A.H. Crisp

Outcome of anorexia nervosa.

100 females with anorexia nervosa were followed up 4-8 years after first presentation. All but 12 had had refeeding and/or psychotherapy. 48 had a good outcome (weight at least near normal, regular menstruation, largely satisfactory mental state and psychosexual and psychosocial adjustments) but outcome was intermediate in 30, and poor in 20 patients. 2 had died. Poor outcome could be positively associated with clinical data such as longer duration of illness, older age of onset and presentation, lower weight during illness and at presentation, presence of symptoms such as bulimia, vomiting, and anxiety when eating with others, poor childhood social adjustment, and poor parental relationships.

Clinical features of anorexia nervosa. A study of a consecutive series of 102 female patients.

Abstract The clinical features, treatment, course and outcome of a consecutive series of 102 anorexia nervosa patients are reported in detail. Data were gathered from systematic retrospective analysis of case records and follow-up assessments conducted after a mean lapse from presentation of 5.9 yr. The patients, all diagnosed according to strict criteria, were found to have a relatively long history of illness and half had failed to respond to previous psychiatric treatment. Over 80% of patients had an onset of illness within 7 yr of menarche, and on the whole the group was premorbidly obese. Over 70% came from professional and managerial class families, and 80% were described as compliant children. They had done well academically but were socially inept before onset of illness. A disturbed premorbid relationship between patient and parents was found in over half of the cases, and this was often related to a disturbed parental relationship. However, no specific anorectic family transactional pattern was found. Weight disorders were common amongst family members. Half of the patients were admitted for intensive inpatient treatment, 30% had outpatient psychotherapy, while 10% had no subsequent treatment following initial consultation. At follow-up nearly 80% had normal or near normal body weight and relatively normal menstruation had recurred in 70%. Nevertheless two-thirds of the patients still showed a highly variable dietary pattern and over 40% still worried intensely about their weight and shape. Other psychiatric symptoms, in particular depression and social phobia, were common but overshadowed by the persistent weight phobia. In general, those who had recovered in terms of weight and menses also had better psychiatric status and psychosocial as well as psychosexual adjustment. The overall length of illness was 4.6 yr in those who had recovered. Two patients had died. Aspects of clinical features, family characteristics and identity of the syndrome are discussed.

Psychoneurotic characteristics of patients with anorexia nervosa before and after treatment and at follow-up 4-7 years later.

Abstract Untreated patients with anorexia nervosa display a moderate degree of varied psychoneurotic symptomatology as measured by the Middlesex Hospital Questionnaire (M.H.Q.). In particular, it is noteworthy that they are not socially phobic. However, vomiting behaviour and longer duration of illness are associated with higher depression scores. On the Eysenck Personality Inventory (E.P.I.), a measure of personality, they display evidence of moderate “neuroticism” and high levels of “introversion”. Immediately following restoration ofweight to normal (an average increase of just under 20 kg) and intensive psychotherapy, apart from a deduction in somatic complaints there is little significant change in the M.H.Q. but there is a tendency to lower anxiety and obsessional scores. There are lower “neuroticism” and higher “extraversion” scores on the E.P.I. than before treatment. At follow-up, 4–7 yr later, and with many, especially and significantly the less obsessional, recovered from their anorexia nervosa, there is evident instead a high level of phobic anxiety related to social circumstances.

Bone density of women who have recovered from anorexia nervosa.

OBJECTIVE To examine bone density in 19 women who had previously experienced classical anorexia nervosa from which they had been fully recovered for a mean of 21 years (current characteristics: median age 40.2 years; Eating Attitudes Test [EAT] score 2; body mass index [BMI] 21.1; average 1.8 offspring). METHOD Probands were compared, blindly, in respect of bone density, with 13 control subjects matched for age and sex and with no history of eating disorders. Dual energy X-ray absorptiometry (DXA) was used to evaluate the bone mineral density (BMD) of the lumbar spine and the head of the femur. RESULTS Femur BMD was still significantly less among ex-anorectic sufferers. Two subjects had experienced pathological fractures while anorectic, both having been strenuous exercisers. None appeared to have suffered post illness fractures. BMD at follow-up did not relate to the severity or chronicity of previous anorexia nervosa. DISCUSSION Full clinical recovery from anorexia nervosa does not quite confer full establishment of normal bone density. However, pathological fractures are not a feature thereafter, within middle life.

Relation between Aspects of Nutritional Disturbance and Menstrual Activity in Primary Anorexia Nervosa

A significantly high number of patients with anorexia nervosa are overweight immediately before the onset of the condition. This premorbid weight may be a feature of their constitution but is sometimes a more transitory phenomenon. Menstruation ceases early in the condition but usually within the context of significant weight loss. However, the subsequent amenorrhoea, related to factors that presumably may not begin to operate until several weeks later, may be a symptom which first draws attention to the condition. Treatment included the restitution of body weight to the matched population mean weight for each patient. This may be important, as the mean weight at which menstrual activity returned was not significantly different from the matched population mean weight. A further treatment aim, so far as nutrition was concerned. was restoration of regular and reasonable feeding behaviour, including adequate carbohydrate ingestion. It is suggested that these findings support the view that the nutritional disturbance in anorexia nervosa is an important factor affecting menstrual activity.

Outcome of outpatient psychotherapy in a random allocation treatment study of anorexia nervosa

Ninety subjects with DSM-III-R anorexia nervosa were randomly allocated to four treatment options, one inpatient, two outpatient, and one comprising an assessment interview only. Twenty were thus offered a package of outpatient individual and family psychotherapy. At 2-year follow-up, 12 of the 20 were classed as well, or very nearly well, according to operationally defined criteria. Statistically significant improvements over time were obtained for weight, mean body mass index (BMI), and also for psychological, sexual, and socioeconomic adjustments. Weight and BMI changes were significantly better than for the assessment only group, some of whom had received extensive treatment elsewhere. The style of the outpatient therapy and compliance with it are described in some detail and prognostic indicators for the treated and untreated groups presented. Lower weights at presentation and vomiting were associated with poorer outcome, although age and length of history were not.

Anorexia nervosa. Psychoneurotic characteristics of parents: relationship to prognosis. A quantitative study.

Abstract Using a standardised measure, the psychoneurotic characteristics of the parents of a consecutive series of female patients with primary anorexia nervosa have been examined in relation to those of a ‘normal’ population comaparable in age, sex and marital status. They have also been examined in relation to the treatment and six-month outcome of the illness in their daughters. Treatment initially involved restoration of weight back to matched population mean levels. Following such treatment the majority of parents became more ‘psychoneurotically’ disturbed and this was particularly so if the marital relationship was poor or the patients pattern of illness included habitual overeating and vomiting. Six-month outcome for the patients illness was importantly related to the initial levels of ‘psychoneurotic’ morbidity in the parents. The findings are briefly discussed.

‘Jolly fat’ revisited

Abstract The title of ‘Jolly Fat’ arose from a previous study of 40–65-yr old ‘suburban’ people wherein obesity was associated with low levels of anxiety and also depression in men. The present study, of a more rural population and aged 17–70 yr, has revealed the same association in men aged 40 yr and older and found this to be due to the strength of the association amongst the working class segment of that population. The associations amongst the women were much weaker and only substantial in respect of an association between obesity and low anxiety in older working class women and between obesity and low depression in younger middle class women. However, the few massively obese younger women were very anxious. As a population they may overlap with that highly self-selected group of the massively obese, mainly females, who persistently seek medical and other help to curb and reduce their obesity and who are also highly anxious and depressed. The nature of the above associations between expressed mood and obesity is discussed with reference to possible biological and social factors.

Some clinical, social and psychological characteristics of migraine subjects in the general population

A very careful enquiry within adequate sub-samples of the general population of a market town and its surrounding villages has revealed (a) no special relationship between so-called tension headaches and migraine as defined; (b) a two-year prevalence of migraine more or less similar to that reported elsewhere, i.e. approximately 10% of males and 25% of females being affected; (c) a greater prevalence of migraine amongst professional and managerial classes; (d) similar clinical features to those commonly described before; (e) that approximately 50% of the subjects had consulted their general practitioners and/or other doctors on account of the headache; (f) that actual migraine female subjects are significantly more anxious and depressed than normal subjects whilst at the same time reporting themselves as more sociable than others; they also complain more of other functional somatic disturbance; (g) that such differences were not always detected in the smaller male sample who showed similar tendencies only in respect of anxiety and other somatic complaint; (h) that subjects who described themselves on the questionnaire as having migraine but who were not on careful scrutiny always found to have it, showed as a population a higher degree of neurotic disability, including phobic avoidance patterns, than the population who actually have the condition. This study supports the view that migraine is associated with certain psychological characteristics, especially amongst females. The profile is that of undefended dysphoria coupled with a definite tendency to be outgoing and engaging in the world. The price is migraine and other somatic complaint.

Weight gain and the sleeping electroencephalogram: study of 10 patients with anorexia nervosa.

The relation between reduced nutritional intake, with consequent weight loss, and sleep disturbance was studied by comparing certain sleep encephalogram patterns in a group of inpatients with anorexia nervosa before, during, and after a regimen of refeeding with a normal diet to a matched population mean weight. At low body weights patients had less sleep and more restlessness, especially in the last four hours of the night. During refeeding and weight gain slow-wave sleep initially increased and then tended to decrease during the final stage of restoration of weight back to matched population mean levels. With the overall weight gain, however, there was a significant increase in length of sleep and rapid eye movement sleep, the latter increasing especially during the later stages of weight gain. These results reaffirm that insomnia, and especially early morning waking, is associated with low body weight in anorexia nervosa, and their implications are discussed with particular reference to a hypothetical association between various anabolic profiles and the need for differing components of sleep.