Anorexia nervosa:Outpatient treatment and medical management

Anorexia nervosa(AN)is a disabling,costly and potentially deadly illness.Treatment failure and relapse are common after completing treatment,and a substantial proportion of patients develop severe and enduring AN.The time from AN debut to the treatment initiation is normally unreasonably long.Over the past 20 years there has been empirical support for the efficacy of several treatments for AN.Moreover,outpatient treatment with family-based therapy or individual psychotherapy is associated with good outcomes for a substantial proportion of patients.Early intervention improves outcomes and should be a priority for all patients.Outpatient treatment is usually the best format for early intervention,and it has been demonstrated that even patients with severe or extreme AN can be treated as outpatients if they are medically stable.Inpatient care is more disruptive,more costly,and usually has a longer waiting list than does outpatient care.The decision as to whether to proceed with outpatient treatment or to transfer the patient for inpatient therapy may be difficult.The core aim of this opinion review is to provide the knowledge base needed for performing safe outpatient treatment of AN.The scientific essentials for outpatient treatment are described,including how to assess and manage the medical risks of AN and how to decide when transition to inpatient care is indicated.The following aspects are discussed:early intervention,outpatient treatment of AN,including outpatient psychotherapy for severe and extreme AN,how to determine when outpatient treatment is safe,and when transfer to inpatient healthcare is indicated.Emerging treatments,ethical issues and outstanding research questions are also addressed.

Experience of Management of Anorexia Nervosa Patients with Extremely Severe Malnutrition in a Transdisciplinary Clinical Nutrition-Eating Disorders Inpatient Unit

Background: The question of where to hospitalize extremely malnourished patients with anorexia nervosa (AN) is a real dilemma. On one hand, psychiatrists have to deal with severe medical complications that are not within their competences and that justify hospitalization in an internal medicine ward. On the other hand, medical doctors have to face psychic decompensations that would justify admission to a psychiatric ward. In this context, we share our experience of management of severely malnourished AN adult patients in a transdisciplinary specialized eating disorders (ED) unit, referral center for AN associated with somatic severity. Method: First, we described the modalities of care proposed to patients with AN hospitalized in the medical unit. Intensive medical care, both somatic and psychiatric, are provided thanks to a transdisciplinary therapeutic program, where objectives are to: medically stabilize the patient, initiate progressive refeeding and start supportive psychotherapy before being transferred to a psychiatric ED unit. Secondly, we conducted a retrospective descriptive study that included all adult patients with AN admitted for the first time to the unit, between November 1997 and January 2014, for severe malnutrition and/or complications of the ED. Objective was to specify patients’ characteristics: demographic, nutritional status, history of ED, care pathway. Results: Among a cohort of 386 adult patients with AN (21 males and 365 females) admitted for the first time in the unit, mean age was 29.4 (±11.5) years, mean BMI was 12.7 (±2.2) kg/m2. Before being supported in the unit, 78.2% of patients had already been hospitalized in other hospitals. Mean length of stay was 35.2 days. Patients were clinically serious and unstable because of life-threatening somatic complications due to a low BMI. During hospital stay, a temporary transfer to medical intensive care unit was necessary for 25.6% of patients. Average patient weight gain was 0.777 kg per week and 81.9% of patients benefited from enteral nutrition. Conclusion: This specialized transdisciplinary unit where physician nutritionists and psychiatrists coordinate medical care together, allow a better understanding and management of extreme malnutrition associated with AN. Thanks to their expertise, care teams are less critical and less rejecting towards patients. Thus, therapeutic alliance could be optimized.

Severe Sinus Bradycardia in Anorexia Nervosa-A Case Report

A case of anorexia nervosa complicated with severe sinus bradycardia and low T3 syndrome was reported.

The Outcome of Adolescent-Onset Anorexia Nervosa: A Study of 144 Cases

Objectives: To evaluate the long-term outcome of adolescents with anorexia nervosa and attempt to define prognostic factors for outcome. Methods: Transversal, descriptive epidemiological study with a strict methodology: minimum interval of 4 years since first admission, evaluation using clearly defined diagnostic criteria (EAT-40 self-evaluation, HSCL, global patient-driven self-evaluation and hetero evaluation: clinical interview and LECE). The 198 subjects are former adolescent anorexics treated at the Hôpital d’Enfants (Children’s Hospital) in Nancy (France). Results: Clinical evaluation of the 144 subjects traced showed positive outcome for 68.1%, intermediate outcome for 23.2% and poor outcome for 8.7%. 5 factors for a good prognosis were found (middle socioeconomic class of parents, no prior treatment, hospitalization > 1 month,

Self-reported and behavioural impulsivity in anorexia nervosa

AIM To examine how self-reported and behavioural impulsivity are related in anorexia nervosa(AN).METHODS Twenty-four females with AN and 25 healthy controls(HC) participant in the study.Self-reported impulsivity was assessed with the Barratt Impulsiveness Scale(BIS-11).The scale yields three second-order factors:Attentional,motor and non-planning.Behavioural impulsivity was investigated with the continuous performance test(CPT),a computer-based task of sustained attention in which numbers are flashed briefly on screen and participants are required to click the mouse when the same number appears consecutively.The rate of commission and omission errors can be used a measure of behavioural imulsivity.RESULTS AN participants self-reported increased attentional [AN:20.67(3.64),HC:13.88(2.91),P = 0.001] and reduced motor impulsivity [AN:11.55(2.28),HC:14.08(2.78),P = 0.002].The rate of omission or commission errors on the CPT did not differ between groups(P > 0.05).BIS-11 and CPT measures did not significantly correlate,but attentional impulsivity was related to negative mood states in AN(depression:r = 0.52,P = 0.010,anxiety:r = 0.55,P = 0.006,stress:r = 0.57,P = 0.004).CONCLUSION The discrepancy between self-reported and behavioural impulsivity are discussed in terms of perfectionism in AN.Furthermore,it is suggested that improving negative mood states may resolve this inconsistency in AN.

Systematic review of evidence for different treatment settings in anorexia nervosa

AIM: To compare outcomes in anorexia nervosa(AN) in different treatment settings: inpatient, partial hospitalization and outpatient. METHODS: Completed and published in the English language, randomized controlled trials comparing treatment in two or more settings or comparing different lengths of inpatient stay, were identified by database searches using terms "anorexia nervosa" and "treatment" dated to July 2014. Trials were assessed for risk of bias and quality according to the Cochrane handbook by two authors(Madden S and Hay P) Data were extracted on trial quality, participant features and setting, main outcomes and attrition. RESULTS: Five studies were identified, two comparing inpatient treatment to outpatient treatment, one study comparing different lengths of inpatient treatment, one comparing inpatient treatment to day patient treatment and one comparing day patient treatment with outpatient treatment. There was no difference in treatment outcomes between the different treatment settings and different lengths of inpatient treatment. Both outpatient treatment and day patient treatment were significantly cheaper than inpatient treatment. Brief inpatient treatment followed by evidence based outpatient care was also cheaper than prolonged inpatient care for weight normalization also followed by evidence based outpatient care. CONCLUSION: There is preliminary support for AN treatment in less restrictive settings but more research is needed to identify the optimum treatment setting for anorexia nervosa.

Clinical Factors Influencing Quality of Life in Anorexia Nervosa Patients

Objective: The purpose of this study was to elucidate clinical factors influencing quality of life (QOL) in anorexia nervosa (AN) patients. Methods: Twenty female patients with AN (median age = 30.0 years, quartile deviation = 6.8) and forty female healthy controls (HC) (median age = 30.0 years, quartile deviation = 8.6) participated in the study. QOL was assessed with the 36-Item Short Form Health Survey (SF-36) and social support was evaluated using the Multidimensional Scale of Perceived Social Support (MSPSS). Clinical symptoms were evaluated with the Structured Interview Guide for the Hamilton Depression Rating Scale (SIGH-D) and the Eating Disorder Inventory-2 (EDI-2). Results: Scores of the SF-36 Mental Component Summary (MCS) (U = 124.0, P U = 223.0, P = 0.006) and scores of total (U = 108.0, P < 0.0001) and subscales of the MSPSS were lower in AN group than HC group, and the SIGH-D score was higher (U = 46.0, P ρ = &minus;0.565, P < 0.05) and subscales of the EDI-2 Interoceptive Confusion (ρ = &minus;0.556, P ρ = &minus;0.581, P ρ = &minus;0.617, P < 0.05) were negatively correlated to MCS, and score of Interoceptive Confusion subscale showed a negative correlation to RCS (ρ = &minus;0.672, P < 0.05). Moreover, stepwise regression analysis showed that the SIGH-D score was an independent predictor of MCS and Interoceptive Confusion score predicted RCS. Conclusion: These results suggest that among a variety of clinical symptoms and psychopathologies, depressive symptoms, poor emotional awareness and impaired sense of control are the most important influencing factors on AN patients’ QOL.

Epidemiology of anorexia nervosa in a French community-based sample of 39,542 adolescents

Purpose: To assess the prevalence of DSM-IV anorexia nervosa criteria, anorexia nervosa and subthreshold subgroups, and their incidence between the ages of 12 and 17 years using Cole’s international thinness cut-offs, and to characterize these anorexic adolescents by parental socioeconomic status and whether or not they reported receiving treatment. Method: In all, a representative sample of 39,542 French adolescents (19,658 girls and 19,884 boys) was recruited in a cross-sectional study in 2008. Anorexia nervosa DSM-IV diagnosis was determined by a self-administered questionnaire. Results: Among females, 0.5% (n = 105) met criteria for anorexia nervosa between the ages of 12 and 17 years, whereas among males, the prevalence was 0.03% (n = 6). In females, the prevalence of sub-threshold anorexia nervosa was found to be between 1.2% (n = 216) and 3.3% (n = 618);more than 75% were of the restrictive subtype. The highest incidence of anorexia nervosa was at 16 years. There was also a greater prevalence of sub-threshold anorexia nervosa subgroups among subjects with high parental socioeconomic status. More than half of the female adolescents who met the anorexia nervosa criteria reported receiving treatment for their disorder, versus 23% to 40% of the adolescents in the sub-threshold subgroups (P sample of adolescents. Using Cole’s international thinness cut-off could improve international comparability among studies. Adolescents from the higher socioeconomic categories were more likely to be anorexic.

Psychotherapy in anorexia nervosa: What does the absence of evidence mean?

Psychological treatment in anorexia nervosa(AN) is disheartening. Psychotherapy is the "treatment of choice" for adults though this recommendation is grounded on the absence of good quality clinical studies. This paper seeks to address the question of why improvements in the psychological treatment of AN have been thwarted, and why one of the best treatments available for adult patients is specialist supportive clinical management that has entered the stage through the backdoor of nonspecific supportive treatments originally serving as a placebo treatment assigned in randomized clinical trials to control for non-specific aspects of true psychosocial treatments. The possibility that most of the psychopathological features that characterise the AN symptoms profile could be best understood as the direct consequences of emaciation would enhance the utility of research with animal models for generating new hypothesis to improve AN treatment.

Is osteoporosis risk in anorexia nervosa underestimated? A case report series

Introduction: Anorexia nervosa (AN) is a mental disorder whose features are deliberate weight loss, disordered body image, and intrusive overvalued fears of gaining weight. Long-term consequences of AN include endocrine dysfunctions leading to secondary amenorrhea, bone loss and/or osteoporosis with an increased risk of bone fracture. Therefore young women with AN may develop a risk for bone fractures comparable to that of postmenopausal women. Methods: In this case report series Bone Mineral Density (BMD) was examined by Dual energy X-ray Absorptiometry (DXA) in 19 hospitalized patients with diagnosis of AN and prolonged amenorrhea. Results: All patients showed a lumbar/femoral bone loss or osteoporosis, with an increased fracture risk comparable to that of postmenopausal women. Conclusions: Our observation suggests that DXA evaluation of anorexic patients with prolonged amenorrhea would be helpful to prevent fracture risk in this population of patients. However, although DXA is almost routinely recommended in women over 65, it is not in young AN patients with prolonged amenorrhea.

Features of gut microbiota in patients with anorexia nervosa

Background:Anorexia nervosa(AN)is a psychological disorder,which is characterized by the misunderstanding of body image,food restriction,and low body weight.An increasing number of studies have reported that the pathophysiological mechanism of AN might be associated with the dysbiosis of gut microbiota.The purpose of our study was to explore the features of gut microbiota in patients with AN,hoping to provide valuable information on its pathogenesis and treatment.Methods:In this cross-sectional study,from August 2020 to June 2021,patients with AN who were admitted into Peking University Third Hospital and Peking University Sixth Hospital(n=30)were recruited as the AN group,and healthy controls(HC)were recruited from a middle school and a university in Beijing(n=30).Demographic data,Hamilton Depression Scale(HAMD)scores of the two groups,and length of stay of the AN group were recorded.Microbial diversity analysis of gut microbiota in stool samples from the two groups was analyzed by 16S ribosomal RNA(rRNA)gene sequencing.Results:The weight(AN vs.HC,[39.31±7.90]kg vs.[56.47±8.88]kg,P<0.001)and body mass index(BMI,AN vs.HC,[14.92±2.54]kg/m^(2)vs.[20.89±2.14]kg/m^(2),P<0.001)of patients with AN were statistically significantly lower than those of HC,and HAMD scores in AN group were statistically significantly higher than those of HC.For alpha diversity,there were no statistically significant differences between the two groups;for beta diversity,the two groups differed obviously regarding community composition.Compared to HC,the proportion of Lachnospiraceae in patients with AN was statistically significantly higher(AN vs.HC,40.50%vs.31.21%,Z=-1.981,P=0.048),while that of Ruminococcaceae was lower(AN vs.HC,12.17%vs.19.15%,Z=-2.728,P=0.007);the proportion of Faecalibacterium(AN vs.HC,3.97%vs.9.40%,Z=-3.638,P<0.001)and Subdoligranulum(AN vs.HC,4.60%vs.7.02%,Z=-2.369,P=0.018)were statistically significantly lower,while that of Eubacterium_halli_group was significantly higher(AN vs.HC,7.63%vs.3.43%,Z=-2.115,P=0.035).Linear discriminant effect(LEfSe)analysis(LDA score>3.5)showed that o_Lachnospirales,f_Lachnospiraceae,and g_Eubacterium_halli_group(o,f andg represents order,family and genus respectively)were enriched in patients with AN.Microbial function of nutrient transport and metabolism in AN group were more abundant(P>0.05).In AN group,weight and BMI were significantly negatively correlated with the abundance of Bacteroidota and Bacteroides,while positively correlated with Subdoligranulum.BMI was significantly positively correlated with Firmicutes;HAMD scores were significantly negatively correlated with Faecalibacterium.Conclusions:The composition of gut microbiota in patients with AN was different from that of healthy people.Clinical indicators have correlations with the abundance of gut microbiota in patients with AN.

Genetics of anorexia nervosa:An overview of genome-wide association studies and emerging biological links

Anorexia nervosa(AN) is a complex disorder with a strong genetic component. Comorbidities are frequent and there is substantial overlap with other disorders. The lack of understanding of the molecular and neuroanatomical causes has made it difficult to develop effective treatments and it is often difficult to treat in clinical practice. Recent advances in genetics have changed our understanding of polygenic diseases,increasing the possibility of understanding better how molecular pathways are intertwined. This review synthetizes the current state of genetic research providing an overview of genome-wide association studies(GWAS) findings in AN as well as overlap with other disorders, traits, pathways, and imaging results. This paper also discusses the different putative global pathways that are contributing to the disease including the evidence for metabolic and psychiatric origin of the disease.

中国神经性厌食症诊疗专家共识

神经性厌食症是以自我饥饿、体质量显著减轻和营养不良为特征的一类进食障碍。在所有精神疾病中,神经性厌食症死亡率最高,其会导致严重的精神病理症状和危及生命的医疗并发症。然而,目前在中国,对于神经性厌食症不能早期识别和诊治,导致病程迁延。因此,在中华医学会心身医学分会进食障碍协作学组的组织下,联合中华医学会精神医学分会进食障碍研究协作组,由16名医学专家基于循证医学证据、国内外指南与专家共识、专家经验等制定本专家共识,以期提高国内专业人员对神经性厌食症的识别和诊治水平。

中国精神疾病外科治疗专家共识

《中国精神疾病外科治疗专家共识》由全国神经外科、精神科等相关领域专家编写。专家共识根据截至2023年12月发表的临床研究并基于循证医学标准,发布神经外科手术在精神疾病临床中的治疗方案推荐,涵盖疾病包括:强迫症、抑郁症、抽动症、双相障碍、神经性厌食症、物质使用相关障碍、精神分裂症等。本专家共识介绍了临床上神经外科手术治疗精神疾病的安全性和有效性,并初步规范了治疗流程和操作技术,旨在为从事精神疾病外科治疗的临床工作人员制定外科治疗技术应用的专业标准,最大程度上提高治疗效果、促进该治疗技术未来的发展。

神经性厌食患者饮食行为管理方案的构建

目的:构建神经性厌食患者饮食行为管理方案,为科学管理这类患者的饮食行为提供依据。方法:采用半结构式访谈、文献回顾和德尔菲专家函询确定神经性厌食患者饮食行为管理方案。结果:对15名专家进行2轮函询,函询问卷的有效回收率均为100.0%,2轮专家权威系数分别为0.910、0.930,2轮专家协调系数分别为0.295、0.332(P<0.001)。形成包含6个一级条目、16个二级条目、32个三级条目的神经性厌食患者饮食行为管理方案。结论:制定的神经性厌食患者饮食行为管理方案科学、可靠,可为临床管理神经性厌食患者饮食行为提供参考依据。

小儿捏脊联合针刺四缝穴治疗脾失健运型小儿厌食症临床研究

目的:观察小儿捏脊联合针刺四缝穴治疗小儿脾失健运型厌食症的临床疗效。方法:采用区组随机法将100例脾失健运型小儿厌食症患者分为治疗组、对照组各50例。治疗组给予小儿捏脊联合针刺四缝穴治疗,对照组予葡萄糖酸锌口服液治疗,2组均治疗8周。比较2组治疗前后中医证候积分、血清锌、血红蛋白、胆囊收缩素(CCK)、瘦素(LEP)、神经肽Y (NPY)水平,比较2组临床疗效、疾病复发率及不良反应发生情况。结果:治疗组总有效率98.00%,高于对照组82.00%(P<0.05)。治疗后,2组中医证候积分、CCK、LEP水平均较治疗前降低(P<0.05),血清锌、血红蛋白、NPY水平均较治疗前升高(P<0.05);治疗组治疗后中医证候积分、CCK、LEP水平低于对照组(P<0.05),血红蛋白、NPY水平高于对照组(P<0.05)。2组治疗后血清锌水平比较,差异无统计学意义(P>0.05)。治疗组疾病复发率低于对照组(P<0.05)。2组均未发生呕吐、晕针、过敏等不良反应。结论:小儿捏脊联合针刺四缝穴治疗脾失健运型小儿厌食症,可以明显改善小儿临床症状,改善摄食功能,降低疾病复发率。

青少年神经性厌食患者父母照护体验的质性研究

目的 深入了解青少年神经性厌食患者父母在照护过程中的体验,为制订针对性干预措施提供参考。方法 2022年9-11月,采用目的抽样法,选取14名青少年神经性厌食患者的父母进行半结构式访谈,运用Colaizzi七步分析法提炼主题。结果 青少年神经性厌食患者父母的主要照护体验可归纳为以下4个主题:负性体验(对疾病缺乏认知、患者低体重带来的冲击与内疚、食物背后的病态亲子关系、病耻感体验、对疾病预后的担忧)、照顾负担(进餐方式及习惯改变、经济负担加重)、积极体验(支持与被支持、照护信念增强、个人成长与蜕变)以及渴望全方位的支持(持续的专业照护支持、更多社会关注)。结论 医护人员应重视疾病照护知识、技能及亲子互动模式等多方面的指导和支持,同时联合积极心理干预,以有效减轻青少年神经性厌食患者父母的负性体验,促进患者更快、更好地康复。

小儿推拿治疗小儿厌食的研究进展

小儿厌食症是一种对儿童生长发育造成不良影响的消化系统疾病,小儿推拿治疗小儿厌食有显著效果,通过特定穴位推拿、捏脊手法推拿可有效改善小儿厌食症的临床症状,提高治疗效果。同时小儿推拿还能与针刺、穴位贴敷、中药内服方案进行有效结合,在小儿厌食症的治疗中亦有良好效果。本文对小儿推拿治疗小儿厌食症的研究进展进行综述。

Balancing the Inpatient-Nurse Relationship in Anorexia Care

Background: Nurses play a central role in the treatment of inpatients with anorexia, where bonding is a key factor. The inpatient-nurse relationship is based on a confident alliance characterized by important factors such as trust, confidentiality, responsiveness, genuineness, and consistency. Aim and Research Question: The aim of this study was to describe patients’ in-depth experiences of their relationship with nurses when hospitalized for anorexia. The research question was: How do women hospitalized due to anorexia nervosa experience the nurse-patient relationship? Method: A hermeneutic approach with in-depth interviews was employed. Five women with previous experience of inpatient care for anorexia were interviewed. Findings: The findings summarized how the women experienced the relationship with professional nurses in a ward characterized by a high degree of structure. The main theme Balancing feelings of emotional contradictions in the patient-nurse relationship was described by two sub-themes;Opening up for a care relationship in a rigid and structured ward atmosphere and Fluctuating in a paradox of conflicting feelings. Discussion: From the patients’ perspective, balancing the patient-nurse relationship when an inpatient involves conflicting emotional challenges. Structured interventions are perceived as effective by the patients, although they may be ambivalent about them. Therefore, a good relationship depends on the establishment of emotional and stable interaction with the nurses. Implications for Nursing Practice: Patients need interventions based on safe and competent quality care. A hermeneutic approach may improve the nurses’ ability to meet these patients in their lifeworld and establish a confident relationship. Special education related to anorexia care should be a priority in nursing.

A neuropsychological evaluation of orthorexia nervosa

Orthorexia nervosa (ON) describes a fixation for proper nutrition and healthy foods that leads to die-tary restrictions and nutritional deficiencies over time. Given symptom overlap among ON, obsessive-compulsive disorder (OCD), and anorexia nervosa (AN), this study examines whether ON has a unique neuropsychological profile. Participants completed symptom checklists and neuropsychological tests chosen for their sensitivity to AN and OCD. Results showed that, across the full sample, ON is independently associated with self-reported weaknesses in Set-Shifting, Emotional Control, Self-Monitoring, and Working Memory. After controlling for AN and OCD variables, high- and low-ON groups differed in total correct trials on the Wisconsin Card Sorting Test. These areas of executive functioning, which are explained in the context of ON symptomatology, represent what would be considered the neuropsychological overlap among OCD and AN profiles.