Claes Norring

Impulsivity and long-term prognosis of psychiatric patients with anorexia nervosa/bulimia nervosa.

Few if any reliable indicators of long-term outcome have been found in eating disorders. Impulsivity was the strongest predictor in the present study of 35 adults with anorexia nervosa or bulimia nervosa. This variable accounted for 25% of anorectic symptoms at 2 to 3 years follow-up and 14% at 4 to 6 years (Eating Attitudes Test). The relationship was specific insofar as impulsivity predicted neither depression nor overall mental health. Cognitive impairment may be one reason for the poor prognosis of impulsive patients.

Validating the EDI-2 in three Swedish female samples: Eating disorders patients, psychiatric outpatients and normal controls

The aim of the current study was to validate the Eating Disorders Inventory 2 (EDI-2) in a Swedish population by investigating how it discriminates between three female samples aged 18 to 50 years: patients with eating disorders (n=978), psychiatric outpatients (n=106) and normal controls (n=602), as well as between different eating disorder diagnoses. The internal consistency of the EDI-2 was above 0.70 for most subscales. The EDI-2 discriminated well between patients with eating disorders and normal controls on all subscales. On the symptom-related subscales, eating disorder patients scored highest followed by psychiatric controls and normals. All subscales except Perfectionism, Interoceptive awareness and Asceticism discriminated eating disorder patients and psychiatric controls. Bulimia patients scored higher than anorexics on the symptom subscales. It is concluded that the EDI-2 discriminates well between eating disorder patients and both psychiatric and normal controls.

The factor structure of the eating disorder inventory in a patient setting

The factor structure of a multidimensional, clinically derived measure of the cognitive and behavioral characteristics of anorexia nervosa and bulimia, the Eating Disorder Inventory (EDI), was investigated in a patient setting. The results showed that eight factors corresponding to the eight original subscales of the EDI were clearly identified in the pattern of factor loadings and that they met conventional standards of internal consistency. The finding of an eight-factor solution using patient responses in this study contrasts with the finding of a clear three-factor solution in an earlier study that employed nonpatient responses. It is suggested that a difference may exist in the meaning of EDI items to patients and nonpatients. However, it is noted that there is a paucity of information in the eating disorders literature that addresses differences between these groups in their attitudes and beliefs regarding eating, weight, body shape, dieting, and self-esteem. This area is clearly one that warrants closer research attention by those working in the eating disorders.

Mortality of eating disorders: a follow-up study of treatment in a specialist unit 1974-2000.

OBJECTIVE To study excess mortality, causes of death, and co-morbidity in patients with eating disorder (ED), treated in a Swedish specialist facility. METHOD A retrospective cohort study of 201 patients with ED followed from 1974 to year 2001 in the Swedish Causes of Death Register (SCODR). Standardized mortality ratio (SMR) was calculated with respect to the Swedish population, by gender, age, and calendar time. RESULTS In the complete follow-up of 201 patients, 23 had died. At a mean follow-up of 14.3 years the overall SMR was 10. Patients with body mass index (BMI) over 11.5 had an average SMR of about 7 and for those with BMI lower than 11.5 had SMR above 30. Six patients died from AN/starvation, nine due to suicide, and eight from other causes. DISCUSSION SMR in anorexia nervosa (AN) is high but not in bulimia nervosa. A risk stratification of AN, based on BMI is suggested.

Eating disorders and oral health: a matched case–control study

The aim was to compare the oral health status of patients with eating disorders (EDs), with sex- and age-matched controls, with a view to identify self-reported and clinical parameters that might alert the dental healthcare professional to the possibility of EDs. All patients who entered outpatient treatment in an ED clinic during a 12-month period were invited to participate. Of 65 ED patients who started psychiatric/medical treatment, 54 agreed to participate. Eating disorder patients and controls answered a questionnaire and underwent dental clinical examinations. Multivariate analysis identified significantly higher ORs for ED patients to present dental problems (OR = 4.1), burning tongue (OR = 14.2), dry/cracked lips (OR = 9.6), dental erosion (OR = 8.5), and less gingival bleeding (OR = 1.1) compared with healthy controls. Sensitivity and specificity for the correct classification of ED patients and controls using the five variables was 83% and 79%, respectively. The ED patients with vomiting/binge eating behaviors reported worse perceived oral health (OR = 6.0) and had more dental erosion (OR = 5.5) than those without such behavior. In ED patients with longer duration of the disease, dental erosion was significantly more common. In conclusion, oral health problems frequently affect ED patients, and this needs to be considered in patient assessment and treatment decisions.

Evaluation of a guided internet self-treatment programme for bulimia nervosa in several European countries

OBJECTIVE The purposes of this study were to evaluate the use of an online guided self-treatment programme for bulimia nervosa (BN) and to determine predictors of outcome. Data were collected in four European countries where the programme was simultaneously used. METHOD One hundred and twenty-seven BN or subthreshold BN female patients (mean age of 24.7 years) participated in a 4-month intervention using a CBT based online-guided self-help programme. Contact during the treatment period included weekly e-mails with a coach. ASSESSMENT Measures included the Eating Disorders Inventory-2 (EDI-2) and the Symptom Check List-Revised (SCL-90R). RESULTS Severity of eating disorders symptoms and general psychopathology improved significantly. Twenty-three per cent of patients were symptom free at the end of treatment. The dropout rate was 25.2%. A better score of general psychological health was a predictor of a better outcome. CONCLUSIONS This study encourages further developments and research on innovative therapy approaches, particularly for those disorders such as BN, with difficult therapy and unclear prognosis.

Psychiatric comorbidity in women and men with eating disorders results from a large clinical database.

Psychiatric comorbidity is common in patients with eating disorders (ED), but prevalence estimates are heterogeneous, probably due to methodological differences between studies (population, diagnostic method, sampling procedure etc.) and a few studies include men. The aim of this study is to investigate psychiatric DSM-IV Axis I comorbidity in a large sample of adult patients, both males and females, with the whole spectrum of DSM-IV ED diagnoses. Initial presentation assessment data on 11,588 adult men and women presenting to specialist ED clinics in Sweden between 2008 and 2012 were extracted from a large clinical database. Diagnostics were based on semi-structured interviews (SCID-I) and the Structured Eating Disorder Interview (SEDI). Seventy-one percent of the patients with ED had at least one other Axis I disorder. The most common type of diagnosis was anxiety disorders (53%), where generalized anxiety disorder was the most common diagnosis. The highest levels of comorbidity were found for women with Binge Eating Disorder (BED) and men with Bulimia Nervosa (BN). Findings are consistent with previous research showing a high prevalence of psychiatric comorbidity in both men and women with ED. The small gender differences observed seem negligible compared to the general similarity in comorbidity.

Interpersonal profiles in eating disorders: ratings of SASB self-image.

INTRODUCTION Although evidence suggests that interpersonal psychotherapy may be an efficacious treatment for eating disorders, there is surprisingly little systematic knowledge about the interpersonal world of these patients. METHOD SASB self-image ratings were used to explore interpersonal profiles in a large heterogeneous sample of eating disorders (N = 830), matched normal controls (N = 105) and a small group of controls with subclinical depression (N = 26). RESULTS Eating disorder patients clearly presented with significantly more negative interpersonal profiles compared to controls. Within the eating disorder group, anorexics were characterized by high self-control, self-blame and self-attack. Patients with binge eating disorder expressed the least negative self-image, and were significantly more self-affirming than bulimics and less self-controlling than patients with atypical eating disorders. CONCLUSIONS Eating disorder patients may have distinct interpersonal profiles that increase the risk of negative therapeutic reaction. Better knowledge of interpersonal processes in eating disorders may help to improve both diagnostic assessment and treatment.

Revision of ICD – status update on feeding and eating disorders

The World Health Organization is currently revising the International Classification of Diseases and Related Health Problems (ICD-10). A central goal for the revision of the ICD classification of mental and behavioural disorders is to improve its clinical utility. Global representation and cultural sensitivity and relevance are important across all mental disorders, but are especially critical to advancing our understanding, diagnosis and treatment of feeding and eating disorders (FED). This paper summarises the current status of the Eating Disorders Consultation Group (EDCG) considerations regarding diagnostic categories for FEDs in ICD-11 and represents work in progress. The recommendations of the EDCG are informed by relevant research evidence, and the consultation group is striving to find a balance between clinical utility and diagnostic purity. Provisional recommendations of the EDCG include: (1) merger of previous FEDs categories in one group; (2) inclusion of six main FED categories that include anorexia nervosa (AN), bulimia nervosa (BN), pica, regurgitation disorder, binge-eating disorder (BED) and avoidant/restrictive food intake disorder, the last two representing new categories; (3) broadening of categories with the aim of reducing the use of the unspecified ED category (e.g. dropping the amenorrhea requirement, increasing the body mass index cut-off for low weight and rewording the cognitive and behavioural features of AN to be more culturally-sensitive). In line with this last recommendation, one point that require further analysis pertain to frequency and severity of the binge-eating and purging behaviours in BN and BED, as the EDCG is considering reducing or eliminating the frequency criterion and broadening the binge-eating criterion to include ‘subjective’ binge episodes.

What happened to the ones who dropped out? Outcome in eating disorder patients who complete or prematurely terminate treatment.

INTRODUCTION There is a lack of knowledge about the outcome of eating disorder patients who terminate treatment prematurely. The present study followed-up eating disorder patients who had previously dropped out of treatment and examined clinical status 36 months after intake. METHOD Dropouts (n = 30) were compared with treatment completers (n = 52) on diagnostic status, clinical symptoms, psychosocial adjustment and treatment satisfaction at follow-up. Patterns of change from intake to follow-up within groups, as well as between groups, were explored. RESULTS No significant differences were found between groups at follow-up, except for more treatment dissatisfaction reported among dropouts. When patterns of change were examined between groups, patients who completed treatment were found to have made significantly greater changes (less eating disorder symptoms, less psychological problems and more positive self-image) compared to dropouts. DISCUSSION Although no significant differences in outcome were found between dropouts and completers, greater clinical improvement was found among those who completed treatment. The dropouts examined in this study did well despite premature termination of treatment. Clinical and research implications are discussed.