTIVE: To study the development of personality disorders, especially those involving obsessions, compulsions, and social interaction problems, in a representative group of anorexia nervosa (AN) cases. METHOD: The prevalence of personality disorders, obsessive-compulsive disorder, and autism spectrum disorders at mean age 24 years (10 years after reported onset) was examined in 51 adolescent-onset AN cases recruited after community screening and 51 comparison cases matched for age, sex, and school. All 102 cases had originally been examined at age 16 years and followed up at 21 years. At 24 years, structured and validated psychiatric diagnostic interviews were performed by a psychiatrist who was blind to original diagnosis. The majority of AN cases (94%) were weight-restored. RESULTS: Personality disorders, particularly cluster C, and autism spectrum disorders were overrepresented in the AN group. Obsessive-compulsive personality disorder and/or autism spectrum disorder was diagnosed in a subgroup of AN cases in all 3 studies. This subgroup had a very poor psychosocial outcome. CONCLUSIONS: Persistent problems with obsessions, compulsions, and social interaction characterized a substantial minority of weight-restored AN cases at 10-year follow-up. These problems appear to be constitutional rather than a result of AN, and they may warrant a different treatment approach.

[Two sides of patients with eating disorders. One wants to get better, the other resists]. / Två sidor finns inom patienten med ätstörning: den ena vill bli frisk, den andra kämpar emot.

Anorexia and bulimia nervosa patients often require long-term treatment. The efficacy of different treatment approaches is insufficiently known, and for many years well-defined treatment goals were lacking. However, treatment studies are being published, or are under way. In this paper, the authors attempt to summarize the current state-of-knowledge in the field of eating disorder treatment.

Alexithymia in anorexia nervosa: a controlled study using the 20-item Toronto Alexithymia Scale.

The 20-item Toronto Alexithymia Scale (TAS) was completed at the age of 22 years by individuals who had previously suffered from anorexia nervosa (AN), and also by members of a comparison group. The AN and comparison groups had been recruited from community samples. Overall, the TAS scores did not clearly discriminate between the two groups. However, the AN group was significantly more often represented among subjects with the highest TAS scores. A subgroup with empathy disorder tended to have particularly high scores. It is concluded that alexithymia, as defined using the TAS-20, is found only in a subgroup of individuals with AN, and possibly more often in those who are also clinically diagnosed as suffering from empathy disorder. The TAS-20 is not suitable for screening of AN in the general population.

Autism in immigrants: a population-based study from Swedish rural and urban areas.

In a population study, 55 children aged 13 years and under were diagnosed as suffering from autistic disorder according to DSM-III-R criteria. Fifteen of these children (27%) were born to parents, at least one of whom had migrated to Sweden. These 15 cases were analysed in some detail with a view to finding possible background factors that could account for the relatively high prevalence of autism among some immigrant populations. In a few cases, autism or Asperger syndrome had been diagnosed in a native Swedish parent who went abroad in order to find a spouse. In several other cases, the child was the first child born in Sweden after the mother had moved there. The contribution of genetic and other prenatal factors to autism in immigrant populations is discussed.

The cognitive profile of anorexia nervosa: a comparative study including a community-based sample.

A community-based sample of adolescent-onset anorexia nervosa (AN) cases (n = 51) was contrasted with an age-, sex-, and school-matched comparison group [comp] (n = 51) on the Wechsler Adult Intelligence Scale-Revised (WAIS-R) at a mean age of 21 years. There were no study dropouts. Fewer than 10% of AN cases were underweight at the time of testing. Overall, there were few differences across the two groups, even though the COMP group performed significantly better on the object assembly subtest. A small subgroup of AN cases showed autism-spectrum disorders. This subgroup tended toward test profiles similar to those observed in autism and Asperger syndrome. These findings are discussed in relation to the clinical need for subgrouping of AN cases with a view to improving treatment programs/interviews.

Autism in immigrants: children born in Sweden to mothers born in Uganda.

Three boys diagnosed as suffering from autistic disorder were born in Sweden to mothers born in Uganda. Two were related but the third boy was unrelated to the others. The prevalence for autistic disorder in Göteborg children born to mothers who were born in Uganda was 15% which is almost 200 times higher than in the general population of children. The possible reason for the high autism rate in this particular ethnic subgroup is discussed.

Anorexia nervosa 6 years after onset: Part II. Comorbid psychiatric problems.

A sample of anorexia nervosa (AN) cases recruited after community screening were contrasted with an age-, sex-, and school-matched comparison (COMP) group with regard to comorbidity at age 21 years, approximately 6 years after the reported onset of the eating disorder. Both groups had originally been examined at age 16 years. Most of the AN cases no longer met criteria for AN, but many continued to meet criteria for bulimia nervosa (BN) or eating disorder NOS. In addition, there was a high rate of obsessive-compulsive disorders (OCDs). Affective disorders had been common throughout the follow-up period, but tended to follow the course of the eating disorder rather than to precede or postdate it. Underlying personality disorders tended to predict poor outcome.

Anorexia nervosa 6 years after onset: Part I. Personality disorders.

Fifty-one adolescent-onset anorexia nervosa (AN) cases recruited after community screening were compared with 51 age-, sex-, and school-matched cases with regard to personality disorders and autism-spectrum disorders (ASD)/empathy disorders at age 21 years. All 102 cases had originally been examined at a mean age of 16 years, slightly over a year after the reported onset of the eating disorder. Structured Clinical Interview for DSM-III-R (SCID) interviews were performed by a psychiatrist blind to the original eating disorder diagnosis. Most of the former AN cases were recovered with respect to weight, but the outcome in social areas was restricted. Personality disorders coded on axis II in the DSM-III-R and empathy disorders were much more common in the AN group than in the comparison (COMP) group. Obsessive-compulsive (OCD) and avoidant personality disorders were particularly common. Obsessive-compulsive behaviors showed a high degree of stability over time and were unrelated to weight problems. Together with empathy disorder, they tended to predict outcome better than the eating disorder as such. It is concluded that in some cases, AN may be seen to reflect but one axis I diagnosis occurring in the life of an individual with a chronic personality disorder.

Children with deficits in attention, motor control and perception (DAMP) almost grown up: psychiatric and personality disorders at age 16 years.

Fifty-six cases with childhood onset deficits in attention, motor control and perception (DAMP) were followed-up at age 16 years and compared with 45 children without DAMP. Both groups had originally been recruited from the general population at the age of 6 years. Psychiatric disorders (affective disorders in particular) were more common in the DAMP group. Personality disorders were common in both groups, but the DAMP group much more often had a combination of several different personality disorders. The reasons for the discrepancies between teenagers with and without a prior history of DAMP are discussed.

Anorexia nervosa: who sees the patients and who do the patients see?

Two samples of patients with DSM-III-R anorexia nervosa, one identified by screening of a total population cohort and the other a mixed screening and referral group, were contrasted with a comparison group of sex-, age- and school-matched individuals. The rates and types of services consulted and treatment given were analyzed. The groups with anorexia nervosa tended to differ somewhat in these respects, although the numbers were too small for meaningful statistical calculations to be made. Only half of the total population sample had ever received any treatment for the eating disorder, even many years after anorexia nervosa onset in the teenage period. The implications of these findings are discussed both in terms of clinical needs and as they relate to previous research in anorexia nervosa, which has almost exclusively referred to non-population-based groups of patient.

Anorexia nervosa: physical health and neurodevelopment at 16 and 21 years.

Fifty-one cases of anorexia nervosa (AN) and 51 age-, sex- and school-matched controls, all drawn from a community sample of 15- to 16-year-olds, were compared at 16 and 21 years with regard to physical health and neurodevelopment. The AN group had significantly lower mean height than the comparison group at age 21 years. There were significantly more individuals that were overweight and underweight in the AN group at age 21 years. Fractures were slightly, but significantly, more common. Dysdiadochokinesis was very much more common in the AN group at both ages, and its occurrence was not correlated with low weight. It is suggested that diadochokinesis in AN might mirror some inherent underlying immaturity or other abnormality of the central nervous system in a subgroup of cases. The presence of dysdiadochokinesis was associated with a tendency towards poorer psychosocial outcome, even in cases that were no longer underweight.

Anorexia nervosa outcome: six-year controlled longitudinal study of 51 cases including a population cohort.

OBJECTIVE: Controlled study of intermediate term outcome of representative cases with adolescent-onset anorexia nervosa. METHOD: A group of 51 cases with anorexia nervosa with a mean age of reported onset of 14.3 years (including a total population of cases from one birth cohort) were compared with a sex-, age-, and school-matched group of 51 comparison subjects on various measures of outcome at a mean age of 21.0 years (6.7 years after reported onset and 4.9 years after the original diagnostic study). There was no attrition. This paper reports on results obtained using the Morgan-Russell scales. RESULTS: Forty-seven percent of the anorexia nervosa cases reported that they were recovered. In the unrecovered group all aspects of outcome were worse in the anorexia nervosa than in the comparison group. Differences between the two groups were particularly pronounced with regard to aspects of social relationships. CONCLUSIONS: Outcome was fairly similar to that reported in recent clinic-based samples. Poor outcome was associated with the presence of empathy deficits (problems understanding about other people's perspectives and difficulties interacting reciprocally). There is a need to find ways of subgrouping anorexia nervosa cases at onset. The subgroup with empathy deficits warrants more intensive study in future research and clinical practice.