Academic journal article Journal of Eating Disorders

Does Anxiety Improve during Weight Restoration in Anorexia Nervosa? A Systematic Review

Academic journal article Journal of Eating Disorders

Does Anxiety Improve during Weight Restoration in Anorexia Nervosa? A Systematic Review

Article excerpt

Author(s): Sarah Kezelman[sup.1], Stephen Touyz[sup.1], Caroline Hunt[sup.1] and Paul Rhodes[sup.1]

Review

Anorexia Nervosa (AN) is a severe ego-syntonic psychiatric illness [1] characterized by a refusal to maintain a minimally normal body weight and an intense fear of gaining weight or becoming fat (DSM-5) [2]. Severe malnutrition associated with AN results in a number of deleterious physiological outcomes [3,4] and moreover, is associated with AN having the highest mortality rate of any psychiatric disorder [1,5,6], with standardized mortality ratios (i.e., the ratio of observed to expected deaths) estimated at approximately 5.86 to 8.85 [7,8]. Inpatient admissions aimed at correcting the biological sequelae of malnutrition are thus indicated for individuals with AN at imminent risk of severe medical compromise [9,10].

At present treatment outcomes for individuals with AN is relatively poor with longitudinal research demonstrating that high dropout rates [11-13], high rates of re-admission [14,15], and low rates of long-term holistic recovery [5,7] should be considered normative [16]. Furthermore, evidence suggests that individuals who are discharged or dropout from inpatient wards prior to achieving weight normalization are more likely to be re-hospitalised and have poorer treatment outcomes in the long-term [17,18]. Importantly, low body mass index (an indicator for those individuals most in need of nutritional rehabilitation) at referral has been associated with poorer treatment outcome and prognosis [19]. While weight restoration is unquestionably a fundamental clinical aspect of AN that needs to be targeted in treatment interventions, there are increasing suggestions that changes in weight restoration alone are insufficient for long-term recovery [8,20,21]. Thus, consideration of additional factors that may be associated with and contribute to this treatment profile is necessitated.

Clinical consensus accepts that psychological variables are affected by the acute stage of malnutrition. That is, starvation can result in psychological complications, including effects on mood and cognitive functioning [22,23]. Less is known, however, about the progression of psychological variables during the different stages of AN and their role in the maintenance of anorectic symptomology. Questions have repetitively been raised as to whether psychological symptoms should be regarded solely as complications of malnutrition, or whether they represent unique psychiatric features that need to be considered independently, and/or whether psychiatric comorbidity needs to be considered as normative. Despite increasing suggestions that core behavioral, attitudinal, and emotional disturbances [24,25] may persist after weight normalization and that core psychological difficulties do not automatically resolve following weight restoration in patients with AN [26-28], research remains limited.

A previous review addressing the aforementioned question considered both depressive and anxiety symptomology [29]. This review included 7 studies representing heterogeneous methodology and reporting largely contradictory findings, rendering a conclusive result impracticable [29]. There have been some theoretical suggestions that depressive symptomology in AN results in response to prolonged illness and symptom chronicity [30], whereas anxiety symptomology may increase vulnerability to eating disorder pathology [31]. Consistent with these suggestions, Hughes [32] in a comprehensive review of comorbid depression and anxiety in childhood and adolescent AN found that while anxiety symptoms tended to pre-date AN onset and persist following recovery, depression was likely to onset after AN and abate following recovery. As such, the current study chose to focus exclusively on anxiety symptomology in order to elucidate possible findings.

Focus on anxiety is further implicated by recent literature indicating high rates of psychiatric comorbidity between anxiety disorders and AN [33], marked symptomological overlap [28,34], evidence purporting the anxiolytic effects of AN behaviours [35], and more recent developments indicating a shared neurobiological profile [36-38]. …

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