A prospective study of predictors of relapse in anorexia nervosa: Implications for relapse prevention
Introduction
Anorexia nervosa (AN) is a serious psychiatric disorder characterized by extreme food restriction, maintenance of an abnormally low body weight, intense fear of weight gain, and body image disturbance (American Psychiatric Association, 1994). In about half of cases, there is also recurrent binge eating and/or purging behavior. The disorder is associated with significant psychiatric comorbidity, serious medical complications, and major impairments in psychosocial functioning. The cumulative mortality rate is approximately 5.6% per decade, with about half of deaths due to cardiac failure and half due to suicide (Sullivan, 1995, Herzog et al., 2000). Nutritional rehabilitation and weight restoration, often involving a period of inpatient or day hospital treatment, usually constitute the first step in the recovery process in severe cases. Cohort studies suggest that most adult patients respond well to hospital-based treatment programs for AN in the short-term (e.g., Olmsted et al., 2010) but that the rate of relapse is high (Carter et al., 2004). Studies have reported a wide range of estimates of the rate of relapse in AN depending upon the definitions of relapse used, the length of follow-up, and the methodologies employed. Reported rates of relapse have ranged from 9% to 65% (e.g., Strober et al., 1997, Carter et al., 2004, Keel et al., 2005, Walsh et al., 2006), with the relapse rates tending to be lower in adolescent samples than among adults. Studies that have examined the timing of relapse have shown that the risk of relapse is highest during the first 4–12 months post-treatment (e.g., Carter et al., 2004, McFarlane et al., 2008).
Identifying variables predictive of relapse in AN that are amenable to change may suggest important targets for both acute and relapse prevention interventions. It may also advance understanding of the psychopathology of AN by shedding light on key maintaining factors. Several studies have found that individuals who present with more severe or chronic eating disorders are more likely to relapse including older age (Deter and Herzog, 1994); a higher number of previous hospitalizations (Treat et al., 2008); higher pre-treatment purge frequency (Deter and Herzog, 1994); and greater dietary restriction (McFarlane et al., 2008). However, baseline variables are not really modifiable, but may identify high risk groups. Several studies have shown that patients who make slower progress during acute treatment are more prone to relapse including a lower rate of weight gain (Castro et al., 2004, Treat et al., 2008) and slower adherence to the prescribed meal plan during day hospital treatment (McFarlane et al., 2008). These variables may reflect lower motivation or greater resistance to change. Other research has identified certain areas of vulnerability following acute treatment that predict subsequent relapse including higher residual weight concern (Carter et al., 2004); greater body image disturbance (Keel et al., 2005); and higher residual weight-based self esteem (McFarlane et al., 2008). Relapse has also been shown to be associated with lower body mass index (BMI) (Kaplan et al., 2009) and lower percent body fat (Mayer et al., 2007) at post-treatment. One study found that patients who reported lower levels of motivation to recover at the end of acute treatment were more prone to relapse (Castro-Fornieles et al., 2007). The aim of the present study was to identify predictors of relapse in AN that might inform the development of more effective treatment and relapse prevention interventions.
Section snippets
Participants
The participants were 100 consecutive patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for AN based on Eating Disorder Examination (EDE; Fairburn and Cooper, 1993) interview. All were admitted to the hybrid inpatient/day treatment unit of the Eating Disorders Program at a large general hospital between 2000 and 2008. This program is a specialized hospital-based program operated by a multi-disciplinary team that focuses on nutritional
Attrition and missing data imputation
Maximum likelihood imputation based on EM algorithm was used to impute missing discharge data for those cases whose discharge assessments had missing data. The frequency (percent) of missing data for the discharge variables ranged from 0 (0%) to 18 (18%) cases out of 100.
Rate and timing of relapse
Fig. 1 presents the survival curve and hazard function for the 100 participants. The highest risk of relapse was between 4 and 9 months post-discharge. After that, the survival curve began to level off suggesting less risk of
Discussion
Comparable to previous studies, we found that, at 12 months follow-up, 41% of patients with AN had relapsed and that the highest risk for relapse occurred between 4 and 9 months post-treatment. Among patients who did not relapse, 25% of them maintained a BMI above 19.5 for the entire 1 year follow-up period, and most of these had the restricting subtype of the disorder. The remainder dropped below a BMI of 19.5, and 40% maintained a BMI between 17.5 and 19.5. This indicates that a significant
Acknowledgments
This research was supported by the Canadian Institute for Health Research (grant MOP-86531). The authors are grateful to Dr. Allison Kelly for her statistical advice and her comments on the manuscript.
Declaration of Interest
None.
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