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Objective: To assess the risk of somatic diseases in connection with anorexia nervosa (AN)., Method: This matched cohort study was based on Danish registries of all patients born 1961-2008 with a first-time diagnosis of AN in 1994-2018 at age 8-32 and matched controls without an eating disorder. For 13 somatic disease categories, time from inclusion date to time of first somatic diagnosis, accounting for censoring, was studied by use of time-stratified Cox models., Results: A total of 9985 AN patients born 1961-2008 and 49,351 controls were followed for a median (interquartile range) of 9.0 (4.4-15.7) years. During the first 2 years after entry there was a 60% higher hazard for any somatic disease among patients with AN than among controls, while the ratio from three to 11 years was reduced to 1.18. Regardless of age at diagnosis, the hazard among patients and controls were no different at approximately a decade after diagnosis of AN and the cumulative risk for patients for 12 of 13 disease categories was always higher or no less that for controls. For all disease categories, the hazard ratio (HR) was higher when close to entry. For most disease categories, age at diagnosis of AN did not modify the effect., Discussion: While around 90% of all individuals had any somatic disease at the end of follow-up, the cumulative incidence over time was higher for patients with AN than for controls. Large HRs were seen in the early years after diagnosis during which patients require extensive medical interventions., Public Significance: Based on Danish registries, a large sample of almost 10,000 patients with AN born 1961-2008 and almost 50,000 matched controls were followed for a median of 9 years. While around 90% of all individuals had any somatic disease at the end of follow-up, the cumulative incidence over time was higher for patients with AN than for controls., (© 2022 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Objective: Comorbid mental disorders in anorexia nervosa during long-term course require detailed studies., Method: This matched cohort study was based on nationwide Danish register data of all patients born 1961-2008 with a first-time ICD-10 diagnosis of anorexia nervosa (AN) between 1994 and 2018 at age 8-32 and matched controls taken from all individuals without an eating disorder (ED). For nine categories of non-eating mental disorders, time from date of first AN-diagnosis (inclusion date) to time of first diagnosis, accounting for censoring, was studied by use of time-stratified Cox models., Results: A total of 9,985 patients with AN (93.5% females) and 49,351 matched controls were followed for a median (IQR) of 9.0 (4.4-15.7) years. For patients, there was about 25% and 55% risk of receiving any non-ED disorder during the first 2 years and two decades after inclusion, respectively. A hazard ratio (HR) of seven for any non-ED was found for the first 12 months after inclusion, a ratio that reduced to two at five or more years after inclusion. During the first years, large HRs ranging in 6-9 were found for affective, autism spectrum, personality, and obsessive-compulsive disorders with the latter displaying the highest continuous increased risk. The HR at 12 months after inclusion was highest for any non-ED disorder and affective disorders in patients aged 8-13 at diagnosis., Discussion: Comorbid mental disorders in AN are most frequently diagnosed in the first years after diagnosis of AN and on longer terms imply a double immediate risk., (© 2021 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Background: Treating patients with anorexia nervosa (AN) remains a major challenge. The choice between an inpatient or an outpatient care setting is an essential issue for the patients and for their relatives with major health economic implications. However, health services-related studies are lacking. The present study was a descriptive exploration of time-trends in treatment modes of patients with free and equal access to health services., Methods: The study was based on a nationwide cohort of patients diagnosed for the first time with AN, each followed for 5 years in the registers covering the years 1994-2018. The per patient number of hospital admissions, cumulated number of days of hospitalization and number of outpatient visits during the first 5 years after initial diagnosis were considered., Results: The cohort of patients with AN with at least 5 years of follow-up amounted to N = 7,505. A clear trend was observed in the per patient five-year cumulated number of inpatient days, decreasing by 6% per year after adjustment for age at diagnosis, parental mental diagnosis, and family income. The five-year number of hospital admissions after initial diagnosis decreased by 2% per year, while no trend was observed for outpatient visits., Conclusions: The per patient number of hospitalizations and cumulated days of hospitalization during 5 years after diagnosis were reduced for patients initially diagnosed with AN while there was no change in the number of outpatient visits. The factors contributing to these changes of treatment modes over time are in need of further study., (© 2020 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Objective: To study recent time trends in the incidence of diagnosed anorexia nervosa (AN) and bulimia nervosa (BN) based on nationwide psychiatric register data., Method: The Danish Psychiatric Central Research Registry was used to identify the incidence of diagnosed cases with AN and BN at the ages of 4-65 years from 1995 to 2010. Age- and sex-adjusted incidence rates per 100,000 person-years were calculated and were adjusted for time trends in the total number of people diagnosed in psychiatry. Time trends were analyzed using JoinPoint regression analysis., Results: A total of N = 5,902 persons had a first-time incidence of AN, and a total of N = 5,113 had first-time incidence of BN. Incidence rates increased for AN from 6.4 to 12.6 per 100,000 person-years, and for BN from 6.3 to 7.2 per 100,000 person-years. In 2010, the male-to-female ratio was 1:8 for AN, and 1:20 for BN. There was an earlier onset for AN than for BN, and age at incidence decreased during the observation period for AN but not for BN. A sizeable part of the increasing incidence rates for AN and in particular, the younger AN age groups, could be attributed to an increase in the total number of N = 249,607 persons with first-time diagnoses in psychiatry., Discussion: Incidence rates had increased slightly for AN, but were stable for BN across 16 years in this nationwide study and to a large extent were reflective of a general increase in diagnosed mental disorders., (© 2015 Wiley Periodicals, Inc.)

Objective: This nation-wide register-based study investigated how often anorexia nervosa (AN) and co-morbid disorders occur in affected families compared with control families. Furthermore, the study addressed the impact of sex, year of birth, and degree of urbanization in terms of risk factors., Method: A total of N = 2,370 child and adolescent psychiatric subjects born between 1951 and 1996 and registered in the Danish Psychiatric Central Research Register (DPCRR) had any mental disorder before the age of 18 and developed AN at some point during their life-time. In addition, N = 7,035 controls without any psychiatric diagnosis before age 18 and matched for age, sex, and residential region were included. Psychiatric diagnoses were also obtained on the first-degree relatives as a part of the Danish Three Generation Study (3GS). A family load component was obtained by using various mixed regression models., Results: AN occurred significantly more often in case than in control families. AN Risk factors included having a sibling with AN, affective disorders in family members, and co-morbid affective, anxiety, obsessive-compulsive, personality, or substance use disorders. Furthermore, female sex, and ascending year of birth were significantly associated with having AN. Urbanization was not related to the family load of AN and case-relatives did not develop AN earlier than control relatives., Discussion: These findings based on a very large and representative dataset provide evidence for the family aggregation and further risk factors in AN., (© 2014 Wiley Periodicals, Inc.)

Objective: The relevance of repeated body mass index (BMI) assessments for long-term outcome in anorexia nervosa (AN) was studied., Method: Two-hundred and twelve adolescent patients aged 10-18 (Mean 14.9) years from five sites were followed up for an average of 8.3 years after first admission. Various predictors of BMI at follow-up were analyzed., Results: In comparison to subjects with normal BMI (>17.5) at final follow-up, subjects with BMI <17.5 had significantly lower age-adjusted BMI prior to onset of the disorder and at discharge from first admission. In addition, all outcome scores indicated poorer functioning in the group with BMI < 17.5. The BMI prior to onset of AN, the BMI at first hospital admission and discharge, and the BMI at final follow up were significantly correlated across time. Higher BMI prior to onset of AN, higher BMI at first discharge, and lower age at first admission predicted a normal BMI (>17.5) at follow-up in a model of logistic regression., Conclusion: The long-term outcome of adolescent AN reflects the normal tracking of BMI over time. Presumably, the tracking in AN patients is somewhat reduced in comparison to healthy subjects., (2008 by Wiley Periodicals, Inc.)

Both Anorexia Nervosa (AN) and Bulimia Nervosa (BN) are marked by a serious course and outcome in many of the afflicted individuals. In AN, there are an almost 18-fold increase in mortality including a high suicide rate, chronic courses in approximately 20 per cent of the cases, and more than half of the patients showing either a complete or a partial eating disorder in combination with another psychiatric disorder or another psychiatric disorder without an eating disorder. Mitigating factors of the outcome include onset of the disorder during adolescence and longer duration of follow-up. Vomiting, bulimia and purgative abuse, chronicity, and obsessive-compulsive features represent unfavourable prognostic factors in various studies. The longer-term outcome of BN is only slightly better result as compared to AN; however, the rate of mortality is low. Diagnostic crossover from bulimia nervosa to other eating disorders is a rather rare phenomenon, whereas the high rates of partial eating disorders may explain a large proportion of chronic courses. Social adjustment and the quality of personal relationship normalize in the majority of the affected patients. At present, the study of prognostic factors in bulimia nervosa does not allow any definite conclusions.

Objective: The course and clinical predictors of rehospitalization were studied in a large sample of adolescent patients with anorexia nervosa who had been treated at five European sites and been followed-up., Method: Two-hundred and twelve adolescent patients first admitted for in-patient treatment, aged 10-18 (Mean 14.9) years and 94.8% female, were followed-up for an average of 8.3 years after first admission at sites in (former East and West Berlin, Zurich, Sofia, and Bucharest). Clinical history data were collected by use of standardized item-sheets at first admission. Semi-structured interviews including ratings of eating pathology and psychosocial outcome were performed at follow-up., Results: About 44.8% (95/212) of the patients required at least one readmission. Rates of rehospitalization were significantly higher at the Eastern sites (Sofia and Bucharest). Significant predictors of readmission were paternal alcoholism, history of anorexia nervosa in the family, eating disorder in infancy, periodic overactivity, lower weight increase at first admission, and lower BMI at first discharge. In a model of logistic regression analysis, five variables (paternal alcoholism, eating disorder in infancy, periodic overactivity, low weight increase during first admission, and low BMI at first discharge) correctly classified 69% of the participants into cases with single or repeated admissions. Patients with repeated admissions had a less favorable long term outcome and had higher rates of persisting psychopathology at follow-up., Conclusion: Rehospitalization reflects the chronic course in a sizable proportion of adolescent patients with anorexia nervosa. Family psychopathology may have an effect both in terms of genetic vulnerability and environmental stress leading to unfavorable courses. The strong effect of insufficient weight gain during first admission and lower BMI at first discharge emphasizes the importance of adequate interventions. Readmissions carry the risk for later poor psychosocial and psychiatric outcomes.

Objective: The present review addresses the outcome of anorexia nervosa and whether it changed over the second half of the 20th century., Method: A total of 119 study series covering 5,590 patients suffering from anorexia nervosa that were published in the English and German literature were analyzed with regard to mortality, global outcome, and other psychiatric disorders at follow-up., Results: There were large variations in the outcome parameters across studies. Mortality estimated on the basis of both crude and standardized rates was significantly high. Among the surviving patients, less than one-half recovered on average, whereas one-third improved, and 20% remained chronically ill. The normalization of the core symptoms, involving weight, menstruation, and eating behaviors, was slightly better when each symptom was analyzed in isolation. The presence of other psychiatric disorders at follow-up was very common. Longer duration of follow-up and, less strongly, younger age at onset of illness were associated with better outcome. There was no convincing evidence that the outcome of anorexia nervosa improved over the second half of the last century. Several prognostic features were isolated, but there is conflicting evidence. Most clearly, vomiting, bulimia, and purgative abuse, chronicity of illness, and obsessive-compulsive personality symptoms are unfavorable prognostic features., Conclusions: Anorexia nervosa did not lose its relatively poor prognosis in the 20th century. Advances in etiology and treatment may improve the course of patients with anorexia nervosa in the future.

Background: A cohort of 60 adolescent eating-disordered patients that was consecutively admitted between 1979 and 1988 to a child and adolescent psychiatric university department in Berlin, Germany was followed up at a mean of 5-0 years and for a second time at a mean of 11.5 years., Methods: Each patient was personally interviewed and findings dealing with eating disorder symptoms and psychosocial functioning were rated on four-point scales. In addition, the duration of both in-patient and out-patient treatment and the Body Mass Index (BMI) were recorded., Results: Patients were in treatment for a mean of 33 % of the initial 5-year follow-up period, but this has dropped to a mean of 17% of the entire 11-year follow-up period. No predictors of treatment duration were found. The mortality rate was 8.3% at the second follow-up. The distribution of abnormal BMIs ( < 17.5) reflected a trend of improvement with increasing duration of follow-up. In comparison to the 5-year follow-up, fewer patients suffered from symptoms of the full clinical picture of an eating disorder at the 11-year follow-up. Among the surviving patients 80% recovered during the long-term course. There were few specific predictors of three different outcome criteria., Conclusion: This outcome study of adolescent eating disorders provides further evidence that the long-term course of the disorders in terms of the eating pathology is better than can be expected after a few years. Very little can be said with regard to individual prognosis.

Objective: This is a study of prevalence rates for anorexia nervosa (AN) and bulimia nervosa (BN) in an epidemiological sample of Swiss adolescents., Method: A two-stage approach was used which involved the screening of a large sample of adolescents aged 14-17 and subsequent interviews of screen-positive and control subjects., Results: The prevalence rates for adolescent girls were 0.7% for AN and 0.5% for BN., Discussion: Full clinical syndromes of AN and BN in adolescents are by far less frequent than individual symptoms of eating disorders. There is more cross-cultural variation for prevalence rates in BN than in AN.

Objective: The authors investigated the hypothesis that in acute anorexia nervosa a low body weight predicts a poor weight prognosis for the future., Method: The body mass indexes at referral of 272 female patients were examined in relation to the body mass indexes of these patients after a mean follow-up of 9.5 years., Results: The overall correlation between body mass indexes at referral and at follow-up was r = 0.33. Despite this low correlation, the 100 patients with body mass indexes less than 13 kg/m2 at referral had low weights at long-term follow-up. Eleven of the 12 deceased patients were among these 100 patients, as were 24 of the 46 surviving patients whose body mass indexes were 17.5 kg/m2 or less at follow-up., Conclusions: For patients with anorexia nervosa, a body mass index less than 13 kg/m2 at referral indicates a substantial risk for chronic anorexia nervosa and death related to emaciation.

Treatment of adolescent anorectic patients includes a comprehensive assessment of the patient's condition, measures leading to effective weight restoration and the choice of the optimal treatment setting. The main psychotherapeutic approaches include supportive individual psychotherapy, behavioural, and family therapy. Individual psychotherapy is provided by a supportive relationship with treatment staff and the therapeutic environment of the ward. Behavioural therapy uses operant conditioning to promote weight gain and may include cognitive methods and social skills training. Family therapy may also be beneficial for some adolescent patients. There is no evidence that pharmacotherapy, besides treating depressive symptoms, has any beneficial effect in anorectic patients. The outcome and prognosis of an individual patient is unpredictable.

Data collected in the 1980's, before the reunification of Germany, and comparing 39 patients in former East Berlin and 60 patients in former West Berlin are presented in this second report on the Berlin longitudinal study of eating disorders in adolescence. The clinical profiles of patients of former East Berlin were found to differ from those of their West Berlin counterparts in the following assessed measures: younger age at disease onset and at admission for inpatient treatment; greater number of siblings; fewer accounts of the clinical symptoms lanugo, bradycardia, hypothermia, constipation; lower rate of premorbid psychopathological features; lower number of psychopathological findings; less frequent sibling rivalry; lower rate of psychopathological attributes among the siblings; lower incidence of maternal mental and physical illness; higher parental educational status; fewer number of complaints, and better sense of well-being.

After more than four years, ten patients in a cohort of 60 consecutively-assessed adolescent patients with eating disorders were no longer available for follow-up--four had died and six refused to participate further. The follow-up interviews indicated varying rates of impairment in relation to eating disorders, menstrual anomalies, sexuality and psychosocial functioning. The distribution of continuing disorders at follow-up was a) 10% anorexia nervosa, b) 4% anorexia nervosa with bulimia, c) 18% anorectic and bulimic partial syndromes. The remaining 68% were found to have recovered. During the course of illness, there were few instances of anorectic symptoms crossing over into bulimic ones. A uniform pattern in the disease course was observed throughout the various self-evaluation questionnaires: reduction of symptoms that occurred during the course of the inpatient treatment could also be observed at the time of the follow-up. As compared with the international literature on follow-up studies, these can be considered as favorable findings.

This third report from the Berlin follow-up study of eating disorders in adolescence reports findings pertaining to evaluation and prognosis. Based on a systematic analysis of the relevant literature on the course of eating disorders, the following items were analyzed with respect to their value in predicting the psychopathological status of the patient at discharge from inpatient treatment and at follow-up: BMI at admission, age at onset of the disease, duration of symptoms before admission, personality features such as depression and neuroticism, the number of physical complaints, diagnosis (anorexia vs. bulimia), type of eating disorder (purger vs. restrictor), premorbid eating disorders or behavioral abnormalities, socioeconomic status, duration of in-patient treatment, and out-patient psychotherapy following discharge from the hospital. None of the factors predicted psychopathological status at either discharge or long-term follow-up.

A consecutive series of 60 adolescent patients with eating disorders was followed up after a mean period of 58 months. At intermediate follow-up, 4 (6.65) of the former patients were reported deceased, and 6 could either not be traced or refused to cooperate. Follow-up assessment revealed the following diagnostic pattern in 50 patients who were followed up: 5 (10%) of the patients still suffered from anorexia nervosa, 2 (4%) from anorexia nervosa with bulimia, 7 (14%) from partial syndromes of anorexia nervosa, 2 (4%) from partial syndromes of bulimia nervosa, and 34 (68%) had recovered. Questionnaire findings indicated that the improvements that occurred during inpatient treatment were intact at follow-up. No significant findings were revealed by the analysis of a large scale of potential prognostic factors.

Questionnaire scores were compared across three outcome groups in a follow-up of eating-disordered patients with onset of the disease during adolescence. Among a total of 40 patients, 7 continued to suffer from either anorexia or bulimia nervosa. Seven additional patients displayed partial syndromes and 26 had recovered. Both a semantic differential measuring body image and the Eating Attitudes Test (EAT) demonstrated limited evidence of clinical sensitivity by differentiating the three outcome groups. The Eating Disorders Inventory (EDI) did not discriminate the three outcome groups. Obviously, clinical interviews and self-report questionnaires tackle different facets of the eating disorders and, therefore, both should be used in outcome studies.

Within a prospective longitudinal outcome study of the eating disorders with onset during adolescence, 26 former patients were reassessed at short-term (19-38 months) and intermediate-term (48-72 months) follow-up periods. It was shown that the outcome was worse at short-term follow-up. In addition, the changes of diagnostic categories within the spectrum of the eating disorders were studied. It is concluded that outcome studies require repeated assessments to study the various patterns of course of the eating disorders.

Forty German adolescent anorectic patients were assessed with regard to self-image components as measured by the Offer Self-Image Questionnaire (OSIQ). The profile of this group deviated negatively from the German standardization group of healthy subjects on measures of impulse control, emotional tone, body image, social relationships, sexual attitudes, and psychopathology. In addition, the OSIQ profile of this German sample was remarkably similar to the profiles of samples reported in two American studies. Finally, it was found that inpatient treatment served to improve the psychological condition of the patients with regard to certain but not all self-image components. Despite a trend of improvement, some of the scores did not fully normalize in this sample.

Following an introductory comment regarding the purpose of this longitudinal study on eating disorders in adolescence, findings based on assessment of the illness course during inpatient treatment are presented. A multidimensional research design that included both self rating and rating by others demonstrates a clear reduction of symptoms in a number of different areas. This is evident in the 'semantic differential' self-evaluation with regard to body-image and personality, the patient's attitudes toward eating, specific characteristics of the eating disorder syndrome, the self-concept, various personality attributes, physical complaints, and the sense of well-being. The analogous assessments made by therapists and ward staff members also indicated definite improvement with regard to those symptoms that are specific to eating disorders.

Eating attitudes were assessed by use of the Eating Attitude Test (EAT) in two samples of normal German female adolescents and young adults. In addition scores from clinical samples of anorectic patients were available. The EAT contributed to an adequate differentiation between normal controls and clinical patients. There were marked transcultural differences with regard to mean and cut-off scores obtained in Anglo-Saxon studies where the present samples scored lowest. Reliability in terms of internal consistency and stability was more satisfactory. Neither age nor SES were significantly related to the total score. Subjects with extreme obesity had significantly increased scores on the EAT.

The psychological characteristics of anorectic patients were compared in studies in Germany and in North America. German adolescent patients scored significantly lower on the Eating Attitude Test and the Eating Disorder Inventory than did Canadian patients. On the other hand, self-image as measured by the Offer Self-Image Questionnaire was strikingly similar among German and American adolescent anorectics.

An abbreviated version of the Goldberg Anorectic Attitude Scale (GAAS) consisting of seven subscales was analyzed with the aid of a sample of 23 adolescent anorexic patients with early onset of the disease. Intercorrelations indicated that the individual scales were sufficiently independent. A test of convergent validity resulted in substantial correlations of some scales of the GAAS with other scales measuring anorexic behaviour and symptoms. Clinical characteristics of the anorexic syndrome and a number of the background variables had no effect on GAAS scores. The validity of the subscale measuring denial of illness is questionable. On the other hand, there is some indication of clinical utility of the GAAS since it adequately reflects change due to inpatient treatment.

Twenty-one female patients between the ages of 15 and 44 years who had suffered from anorexia nervosa between the ages of 11 and 17 were re-evaluated at a mean follow-up of 9.4 years. The continuing psychic impairment of the former patients was apparent both in interviews and questionnaires. Abnormalities were found in 10 to 66% of the patients according to different symptoms and criteria. The outcome was less favourable for patients who had experienced a high initial weight loss and had been subjected to repeated in-patient treatment. Three variables were most significant in terms of poor long-term prognosis: pre-morbid obesity, pre-morbid eating disorders and complications during pregnancy.

After some introductory remarks dealing with evaluation research of the course of anorexia nervosa the sample and methodology of the author's prospective study of young anorexic patients are outlined. Selected findings coming from systematic assessment at the time of admission and discharge are presented. Furthermore, findings coming from analyses predicting change during in-patient treatment are reported.