Pediatric Eating Disorders That Do Not Meet Full DSM-IV Criteria Linked to Serious Medical Complications

Pam Harrison

April 14, 2010

April 14, 2010 — Serious medical complications occur in children and adolescents with eating disorders who do not meet full Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria for anorexia nervosa (AN) or bulimia nervosa (BN), according to the first published comparison of complications among adolescents with an eating disorder from all DSM-IV diagnostic groups.

Rebecka Peebles, MD, Standard University School of Medicine in California, and colleagues found that the medical severity of young female patients with eating disorders not otherwise specified (EDNOS) was intermediate to that of patients with either AN or BN in prespecified primary outcomes measured.

In fact, patients with partial AN (pAN) had significantly higher heart rates, systolic blood pressure, and temperature than patients who meet the full criteria for AN, whereas patients with partial BN (pBN) did not differ significantly from those with BN in any primary outcome variable.

The study was published online April 12 in Pediatrics.

In contrast, patients with pAN and pBN differed significantly from each other in all outcome variables, the study authors add.

"Our study was designed to look at how commonly used markers of medical severity correlated with diagnosis criteria, and while it is premature to say that diagnostic criteria should be broadened, I think [this study suggests] that patients with partial AN and partial BN are much closer to patients with full threshold disease than to each other. So from a clinical perspective it would be useful to have more definition and more guidelines for this large category of patients with EDNOS," Dr. Peebles told Medscape Psychiatry.

High Complication Rate

Study authors reviewed medical records of 1310 female patients between the ages of 8 and 19 years who were treated for AN, BN, or EDNOS in an academic pediatric eating disorders (ED) program between January 1997 and April 2008.

"All patients initially received a clinical diagnosis from a board-certified psychiatrist or psychologist with expertise in the assessment of children and adolescents with ED," the study authors write. Both inpatients and outpatients were included in the study.

The primary outcome variables included heart rate, blood pressure, temperature, and QTc interval.

Results showed that the mean heart rate for patients with AN was 56/min vs 63/min for those with EDNOS and 66/min for those with BN. Mean systolic BP was 101 mm Hg for AN patients vs 107 mm Hg and 111 mm Hg for EDNOS and BN patients, respectively. Mean body temperature was 36.6°C, 36.7°C, and 36.9°C for AN, EDNOS, and BN patients, respectively.

Mean QTc intervals were 388, 393, and 401 for AN, EDNOS, and BN patients, respectively.

Secondary outcomes included rates of hospital admission within 2 weeks of presentation, length of disease, complications attributable to the eating disorder before presentation, and complications that occurred during the first hospital stay if the hospitalization occurred within 2 weeks of presentation. Mean duration of disease was 14 months in the AN group, 13.7 months in the EDNOS group, and 26.6 months in BN patients.

No deaths occurred during the first hospitalization, but 8.18% of AN patients met admission criteria for any hospitalization as did 61.6% of patients with EDNOS and 45.7% of patients with BN.

Serious hospital complications occurred in 23.2%, 16.5%, and 20.3% in AN, EDNOS, and BN patients, respectively, whereas 16.4% of AN patients, 19.7% of EDNOS patients, and 31.5% of BN patients had serious complications attributable to the eating disorder before presentation.

Table. Comparison of EDNOS With AN and BN

  AN EDOS BN
Disease duration, mo 14 13.7 26.6
Mean heart rate, /min 56 63 66
Mean SBP, mm Hg 101 107 111
Mean temperature, °C 36.6 36.7 36.9
Mean QTc interval 388 393 401

AN = anorexia nervosa; BN, bulimia nervosa; EDOS, eating disorders not otherwise specified; SBP, systolic blood pressure

Early Intervention Important

According to investigators, 62.4% of the cohort received a proper diagnosis of EDNOS when current DSM-IV standards were strictly applied. "However, 61.6% of these patients with EDNOS met recommended criteria for medical hospitalization and were more compromised than patients with BN in most medical outcomes."

Patients with EDNOS also had similar duration of disease and rates of weight loss, QTc prolongation, orthostasis, and hypokalemia as their full diagnosis counterparts — despite the fact that they weighed significantly more than patients with AN. The study authors also note that when patients with pAN were compared with those with AN, there were few differences.

Patients with pBN were younger, had a shorter duration of disease, weighed less, and had lost weight more rapidly than patients with BN, but they did not differ significantly from adolescents with BN on most other medical outcomes.

"The hope is that with early intervention, we can prevent medical complications and chronicity of the illness, because studies in both pediatrics and adults indicate that when you do not intervene early in eating disorders, you are much more likely to have a chronic relapsing course, and in pediatric studies, it is very clear that early intervention leads to the best outcomes," Dr. Peebles said.

Need to Address Diagnostic Limitations

Debra Katzman, MD, Hospital for Sick Children, Toronto, Ontario, Canada, told Medscape Psychiatry that what the study essentially highlighted was the fact that patients with EDNOS, though a mixed group of patients, can be quite medically compromised.

"Just because patients don't fit into the diagnosis of AN or BN, they may still have EDNOS and may be medically compromised," she said.

The other message to parents and pediatricians alike, she added, is that they both need to take EDNOS seriously. "We can say this isn’t AN or it isn’t BN and parents may be reassured when they hear this, but they should not be reassured because EDNOS comes with medical complications that need to be taken very seriously as well," she said.

Dr. Katzman also pointed out that with more than 1300 patients in the cohort, the fact that two-thirds of them fit into the EDNOS category suggests that there are a lot of children and adolescents physicians could potentially miss if they just stick to strict diagnostic criteria.

As president elect of the Academy for Eating Disorders, Dr. Katzman also suggested that with the DSM-V coming out soon, “hopefully we will be reassured that some of the diagnostic limitations that Dr. Peebles noted in her study are being attended to.”

The study authors have disclosed no relevant financial relationships. Dr. Katzman has received grants from the National Institutes of Health.

Pediatrics. Published online April 12, 2010.

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