Liam Davenport

September 07, 2017

PARIS ― Young women with anorexia nervosa (AN) who resume menstruation by the end of treatment experience greater improvement in both psychological and physiologic well-being than those who do not, new research suggests. Furthermore, these improvements persist after treatment ends.

The research also showed that recovery 2 years after completing cognitive-behavioral therapy (CBT) was predicted by factors related to sexual function and improvements in a patient's relationship with their body. This was found to be the case both in patients with AN and in those with bulimia nervous (BN).

Investigators led by Emanuele Cassioli, MD, Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Italy, note their results challenge a notion of recovery in eating disorders (EDs) that is "exclusively based on weight restoration or behavioral changes.

"A psychopathological assessment including sexual functioning and core psychopathology might identify the residual pathological condition [and] provide information regarding the long-term recovery process," they add.

The study was presented here at the 30th European College of Neuropsychopharmcology (ECNP) Congress.

Novel Predictor

It is recommended that in addition to weight restoration, dietary normalization, and reductions in binge eating, factors such as concern over body image, poor overall quality of life, and subjective experiences be taken into account when monitoring recovery from EDs.

Noting that sexual functioning is not commonly regarded as a factor predictive of outcome for patients with EDs, the researchers studied 39 AN and 40 BN patients to examine the role of sexuality as a moderator of recovery and to identify factors associated with the restoration of regular menstruation and sexual function.

All of the patients underwent individualized CBT for 1 year; they were assessed at baseline, at the end of treatment, and 2 years after treatment (year 3 of follow-up).

The evaluation included face-to-face interviews and self-reported questionnaires, including the Body Uneasiness Test (BUT), the Eating Disorder Examination Questionnaire (EDE-Q), and the Female Sexual Functioning Index (FSFI), among others. Serum hormone levels and biomarkers were also assessed.

At the end of CBT, 22 (56.4%) AN patients and 23 (57.5%) BN patients were considered to have recovered. Two years later, at the 3-year follow-up, 19 (48.7%) AN and 24 (60.0%) BN patients were considered to have recovered.

Both AN and BN patients experienced significant improvements in sexual functioning after CBT, although improvements were greater in AN patients, as measured by EDE-Q total score and Restraint subscale score and by reduction in body uneasiness.

The researchers also found that among AN patients, the pattern of recovery at the end of CBT differed between those with and those without amenorrhea.

Specifically, for those who had resumed menstruation by the end of treatment, there were greater reductions in EDE-Q total score and Restraint subscale score, and there were greater improvements in body mass index, FSFI total score, and triglyceride profiles at the end of CBT than was seen in those who had not resumed menstruation. The difference was maintained at the 3-year follow-up.

Further analysis revealed that among AN patients, recovery at 3-year follow-up was significantly associated with regular menstruation (odds ratio [OR], 6.2), FSFI total score (OR, 1.1), FSFI desire subscale score (OR, 2.6), arousal subscale score (OR, 2.0), lubrication score (OR, 3.5), and satisfaction score (OR, 1.8).

Recovery among AN patients was also inversely associated with BUT-Global Severity Index (GSI) score (OR, 0.3).

Among BN patients, 3-year recovery was significantly associated with FSFI total score (OR, 1.1), FSFI desire subscale score (OR, 2.2), and satisfaction score (OR 2.5) and was inversely associated with Symptom Checklist-90 score (OR, 0.09), EDE-Q total score, (OR, 0.1) and BUT-GSI score (OR, 0.1).

Dr Cassioli told Medscape Medical News that assessing patients' sexual functioning could help in determining ongoing treatment.

"We think that after the first cycle of psychotherapy, the clinician should reevaluate the sexual functioning of the patients and, of course, give more consideration to the recovery of regular menses, which is one of the moderators of the final outcome of our follow-up," he said.

"In the patients that don't show this improvement, maybe start another cycle of psychotherapy, maybe give another evaluation. Something needs to be done if these endpoints are not met after the first year of psychotherapy," Dr Cassioli added.

Causes vs Consequences

Approached for comment, Philip Gorwood, MD, PhD, head of the Clinique des Maladies Mentales et de l'Encéphale at Centre Hospitalier Sainte Anne, Paris, France, who was not involved with the study, told Medscape Medical News that the idea that sexual function is related to recovery for patients with EDs "is not completely new."

He pointed out that the question of sexuality was a central part of psychoanalytic approaches to the treatment of AN; indeed, the condition was even regarded as a "kind of refusal of sexuality."

However, he said that such approaches were "frustrating" because it was too easy to confuse causes and consequences, and "we are now extremely careful" to avoid doing that when assessing patients with EDs.

Dr Gorwood observed that sexuality is very much "at the borderline" of the biological and psychosocial aspects of AN and that it represents "the quality of your relationship with your own body, which [dictates] your capacity to have sexual intercourse."

Furthermore, at the genetic level, sexuality can be considered from a neurohormonal perspective, in that genes encode for sexual hormones, such as estrogen and progesterone, as well as their receptors, and the expression of such genes is modified by environmental and developmental factors.

"They, at the end of the day, translate into a psychological well-being with others, which is, of course, also sexual intercourse," he said.

Regarding the current study, Dr Gorwood agreed with the researchers that, in the assessment of remission, considering only weight may be too limiting.

"Looking at weight that meets the remission criteria is not enough...and so sexuality would be much more interesting. But sexuality is also completely associated with weight. So it's very important not to say that it's one instead of the other, because all of them are highly connected," he said.

No significant financial relationships have been disclosed.

30th European College of Neuropsychopharmacology (ECNP) Congress. Poster P.1.e.001, presented September 3, 2017.

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