Outcome in patients with eating disorders: a 5-year study

doi:10.1016/S0140-6736(00)04406-8

The Lancet

Volume 357, Issue 9264, 21 April 2001, Pages 1254-1257

https://doi.org/10.1016/S0140-6736(00)04406-8 Get rights and content

Summary

Background

Eating disorders are disabling, unpredictable, and difficult to treat. We did a prospective 5-year investigation of a representative sample of patients with eating disorders. Our aim was to identify predictors of outcome and to assess effects of available treatments.

Methods

We prospectively investigated 95 patients with anorexia nervosa, 88 with bulimia nervosa, and 37 with eating disorders not otherwise specified (EDNOS), who sought treatment in Adelaide, South Australia. We divided patients into those who had, and had not, received treatment in specialist units and reached a safe body weight. Individuals were then further classified dependent on intensity of any treatment received. We assessed clinical symptoms, body-related attitudes, and psychosocial function.

Findings

216 (98%) patients were available for follow-up after 5 years. Three patients with anorexia nervosa and two with EDNOS died. 65 (74%) bulimic, 29 (78%) EDNOS, and 53 (56%) anorexic patients had no diagnosable eating disorder. A small proportion of patients in every group had poor Morgan-Russell-Hayward scores at outcome. Final outcome was predicted by extent and intensity, but not duration, of initial symptoms in patients with anorexia nervosa, and by initial body-related attitudes and impaired psychosocial functioning in bulimia patients. We were unable to predict EDNOS outcome. Treatment did not affect outcome for any group.

Interpretation

Deaths in the study confirm the serious nature of eating disorders. However, our results suggest that the efficacy of existing interventions is questionable.

Introduction

Studies of the outcome of patients with eating disorders, such as those with anorexia nervosa or bulimia nervosa, have been limited by technical and sampling difficulties.1, 2, 3, 4, 5 Our aim was to investigate whether or not predictors of patient outcome could be identified from measures obtained at the point that individuals first make contact with secondary or tertiary health services, alone or in combination with measures from a subsequent assessment 6 months later.

Section snippets

Methods

We enrolled women aged 15 years or older, who were living in Adelaide, South Australia, and who were either making first contact with secondary or tertiary services for treatment of an eating disorder, or were recontacting such services after a treatment break of at least 6 months. The study protocol was agreed by the Flinders Medical Centre ethics committee and all patients gave informed consent.

We did the initial research assessment within 48 h of index contact with the patient, and we

Results

Agreement to participate was obtained from all identifiable specialist service providers in Adelaide, apart from one psychiatrist in individual practice. Recruitment took 27 months. We excluded ten of the patients screened because they did not have a clinical eating disorder. 235 patients who fulfilled the recruitment criteria were seen at participating centres. 220 agreed to take part in our study. The study cohort contained 95 patients with anorexia, 88 with bulimia, and 37 with EDNOS. Table 1

Discussion

Our results provide strong support for separate identities for anorexia and bulimia.21, 22 We report clear differences in overall outcomes of these two groups and in the characteristics that predicted those outcomes. There was also little crossover between the conditions.

The size, relative isolation, and diversity of resources available for treatment of eating disorders in Adelaide made this city well suited to a study of a more representative sample of patients than has previously been

References (23)

S Zipfel et al.
Long-term prognosis in anorexia nervosa: lessons from a 21-year follow-up study
Lancet
(2000)
M Fichter et al.
Six-year course and outcome of anorexia nervosa
Int J Eat Disord
(1999)
HC Steinhausen et al.
Follow-up studies of anorexia nervosa: a review of four decades of outcome research
Psychol Med
(1991)
LK Hsu
The outcome of anorexia nervosa: a reappraisal
Psychol Med
(1988)
MM Fichter et al.
Six-year course of bulimia nervosa
Int J Eat Disord
(1997)
PK Keel et al.
Long-term outcome of bulimia nervosa
Arch Gen Psychiatry
(1999)
HG Morgan et al.
Clinical assessment of anorexia nervosa: the Morgan-Russell outcome assessment schedule
Br J Psychiatry
(1988)
F Rosenberg et al.
Self-esteem and delinquency
J Youth Adolescence
(1978)
N Sartorius et al.
Psychiatric assessment instruments developed by the World Health Organisation
Soc Psychiatry andPsychiatr Epidemiol
(1996)
D Ben-Tovim et al.
The development of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ), a new measure of women's attitudes towards their own bodies
Psychol Med
(1991)

D Ben-Tovim et al.

A quantitative study of body related attitudes in patients with anorexia and bulimia nervosa

Psychol Med

(1992)

Cited by (206)

The intersection between eating disorders and gastrointestinal disorders: a narrative review and practical guide
2023, The Lancet Gastroenterology and Hepatology
Eating disorders include a spectrum of disordered thinking patterns and behaviours around eating. There is increasing recognition of the bi-directional relationship between eating disorders and gastrointestinal disease. Gastrointestinal symptoms and structural issues might arise from eating disorders, and gastrointestinal disease might be a risk factor for eating disorder development. Cross-sectional research suggests that individuals with eating disorders are disproportionately represented among people seeking care for gastrointestinal symptoms, with avoidant-restrictive food intake disorder in particular garnering attention for high rates among individuals with functional gastrointestinal disorders. This Review aims to describe the research to date on the relationship between gastrointestinal disorders and eating disorders, highlight research gaps, and provide brief, practical guidance for the gastroenterology provider in detecting, potentially preventing, and treating gastrointestinal symptoms in eating disorders.
Intuitive eating mediates the relationship between interoceptive accuracy and eating disorder risk
2021, Eating Behaviors
Research supports an association between altered interoceptive accuracy, or the ability to accurately monitor sensations from the body, and disordered eating. However, the behavioral mechanism through which interoceptive accuracy may influence eating behaviors is unclear. Intuitive eating, the ability to regulate food intake according to visceral cues of hunger and satiety, is positively related to interoceptive accuracy and negatively related to disordered eating. Therefore, we hypothesized that interoceptive accuracy would be negatively associated with intuitive eating which would, in turn, influence eating disorder risk. A mediation analysis was performed to test this hypothesis in a sample of 41 undergraduate women who completed a heartbeat counting task to assess interoceptive accuracy, followed by self-report measures of intuitive eating ability and eating disorder risk. We found that eating for physical rather than emotional reasons and reliance on hunger and satiety cues, two aspects of intuitive eating, mediated the relationship between interoceptive accuracy and eating disorder risk. Although further research is necessary, it is possible that findings regarding the association between interoceptive accuracy and intuitive eating may inform the development of eating disorder prevention efforts.
The role of body image disturbance in the onset, maintenance, and relapse of anorexia nervosa: A systematic review
2019, Clinical Psychology Review
Citation Excerpt :
In 14 studies, overvaluation and concerns regarding weight and shape were investigated as a factor in the maintenance of AN. Seven studies found a positive association between overvaluation of weight and shape and maintenance of AN (Amianto et al., 2017; Ben-Tovim et al., 2001; Calugi et al., 2018; Castellini et al., 2011; Ricca et al., 2010; Tabri et al., 2015; Woodside et al., 2004). In four of these studies, AN was operationalized as a combination of eating disorder symptoms and weight, and in two studies as eating disorder symptoms only.
Body image disturbance is an important feature of Anorexia Nervosa (AN). Some researchers have argued that body image disturbance is not just a symptom of AN, but plays a causal role in the development, persistence, and relapse of AN. Our aim was to systematically review the existing empirical evidence concerning the role of the cognitive-affective, perceptual, and behavioral components of body image disturbance in AN. 46 studies fulfilled eligibility criteria reporting about 4928 participants with AN. There is some evidence suggesting that body image disturbance is related to the course of AN. However, experimental studies were missing and operationalizations of body image constructs and AN outcome measures varied greatly across studies. Therefore, on the basis of the available empirical data, it remained unclear whether body image disturbance is indeed a causal risk factor for AN. For future studies, it is crucial to use more consistent terminology and more specific and precise definitions of body image constructs as well as experimental designs, adequately powered samples, and well-validated measures. Altogether, this would set the stage to generate the high-quality data that are necessary to clarify the role of body image disturbance in the onset, maintenance and relapse of AN.
Neuromodulation in Anorexia Nervosa
2018, Neuromodulation: Comprehensive Textbook of Principles, Technologies, and Therapies, Second Edition: Volume 1-3
Anorexia nervosa (AN) is a chronic and debilitating illness that especially affects women during adolescence. It is characterized by a multitude of clinical, psychiatric, and psychological symptoms, including weight loss or failure to gain weight, excessive worry about weight and body image, checking behaviors, and the misperception of being fat. To lose weight or maintain a low weight gain, patients often exercise in excess, diet, and develop rules and strategies to control food intake. In addition, patients often present symptoms associated with low caloric consumption, starvation, and the consequences of weight loss.
The mainstay of treatment consists of psychotherapeutic approaches. Medications have largely been shown to be ineffective in randomized trials. In the long term, estimates of recurrence may be as high as 40%–50%. This is problematic if one takes into account the relatively high mortality rate associated with AN. For patients who do not respond to or cannot tolerate conventional treatment, invasive and/or noninvasive neuromodulation may be suitable options. In this chapter we review neuromodulation therapies under investigation for patients with AN, including deep brain stimulation, transcranial magnetic stimulation, and transcranial direct current stimulation.
Deep brain stimulation of the subcallosal cingulate for treatment-refractory anorexia nervosa: 1 year follow-up of an open-label trial
2017, The Lancet Psychiatry
Anorexia nervosa is a life-threatening illness. Brain circuits believed to drive anorexia nervosa symptoms can be accessed with surgical techniques such as deep brain stimulation (DBS). Initial results suggest that DBS of the subcallosal cingulate is safe and associated with improvements in mood and anxiety. Here, we investigated the safety, clinical, and neuroimaging outcomes of DBS of the subcallosal cingulate in a group of patients during 12 months of active stimulation.
We did this prospective open-label trial at the Department of Surgery of the University of Toronto (Toronto, ON, Canada). Patients were eligible to participate if they were aged 20–60 years and had a diagnosis of anorexia nervosa (restricting or binge–purging subtype) and a demonstrated history of chronicity or treatment resistance. Following a period of medical stabilisation, patients underwent surgery for DBS and received open-label continuous stimulation for the entire 1 year study duration. The primary outcome was safety and acceptability of the procedure. The secondary outcomes were body-mass index (BMI), mood, anxiety, affective regulation, and anorexia nervosa-specific behaviours at 12 months after surgery, as well as changes in neural circuitry (measured with PET imaging of cerebral glucose metabolism at baseline and at 6 and 12 months after surgery). This trial was registered with ClinicalTrials.gov, number NCT01476540.
16 patients with treatment-refractory anorexia nervosa were enrolled between September, 2011, and January, 2014, and underwent DBS of the subcallosal cingulate between November, 2011, and April, 2014. Patients had a mean age of 34 years (SD 8) and average illness duration of 18 years (SD 6). Two patients requested that their devices be removed or deactivated during the study, although their reasons for doing so were poorly defined. The most common adverse event was pain related to surgical incision or positioning that required oral analgesics for longer than 3–4 days after surgery (five [31%] of 16 patients). Seven (44%) of 16 patients had serious adverse events, most of which were related to the underlying illness, including electrolyte disturbances. Average BMI at surgery was 13·83 (SD 1·49) and 14 (88%) of the 16 patients had comorbid mood disorders, anxiety disorders, or both. Mean BMI after 12 months of stimulation was 17·34 (SD 3·40; p=0·0009 vs baseline). DBS was associated with significant improvements in measures of depression (mean Hamilton Depression Rating Scale scores 19·40 [SD 6·76] at baseline vs 8·79 [7·64] at 12 months; p=0·00015), anxiety (mean Beck Anxiety Inventory score 38·00 [15·55] vs 27·14 [18·39]; p=0·035), and affective regulation (mean Dysfunction in Emotional Regulation Scale score 131·80 [22·04] vs 104·36 [31·27]; p=0·019). We detected significant changes in cerebral glucose metabolism in key anorexia nervosa-related structures at both 6 months and 12 months of ongoing brain stimulation.
In patients with chronic treatment-refractory anorexia nervosa, DBS is well tolerated and is associated with significant and sustained improvements in affective symptoms, BMI, and changes in neural circuitry at 12 months after surgery.
Klarman Family Foundation Grants Program in Eating Disorders Research and Canadian Institutes of Health Research.
Anorexia nervosa: 30-year outcome
2020, British Journal of Psychiatry

View all citing articles on Scopus

View full text

ArticlesOutcome in patients with eating disorders: a 5-year study

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Methods

Results

Discussion

Lancet

Six-year course and outcome of anorexia nervosa

Int J Eat Disord

Follow-up studies of anorexia nervosa: a review of four decades of outcome research

Psychol Med

The outcome of anorexia nervosa: a reappraisal

Psychol Med

Six-year course of bulimia nervosa

Int J Eat Disord

Long-term outcome of bulimia nervosa

Arch Gen Psychiatry

Clinical assessment of anorexia nervosa: the Morgan-Russell outcome assessment schedule

Br J Psychiatry

Self-esteem and delinquency

J Youth Adolescence

Psychiatric assessment instruments developed by the World Health Organisation

Soc Psychiatry andPsychiatr Epidemiol

The development of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ), a new measure of women's attitudes towards their own bodies

Psychol Med

A quantitative study of body related attitudes in patients with anorexia and bulimia nervosa

Psychol Med

Articles
Outcome in patients with eating disorders: a 5-year study