Objective
A description of atypical anorexia nervosa (atypical AN) was provided in DSM‐5 in 2013 and a sizable literature has since developed describing the clinical features of individuals with ...atypical AN and comparing them to those of individuals with anorexia nervosa (AN) and those of healthy individuals. The purpose of this study was to conduct a systematic review of this literature.
Method
A systematic review following PRISMA guidelines was conducted of studies published since 2013 that compared the clinical characteristics of individuals with atypical AN to those of individuals with AN and/or healthy controls. Meta‐analyses were conducted when similar measures were reported in three or more studies.
Results
Twenty‐four publications met criteria for inclusion. Their results indicated that the level of eating disorder‐specific psychopathology is significantly higher among individuals with atypical AN than among controls and as high or higher as among individuals with AN while levels of non‐eating disorder psychopathology are similar. Individuals with atypical AN experience many of the physiological complications associated with AN, but some complications appear less frequent.
Discussion
The psychological symptoms and physiological complications of individuals with atypical AN are generally similar to those of individuals with AN, although there may be differences in the frequency of some physical complications. Little information is available on the course, outcome, and treatment response of individuals with atypical AN. In addition, full diagnostic criteria for atypical AN have not been developed, and the nosological relationship of atypical AN to established eating disorders such as bulimia nervosa is unclear.
Public Significance
Atypical anorexia nervosa as described in the DSM‐5 identifies individuals with many of the psychological characteristics of typical anorexia nervosa who, despite significant weight loss, are not underweight. The current systematic review found that the psychological symptoms and physiological characteristics of individuals with atypical AN are generally similar to those of individuals with AN, although there may be differences in the frequency of some physical complications.
Objetivo
En 2013 se realizó una descripción de la anorexia nerviosa atípica (ANA) en el DSM‐5 y desde entonces se ha desarrollado una literatura considerable que describe las características clínicas de los individuos que padecen anorexia nerviosa atípica y los compara con los de los individuos que padecen anorexia nerviosa (AN) y los de individuos sanos. El propósito de este estudio fue realizar una revisión sistemática de esta literatura.
Método
Se realizó una revisión sistemática siguiendo las guías PRISMA de estudios publicados desde 2013 que compararon las características clínicas de individuos que padecen anorexia nerviosa atípica con las de individuos que padecen anorexia nerviosa y/o controles sanos. Se realizaron metaanálisis cuando se reportaron medidas similares en tres o más estudios.
Resultados
Veinticuatro publicaciones cumplieron con los criterios de inclusión. Sus resultados indicaron que el nivel de psicopatología específica del trastorno de conducta alimentaria es significativamente mayor entre los individuos que padecen anorexia nerviosa atípica que entre los controles y tan alto o más alto como entre los individuos que padecen anorexia nerviosa, mientras que los niveles de psicopatología del no trastorno de la conducta alimentaria son similares. Los individuos que padecen anorexia nerviosa atípica experimentan muchas de las complicaciones fisiológicas asociadas con la anorexia nerviosa, pero algunas complicaciones parecen menos frecuentes.
Discusión
Los síntomas psicológicos y las complicaciones fisiológicas de los individuos que padecen anorexia nerviosa atípica son generalmente similares a los de los individuos que padecen anorexia nerviosa, aunque puede haber diferencias en la frecuencia de algunas complicaciones físicas. Hay poca información disponible sobre el curso, el resultado y la respuesta al tratamiento de los individuos que padecen AN atípica. Además, no se han desarrollado criterios diagnósticos completos para la anorexia nerviosa atípica, y la relación nosológica de la anorexia nerviosa atípica con los trastornos de la conducta alimentaria establecidos, como la bulimia nerviosa, no está clara.
Characterized primarily by a low body-mass index, anorexia nervosa is a complex and serious illness
, affecting 0.9-4% of women and 0.3% of men
, with twin-based heritability estimates of 50-60%
. ...Mortality rates are higher than those in other psychiatric disorders
, and outcomes are unacceptably poor
. Here we combine data from the Anorexia Nervosa Genetics Initiative (ANGI)
and the Eating Disorders Working Group of the Psychiatric Genomics Consortium (PGC-ED) and conduct a genome-wide association study of 16,992 cases of anorexia nervosa and 55,525 controls, identifying eight significant loci. The genetic architecture of anorexia nervosa mirrors its clinical presentation, showing significant genetic correlations with psychiatric disorders, physical activity, and metabolic (including glycemic), lipid and anthropometric traits, independent of the effects of common variants associated with body-mass index. These results further encourage a reconceptualization of anorexia nervosa as a metabo-psychiatric disorder. Elucidating the metabolic component is a critical direction for future research, and paying attention to both psychiatric and metabolic components may be key to improving outcomes.
Abstract Anorexia nervosa and bulimia nervosa are serious psychiatric illnesses related to disordered eating and distorted body images. They both have significant medical complications associated ...with the weight loss and malnutrition of anorexia nervosa, as well as from the purging behaviors that characterize bulimia nervosa. No body system is spared from the adverse sequelae of these illnesses, especially as anorexia nervosa and bulimia nervosa become more severe and chronic. We review the medical complications that are associated with anorexia nervosa and bulimia nervosa, as well as the treatment for the complications. We also discuss the epidemiology and psychiatric comorbidities of these eating disorders.
There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive ...clinical management (SSCM) for adults with SE-AN.
Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes.
Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM.
Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.
In this special issue, international researchers investigate how atypical anorexia nervosa (atypical AN) differs from anorexia nervosa (AN) and other eating disorders with respect to demographics, ...psychological and physiological morbidity, as well as treatment course and outcome. Manuscripts in this special issue report that atypical AN is associated with substantial medical and psychological morbidity, and the majority of studies find few differences between atypical AN and AN. While much remains to be learned about the long‐term course and treatment response of individuals with atypical AN to psychological and pharmacological interventions, the evidence supports conceptualization of atypical AN as part of a spectrum‐based restrictive eating disorder. These findings together with the potentially stigmatizing use of the term “atypical” suggest it may be time to revise the existing definition of atypical AN.
Purpose of Review
There is growing interest in the relationship between anorexia nervosa (AN) and autism spectrum disorder (ASD). This review aimed to synthesise the most recent research on this ...topic to identify gaps in current knowledge, directions for future research and reflect on implications for treatment.
Recent Findings
Eight studies assessing the presence of ASD in AN were identified in the literature along with three studies examining the impact of symptoms of ASD on treatment outcome. Research with young people and using parental-report measures suggest lower rates of co-morbidity than previous adult studies.
Conclusions
The wide range of diagnostic tools, methodologies and populations studied make it difficult to determine the prevalence of ASD in AN. Despite this, studies consistently report over-representation of symptoms of ASD in AN. Co-morbid AN and ASD may require more intensive treatment or specifically tailored interventions. Future longitudinal research and female-specific diagnostic tools would help elucidate the relationship between these two disorders.
In this issue of International Journal of Eating Disorders, Walsh et al. review the research to date comparing atypical anorexia nervosa (atypical AN) and AN. Most of the differences observed related ...to weight; eating disorder and noneating disorder psychopathology and complications were similar. The results could suggest that atypical AN and AN are not really different, and these findings should spur further research. Whether informative weight thresholds exist is a critical question. Beyond, why weight differs in these two groups is of great interest. If the two entities can be separated, does this separation predict longitudinal outcome or response to treatment? The high prevalence of atypical AN in clinical settings emphasizes the urgency of continuing research.
Objective
Little is known about how individuals with atypical anorexia nervosa (AN) respond to eating disorder (ED) treatment in a partial hospitalization program (PHP), nor how certain factors such ...as trauma, childhood abuse, psychiatric comorbidity, and suicidal thoughts and behaviors might contribute to poor treatment outcomes. Thus, the current study (1) compares prevalence of these factors between individuals with AN and atypical AN upon admission to an ED PHP, (2) compares PHP treatment response between groups, and (3) investigates whether experiencing these factors impacts treatment outcomes.
Method
We conducted a retrospective chart review of young adults admitted to a PHP with AN (n = 95) and atypical AN (n = 59). Histories of psychiatric comorbidities and adverse childhood experiences were obtained from initial psychiatric evaluations. ED symptoms were assessed at intake and discharge with the Eating Disorder Examination‐Questionnaire (EDE‐Q).
Results
No significant differences were found at intake in ED symptom severity or prevalence of lifetime trauma, childhood abuse, number of psychiatric diagnoses, or suicidal thoughts and behavior. Symptomatology at discharge also did not differ between groups. Emotional abuse was significantly related to discharge shape and weight overvaluation. No other intake characteristics were significantly related to discharge symptomatology.
Discussion
To our knowledge, this is the first study to compare the prevalence of comorbidities for both AN and atypical AN, as well as differential treatment outcomes for these individuals in a PHP. Results add to growing literature suggesting that, other than weight, AN and atypical AN have few properties that reliably distinguish them from one another.
Public Significance
This study adds to a growing body of literature that raises questions about whether anorexia nervosa (AN) and atypical AN are truly different diagnoses. Our findings suggest these two groups present to treatment in a partial hospitalization program (PHP) with similar ED symptoms, as well as prevalence of lifetime trauma, childhood abuse, suicidal thoughts and behavior, and number of psychiatric comorbidities, and demonstrate similar treatment trajectories in PHP.
The main aims of this study were to describe change in psychological outcomes for adolescents with anorexia nervosa across two treatments, and to explore predictors of change, including baseline ...demographic and clinical characteristics, as well as weight gain over time. Participants were 121 adolescents with anorexia nervosa from a two-site (Chicago and Stanford) randomized controlled trial who received either family-based treatment or individual adolescent supportive psychotherapy. Psychological symptoms (i.e., eating disorder psychopathology, depressive symptoms, and self-esteem) were assessed at baseline, end of treatment, 6-month, and 12-month follow-up. Conditional multilevel growth models were used to test for predictors of slope for each outcome. Most psychological symptoms improved significantly from baseline to 12 month follow-up, regardless of treatment type. Depressive symptoms and dietary restraint were most improved, weight and shape concerns were least improved, and self-esteem was not at all improved. Weight gain emerged as a significant predictor of improved eating disorder pathology, with earlier weight gain having a greater impact on symptom improvement than later weight gain. Adolescents who presented with more severe, complex, and enduring clinical presentations (i.e., longer duration of illness, greater eating disorder pathology, binge-eating/purging subtype) also appeared to benefit more psychologically from treatment.
•Psychological symptoms improved significantly across two adolescent AN treatments.•Weight gain was one of the best predictors of eating disorder symptom improvement.•Improvements in weight and shape concerns were small and not impacted by weight gain.•More severe, complex, and enduring cases of AN had greater psychological improvement.
Objective:
Many patients with anorexia nervosa develop an intractable and debilitating illness course. Our aims were to (i) conduct a systematic review of randomised controlled trials (RCTs) of ...treatment for chronic anorexia nervosa participants, and (ii) identify research informing novel therapeutic approaches for this group.
Methods:
Systematic search (SCOPUS plus previous reviews date 2011) of literature for (i) RCTs of treatment that included anorexia nervosa participants with a mean duration of illness of at least 3 years, (ii) studies reporting new treatments addressing factors associated with chronicity.
Results:
Evidence of efficacy for treatment approaches in severe and enduring anorexia nervosa is limited. Only one unpublished RCT designed to test a specific psychological approach for these patients was identified. There is a probable advantage for specialist psychotherapy over treatment as usual, and a promising study of relapse prevention with cognitive behaviour therapy (CBT) for anorexia nervosa (CBT-AN). Open trials have, however, reported developments in psychological therapies that warrant further specific evaluation. These include forms of CBT modified for anorexia nervosa, cognitive remediation therapy with emotion skills training, the Maudsley Model for Treatment of Adults with Anorexia Nervosa, the Community Outreach Partnership Program, Specialist Supportive Clinical Management and the approach of Strober with its emphasis on therapeutic alliance and flexible goals.
Conclusions:
Treatment trials need to move beyond targeting core eating disorder pathology (primarily weight restoration) and examine efficacy and effectiveness in minimising harm and reducing personal and social costs of chronic illness. There is also a need to develop better definitions of chronicity, with or without treatment ‘resistance’ specifiers.
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