Long-Term Outcome and Mortality in Adolescent Girls 8 Years After Treatment for Anorexia Nervosa.

OBJECTIVE: Assessment of the longer-term outcome of anorexia nervosa (AN) in female adolescent inpatients (N = 132). METHOD: A follow-up (mean 8.2 years) after treatment was conducted. A subsample of 39 patients with at least 10 years of follow-up (mean 14 years) was defined. RESULTS: Over the 8-year follow-up period, the body mass index (BMI) increased from 14.33 (1.65) to 19.04 kg/m2 (2.97; t[112] = 17.33, p < 0.001, d = 1.63), and BMI percentiles increased from 0.50 (1.14) to 24.96 (26.81; t[112] = 9.83, p < 0.001, d = 0.92). Remission was found in 32.5% (8-year total sample) and 48.6% (14-year subsample). In the 8-year total sample, 15.1% still had AN or had relapsed (8.1% in the 14-year subsample). A cross-over from AN to binge-eating disorder was rare. The main cross-over occurred from AN to an eating disorder not otherwise specified (37.5% and 27.0%, respectively). The standardized mortality ratio was 21.7. DISCUSSION: In the long run, eating disorder diagnoses decreased significantly. Although a considerable proportion of patients recovered from their eating disorder, the number of recovered patients remained limited, with long-term negative consequences in a large proportion of patients. Standardized mortality was excessive, calling for ever-better therapies. Additional studies are needed to show if improved therapies lead to a better long-term outcome.

Comparing ICD-11 and DSM-5 eating disorder diagnoses with the Munich eating and feeding disorder questionnaire (ED-Quest).

OBJECTIVE: The new ICD-11 eating disorders (ED) guidelines are similar to the DSM-5 criteria. One difference to the DSM-5 is the inclusion of subjective binges in the definition of bulimia nervosa (BN) and binge-eating disorder (BED). The aim of this study was to identify differences between the ICD-11 guidelines and DSM-5 ED criteria, which could impact access to medical care and early treatment. METHOD: Data of 3863 ED inpatients who completed the Munich Eating and Feeding Disorder Questionnaire were analyzed using standardized diagnostic algorithms for DSM-5 and ICD-11. RESULTS: Agreement of diagnoses was high (Krippendorff's α = .88, 95% CI [.86, .89]) for anorexia nervosa (AN; 98.9%), BN (97.2%) and BED (100%), and lower for other feeding and eating disorders (OFED; 75.2%). Of the 721 patients with a DSM-5 OFED, 19.8% were diagnosed with AN, BN or BED by the ICD-11 diagnostic algorithm, reducing the number of OFED diagnoses. One-hundred and twenty-one patients received an ICD-11 diagnosis of BN or BED because of subjective binges. DISCUSSION: For over 90% of patients, applying either DSM-5 or ICD-11 diagnostic criteria/guidelines resulted in the same full-threshold ED diagnosis. Sub-threshold and feeding disorders exhibited a discrepancy of 25%. PUBLIC SIGNIFICANCE STATEMENT: For about 98% of inpatients, the ICD-11 and DSM-5 agree on the same specified eating disorder diagnosis. This is important when comparing diagnoses made by different diagnostic systems. Including subjective binges in the definition of bulimia nervosa and binge-eating disorder contributes to improved ED diagnoses. Clarifying the wording of diagnostic criteria at several places could further increase this agreement.

Long-term outcome in males with anorexia nervosa: A prospective, sex-matched study.

OBJECTIVE: The objective of this study is to report on the 5.5-years outcome of anorexia nervosa (AN) in male adolescent inpatients and compare it to the outcome of female adolescent inpatients with AN. METHOD: Diagnostic eating disorder outcome was assessed by the Structured Inventory of Anorexic and Bulimic Syndromes (DSM-IV) in 20 males and 20 females matched for AN diagnosis, age at treatment, and length of follow-up. For documentation, follow-up scores of the Eating Disorder Inventory and the Brief Symptom Inventory are reported. RESULTS: Diagnostic outcome did not differ between sexes. Four male and six female participants had AN at follow-up. One male and four females had crossed to bulimia nervosa, and five males and three females to eating disorder not otherwise specified. Remission was found in 10 males and 7 females. Effect sizes were mostly small. At follow-up females had higher scores than males with large effect sizes for drive for thinness (Cohen's d = 0.86) and body dissatisfaction (d = 1.07). DISCUSSION: Few significant sex differences were found. Additional research involving larger samples of males and a broader range of assessed outcomes (e.g., drive for muscularity) in both sexes is urgently needed.

How precisely can psychotherapists predict the long-term outcome of anorexia nervosa and bulimia nervosa at the end of inpatient treatment?

OBJECTIVE: To assess the ability of psychotherapists to predict the future outcome for inpatients with anorexia nervosa (AN) and bulimia nervosa (BN). METHOD: Psychotherapists rated the prognosis of the patient's eating disorder on a five point Likert scale on several dimensions at the end of inpatient treatment. Actual outcome was assessed about 10 years after treatment. The sample comprised 1,065 patients treated for AN, and 1,192 patients treated for BN. RESULTS: Psychotherapists' rating of their patient's prognosis was not better than chance for good outcome in AN and BN and for poor outcome in BN. Prediction of poor outcome in AN was somewhat better with approximately two thirds of correct predictions. In logistic regression analysis, psychotherapists' rating of the patients' prognosis for AN contributed to the explained variance of long-term outcome, increasing the variance explained from 7% (by conventional predictors) to 8% after including psychotherapists' prognosis. In BN, there was no significant contribution of psychotherapists' prognosis to overall prediction. DISCUSSION: Our current knowledge of risk and protective factors for the course of eating disorders is unsatisfying. More specialized research is urgently needed.

[Eating and feeding disorders : New developments]. / Ess- und Fütterstörungen : Neue Entwicklungen.

An overview of eating and feeding disorders according to the future criteria of the International Classification of Diseases (ICD-11) is presented, including information on differential diagnosis, epidemiology, etiology, pathogenesis as well as therapy. Binge-eating disorder is new and the most frequent eating disorder. While anorexia nervosa and bulimia nervosa mostly affect women, the gender ratio in binge-eating disorder is more balanced. Concerning etiology, socio-cultural, biological and psychological factors are discussed. Cognitive behavioral psychotherapy is the best-validated treatment for all three eating disorders. According to the German guidelines for treatment (2019), focal psychodynamic psychotherapy is also a treatment option for anorexia nervosa. Evidence for the positive effect of psychopharmacologic drugs in the treatment of anorexia nervosa is still lacking. Fluoxetine has been shown to have a limited effect in the treatment of bulimia nervosa.

Mortality in males as compared to females treated for an eating disorder: a large prospective controlled study.

PURPOSE: To report on the mortality of DSM-IV eating disorders and predictors of premature death in males compared to females after inpatient treatment. METHODS: Crude mortality rate (CMR) and standardized mortality ratio (SMR) were computed for a large sample of males aged at treatment 16-61 years [N = 66 anorexia nervosa (AN), 52 bulimia nervosa (BN), 70 eating disorder not otherwise specified (ED-NOS)] and females aged 14-65 years (N = 2066 AN, 1880 BN, 1350 ED-NOS). In addition, a survival analysis and Cox regression analyses for identifying predictors of death were computed. RESULTS: CMRs for males and females, respectively, were 15% and 5% in AN, 8% and 3% in BN, and 4% and 3% in ED-NOS. Compared to the general population, mortality was elevated in males with AN (SMR = 4.93) and in all female diagnostic groups (AN, BN, ED-NOS). No significant sex differences for SMR emerged in any diagnostic group. Compared to females with AN or BN, males with AN or BN showed a shorter survival time after onset (survival analysis). Being male, and having AN, increased the risk of premature death. CONCLUSION: Mortality in inpatients with eating disorder is high, especially in AN. Males appear to have about the same outcome in terms of mortality as females with AN, BN, and ED-NOS. However, long-term survival was shorter in males with AN or BN compared to females. The need for intensive treatment in both males and females with an eating disorder remains an important issue. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Long-term outcome of inpatients with bulimia nervosa-Results from the Christina Barz Study.

OBJECTIVE: To assess the long-term outcome and identify outcome predictors in a very large sample of inpatients treated for bulimia nervosa (BN). METHOD: Out of a total of 2,033 patients admitted consecutively to specialized treatment, 1,351 patients (mean age at treatment 25.94) were assessed for follow-up on average 11 (SD 6) years after admission. Also a very long-term (21 years) subsample (N = 147; mean age 25.92) was defined. Bivariate and logistic regression analyses identified predictors of poor outcome. RESULTS: For more than 70% of the patients follow-up information could be gathered. Severity of eating disorder (ED) and other symptoms decreased over time but remained higher than in healthy controls, using published normative data. Remission rate was 38% after 11 years and 42% in the subsample after 21 years. Out of the total sample of N = 2,033 patients, 49 had died (2.4%). Persistent BN was found in 14.2% and the most frequent crossover was to ED not otherwise specified. Predictors of poor outcome were fewer follow-up years, higher drive for thinness, higher age at treatment, and less global functioning. DISCUSSION: Based on clinical indicators, patients presented with a high level of ED and psychiatric symptomatology. With less than half of the patients remitted after 22 years, efforts are needed to improve treatment outcome.

Mortality in males treated for an eating disorder-A large prospective study.

OBJECTIVE: To report on the long-term mortality of eating disorders in male inpatients. METHOD: Crude mortality rates (CMR) and standardized mortality ratios (SMR) were computed for a large sample of males (147 anorexia nervosa [AN], 81 bulimia nervosa [BN], 110 eating disorder not otherwise specified [ED-NOS]; DSM-IV). In addition, a survival analysis from onset of eating disorder to death or end of observation was computed. RESULTS: CMR was 12.9% in AN, 11.1% in BN, and 6.4% in ED-NOS. Standardized mortality was significantly elevated in males with AN (SMR = 5.91; 95% confidence interval 3.56-9.23) as well as ED-NOS (SMR = 3.40; 95% confidence interval 1.37-7.01) but not in males with BN (SMR = 1.88; 95% confidence interval 0.86-3.58). Males with AN died sooner after onset of eating disorder than males with BN or ED-NOS. DISCUSSION: Mortality in male inpatients with eating disorder is high, especially in AN. There is need for developing more effective treatments to achieve better outcome.

Long-term outcomes in treated males with anorexia nervosa and bulimia nervosa-A prospective, gender-matched study.

OBJECTIVE: We report on the long-term outcome of males compared to females treated for anorexia nervosa (AN) or bulimia nervosa (BN). METHODS: A total of 119 males with AN and 60 males with BN were reassessed 5.8 ± 4.6 and 7.5 ± 5.9 years (respectively) after treatment and compared to matched female patients. RESULTS: At follow-up, males with AN had a higher body weight than females. For AN, remission rates (40% males vs. 41% females) did not differ at follow-up. And at follow-up, more males (34%) than females (19%) had an eating disorder not otherwise specified (ED-NOS; p < .01). At follow-up of AN, there was no binge-eating disorder (BED) and obesity was rare. For BN, remission rates (44% males vs. 50% females) and frequency of AN, BN, BED and ED-NOS did not differ at follow-up. Males with AN scored lower than females at follow-up on most subscales of the Eating Disorder Inventory (EDI) and on somatization, obsessive-compulsive symptoms, and depression (Brief Symptom Inventory). Males with BN scored lower than females with BN on perfectionism and higher on interpersonal distrust (EDI) at follow-up. DISCUSSION: Results from the scarce literature on males with ED are inconclusive regarding longer term outcome. In the present study, males with AN showed a slightly better outcome than females. In BN, outcome was about the same in males and females. According to our study, existing treatment is equally effective in both males and females. Additional research on the need of gender-specific diagnosis and therapy is required.

An investigation of indirect effects of personality features on anorexia nervosa severity through interoceptive dysfunction in individuals with lifetime anorexia nervosa diagnoses.

OBJECTIVE: This study examined a hypothesized pathway by which interoceptive dysfunction accounted for associations between personality features (harm avoidance, self-directedness, and perfectionism) and anorexia nervosa (AN) severity (indicated by drive for thinness, eating disorder-related preoccupations and rituals, and body mass index). METHOD: The study sample (n = 270, mean age = 28.47, 95.2% female, 98% White/Caucasian) consisted of probands and biological relatives who met DSM-IV criteria for lifetime diagnoses of AN (omitting criterion D, amenorrhea) drawn from the Price Foundation Anorexia Nervosa Affected Relative Pairs Study (AN-ARP). Participants completed measures assessing personality, interoceptive dysfunction, and eating pathology. RESULTS: Associations between personality features of low self-directedness and high perfectionism and indicators of AN severity (drive for thinness and eating disorder-related preoccupations and rituals) were significant, as were the hypothesized indirect pathways through interoceptive dysfunction. Neither harm avoidance nor body mass index was significantly related to other study variables, and the proposed indirect pathways involving these variables were not significant. DISCUSSION: Findings suggest that certain personality features may relate to AN severity, in part, through their associations with interoceptive dysfunction. Future research should examine prospective associations and the value of interventions targeting interoceptive dysfunction for interrupting the link between personality and AN severity.

Are there differences between men and women in outcome of intensive inpatient treatment for anorexia nervosa? An analysis of routine data.

OBJECTIVE: Anorexia nervosa (AN) in men is rare and understudied. We compared admission characteristics and response to specialized inpatient treatment between men and women with AN. METHOD: One hundred sixteen consecutive male patients with AN were matched to 116 female patients. Patients completed the self-rating Structured Inventory for Anorexic and Bulimic Syndromes (SIAB-S) at admission and discharge. Differences at admission and in treatment response were examined with independent samples t-tests and ANOVA for repeated measures, respectively. RESULTS: Men had lower body mass index (BMI)-percentiles (Cohen's d = -0.55), higher levels of weight suppression (d = 0.65), and higher scores in the SIAB-S general psychopathology and social integration scale (d = 0.47) at admission. There were no differences in response to treatment except for changes in BMI-percentile (F = 4.49, p = 0.035). CONCLUSIONS: There were more similarities than differences between genders in AN. Because this similarity might be confounded with traditionally "feminine" conceptualizations of AN, further studies of male AN are needed.

Associations between dimensions of anorexia nervosa and obsessive-compulsive disorder: An examination of personality and psychological factors in patients with anorexia nervosa.

OBJECTIVE: Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are highly comorbid. However, the factors that account for this comorbidity are poorly understood. We examined the core dimensions of AN and OCD and psychological and personality factors shared by both disorders. METHOD: In path analyses (N = 732 women with either current AN or recovered from AN), we examined which factors were uniquely and independently associated with the core dimensions of AN and OCD. We also examined recovery from AN as a moderator. RESULTS: When individuals with AN reported greater concern over mistakes, they endorsed more severity in both AN and OCD core dimensions. These unique associations existed above and beyond all other transdiagnostic personality and psychological factors and regardless of AN recovery status. CONCLUSIONS: Concern over mistakes partially accounts for severity in the core dimensions of both AN and OCD. Concern over mistakes may represent an important target in the aetiology of AN and OCD.

Short- and long-term outcome of males treated for anorexia nervosa: a review of the literature.

PURPOSE: To give an overview of existing studies on the short- and long-term outcome for males treated for anorexia nervosa and to compare the outcome between adolescents and adults as well as between males and females. METHODS: A systematic literature search was conducted in PubMed, PsycINFO and PSYNDEX and complemented by a manual search of the references from all relevant studies. RESULTS: Out of 1064 search results, 18 studies met our inclusion criteria. A combined total of 1129 males of varying age groups were followed 0.5-27 years post-treatment. For 1009 individuals, only vital status was ascertained. Length of follow-up and outcome definitions varied considerably. Limited data-especially in adults-prevented adequate age comparisons. In both adolescents and adults outcome and mortality differed widely across studies with no firm evidence for gender differences. Outcome in mixed samples of adolescents and adults was inconsistent. Studies rarely compared the genders statistically, and when they did, the results were nonsignificant. CONCLUSIONS: Knowledge on the outcome of males treated for anorexia nervosa is scarce. Only few studies comprising insufficient numbers of males exist. Results based on these findings are inconclusive and in part contradicting. Further research is needed, including large sample sizes of reliably diagnosed males, adequate follow-up intervals, follow-up assessments with carefully defined outcome criteria, and comparisons to matched female patient samples. LEVEL OF EVIDENCE: Level I, Systematic review.

Long-term outcome of anorexia nervosa: Results from a large clinical longitudinal study.

OBJECTIVE: Assessment of the long-term outcome of anorexia nervosa (AN) in a very large sample of inpatients (N = 1,693) and identification of predictors for poor outcome. METHOD: Over 25 years (mean 10 years), consecutively admitted inpatients of a specialized hospital were followed. A subsample of 112 patients with 20-year follow-up was defined. Bivariate comparisons and logistic regression analysis identified risk factors of poor outcome. RESULTS: Body mass index (BMI) increased during the follow-up period. Eating behavior as well as general psychopathology improved but did not reach the level of healthy controls. Remission was found in 30% (total sample) and in 40% (20-year follow-up subsample). Crossover from AN to binge-eating disorder or obesity was rare. The predictors of a negative course of illness included lower BMI at admission; a higher score on the Eating Disorder Inventory Maturity Fears subscale at admission; fewer follow-up years; and higher age at admission. The main diagnostic crossover occurred from AN to eating disorder not otherwise specified. Motherhood was related to better outcome. DISCUSSION: Many patients with very severe AN recover from their illness but AN also shows considerable long-term negative consequences. Over long time periods, survivors show improvement but better treatments for severe cases are still needed. Predictors of outcome included symptom severity, chronicity, and length of follow-up but not psychiatric comorbidity.

RCT of a Video-based Intervention Program for Caregivers of Patients with an Eating Disorder.

OBJECTIVE: This paper presents the results of a randomized controlled trial measuring the efficacy of a video-based skills training to decrease burden and psychological distress in caregivers of inpatients treated for an eating disorder in specialized hospital units. METHOD: Two hundred eighty-five caregivers were randomized to either the video intervention (N = 147) or the control group (N = 138). Caregivers' primary outcomes were assessed via Eating Disorder Symptom Impact Scale, Accommodation and Enabling Scale and General Health Questionnaire-12 at baseline and three-months follow-up. RESULTS: Acceptability of the intervention was high. Receiving additional external professional help like psychotherapy or clinical counselling was identified as a moderator contributing to the efficacy of the intervention. Caregivers' burden (Eating Disorder Symptom Impact Scale) and psychological distress (General Health Questionnaire-12) were reduced by the intervention but not caregivers' accommodating behaviours (Accommodation and Enabling Scale). CONCLUSION: The video training is a promising approach and effective supplement for caregivers of patients with an eating disorder. Additional professional help to caregivers increases the effectiveness of the intervention. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Mortality in eating disorders - results of a large prospective clinical longitudinal study.

OBJECTIVE: To report on long-term mortality in anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (ED-NOS), causes of death, and predictors of early death. METHOD: A large sample of consecutively admitted inpatients (N = 5,839) was followed-up on vital status through the German civil registry office. Of these patients 1,639 were treated for AN, 1,930 for BN, 363 for BED, and 1,907 for ED-NOS. Data from the main inpatient hospital treatment were applied to bivariate and multivariate Cox regression analyses on survival time from onset of eating disorder to death or end of observation. Standardized mortality ratios (SMR) were computed matched for age, gender, and person-years. RESULTS: SMR were 5.35 for AN, 1.49 for BN, 1.50 for BED, 2.39 for narrowly defined ED-NOS, and 1.70 for widely defined ED-NOS. Patients with AN died earlier than patients with BN, BED, or ED-NOS who did not differ. A diagnosis of AN, chronicity, later age of onset, not living in a relationship, and an irregular type of discharge from index inpatient treatment were major predictors of a shorter time to death. Suicidality was a univariate predictor of a shorter time to death in BN only. AN patients mostly died from natural causes related to their eating disorder. DISCUSSION: Mortality in AN is excessive and considerably higher than in BN, BED, and ED-NOS.

The Munich eating and feeding disorder questionnaire (Munich ED-Quest) DSM-5/ICD-10: validity, reliability, sensitivity to change and norms.

OBJECTIVE: The aim of the article is to report on the psychometric properties of a newly developed self-rating scale (Munich Eating and Feeding Disorder Questionnaire) for the detailed assessment of eating and feeding disorders on the basis of the DSM-5 criteria. The questionnaire aims at developing a comprehensive assessment of eating disorder symptoms suitable for severity ratings with regard to total scale and subscales, for deriving eating disorder diagnoses according to DSM-5 and ICD-10 and for measuring (intervention induced) changes over time. METHODS: Items were formulated by clinical experts and entered into factor analysis in two separate samples of eating-disordered inpatients. Additionally, 47 clinical and 547 community control participants were assessed. Internal consistency and sensitivity to change over time are also reported. RESULTS: Three subscales were identified covering 'preoccupation with figure and weight', 'bingeing and vomiting' and 'inappropriate compensatory behaviour' for current and past state. Test-retest reliability for the three subscales ranged between .95 and .98 (current status). A high sensitivity to change during inpatient treatment from admission to discharge was expressed in high effect sizes; for the total score (current status) for all eating disorders, the effect size was 1.70. Effect sizes for anorexia nervosa were mostly lower than those for bulimia nervosa. Clinical and community controls obtained significantly lower scores compared with eating-disordered patients. CONCLUSION: This new DSM-5 questionnaire shows satisfying psychometric properties and is well suited for the rating of eating disorder severity in clinical practice and research.

Functional disability and death wishes in older Europeans: results from the EURODEP concerted action.

PURPOSE: Physical illness has been shown to be a risk factor for suicidal behaviour in older adults. The association between functional disability and suicidal behaviour in older adults is less clear. The aim of this study was to examine the relationship between functional disability and death wishes in late life. METHODS: Data from 11 population studies on depression in persons aged 65 and above were pooled, yielding a total of 15,890 respondents. Level of functional disability was trichotomised (no, intermediate, high). A person was considered to have death wishes if the death wish/suicidal ideation item of the EURO-D scale was endorsed. Odds ratios for death wishes associated with functional disability were calculated in a multilevel logistic regression model. RESULTS: In total, 5 % of the men and 7 % of the women reported death wishes. Both intermediate (OR 1.89, 95 % CI 1.42; 2.52) and high functional disability (OR 3.22, 95 % CI 2.34; 4.42) were associated with death wishes. No sex differences could be shown. Results remained after adding depressive symptoms to the model. CONCLUSIONS: Functional disability was independently associated with death wishes in older adults. Results can help inform clinicians who care for older persons with functional impairment.

Set-shifting and its relation to clinical and personality variables in full recovery of anorexia nervosa.

OBJECTIVE: First, this study aimed to explore whether set-shifting is inefficient after full recovery of anorexia nervosa (recAN). Second, this study wanted to explore the relation of set-shifting to clinical and personality variables. METHOD: A total of 100 recAN women were compared with 100 healthy women. Set-shifting was assessed with Berg's Card Sorting Test. Expert interviews yielded assessments for the inclusion/exclusion criteria, self-ratings for clinical and personality variables. RESULTS: Compared with the healthy control group, the recAN participants achieved fewer categories, showed more perseverations and spent less time for shifting set. Perfectionism is correlated with set-shifting but in converse directions in the two groups. DISCUSSION: Our study supports the findings of inefficiencies in set-shifting after full recovery from AN. Higher perfectionism in the recAN group is associated with better set-shifting ability, whereas higher perfectionism in the healthy control group is related to worse set-shifting ability.

Primary amenorrhea in anorexia nervosa: impact on characteristic masculine and feminine traits.

Animal studies indicate that gonadal hormones at puberty have an effect on the development of masculine and feminine traits. However, it is unknown whether similar processes occur in humans. We examined whether women with anorexia nervosa (AN), who often experience primary amenorrhea, exhibit attenuated feminization in their psychological characteristics in adulthood due to the decrease/absence of gonadal hormones at puberty. Women with AN were compared on a number of psychological characteristics using general linear models on the basis of the presence/absence of primary amenorrhea. Although women with primary amenorrhea exhibited lower anxiety scores than those without primary amenorrhea, in general, results did not provide evidence of attenuated feminization in women with AN with primary amenorrhea. Future research should utilize novel techniques and direct hormone measurement to explore the effects of pubertal gonadal hormones on masculine and feminine traits.