Psychiatric comorbidity and severity in anorexia nervosa: a comparative study of the DSM-5, the ICD-11, and overvaluation of Weight/Shape severity ratings.

This study assessed the rate of a.) the total and b.) specific psychiatric comorbidities among the three severity ratings for Anorexia Nervosa (AN): DSM-5, ICD-11 and overvaluation of weight and shape (OWS). The sample comprised 312 treatment-seeking patients with AN (mean age = 26.9). Weight and height were taken at intake to calculate BMI, the foundation for the DSM-5 and ICD-11 severity indices. The EDE-Q was used to assess OWS, and the Mini International Neuropsychiatric Interview was conducted to assess psychiatric comorbidities. For the DSM-5, the mild severity group showed a higher total number of psychiatric comorbidities, especially for panic, social anxiety, generalised anxiety, and post-traumatic stress disorders compared to the severe and extremely severe groups. ICD-11 and OWS severity groups did not significantly differ in total comorbidities, except for major depressive disorder and obsessive-compulsive disorders being more prevalent in the "significantly low BMI" ICD-11 group. The high OWS group displayed a notably higher rate of major depressive disorder than the low OWS group. The study underscores inconsistent patterns across the three severity systems, emphasising the need to recognise the current limitations of the assessed severity classification systems in AN assessment and guiding treatment.

Is there a basis for a weight cut-off point? A large-scale investigation of atypical anorexia and anorexia nervosa subtypes among patients at a residential treatment centre.

OBJECTIVE: There is debate surrounding how to differentiate between anorexia nervosa (AN) and atypical AN (atypAN) as diagnostic entities, and whether a distinction based on BMI is warranted. Better understanding eating disorder (ED) and emotional symptoms across atypAN and AN subtypes [AN-restricting (AN-R), AN-binge/purge (AN-BP)], with and without controlling for BMI, can elucidate how atypAN differs from AN subtypes and whether there is a basis for a BMI cut-off. METHODS: 1810 female patients at an ED treatment centre completed intake surveys. ANCOVAs assessed differences across AN-R (n = 853), AN-BP (n = 726), and atypAN (n = 231) groups on ED, depressive, and anxiety symptoms, anxiety sensitivity, experiential avoidance, and mindfulness, with and without controlling for BMI. RESULTS: Relative to AN-R, atypAN and AN-BP groups endorsed significantly higher ED and depressive symptoms, anxiety sensitivity, experiential avoidance, and significantly lower mindfulness (all p < 0.001), but atypAN and AN-BP groups did not differ from one another. When controlling for BMI, all previously significant differences between atypAN and AN-R did not remain significant. CONCLUSION: Individuals with atypAN who have a higher BMI experience more pronounced ED and emotional symptoms, suggesting that relying solely on BMI as a marker of illness severity may be problematic.

Characteristics and clinical trajectories of patients meeting criteria for avoidant/restrictive food intake disorder that are subsequently reclassified as anorexia nervosa.

OBJECTIVE: To examine the initial assessment profiles and early treatment trajectories of youth meeting the criteria for avoidant/restrictive food intake disorder (ARFID) that were subsequently reclassified as anorexia nervosa (AN). METHOD: A retrospective cohort study of patients assessed and treated in a tertiary care eating disorders (ED) program was completed. RESULTS: Of the 77 included patients initially meeting criteria for ARFID, six were reclassified as having AN (7.8%) at a median rate of 71 days after the first assessment. Patients in this cohort presented at very low % treatment goal weight (median 71.6%), self-reported abbreviated length of illness (median 6 months), and exhibited low resting heart rates (median 46 beats per minute). Nutrition and feeding focused worries related more to general health as opposed to specific weight and shape concerns or fears at assessment in half of those reclassified with AN. Treatment at the 6-month mark varied among patients, but comprised family and individual therapy, as well as prescription of psychotropic medication. CONCLUSION: Prospective longitudinal research that utilizes ARFID-specific as well as traditional eating disorder diagnostic measures is required to better understand how patients with restrictive eating disorders that deny fear of weight gain can be differentiated and best treated.

Anthropometrical and Bioelectrical Impedance Analysis Parameters in Anorexia Nervosa Patients' Nutritional Status Assessment.

Background and Objectives: Body mass index (BMI) is still the only recommended measurable nutritional status assessment parameter in anorexia nervosa (AN). The aim of this study was to measure other anthropometrical and bioelectrical impedance analysis (BIA) parameters in AN patients and to evaluate their nutritional status assessment value. Materials and Methods: The 46 AN female patients were examined at the beginning of hospitalization and followed-up in three measurements (in 6 ± 2 weeks' intervals). Anthropometrical assessment was based on BMI, circumferences of arm, calf, thigh, hips, waist, their ratio (waist-to-hip ratio (WHR)), and a skinfold test over biceps and triceps muscle, under the scapula, over the hip, and 2 cm from the umbilicus. The BIA parameters included phase angle (PA), membrane capacitance (Cm), and impedance at 200 kHz, and a 5 kHz ratio (Z200/5). Results: In the 1st measurement, BMI correlated with all anthropometric and BIA parameters (p < 0.05). For BIA parameters, the correlation included arm circumference and WHR (p < 0.05). In the follow-up, significant changes were observed in BMI and all BIA parameters. The correlation between BMI and all BIA parameters was present in the 2nd and 3rd measurements (p < 0.05). In the 4th measurement, BMI correlated only with Cm (p = 0.0114). Comparison of BIA parameters according to the state of starvation (BMI < 16.0 kg/m2) revealed that all studied BIA parameters were characterized by statistically significant sensitivity and specificity in the detection of this condition (p < 0.05), except PA in the 4th measurement (p = 0.2099). Conclusions: Selected BIA and anthropometrical parameters could be used for AN patients' assessment. The study confirmed dynamic changes of BIA parameters during the follow-up. They could be useful in the detection of the state of starvation.

Differences in set-shifting and central coherence across anorexia nervosa subtypes in children and adolescents.

OBJECTIVE: Regarding executive functioning in anorexia nervosa (AN), little is known about differences between the restricting (AN-R) and binge eating/purging (AN-BP) subtypes. Especially for adolescents, there is sparse data. Hence, the current aim is to investigate differences in set-shifting, central coherence, and self-reported executive functioning across adolescent AN subtypes. METHODS: Ninety AN-R, 21 AN-BP, and 63 controls completed an extensive assessment battery including neuropsychological tests for executive functioning and the self-report questionnaire Behavior Rating Inventory of Executive Functioning. RESULTS: Patients with AN-R and AN-BP did not differ on neuropsychological measures, and both performed similarly to controls. Behavior Rating Inventory of Executive Functioning scores fell within the normal range with AN subtypes showing mostly comparable ratings. AN-BP patients scored higher on 2 composite indices and the "shift" subscale compared with AN-R. CONCLUSIONS: The results suggest similar cognitive functioning in adolescent AN subtypes as well as healthy controls. However, more research is needed to draw more general conclusions.

Less symptomatic, but equally impaired: Clinical impairment in restricting versus binge-eating/purging subtype of anorexia nervosa.

OBJECTIVE: This study investigated subtype differences in eating disorder-specific impairment in a treatment-seeking sample of individuals with anorexia nervosa (AN). METHOD: The Clinical Impairment Assessment (CIA) and the Eating Disorder Examination-Questionnaire (EDE-Q) were administered to 142 patients. Of these, 54.9% were classified as restricting type (AN-R) and 45.1% were classified as binge-eating/purging type (AN-B/P) based on an average weekly occurrence of binge eating and/or purging episodes (≥4 episodes/28days). RESULTS: Individuals with AN-B/P exhibited higher levels of core ED psychopathology (dietary restraint, eating concern, shape/weight concerns) in addition to the expected higher frequency of binge/purge episodes. No significant differences existed between AN subtypes in the severity of ED-related impairment. Weight/shape concerns and binge eating frequency significantly predicted level of impairment. Differential associations were observed between the type of ED pathology that significantly contributed to impairment according to AN subtype. DISCUSSION: Although those with AN-B/P displayed higher levels of core attitudinal and behavioral ED pathology than AN-R, no significant differences in ED-specific impairment were found between AN subtypes. Eating disorder-related impairment in AN was not related to the severity of underweight or purging behaviors, but was uniquely and positively associated with weight/shape concerns and binge eating frequency.

Consenso sobre la evaluación y el tratamiento nutricional de los trastornos de la conducta alimentaria: anorexia nerviosa / No disponible

La anorexia nerviosa es la enfermedad psiquiátrica más frecuente entre las mujeres jóvenes y se asume de origen multifactorial. Los criterios diagnósticos han sido recientemente modificados de forma que la amenorrea deja de formar parte de ellos. Esta enfermedad muestra una gran variabilidad en su presentación y gravedad, lo que condiciona diferentes abordajes terapéuticos y la necesidad de individualizar el tratamiento, haciéndose indispensable un enfoque multidisciplinar. Los objetivos persiguen restaurar el estado nutricional (a través de un plan dietético individualizado y basado en un patrón de consumo saludable), tratar las complicaciones y comorbilidades, la educación nutricional (basada en patrones alimentarios y nutricionales sanos), corrección de las conductas compensatorias y la prevención de recaídas. El tratamiento variará según la situación clínica del paciente, pudiendo realizarse en consultas externas (cuando existe estabilidad clínica), en hospital de día (modalidad intermedia entre el tratamiento ambulatorio tradicional y la hospitalización) o en hospitalización (fracaso del manejo ambulatorio o presencia de complicaciones médicas o psiquiátricas graves). La nutrición artificial a través del empleo de suplementos nutricionales orales, nutrición enteral y excepcionalmente nutrición parenteral puede ser necesaria en determinados escenarios clínicos. En pacientes severamente desnutridos se debe evitar el síndrome de realimentación. La anorexia nerviosa está asociada a numerosas complicaciones médicas que condicionan el estado de salud, la calidad de vida y que se relacionan estrechamente con la mortalidad. Existe poca evidencia clínica para evaluar los resultados de los distintos tratamientos en la anorexia nerviosa, estando basados la mayoría de las recomendaciones en consenso de expertos

Anorexia nervosa is the most common psychiatric disease among young women and it is assumed to be of multifactorial origin. Diagnostic criteria have recently been modified; therefore amenorrhea has ceased to be a part of them. This disease shows a large variability in its presentation and severity which conditions different therapeutic approaches and the need to individualize the treatment, thus it is indispensable a multidisciplinary approach. The goals are to restore nutritional status (through an individualized diet plan based on a healthy consumption pattern), treat complications and comorbidities, nutritional education (based on healthy eating and nutritional patterns), correction of compensatory behaviors and relapse prevention. The treatment will vary according to the patient's clinical situation, and it may be performed in outpatient clinics (when there is clinical stability), in a day hospital or ambulatory clinic (intermediate mode between traditional outpatient treatment and hospitalization) or hospitalization (when there is outpatient management failure or presence of serious medical or psychiatric complications). Artificial nutrition using oral nutritional supplements, enteral nutrition and exceptionally parenteral nutrition may be necessary in certain clinical settings. In severely malnourished patients the refeeding syndrome should be avoided. Anorexia nervosa is associated with numerous medical complications which determines health status, life quality, and is closely related to mortality. There is little clinical evidence to assess the results of different treatments in anorexia nervosa, when most of the recommendations are being based on expert consensus

Differences in neural responses to reward and punishment processing between anorexia nervosa subtypes: An fMRI study.

AIM: Anorexia nervosa (AN) includes the restricting (AN-r) and binge-eating/purging (AN-bp) subtypes, which have been reported to differ regarding their underlying pathophysiologies as well as their behavioral patterns. However, the differences in neural mechanisms of reward systems between AN subtypes remain unclear. The aim of the present study was to explore differences in the neural processing of reward and punishment between AN subtypes. METHODS: Twenty-three female patients with AN (11 AN-r and 12 AN-bp) and 20 healthy women underwent functional magnetic resonance imaging while performing a monetary incentive delay task. Whole-brain one-way analysis of variance was conducted to test between-group differences. RESULTS: There were significant group differences in brain activation in the rostral anterior cingulate cortex and right posterior insula during loss anticipation, with increased brain activation in the AN-bp group relative to the AN-r and healthy women groups. No significant differences were found during gain anticipation. CONCLUSION: AN-bp patients showed altered neural responses to punishment in brain regions implicated in emotional arousal. Our findings suggest that individuals with AN-bp are more sensitive to potential punishment than individuals with AN-r and healthy individuals at the neural level. The present study provides preliminary evidence that there are neurobiological differences between AN subtypes with regard to the reward system, especially punishment processing.

Assessment of Sex Differences in Body Composition Among Adolescents With Anorexia Nervosa.

PURPOSE: To compare deficits in fat mass (FM) and lean body mass (LM) among male and female adolescents with anorexia nervosa (AN) and to identify other covariates associated with body composition. METHODS: We retrospectively reviewed electronic medical records of all subjects aged 9-20 years with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of AN and dual-energy x-ray absorptiometry scans after initial evaluation at Stanford between March 1997 and February 2011. From the dual-energy x-ray absorptiometry scans, LM and FM results were converted to age-, height-, sex-, and race-specific Z-scores for age using the National Health and Nutrition Examination Survey reference data. RESULTS: A total of 16 boys and 119 girls with AN met eligibility criteria. The FM Z-score in girls with AN (-3.24 ± 1.50) was significantly lower than that in boys with AN (-2.41 ± .96) in unadjusted models (p = .007). LM was reduced in both girls and boys with AN, but there was no significant sex difference in LM Z-scores. In multivariate models, lower percentage median body mass index was significantly associated with lower FM Z-scores (ß = .08, p < .0001) and lower LM Z-score (ß = .03, p = .0002), whereas lower whole body bone mineral content Z-score was significantly associated with lower LM Z-score (ß = .21, p = .0006). CONCLUSIONS: FM deficits in girls were significantly greater than those in boys with AN in unadjusted models; however, the degree of malnutrition appeared to be the primary factor accounting for this difference. There were no significant sex differences in FM or LM in adjusted models.

A comparison of the metabolic complications and hospital course of severe anorexia nervosa by binge-purge and restricting subtypes.

This study examines adult patients with severe, life-threatening anorexia nervosa who were admitted to an inpatient, medical stabilization unit between October 1, 2008 and December 31, 2014. Specifically, the study compares anorexia nervosa, binge purge subtype (AN-BP) and anorexia nervosa, restricting subtype (AN-R) on admission measures, hospital course, and outcomes. Of the 232 patients, 46% (N = 108) had AN-BP. Patients with AN-R manifested a higher frequency of underweight-mediated medical complications, including bone marrow dysfunction, hepatic dysfunction, and hypoglycemia. Understanding the pathophysiologic differences between severe AN-R and AN-BP is essential to understanding the abnormalities seen on clinical presentation, guiding appropriate clinical treatment, and predicting medical complications during refeeding.

Eating disorders.

Twenty years have passed from the International Classification of Diseases, Tenth Revision (ICD-10) to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and, in the meanwhile, a lot of research data about eating disorders has been published. This article reviews the main modifications to the classification of eating disorders reported in the "Feeding and Eating Disorders" chapter of the DSM-5, and compares them with the ICD-10 diagnostic guidelines. Particularly, we will show that DSM-5 criteria widened the diagnoses of anorexia and bulimia nervosa to less severe forms (so decreasing the frequency of Eating Disorders, Not Otherwise Specified (EDNOS) diagnoses), introduced the new category of Binge Eating Disorder, and incorporated several feeding disorders that were first diagnosed in infancy, childhood, or adolescence. On the whole, the DSM-5 revision should allow the clinician to make more reliable and timely diagnoses for eating disorders.

Examining the utility of narrowing anorexia nervosa subtypes for adults.

OBJECTIVE: The purpose of this investigation was to examine whether narrowing the criteria of anorexia nervosa (AN) subtypes among adults based on further delineations of current binge eating and purging (i.e., binge eating only, purging only, binge eating and purging, and restricting only) improves the potential clinical utility of the current DSM-5 system that specifies two types (i.e., current binge eating and/or purging and restricting, specified as the absence of current binge eating and/or purging). METHOD: Self-reported eating disorder and psychiatric symptoms based on the Eating Disorder Questionnaire were examined in 347 adults from a multisite clinical sample who met DSM-IV criteria for AN. Classification based on binge eating and purging symptoms yielded the following subtypes: 118 restricting only (AN-R; no current binge eating or purging); 133 binge eating and purging (AN-B & P; current binge eating and purging); 43 binge eating only (AN-B; current binge eating and no current purging); and 53 purging only (AN-P; current purging and no current binge eating). RESULTS: The AN-R group had lower current body mass index compared to AN-B & P and AN-P with no group differences in highest, lowest, or desired body mass index. The probability of amenorrhea was higher for the AN-R and AN-B & P groups than the AN-P group. The probability of diet pill use was elevated for the AN-B & P and AN-P groups compared to the AN-R group. The AN-P group also had a higher probability of fasting than the AN-R group. The probability of substance use including tobacco was lower in the AN-R group than the other three groups. No group differences were found on measures of hospitalization, body image, physical symptoms, exercise, or dieting behaviors. CONCLUSIONS: These findings do not support the validity or clinical utility of classifying AN into narrower subtypes based on current binge eating, purging, and binge eating with purging given that few differences were found among groups who reported any combination of current binge eating and purging. Future research is needed to replicate these findings and to further examine the AN subtype classification schemes.

Differential Neural Correlates of Set-Shifting in the Bingeing-Purging and Restrictive Subtypes of Anorexia Nervosa: An fMRI Study.

In this study, possible differences in the neural correlates of set-shifting abilities between the restrictive (AN-R) and bingeing/purging (AN-BP) subtypes of anorexia nervosa have been explored. Three groups of participants performed a set-shifting task during functional magnetic resonance imaging: patients with AN-R (N = 16), AN-BP (N = 13) and healthy control participants (N = 15). As in a typical set-shifting experiment, participants had to switch between two easy tasks (i.e. 'Is the presented number odd/even' or 'Is the presented number smaller/larger than 5'). The trials in which the task was repeated (repeat trials) were compared with trials in which the task was switched (switch trials). With regards to the level of task performance, no significant group differences could be established. However, when comparing switch specific brain activity across study groups, a stronger activation was found in the insula and the precuneus in AN-R when compared to AN-BP and HC. These results suggest that the both subtypes of AN might have different neurobiological correlates, and thus, might benefit from different treatment approaches. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Classifying symptom change in eating disorders: clinical significance metrics for the Change in Eating Disorder Symptoms Scale.

The purpose of this study was to determine clinically significant change criteria and change trajectories for the Change in Eating Disorder Symptoms Scale (CHEDS). Participants included non-eating disordered (n=95) and eating disordered (n=58) samples. The clinical sample was undergoing enhanced cognitive-behavior therapy (CBT-E) for eating disorders. Reliable change indices (RCI), cutscores, and change trajectories were calculated. CHEDS total score RCI was 12 points while the cutscore between eating disordered and non-eating disordered groups was 65. Trajectory models for benchmarking were successfully derived based on initial scores. The change indices and trajectories permit session-by-session analyses and benchmarking of change. These empirically-calibrated indices of patient change and progress allow for empirically-guided treatment decision-making.

The understanding of risk factors for eating disorders in male adolescents.

OBJECTIVE: The study aimed to describe the medical, psychiatric, and cultural features of adolescent males with an eating disorder (ED). MATERIALS AND METHODS: This retrospective evaluation took place at Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey, and covered a 4-year period between 2010 and 2013. Sixty adolescents were diagnosed with an ED during this period, 47 (78.3%) were females and 13 were males (21.7%) male. All 13 male patients who met full criteria for an ED according to the DSM criteria were included. Medical and psychiatric records of male patients treated for an ED were re-evaluated. RESULTS: The most striking finding of the study was that the female to male ratio became 3.6:1, with the increasing number of male adolescents with an ED. In our study, medical findings and complications of males with ED were similar to those seen in females. However, the most predominant gender difference was the co occurrence of a comorbid physical or mental illness. CONCLUSION: It is imperative to raise awareness of EDs in males. Although the medical findings of the study suggest that male and female adolescents with EDs are clinically similar to each other, the understanding of certain gender-specific risk factors shown in our study, such as a medical illness and/or obesity and co-morbid psychiatric diagnosis, are essential in raising suspicion. Further studies that especially evaluate cultural and social factors that affect parenting styles for boys are important in addessing possible risk factors for the development of EDs in males within different societies.

Are There Differences in Central Coherence and Set Shifting Across the Subtypes of Anorexia Nervosa?: A Systematic Review.

Anorexia nervosa (AN) has been associated with weaknesses in central coherence and set shifting. In this line, it has been proposed to directly address these neuropsychological features in treatment (e.g., cognitive remediation therapy). It is not clear, however, whether the 2 subtypes of AN, the restricting (AN-R) and bingeing/purging (AN-BP) type, have the same amount of problems in these domains. A systematic search of the literature was conducted, using the databases Web of Science and PubMed, looking for studies on the comparison of AN-R and AN-BP in performing central coherence/set-shifting tasks. Notably, very few authors describe the results of a direct comparison of the performance of patients with AN-R and AN-BP. In summary, the available indications for possible group differences are not strong enough to draw definitive conclusions.

[Anorexia nervosa is frequently associated with psychiatric co-morbidity]. / Anorexia nervosa ses ofte sammen medandre psykiatriske lidelser.

Recent literature is explored focusing on the relationship between symptoms of anorexia nervosa (AN) and other psychiatric disorders and lines of treatment. In AN, restrictive subtype, anxiety and obsessive-compulsive disorders are the most frequent co-morbidities. In AN, bulimic subtype, depression, emotional instability/borderline and dependency disorders are most frequent. Psychopharmacological treatment could be tried in cases with AN and co-morbid depression, but otherwise the evidence base is lacking and pharmacological treatment relies on case stories and experience.

Typical Versus Atypical Anorexia Nervosa Among Adolescents: Clinical Characteristics and Implications for ICD-11.

There is scant research on the clinical utility of differentiating International Classification of Diseases (ICD) 10 diagnoses F50.0 anorexia nervosa (typical AN) and F50.1 atypical anorexia. We reviewed systematically records of 47 adolescents who fulfilled criteria for ICD-10 F50.0 (n = 34) or F50.1 (n = 13), assessing the impact of diagnostic subtype, comorbidity, background factors and treatment choices on recovery. Atypical AN patients were significantly older (p = 0.03), heavier (minimum body mass index 16.7 vs 15.1 kg/m(2) , p = 0.003) and less prone to comorbidities (38% vs 71%, p = 0.04) and had shorter, less intensive and less costly treatments than typical AN patients. The diagnosis of typical versus atypical AN was the sole significant predictor of treatment success: recovery from atypical AN was 4.3 times (95% confidence interval [1.1, 17.5]) as likely as recovery from typical AN. Overall, our findings indicate that a broader definition of AN may dilute the prognostic value of the diagnosis, and therefore, ICD-11 should retain its distinction between typical and atypical AN.