Use and misuse of the emergency room by patients with eating disorders in a matched-cohort analysis: What can we learn from it?

We examined the pattern of access to hospital emergency room (hER) in 2018-2021 among patients with eating disorders (ED) from Florence, Italy, diagnosed during 1994-2018, using a matched cohort design. We included 902 ED patients and an equal number of sex-, age-, and residence-matched individuals. We fitted conditional Poisson regression models with robust variance estimator to estimate incidence rate ratios (IRR) and 95% confidence intervals. ED patients accessed hER more than twice as often as matched individuals: the IRR was 2.11 (1.21-3.70), 2.02 (1.36-3.00), and 2.49 (1.71-3.61) among AN, BN, and BED patients. Factors associated with increased hER use were older age (≥40 years; for AN patients, also younger age, <20 years), BMI ≤ 16 kg/m2 (for AN), and psychopathological severity. The rise in access to hER was particularly marked during the early phases of the COVID-19 pandemic and declined only partially thereafter. Acute psychiatric symptoms and non-specific medical conditions represented the main causes of increased access to hER. Use of hER was more often inappropriate among ED patients than matched individuals. Integration of primary and mental health care may be necessary to counteract the high and often inappropriate use of hER by patients with ED.

Mortality and care of eating disorders.

INTRODUCTION: Eating disorders (EDs) are considered serious mental illnesses, with one of the highest lethality among psychiatric disorders, even though the issue of mortality due to these conditions is still controversial. The present study was aimed at comparing the mortality rate in a cohort of ED patients representative of the geographic area with that of the age and gender-matched general population of central Italy. METHODS: Patients were enrolled between 1994 and 2018, among those attending the eating disorders treatment network of the Florence area (EDTN), which is a regional multidisciplinary treatment reference center for EDs covering the clinical population of the metropolitan Florence area (Italy). The life status of participants was determined through linkage with the Regional Mortality Registry. RESULTS: A total of 1277 individuals with EDs were included, including 368 with Anorexia Nervosa (AN), 312 with Bulimia Nervosa (BN), and 597 individuals with Binge Eating Disorder (BED). Twenty-two patients (1.72%) died, during a median follow-up of 7.4 years. The mortality rates among ED patients did not significantly differ from that of the general population of the same age and sex with a Standardized Mortality Ratio (SMR) of 1.19, 95% CI 0.79-1.81. Only among BN patients, the mortality was significantly increased after 10 years from clinical evaluation (SMR 11.24, 95% CI 3.62-34.84). CONCLUSION: The low mortality in EDs, compared to published studies, might be due to the EDTN treatment strategy, based on a large network which makes an integrated multidisciplinary team available for almost all the patients with EDs of the geographical area.

Suicidality in adolescents with onset of anorexia nervosa.

OBJECTIVES: The mortality rate in patients with anorexia nervosa (AN) is 5 to 10 times higher than in general population and, suicide is one of the main causes of death. We evaluated the prevalence of suicidality (ideation, self-injurious behaviour, suicidal attempts) in 100 adolescents with onset of AN and we explored the correlation between suicidality, severity of AN symptoms and psychiatric comorbidity. METHODS: We subdivided AN patients into restrictive (R-AN; n = 66) and restrictive atypical (A-AN; n = 34), according to the European Guidelines criteria. Assessment was performed using the eating disorder inventory 3rd version, the schedule for affective disorders and schizophrenia for school-age children-present and lifetime version interview, and the Columbia-suicide severity rating scale. Fisher's exact test and Mann-Whitney test (with correction for multiple testing) were used to compare the distribution of categorical and continuous variables between R-AN and A-AN patients, and between patients with vs. without suicidal behaviours. RESULTS: Twenty-seven patients (27%) presented suicidality as clinical feature, expressed as at least one of the following: suicidal ideation (24%), self-cutting (19%), and suicidal attempt (6%). Patients with suicidality showed greater severity of psychiatric symptoms related to AN psychopathology and presented psychiatric comorbidity, especially depression, more often than patients who did not reported suicidality (70,4% vs 29,6%). No significant differences in terms of suicidal behaviours and AN-specific psychopathology were found between R-AN and A-AN. CONCLUSIONS: Suicidality in adolescent patients with R-AN and A-AN seems to be related to ED symptoms. These data highlight the importance of screening for suicidality among adolescents at onset of AN, and confirms that A-AN should not be considered a milder disease. LEVEL OF EVIDENCE: Level IV: Evidence obtained from multiple time series analysis such as case studies. (NB: Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

Living with someone with an eating disorder: factors affecting the caregivers' burden.

We focused on carers of subjects suffering from eating disorders (ED), and studied the characteristics that mostly expose them to high levels of stress, anxiety, depression and expressed emotion, favoring the accommodation of the family system to the cared person. We administered the accommodation and enabling scale for eating disorders (AESED) questionnaire, the family questionnaire (FQ) and the depression, anxiety and stress scale (DASS-21) questionnaire to 97 carers of 62 ED patients, and investigated the carer's characteristics associated with the scores in the three questionnaires. A personal history of ED, being the primary carer, and caring for a person with a diagnosis of anorexia nervosa are the characteristics that contribute most to aggravate the carers' burden in terms of stress, anxiety, depression, accommodation and enabling. Our findings may help doctors to provide effective support to caregivers and eventually improve the treatment of subjects with ED.

Perfectionism, weight and shape concerns, and low self-esteem: Testing a model to predict bulimic symptoms.

Previous studies have tested multivariate models of bulimia pathology development, documenting that a confluence of perfectionism, body dissatisfaction, and low self-esteem is predictive of disordered eating. However, attempts to replicate these results have yielded controversial findings. The objective of the present study was to test an interactive model of perfectionism, weight and shape concerns, and self-esteem in a sample of patients affected by Eating Disorder (ED). One-hundred-sixty-seven ED patients received the Structured Clinical Interview for DSM-IV Axis I (SCID-I), and they completed the Eating Disorder Examination Questionnaire (EDE-Q), the Rosenberg Self-Esteem Scale (RSES), and the Multidimensional Perfectionism Scale (MPS-F). Several mediation analysis models were fit to test whether causal effects of concern over weight and shape on the frequency of bulimic episodes were mediated by perfectionism and moderated by low levels of self-esteem. Contrary to our hypotheses, we found no evidence that the causal relationship investigated was mediated by any of the dimensions of perfectionism. As a secondary finding, the dimensions of perfectionism, perceived criticism and parental expectations, were significantly correlated with the presence of bulimic symptoms. The validity of the interactive model remains controversial, and may be limited by an inadequate conceptualization of the perfectionism construct.

Pretreatment outcome indicators in an eating disorder outpatient group: the effects of self-esteem, personality disorders and dissociation.

OBJECTIVE: The prognosis for eating disorders (ED) is unsatisfactory, and the literature about outcome indicators is controversial. The present study evaluates the roles of self-esteem, personality disorders (PD), and dissociation as outcome predictors. METHOD: Fifty-seven ED outpatients were recruited from a population beginning a Cognitive Behavioral Therapy-Enhanced (CBT-E) treatment. All patients received the Structured Clinical Interview for DSM-IV Axis I (SCID-I), the Structured Clinical Interview for DSM-IV Axis II (SCID-II), and completed the Eating Disorder Examination Questionnaire (EDE-Q), the Dissociation Questionnaire (DIS-Q), and the Rosenberg Self-Esteem Scale (RSES). One month after the end of treatment, recovery was evaluated as meeting the DSM-IV criteria for EDs. RESULTS: A small group of patients recovered (42.2%). Low self-esteem and dissociation results correlated with a negative outcome. DISCUSSION: Dissociation may be an important moderator of psychotherapy and treatment success, as already suggested by previous studies on non-eating-related disorders.

Dissociation in eating disorders: relationship between dissociative experiences and binge-eating episodes.

OBJECTIVE: Several findings support the hypothesis that there is a relationship between dissociation and eating disorders (EDs). The aims of this study were as follows: (1) to assess whether ED patients show a higher level of dissociation than healthy control (HC) individuals or psychiatric control patients with anxiety and mood disorders and (2) to investigate the effects of dissociation on ED symptoms, specifically binge eating behavior. METHOD: Fifty-four ED patients, 56 anxiety and mood disorders control patients, and 39 HC individuals completed the Eating Disorder Examination Questionnaire and the Dissociation Questionnaire. Each participant was asked about the number of binge eating episodes he or she had experienced in the past 4 weeks. RESULTS: The ED patients had higher levels of dissociation than both the psychiatric control group and the HC group. In the ED group, the number of binge episodes was related to the level of dissociation. DISCUSSION: Dissociative experiences are relevant in EDs, and binge eating is related to dissociation. In patients affected by the core psychopathologic beliefs of EDs (overevaluation of shape and weight), dissociation may allow an individual to initiate binging behavior, thus decreasing self-awareness and negative emotional states, without having to deal with the long-term consequences of their actions.