An eight-year follow-up: Outcome from adolescent compared to adult onset anorexia nervosa

Seventy-five women were traced and reassessed on average eight years after the onset of anorexia nervosa. All patients received treatment and 88% were hospitalized at least once. Comparisons between early (11–15 years; N=35), late (16–18 years; N=24) adolescent and adult (19–27 years; N=14) onset revealed no significant differences in outcome for age at onset. For 70% of adolescent and 42% of adult onset patients the outcome was good, meaning that the weight was within ± 15% of norm with regular cyclical menstruation,17% and 21% had an intermediate, and 9% and 21%, respectively, had a poor outcome, 5.3% had died. Taken together, 59% had physically recovered and were free of any eating disorder. Severity of illness reflected in a low body mass index, excessive exercise, and poor psychosocial functioning at intake were poor prognostic indicators;length of illness and food restriction or bulimia as eating patterns were unrelated to outcome. The observation that all women with chronic anorexia nervosa, and even a third of those who had physically recovered from anorexia nervosa, qualified for one or more psychiatric diagnoses suggests that the psychosocial correlates of anorexia nervosa require further study.Supported by grant MH ROI35585-01A1.Received an M.D.-Ph.D. degree from Albert-Ludwig University in Freiburg, Germany. Research interests have been depressive disorders, eating disorders, in particular anorexia nervosa, and more recently women's health.Received M.D. degree from the University of Illinois in Chicago, Illinois. Research interest is in preventive medicine.     

The relationship of sex role to physical and psychological health

This study examined the relationship of sex-role typology, medical and psychiatric symptomatology, and personality functioning in adolescents. Seventy-nine males and 101 females with an average age of 18.3 were administered the Bem Sex Role Inventory (BSRI), Offer Self Image Questionnaire (OSIQ), Self Rating Depression Scale (SRDS), and Cornell Medical Index (CMI). In comparison to males, females reported significantly more medical and psychiatric symptomatology, including depression. Females were also found to have more concern and empathy for others and a better developed superego. They reported greater involvement in making future plans and were more conservative in their sexual attitudes. Sex-role typology yielded no significant differences on the medical and psychiatric scales, but consistent differences were found on the OSIQ, a measure of adolescent personality functioning. In general, the results indicated that androgynous teenagers in every case differed from the undifferentiated ones, with the masculine and feminine groups occupying a mid-position. Androgynous individuals always showed a more favorable adjustment. Undifferentiated individuals had a poorer defensive structure, less adequate coping mechanisms and affective integration, more confusion about body boundaries, and more difficulty in object relations. Androgynous individuals, in short, possessed adaptive capabilities and resources, such as effective coping techniques, emotional integration, communication skills, and a well-defined self-concept (i.e., ego strength and a high level of psychological integration). Since these results were obtained on a measure constructed solely to assess adolescent functioning, it seems possible to screen and identify adolescents who may be entering adulthood lacking the emotional, social, and occupational capacity to function in an optimal fashion.Received Ph.D. from University of Rhode Island. Current interests are adjustive dimensions of sex role in adolescents, adolescent psychopathology and psychotherapy.Currently pursuing a doctorate in human development at the University of Maryland. Holds an M.A. in clinical psychology from George Mason University. Interests include sex-role development, determination of psychological test parameters of anorexia nervosa.Completing an M.A. in clinical psychology at George Mason University. Besides sex-role and social dimensions, interests center on adolescent psychotherapy.     

Ten-Year outcome in adolescent onset anorexia nervosa

The purpose of the present study was to characterize the psychopathology measured ten years posttreatment in 51 women who had an adolescent onset of anorexia nervosa. Outcome status was determined using the modified categories of Ratnasuriya et al.[1991]. Anorexia Nervosa: Outcome and Prognostic Factors After 20 Years, British Journal of Psychiatry, Vol. 158, pp. 495–502). Psychopathology was assessed using a number of self-report questionnaires: Beck Depression Inventory, Hamilton Depression Inventory, Leyton Obsessionality Inventory, Social Adjustment Scale, and Minnesota Multiphasic Personality Inventory. Within this adolescent age of onset sample of anorexia nervosa, age of onset was not, in and of itself, associated with increased psychopathology at follow-up. Rather, severity of eating disorder outcome was associated with general psychopathology, with patients in the poor outcome group displaying elevations on several of the measures of psychopathology.Received Ph.D. in psychology from Rutgers Univesity. Major research interests are in eating behavior and attitudes toward foods in anorexia and bulimia nervosa, preoccupations and rituals associated with eating disorders, and comorbidity and eating disorders.Received M.D. from the University of Medicine and Dentistry in New Jersey. Research interests are in eating disorders.Received M.D. from University of Minnesota Medical School-Minneapolis, MN. Major research interests are anorexia nervosa and other eating disorders.Received M.D. from the University of Iowa—Iowa City. Research interests are in eating disorders.     

A prospective follow-up of children with anorexia nervosa

We report on a prospective follow-up (mean 3.1 years) of 22 children with anorexia nervosa (mean age at onset—12.1). Adequate information was obtained for 18 children. The specific outcome was good in 10 (55.5%), intermediate in 5 (27.8%), and poor in 3 (16.7%); none had died. No prognostic factors were identified. The findings are compared with those from the long term follow-up of a previous cohort of children with anorexia nervosa, and confirm the unsatisfactory prognosis for this age group.Major research interest concerns the etiology and treatment of eating disorders in children and adolescents.Has been with the Eating Disorders Research Team since 1992. His major interest is research methodologyHas been with the eating disorders Research Team since 1989. Her major interests are in obsessional-compulsive problems and eating disorders in children.Major research interests include eating disorders in children and adolescents, cystic fibrosis, the effects of transplantation in children and adherence to treatment. Chief Editor ofClinical Child Psychology and Psychiatry. Has been collaborating with the Eating Disorders Research Team since 1985.     

A six-year follow-up study of anorexia nervosa subjects with teenage onset

Fifty-one adolescent onset anorexia nervosa (AN) cases recruited after community screening were compared with fifty-one age-, sex- and schoolmatched cases with regard to comorbidity and personality disorders at age 21 years. All 102 cases had originally been examined at a mean age of 16 years. Outcome according to the Morgan-Russell scales was fairly similar to that reported in recent clinic-based samples. Most of the former AN cases were recovered in respect of weight but outcome in social areas was restricted. Obsessive compulsive and avoidant personality disorders and empathy disorders were very much more common in the AN than in the comparison group. Obsessive compulsive behaviors showed a high degree of stability over time and were unrelated to weight problems. Together with empathy disorders they tended to predict outcome better than the eating disorder as such. Affective disorders were common but tended to follow the course of the eating disorder rather than precede or postdate it.Received Ph.D. on Anorexia Nerevosa in Swedish Urban Teenagers at Göteborg University in 1990. Major research interests concern the epidemiology and background factors of eating disorder.Received Ph.D. in 1981 at the University of Uppsala on Neuropsychiatric aspects of perceptual, motor, and attentional deficits in seven-year-old Swedish children. Major research interests are autism, Asperger syndrome, anorexia nervosa, attention deficit hyperactivity disorder, dyslexia, mental retardation, lefthandedness, and behavioral phenotypes.Received Ph.D. in 1987 at The University of Uppsala on Deficits in Attention, Motor Control and Perception: Follow-Up from Pre-School to Early Teens. Her major research interests concern attention deficit hyperactivity disorder.     

Outcome,psychosocial functioning,and prognostic factors in adolescent anorexia nervosa as determined by prospective follow-up assessment

The aim of this prospective longitudinal study was to examine outcome, psychosocial functioning, and prognostic factors in adolescent anorexia nervosa. Thirty-four (88%) out of a consecutive series of 39 inpatients were reinvestigated three and seven years after discharge. The patients and 34 controls matched for age, sex, and occupational status were interviewed using structured interviews on their Diagnostic Statistical Manual, third edition, revised (DSM-III-R) eating disorder diagnoses, specific eating disorder psychopathology, comorbid psychiatric disorders, and psychosocial functioning. At the seven-year follow-up 15 patients (44%) still fulfilled DSM-III-R criteria for some form of eating disorder diagnosis, 21 (62%) for some other psychiatric diagnosis. Patients with a poor outcome showed significantly more problems in most areas of psychosocial functioning than the good-outcome group, but even recovered anorectic patients had more psychosexual difficulties than healthy controls. From a large range of potential prognostic factors, only low body weight at intake and low minimum weight during course of illness proved to be of predictive value.Received M.D. from Rheinische Friedrich-Wilhelms University, Bonn. Major research interests are childhood and adolescent eating disorders including links to affective disorders.Received M.D. from Philipps University. His current interests include follow-up studies of adolescent eating disorders.Received M.D. from Philipps University. His interests are body image disturbances in eating disorders and research in neurophysiology and neuropsychology.Received M.D. from Friedrich-Alexander University, Erlangen, Germany, and Ph.D. from Rupprecht-Karls University, Tübingen. Current research interests are eating disorders, affective disorders, and early onset schizophrenia.     

Binge eating in anorexia nervosa predicts later onset of substance use disorder: A ten-year prospective,longitudinal follow-up of 95 adolescents

The cooccurrence of binge eating and increased alcohol intake and substance abuse has been reported in clinical and community epidemiological samples. To further investigate the nature and causes of this comorbidity, we examined the 10-year prospective, longitudinal course of illness in 95 nonsubstance abusing adolescents hospitalized for treatment of anorexia nervosa. Survival analysis with Cox regression was used to quantitate the cumulative risk of developing substance use disorder (SUD) as a function of patterns of binge eating vs. dietary restraint within this cohort. Subjects who were binge eating at the time of intake were robustly distinguished from restrictors, having increased risk of SUD as well as greater likelihood of having at least one first-degree relative with SUD. The findings suggest binge eating that develops in the underweight stage of anorexia nervosa may reflect developmental, biological, and genetic risk processes shared in common with SUD.Received Ph.D. in clinical psychology from the University of Pittsburgh. Research interests include the etiology, course, and treatment of eating disorders, and the natural history and treatment of juvenile mood disorders.Received R.N. from Rush-Presbyterian Hospital. Research interests are in the area of adolescent mental health treatment and the treatment of anorexia nervosa.Received R.N. from Northeastern Univeristy. Research interest is the inpatient psychiatric treatment of adolescents.Received R.N. from the University of Windsor and her M.N. from UCLA. Research interest is the outcome studies of treatment effectiveness in adolescent and adult psychiatry.     

Outcome of early onset anorexia nervosa: What do we know?

Six recent studies on the outcome of early onset anorexia nervosa (AN) are reviewed. It would appear that the intermediate term outcome of early onset AN is not different from that of later onset AN. No prognostic indicators were identified and effect of treatment is unknown. Early onset AN may be a disabling and chronic disorder for 25% of patients seen at psychiatric clinics.Received M.D. from the University of Hong Kong, Faculty of Medicine. Major research intersts are eating disorders and cross-cultural psychiatry.     

Anorexia nervosa and the problem of “men”

The essay explores anorexia nervosa as clinical historiographical performance, focusing in particular on the role of masculinity and male subjectivity in the development of diagnostic standards for the “disorder” and in contemporary non-traditional patients diagnosed with the condition.     

Introduction to special issue

As regards prognosis, none of these cases, however exhausted, are really hopeless whilst life exists: and, for the most part, the prognosis may be considered favourable. (Gull, 1873)Received M.D. Ph.D. from Albert-Ludwig University in Freiburg, Germany. Research Interests are depressive disorders, eating disorders, in particular anorexia nervosa, and more recently women's health.     

Invited commentary: applying psychodynamic developmental assessment to explore mental functioning in adolescents

Recent publications in the Journal of Youth and Adolescence present a variety of topics exploring adolescents' mental functioning in the twenty first century. Conceptually, many of the articles address the intriguing, though rarely explicit, question of developmental continuities and change from adolescence to adulthood. Such investigations, which are particularly prominent in articles that discuss personality dispositions such as impulsivity or lack of empathy and their relationship to emotionally disturbed or maladaptive interpersonal behaviors, examine interactional effects of these dispositions within the personality-context matrix. From a methodological perspective, however, the major tools used for assessing personality dispositions are self-report inventories while performance-based methods, previously defined as projective tests, are not used at all despite the wide range of empirical studies that provide support for their psychometric properties. This commentary suggests that applying a theoretically based, multi-method assessment procedure in empirical research would be most fruitful for any study aimed at exploring mental functioning in adolescents. As an example, I would use the Rorschach Inkblot Method, currently being internationally considered as the most frequently applied personality test for assessing adolescents. Implications for research, practice and policy decision-making are discussed.     

Is thin a feminist issue?

Anorexia nervosa and similar disorders preponderate in women and therefore seem particularly suited to feminist models of understanding. Boskind-Lodahl (1976) and Orbach (1979, 1982) have put forward similar views on the subject, and their work is well known.This article explores the assumptions behind the Boskind-Lodahl/Orbach hypothesis, and argues that the most fundamental of these lies in a problematic distinction between the concepts of nature and culture. Some implications of the hypothesis are discussed with emphasis on the extent to which these authors normalize anorectic behaviour. The question is raised as to whether this normalizing approach may be read as legitimating symptoms. Feminist, anthropological, and other writing is used to examine the potential for alternative models of understanding anorexia nervosa which do not rely on a nature/culture split and which address the issue of the social function of anorectic symptoms. These models point towards a more general concern in feminist theory with the relationship between culture and psychological disorder.     

Education and identity: Thoughts on the social origins of anorexia

Anorexia nervosa is often said to be a condition which afflicts mainly middle-class girls. This paper suggests that it is not social class but a high level of educational attainment which is associated with the onset of anorexia.The effect of education is analysed in terms of it's influence on the identity -formation of the young woman. Anorexia can be seen as an attempt to rescue a spoilt identity.     

Depression and suicidal behavior among delinquent females

Depressive symptomatology and suicidal behavior were evaluated in a multiethnic sample of 48 delinquent females through ratings on self-reports and probation officers' reports. Psychological functioning of the subjects was also evaluated through the Diagnostic Interview for Borderlines, the Rorschach, and the WAIS or WISC-R in order to identify delinquent personality patterns. Four personality patterns were identified: the borderline, the antisocial, the neurotic, and the socialized delinquent personalities. A chi-square analysis of the data demonstrated that level of depression and frequency of suicidal behavior were both significantly related to personality patterns. Level of depression was also significantly related to ethnicity, but not to socioeconomic status. The results have implications for assessment and treatment of delinquent females and also raise issues concerning the interaction of personality, cultural factors, and delinquent behavior which should be addressed in future research with larger, socioculturally diverse samples.This research is based on the author's doctoral dissertation and was supported by a Pre-Doctoral National Research Service Fellowship award from the National Institute of Mental Health.Received her Ph.D. from the University of California at Berkeley in 1980. Major interest is adolescent psychopathology and delinquency.     

Dependency,self-criticism,and perceptions of inferiority at summer camp: I'm even worse than you think

This research examined dependency and self-criticism and their relation to depression and social-personal adjustment. Seventy-seven subjects at a summer day camp, aged 8–14 years, completed the Depressive Experiences Questionnaire devised by Blatt et al. in 1992, the Center for Epidemiological Studies Depression Scale for Children devised in 1980, and a measure of self-esteem (SE) devised by Harter in 1982. Each subject was rated independently by two counselors on social, athletic, and general functioning. Results revealed that self-criticism, but not dependency, was positively related to depression. Moreover, self-criticism was associated with negative self-ratings in social and sports domains and in general SE. Counselor ratings confirmed social problems and perceptions of low SE for self-critics. Dependency was unrelated to self or counselor ratings, except for a trend toward a positive relation for social functioning. Analyses indicated a discrepancy between self and counselor ratings for self-critics but not for dependents, so that self-critics appear to exaggerate their weaknesses in social and athletic functioning. Finally, self-criticism decreased with age, while dependency was unrelated to age.Received B. A. from McGill University. Research interests include personality development and psychosocial adjustment. To whom correspondence should be addressed.Received Ph.D. from the University of Rochester. Research interests include motivation, personality, and life-span development.Received Ph.D. from the University of Connecticut. Research interests include dependency, self-criticism, and vulnerability to depression.     

Reciprocity,agreement, and family style in family systems with a disturbed and nondisturbed adolescent

Doane's recent review of interaction studies of families with disturbed and nondisturbed adolescents enumerated a number of conclusions concerning relationships and family functioning in families with a disturbed adolescent. The present study used a questionnaire approach to test hypotheses based on these conclusions, hypotheses which were largely supported in the analyses. When a disturbed adolescent was involved, families evidenced less reciprocity of needs, had greater disagreement about parents' needs, greater disagreement about family-related issues, more marital dysfunction, more rigidity and less clarity about expectations, and less satisfaction and more anxiety on the part of the adolescents. That families with a disturbed adolescent were discriminably different from families without a disturbed adolescent is supportive of a family systems perspective to family functioning. Speculations of a causal nature are offered, with suggestions that future research be designed to take advantage of causal analysis procedures.NIMH Predoctoral Research Fellowship 7F01 MH 3253502 provided partial support for this research.Received her Ph.D. in social personality psychology from the University of Colorado. Current research interests include the transition to adulthood, friendship and sex-role development in adolescence.     

The impact of the identity crisis on the adjustment of late adolescent males

The relationship between ego identity status and MMPI scores was investigated using 73 college males. Identity status was assessed using a semistructured interview. The results obtained indicated that subjects in the identity achievement status obtained MMPI scores which fell within the normal range of functioning. Subjects currently involved in working on identity issues (moratorium status) obtained a pattern of scores indicating the presence of psychological conflict, as did foreclosure subjects—that is, subjects who are characterized by rigid adherence to parental norms and values. Subjects who had not successfully resolved their identity crisis (identity diffusion status) had MMPI scores within the normal range. The findings partly support Erikson's theorizing on ego identity and indicate that further analysis and refinement of Marcia's typology is required. Results from the present study also indicate that future research with male subjects on ego identity status should include some assessment of sexual attitudes.This research was partly supported by research grants from the National Science Foundation (NSF-USDP No. GU 1598) and a grant from the National Institute of Mental Health (MH 16899). The senior author was supported by a National Science Foundation traineeship during the time this study was performed.Clinical psychology graduate student, doing research on adolescent personality development from an Eriksonian perspective.Received Ph.D. from the University of Minnesota. Current research is on adolescent personality development from an Eriksonian perspective.     

Psychiatric Morbidity Differences in Male and Female Adolescent Inpatients With Alcohol Use Disorders

Objective: To examine gender differences in demography, cooccurrence of Diagnostic Statistical Manual (third edition, revised; DSM-III-R) axis I disorders and axis II personality disorders, and self-reported psychological distress in adolescent psychiatric inpatients with alcohol use disorders. Method: A consecutive series of 61 adolescent inpatients (36 boys and 25 girls) with either alcohol abuse or dependence were reliably assessed with structured diagnostic interviews for DSM-III-R Axis I and Axis II personality disorders. Results: Boys and girls did not differ in age, ethnicity, socioeconomic status, global functioning, age at first psychiatric contact, or number of hospitalizations. Girls were more likely to meet criteria for oppositional defiant disorder, eating disorders, and additional drug use disorders. Girls were also more likely than boys to meet criteria for at least one personality disorder and borderline personality Contrary to gender patterns in the general population, the proportion of girls and boys with affective disorders and conduct disorders did not differ significantly. Conclusions: Relatively few gender differences were found in adolescent inpatient alcohol abusers even where they would be expected, based on non substance-abuse general population gender patterns. When observed, gender differences were in the direction of greater psychiatric disturbance among girls. Some of the gender patterns observed among alcohol abusing adolescents are at odds with gender differences observed in non substance-abuse samples.     

Ego identity formation in middle adolescence

Assumed determinants of ego identity were investigated in this study using sophomore, junior, and senior high school males and females. Subjects were administered the Marcia Ego Identity Status Scale and measures of sex-role identification, personality development, psychological functioning, self-concept, and parental socialization practices. Data analyses, using a median split on identity score, showed that high-identity adolescents obtained more positive scores on sex-role identification, personality development, psychological adjustment, and self-concept than low-identity adolescents. Socialization practices also differed for the two groups. The sex differences which emerged were congruent with the identity literature. Overall, the data supported Erikson's theory of ego identity development.This study was funded by Grant No. 791-01-010-502 from the Senate Research Committee, University of Nebraska at Omaha.Received his Ph.D. in developmental psychology from the University of Wisconsin-Madison. Major interests are in the area of social and personality development in children and adolescents.An earlier version of this paper was presented at the Annual Meeting of the American Psychological Association, Chicago, September 1975.