Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden

Treatment of Eating Disorders in Children, Adolescents, and Young Adults

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders.

The diagnostic category of eating disorders encompasses anorexia nervosa, bulimia nervosa, and the heterogeneous group of eating disorders not otherwise specified, most prominent among which is binge-eating disorder, currently detailed in research criteria in DSM-IV-TR and under consideration for inclusion as a separate diagnosis. In recent decades researchers have increasingly appreciated the multifaceted contributions to the etiology and pathogenesis of eating disorders, including genetic, familial, developmental, and psychosocial influences. Comorbidity with other axis I and axis II disorders is common, and medical comorbidity is of particular significance because of marked nutritional impairments that often accompany these disorders. Although the evidence-based treatment literature is sparse, particularly for anorexia nervosa, progress has been made with respect to nutritional, psychosocial, and psychopharmacological interventions for these disorders, and a growing consensus among clinicians has resulted in practice guidelines that attend to each of these dimensions.

This guideline watch reviews new evidence and highlights salient developments since the 2006 publication of APA’s Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd Edition. The authors of this watch constituted the work group that developed the 2006 guideline. We find the guideline to remain substantially correct and current in its recommendations. The sole exception is a recommendation (with moderate-level confidence) for sibutramine for binge-eating disorder. In 2010, the U.S. Food and Drug Administration (FDA) withdrew approval for sibutramine because clinical trials showed increased risk of heart attack and stroke, and the manufacturer, Abbott Laboratories, subsequently withdrew this medication from the U.S. market. Noteworthy recent publications about the treatment of eating disorders include systematic reviews by the Agency for Healthcare Research and Quality (Berkman et al. 2006; Bulik et al. 2007); practice guidelines from international groups, including the Catalan Agency for Health Information, Assessment and Quality (Working Group of the Clinical Practice Guideline for Eating Disorders 2009), the World Federation of Societies of Biological Psychiatry (Aigner et al. 2011), and the German Society of Psychosomatic Medicine and Psychotherapy and the German College for Psychosomatic Medicine (Herpertz et al. 2011); and a 2011 guidance statement by the Academy for Eating Disorders, which was written by some of the authors of this

The evolving epidemiology and differential etiopathogenesis of eating disorders: implications for prevention and treatment.

Capacités d’adaptation et fonctionnement défensif dans les troubles du comportement alimentaire. Étude structurale comparée basée sur le codage optimal

Facteurs pronostiques des greffes de peau totale sur les membres inférieurs

Obsessive-compulsive disorder (OCD) symptoms are common in people who are ill with bulimia nervosa. However, little is known about whether OCD symptoms persist after long-term recovery from bulimia. Thirty-one female patients with bulimia nervosa, 29 women who had been recovered from bulimia for more than 1 year, and 19 healthy female comparison subjects completed the Yale-Brown Obsessive Compulsive Scale, which measures OCD-like symptoms. Items related to symptoms of core eating disorders were omitted from the Yale-Brown scale. The Yale-Brown scale scores of the women with bulimia (mean = 13.1, SD = 10.6) and those who had recovered from bulimia (mean = 7.9, SD = 7.0) were significantly higher than the scores of the normal comparison subjects (mean = 1.9, SD = 2.6). Women with bulimia and those who had recovered from bulimia had similar Yale-Brown scale scores and endorsed similar Yale-Brown scale target symptoms, such as obsessions related to symmetry and exactness. OCD symptoms persist after recovery from bulimia. Moreover, the types of OCD symptoms experienced by bulimia patients do not vary dramatically with improvement in bulimic symptoms. Persistent OCD symptoms after recovery from bulimia raise the possibility that these behaviors are trait-related and contribute to the pathogenesis of bulimia.

Substance Use Disorders Are Deadly.

This editorial was prompted by the paper written by Watson & Andersen (1) in this issue on weight and amenorrhoea as diagnostic criteria for anorexia nervosa (AN). However, there is much else to question about the classification of eating disorders. An ideal classification should consist of categories that are mutually exclusive and collectively exhaustive. Its entities should be discreet and together they should cover the ground. The classification of eating disorders in the two main systems, ICD 10 and DSM IV (2, 3) measures up to these standards rather poorly (4). In each, the canon contains only two major categories – AN and bulimia nervosa (BN). AN has low-weight and BN has binge-eating as an essential criterion. The two disorders share the criterion of what in broad terms might be described as an over-concern about body weight and size although some would see an important difference in degree or emphasis in the typical ideas held by sufferers from AN and BN. In DSM-IV, AN takes precedence over BN in the sense that the presence of the former bars the diagnosis of the latter but the reverse is true in ICD10. There is in DSM-IV, however, a new subclassification of AN into binge-purging and pure restricting subtypes. The rules in these sets of criteria represent different responses to the fact that low-weight and bingeing occur together commonly and that the cardinal features of AN and BN may co-exist even in cross-section. When longitudinal course over time is considered, then the overlap becomes even more striking. In many series, a substantial minority of BN sufferers have a past history of AN. The reverse transition from BN to AN is less common, but it does occur. Thus AN and BN are far from being entirely discreet disorders and can be made to seem so only by the use of somewhat abitrary rules of definition. Thus the classification of the eating disorders fails to provide discreet entities that are truly, mutually exclusive. However, it fails even more to cover the ground. Many people present with clinically relevant eating disorders that fulfil criteria for neither of the two main eating disorders. How are these to be classified? DSM-IV provides a single catch-all diagnosis for eating disorders that are neither AN nor BN, namely eating disorder not otherwise specified (EDNOS). This is essentially a diagnosis of exclusion although the diagnosis of binge eating disorders (BED) is included as a provisional subcategory of EDNOS ‘for further study’. However, in practice, BED has come already to be accorded the status of a diagnosis in its own right at least in the USA. ICD10 by contrast provides the additonal categories of ‘atypical AN’ and ‘atypical BN’ together with a number of rarely used entities and its own residual category ‘other eating disorders’. EDNOS is common. In many clinical series it is the single most common diagnosis, and in some eating disorder services EDNOS patients form the majority of cases. Many people suffer from clinical eating disorders without ever fulfilling criteria for either AN or BN. Furthermore, a considerable cross-over occurs from AN to BN, and also a smaller amount of cross-over from BN to AN and EDNOS may be the only permissible diagnostic entity in the interim periods. What is the clinical meaning of this? There are many unanswered questions. For instance, is EDNOS in a patient, changing from AN to BN the same as that of changing from BN to AN? And what about course and outcome in the long-term? There are clear differences in mortality between typical AN and typical BN, AN having a well-documented excess mortality in treatment seeking samples (but not in population-based studies) (5–7). In BN, the evidence on mortality is inconclusive at present. Is this true of atypical cases? Likewise, for AN there is evidence of a significantly increased fracture risk from a population-based study (8) and a nationwide register study (9). The dire consequences with respect to procreation, education and social life is amply documented for former AN-patients, both in clinical and population-based studies (7). Is the same true of EDNOS or rather, which cases of EDNOS are at particular risk? And what should be offered as treatment to people suffering from EDNOS? The research literature tends to select patients for inclusion in trials using the main diagnostic categories. It is largely silent on the appropriate treatment of EDNOS. ICD10 and DSM IV are the products of committees informed by tradition. To be useful, our classifications need to have some stability but we should be critical of them. We should not believe in them too much. The categories they advocate are useful tools and we cannot and should not do without them. However, the use of either tool box has problems. They share the most egregious defect of excluding from clear categorization at least a substantial minority of those who suffer from a clinically important eating disorder. There is room for a measure of conservatism but we cannot be satisfied until the EDNOS issue is more adequately addressed.

Patient-Centered Care for Obesity: How Health Care Providers Can Treat Obesity While Actively Addressing Weight Stigma and Eating Disorder Risk

K. Halmi presents the salient components of a comprehensive service for eating disorders. In planning such a service, health policy makers need to understand the prevalence of eating disorders in the catchment area to be served. The size of an eating disorder service is not only dependent on the size of the catchment area, but also on the demographic characteristics of its population. Because eating disorders occur mainly among young females, it is important to know the proportion of this high risk group in the total population served. But characteristics of the catchment area itself are also important, such as the degree of urbanization. For example, in the Netherlands, the incidence of bulimia nervosa was found to be five times higher in cities than in rural areas 1. Also, most epidemiological data on eating disorders are derived from studies in Western countries, especially from Western Europe, because of the availability of comprehensive health registration systems and population statistics. With eating disorders, one has to be especially careful about applying the results from studies in Western countries for planning health care facilities in non-Western countries. In a comprehensive study on the Caribbean island of Curaçao, the incidence of eating disorders among the minority mixedrace and white population was similar to the incidence in the United States and Western Europe, while no cases were found among the majority black population 2. In a meta-analysis providing one-year prevalence rates per 100,000 young females in the Netherlands at different levels of care 3, we reported that the rates for anorexia nervosa were 370 in the community, 160 at the primary care level, and 127 at the level of outpatient and inpatient mental health services. The corresponding rates for bulimia nervosa were 1,500, 170 and 87. These data confirm that only a minority of eating disorder patients in the community enters the mental health care system. This is particularly true for bulimia nervosa. These low rates of persons with eating disorders in care is likely to be the result of patient delay, due to denial or shame, and doctor delay, due to inadequate detection of these severe disorders. In a community study of Finnish twins 4, the lifetime prevalence of DSM-IV bulimia nervosa was 2.3%, but few of these women were identified by the health care system. The lifetime prevalence of DSM-IV anorexia nervosa was 2.2% and as high as 4.2% for broadly defined anorexia nervosa 5. Only half of the anorexia nervosa cases ascertained in this study had been detected in the health care system, though most of them had suffered from anorexia nervosa for several years. Another remarkable finding was that the lifetime prevalence of anorexia nervosa in young males in the Finnish community was 0.24%, also much higher than previously thought 6. Studies in the Netherlands and Sweden provide circumstantial evidence that early detection of anorexia nervosa is of major importance for a favorable outcome 7,8. Anorexia nervosa is still characterized by high lifetime mortality from both natural and unnatural causes 9. However, 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 10. Eating disorder treatment programs are traditionally developed for patients with anorexia or bulimia nervosa. However, nowadays the majority of cases suffering from an eating disorder can only be classified in the DSM-IV category of eating disorders not otherwise specified (EDNOS). These include partial syndromes of anorexia or bulimia nervosa as well as binge eating disorder, a proposed new category in DSM-IV for research purposes 11. In a community study of eating disorders in Portugal, three quarters of young females with an eating disorder were classified as EDNOS 12. Even in outpatient settings, EDNOS cases account for an average of 60% of all cases 13. Although these patients are characterized by similar core cognitive psychopathology, they represent the least studied group of patients with eating disorders. Setting up an eating disorder service requires knowledge of its catchment area and of the epidemiology of eating disorders in general. But it is perhaps even more important to realize that most persons with eating disorders never come into treatment. In planning health services for persons with eating disorders, it is essential to take into account this enormous hidden morbidity of the disorders among the population and to develop methods to address it.

ObjectiveThis review aimed to examine the validity of self‐report screening questionnaires for identifying eating disorder (ED) risk in adults and adolescents with overweight/obesity.MethodFive databases were searched from inception to September 2020 for studies assessing validation of self‐report ED screening questionnaires against diagnostic interviews in adolescents and adults with overweight/obesity. The review was registered with PROSPERO (https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=220013).ResultsTwenty‐seven papers examining 15 questionnaires were included. Most studies validated questionnaires for adults (22 of 27 studies), and most questionnaires (12 of 15) screened for binge eating or binge‐eating disorder (BED). The Eating Disorder Examination Questionnaire (sensitivity = .16–.88, specificity = .62–1.0) and Questionnaire on Eating and Weight Patterns (sensitivity = .07–1.0, specificity = .0–1.0) were most frequently validated (six studies each). Five studies of three questionnaires were in adolescents, with the Adolescent Binge‐Eating Disorder Questionnaire having highest sensitivity (1.0) but lower specificity (.27). Questionnaires designed to screen for BED generally had higher diagnostic accuracy than those screening for EDs in general.DiscussionQuestionnaires have been well validated to identify BED in adults with overweight/obesity. Validated screening tools to identify other EDs in adults and any ED in adolescents with overweight/obesity are lacking. Thus, clinical assessment should inform the identification of patients with co‐morbid EDs and overweight/obesity.Public SignificanceIndividuals with overweight/obesity are at increased risk of EDs. This review highlights literature gaps regarding screening for ED risk in this vulnerable group. This work presents possibilities for improving care of individuals with overweight/obesity by reinventing ED screening tools to be better suited to diverse populations.

The aim of the present prospective-naturalistic study was the evaluation of psychosomatic inpatient treatment for anorexia nervosa (AN) and bulimia nervosa (BN). 128 patients with eating disorders (n=59 AN and n=69 BN) were investigated on admission and discharge using the following standardized questionnaires: eating disorder symptoms (EDI), general psychopathology (BSI), quality of life (SF-12), and personal resources (SOC-13, SWE). Moderate to large effect sizes were achieved for the eating disorder symptoms; in addition, general psychopathology was substantially reduced at the end of treatment, and quality of life as well as personal resources were enhanced. Personal resources were found to be the strongest predictors for therapy outcome. Based on our data, important insights and recommendations may be gained for the inpatient treatment of eating disorders, especially with regard to the potential influence of personal resources.

Anorexia nervosa and bulimia nervosa are complex mental disorders, and their etiology is still not fully understood. This paper reviews the literature on diffusion tensor imaging studies in patients with anorexia nervosa and bulimia nervosa to explore the usefulness of white matter microstructural analysis in understanding the pathophysiology of eating disorders. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify diffusion tensor imaging studies that compared patients with an eating disorder to control groups. We searched relevant databases for studies published from database inception to August 2018, using combinations of select keywords. We categorized white matter tracts according to their 3 main classes: projection (i.e., thalamo–cortical), association (i.e., occipital–parietal–temporal–frontal) and commissural (e.g., corpus callosum). We included 19 papers that investigated a total of 427 participants with current or previous eating disorders and 444 controls. Overall, the studies used different diffusion tensor imaging approaches and showed widespread white matter abnormalities in patients with eating disorders. Despite differences among the studies, patients with anorexia nervosa showed mainly white matter microstructural abnormalities of thalamo–cortical tracts (i.e., corona radiata, thalamic radiations) and occipital–parietal–temporal–frontal tracts (i.e., left superior longitudinal and inferior fronto-occipital fasciculi). It was less clear whether white matter alterations persist after recovery from anorexia nervosa. Available data on bulimia nervosa were partially similar to those for anorexia nervosa. Study sample composition and diffusion tensor imaging analysis techniques were heterogeneous. The number of studies on bulimia nervosa was too limited to be conclusive. White matter microstructure appears to be affected in anorexia nervosa, and these alterations may play a role in the pathophysiology of this eating disorder. Although we found white matter alterations in bulimia nervosa that were similar to those in anorexia nervosa, white matter changes in bulimia nervosa remain poorly investigated, and these findings were less conclusive. Further studies with longitudinal designs and multi-approach analyses are needed to better understand the role of white matter changes in eating disorders.