Nathalie Godart

Anxiety disorders in anorexia nervosa and bulimia nervosa: co-morbidity and chronology of appearance

The objectives of the study were to assess lifetime prevalence of specific anxiety disorders, and their age of onset relative to that of eating disorders (ED), in a French sample of patients with anorexia nervosa (AN) or bulimia nervosa (BN). We assessed frequencies of seven anxiety disorders and childhood histories of separation anxiety disorder among 63 subjects with a current DSM-IV diagnosis of an ED, using the Composite International Diagnostic Interview (CIDI). Eighty-three percent of subjects with AN and 71% of those with BN had at least one lifetime diagnosis of an anxiety disorder. By far, the most frequent was social phobia (55% of the anorexics and 59% of the bulimics). When present, the co-morbid anxiety disorder had predated the onset of the ED in 75% of subjects with AN, and 88% of subjects with BN. Our results are consistent with those of studies conducted in other countries, and show that an anxiety disorder frequently exists before an ED. This has to be taken in consideration for successful treatment of patients with AN or BN.

Anxiety disorders in subjects seeking treatment for eating disorders: a DSM-IV controlled study

Women who were referred with an eating disorder (ED) were compared with a matched normal control group to answer the following questions: What are the frequencies of anxiety disorders in cases of anorexia and bulimia nervosa diagnosed according to DSM-IV criteria? Are anxiety disorders significantly more frequent among women with an eating disorder than among women from the community? We assessed the frequencies of six specific anxiety disorders among 271 women with a current diagnosis of anorexia or bulimia nervosa and 271 controls, using the Mini-International Neuropsychiatric Interview, French DSM-IV version. A lifetime comorbidity with at least one anxiety disorder was found in 71% of both the anorexic and the bulimic subjects, significantly higher than the percentage of controls with an anxiety disorder. The prevalence was significantly higher in the eating disorder groups than in controls for most types of anxiety disorder, and between 41.8 and 53.3% of comorbid cases had an anxiety disorder preceding the onset of the eating disorder. Anxiety disorders are significantly more frequent in subjects with eating disorders than in volunteers from the community, a finding that has important etiological and therapeutic implications.

A randomized controlled trial of adjunctive family therapy and treatment as usual following inpatient treatment for anorexia nervosa adolescents.

Research on treatments in anorexia nervosa (AN) is scarce. Although most of the therapeutic programs used in ‘real world practice’ in AN treatment resort to multidisciplinary approaches, they have rarely been evaluated. Objective To compare two multidimensional post-hospitalization outpatients treatment programs for adolescents with severe AN: Treatment as Usual (TAU) versus this treatment plus family therapy (TAU+FT). Method Sixty female AN adolescents, aged 13 to 19 years, were included in a randomized parallel controlled trial conducted from 1999 to 2002 for the recruitment, and until 2004 for the 18 months follow-up. Allocation to one of the two treatment groups (30 in each arm) was randomised. The TAU program included sessions for the patient alone as well as sessions with a psychiatrist for the patient and her parents. The TAU+FT program was identical to the usual one but also included family therapy sessions targeting intra-familial dynamics, but not eating disorder symptoms. The main Outcome Measure was the Morgan and Russell outcome category (Good or Intermediate versus Poor outcome). Secondary outcome indicators included AN symptoms or their consequences (eating symptoms, body mass index, amenorrhea, number of hospitalizations in the course of follow-up, social adjustment). The evaluators, but not participants, were blind to randomization. Results At 18 months follow-up, we found a significant group effect for the Morgan and Russell outcome category in favor of the program with family therapy (Intention-to-treat: TAU+FT :12/30 (40%); TAU : 5/29 (17.2%) pu200a=u200a0.05; Per Protocol analysis: respectively 12/26 (46.2%); 4/27 (14.8%), pu200a=u200a0.01). Similar group effects were observed in terms of achievement of a healthy weight (i.e., BMI≥10th percentile) and menstrual status. Conclusions Adding family therapy sessions, focusing on intra-familial dynamics rather than eating symptomatology, to a multidimensional program improves treatment effectiveness in girls with severe AN. Trial Registration Controlled-trials.com ISRCTN71142875

Dropout from Inpatient Treatment for Anorexia Nervosa: Critical Review of the Literature

OBJECTIVEnHigh dropout rates from inpatient treatment for Anorexia Nervosa (AN) pose a serious obstacle to successful treatment. Because dropping out of inpatient treatment may have a negative impact on outcome, it is important to understand why dropout occurs so that treatment can be targeted toward keeping patients in care. We therefore conducted a critical literature review of studies on dropout from inpatient treatment for AN.nnnMETHODnSearches of Medline and PsycINFO revealed nine articles on this subject. Two were excluded because they did not differentiate AN from other eating disorders in analyses.nnnRESULTSnResults were scarce and conflicting, with methodological issues complicating comparisons. Weight on admission, AN subtype, eating disorder symptoms, greater psychiatric difficulty in general, and the absence of depression were related to dropout in multivariate analyses.nnnDISCUSSIONnAuthors should use a common definition of dropout and continue research on the identified predictors as well as potential predictors such as impulsivity and family factors.

Obsessive compulsive disorders in eating disorders

OBJECTIVEnThe aim of this study is to explore current and lifetime prevalence of obsessive compulsive disorders (OCD) in eating disorder (ED) subgroups and subtypes defined by the DSM-IV and to study the chronology of appearance of these disorders taking into account the role played by denutrition.nnnMETHODnCurrent and lifetime prevalence were investigated using the Mini International Neuropsychiatric Interview (MINI) and the Yale-Brown Obsessive Compulsive Scale in a sample of 89 DSM-IV ED patients (58 AN and 31 BN) and 89 matched controls.nnnRESULTSnCurrent and lifetime prevalence of OCD in ED was significantly higher than in general population (15.7% and 19% vs. 0% and 1.1%, P<.05). Anorexic patients presented a slightly higher current and lifetime comorbidity than bulimic patients (19% and 22.4% vs. 9.7% and 12.9%, n.s.). Purging anorexia was the diagnostic subtype, which presented the higher prevalences (29% and 43%), followed by restrictive anorexia (16%) and purging bulimia (13%). In the great majority of cases (65%), OCD diagnosis preceded ED diagnosis. Finally, OCD current prevalence and Y-BOCS scores of underweight patients were not significantly higher than normal-weight patients, suggesting that there were only limited links between denutrition and obsessionality.

Predictive factors of length of inpatient treatment in anorexia nervosa

ObjectiveTo identify clinical variables influencing the length of stay (LOS) of inpatient treatment for anorexia nervosa (AN).MethodWe analyzed structured clinical charts of 300 consecutive hospitalizations for AN in a specialized eating disorder unit. The sample included patients from 12 to 22xa0years old. Factors related to the patient and events occurring during the stay were investigated as possible predictors of LOS.ResultsMean LOS was 135xa0days. The best model of linear regression revealed that the following factors were significantly related to LOS: duration of AN at admission, use of tube feeding during the stay, accomplishment of the therapeutic weight contract and presence of a comorbid disorder.ConclusionsThe identification of factors influencing duration of stay, both at the outset and during the hospitalization, could help clinicians to optimize and individualize treatments, as well as increase patient and family compliance.

Depression, anxiety and obsessive-compulsive symptoms in relation to nutritional status and outcome in severe anorexia nervosa.

Depression, anxiety and obsessive-compulsive disorder are frequently reported to co-occur with anorexia nervosa (AN). There is clinical consensus that depressive symptoms and anxiety may in part be sequelae of malnutrition in AN. However, evidence-based data are still very rare. The present study among severe AN patients investigates links between these psychological variants and nutritional status at admission and subsequent to nutritional rehabilitation. Twenty-four women with AN diagnosed according to the Diagnostic and Statistical Manual IV (DSM-IV) were included prospectively and consecutively at hospitalisation. Nutritional status was assessed by body mass index (BMI). Several psychological aspects were assessed using various scales for depression, anxiety, social phobia, obsessive and eating behaviour symptoms. Follow-up weights and heights at 4-12 years after hospital discharge were measured in 18 patients. BMI and all the scores except the Yale-Brown obsessive-compulsive scale (Y-BOCS) showed significant improvement between admission and discharge. This study highlights the fact that some of the depressive and anxiety symptoms at least partially decrease with nutrition rehabilitation. The improvement in the scores on the psychometric scales between admission and discharge was not correlated with BMI improvement. Psychometric scores at admission and at discharge were not correlated with BMI at follow-up. BMI at follow-up was correlated with minimum lifetime BMI (r=0.486, P=0.04). Future studies should use a better indicator for nutritional status than BMI alone, and should also consider the initial degree of weight loss and the rate at which weight was lost.

Drop-out from adolescent and young adult inpatient treatment for anorexia nervosa

We examined factors predictive of dropout from inpatient treatment for anorexia nervosa (AN) among adolescents in a prospective study of 359 consecutive hospitalizations for AN (DSM-IV). Patients were assessed at admission (clinical, socio-demographic, and psychological data). Multivariate analyses were performed. Drop-out (i.e. leaving hospital before the target weight is achieved) occurred in 24% (n=86) of hospitalizations; in 42.3% (n=30) of the cases, dropout was initiated by the treatment team and in 58.6% (n=41) by the patients and/or their parents. 18.6% (16/86) occurred during the first half of the inpatient program. Frequency of drop-out was significantly higher when the patient was living with only one parent, had been hospitalized previously, had a lower BMI at admission and was over 18 at admission. These elements should draw the attention of the clinician, so that he/she can prepare hospitalization with patients presenting lower admission BMI, particularly by motivational interventions for a better therapeutic alliance, and by the deployment of intensive accompaniment of single parents. Further studies aiming to replicate these results, and including the evaluation of other clinical dimensions such as impulsivity and other personality traits, are needed to elucidate this important topic.

Comorbidite et chronologie d'apparition des troubles anxieux dans les troubles du comportement alimentaire

Resume Les objectifs de cette etude sont d’evaluer la prevalence « vie entiere » des troubles anxieux et leur âge de debut, en comparaison avec l’âge de debut des Troubles du Comportement Alimentaire (TCA), dans un echantillon de patients souffrant d’anorexie (AN) ou de boulimie (BN). Methode. – Nous avons evalue la presence de troubles anxieux et d’antecedent d’anxiete de separation dans un echantillon de 63 patientes presentant un diagnostic actuel de TCA. Les evaluations ont ete realisees avec le CIDI ( Composite International Diagnostic Interview ). Resultats. – Quatre-vingt trois pour cent des anorexiques et 61xa0% des boulimiques souffrent au moins d’un trouble anxieux «xa0vie entierexa0». Le trouble anxieux le plus frequent est la phobie sociale (55xa0% des anorexiques et 59xa0% des boulimiques). Soixante-quinze pour cent des sujets AN et 88xa0% des sujets BN souffrant d’un trouble anxieux ont vu ce trouble debuter avant leurs troubles du comportement alimentaire. Conclusion. – Les troubles anxieux precedent tres souvent les troubles du comportement alimentaire et sont tres frequents chez les AN et les BN. Ces elements doivent etre consideres lorsque l’on prend en charge des sujets AN ou BN.

Relationship between Affective Symptoms and Malnutrition Severity in Severe Anorexia Nervosa

Background Very few studies have investigated the relationship between malnutrition and psychological symptoms in Anorexia Nervosa (AN). They have used only body weight or body mass index (BMI) for the nutritional assessment and did not always report on medication, or if they did, it was not included in the analysis of results, and they did not include confounding factors such as duration of illness, AN subtype or age. The present study investigates this relationship using indicators other than BMI/weight, among which body composition and biological markers, also considering potential confounders related to depression and anxiety. Methods 155 AN patients, (DSM-IV) were included consecutively upon admission to inpatient treatment. Depression, anxiety, obsessive behaviours and social functioning were measured using various scales. Nutritional status was measured using BMI, severity of weight loss, body composition, and albumin and prealbumin levels. Results No correlation was found between BMI at inclusion, fat-free mass index, fat mass index, and severity of weight loss and any of the psychometric scores. Age and medication are the only factors that affect the psychological scores. None of the psychological scores were explained by the nutritional indicators with the exception of albumin levels which was negatively linked to the LSAS fear score (pu200a=u200a0.024; betau200a=u200a−0.225). Only the use of antidepressants explained the variability in BDI scores (pu200a=u200a0.029; betau200a=u200a0.228) and anxiolytic use explained the variability in HADs depression scores (pu200a=u200a0.037; betau200a=u200a0.216). Conclusion The present study is a pioneer investigation of various nutritional markers in relation to psychological symptoms in severely malnourished AN patients. The clinical hypothesis that malnutrition partly causes depression and anxiety symptoms in AN in acute phase is not confirmed, and future studies are needed to back up our results.