Since opening my practice in 2009, I have evaluated 49 patients with primary diagnoses of Anorexia Nervosa (AN). All patients who attended an evaluation and at least one treatment session with me, and who are no longer in treatment with me, were included in this sample. In addition, there were several patients who have completed their treatment but have elected to see me two or three times per year for check-ins; these patients were included in this sample as well. Patients who are currently in treatment with me were not included. Patients who saw me for an evaluation and / or consultation only, but did not attend any treatment sessions, were not included either. Thirty patients met criteria for inclusion in this sample. The remaining 19 did not meet criteria, either because they saw me for evaluation and consultation only or because they are currently in treatment with me.
Please bear in mind that this is not a randomized, controlled study. The results I am posting are specific to my practice and my patients. They are not intended to be generalized to other clinicians or other patients. While many of my patients are referred to me by their pediatrician or psychiatrist, the majority of my patients are self-selecting. That is, their families researched their treatment options on their and chose to work with me for a specific reason. The self-selecting nature of many of these families also limits the generalizability of the results.
The sample described in this post contains 30 patients. These patients ranged in age from 10 – 37 (median age = 15). Eighty-three percent of these patients (n = 25) met criteria for restricting subtype (AN-R) and the remaining 17% (n = 5) met criteria for binge-purge subtype (AN-BP). Half of these patients (n = 15) had a co-morbid diagnosis, with the most common being Major Depressive Disorder and Depressive Disorder Not Otherwise Specified. Fifty-three percent of patients (n = 16) took some type of psychotropic medication during their treatment with me.
The patients varied widely in terms of length of illness and severity of symptoms. Duration of illness before intake ranged from 3 months to 21 years (median duration = 19 months). Importantly, these figures reflect the duration since the onset of illness, which is typically longer (and often much longer) than the duration since diagnosis. For the purpose of calculating duration of illness, onset of illness was defined as the period of time in which patient began engaging in behavioral symptoms of AN (e.g., restricting, compulsive exercise, purging) as reported by the patient and/or parents.
The majority of these patients arrived at my office with some history of treatment. Seventy percent of patients (n = 21) had already received some type of treatment before beginning therapy with me. As expected, most of those who were new to treatment had a much shorter duration of illness. One-third of patients (n = 10) had been hospitalized for their eating disorder or a related psychiatric issue (e.g., suicide attempt) prior to their evaluation with me. Seventeen percent of the patients (n = 5) had previously been in residential treatment and 27% (n = 8) had previously been in partial hospitalization, day treatment, or intensive outpatient treatment eating disorder treatment.
Duration of treatment with me ranged from one week to 48 months (median duration of treatment = 11 months). Number of treatment sessions with me ranged from 1 – 82. For those whose treatment lasted 18 months or longer, the duration of treatment can be explained by either a relapse after a period of remission or continued treatment to address a comorbid condition, such as anxiety or depression. Seventeen percent of patients (n = 5) had to be hospitalized during their treatment with me.
Prior to reporting end-of-treatment outcomes, it is important to clarify how I defined outcomes. I created the following definitions, each with specific criteria, in order to categorize patient outcomes:
1. Patient must meet ALL of the following criteria to be classified as in full remission:
a.) Patient is 100% weight-restored. Target weights were calculated based on patient’s individual historic growth chart and parent input. Patients under age 20 were expected to return to their historic percentiles for height, weight, and BMI. For patients age 20 and up, target weights were calculated based on the patient’s height, body build, weight history, menstrual history, and parental input (when available).
b.) Patient has started or resumed menstrual periods (for females ages 14 +).
c.) Patient is medically healthy.
d.) Complete abstinence from binge/purge behaviors, laxatives, and diet pills.
e.) Patient eats regular, balanced meals most of the time or always , as reported by patient and parent (when applicable)
f.) For children under 18 – child eats independently in an age-appropriate way most of the time or all of the time. For patients ages 18 and up, patient is able to eat independently while maintaining his/her weight.
g.) No more than mild preoccupation with food, weight, body image, or fear of weight gain
2. Patient is classified as in physical remission if he/she meets criteria a, b, c, d, and e under full remission, but does not meet criteria f or g under full remission. Essentially, a patient in physical remission is physically well and free of eating disorder behaviors, but cannot eat well independently, and/or continues to be preoccupied with thoughts about food, weight, and body image.
3. Patient is classified as having made significant progress if:
a.) Patient has made significant improvement in dietary habits (e.g., eats regular, balanced meals and snacks and has expanded the variety of foods he/she eats) as reported by patient and parents (when applicable)
b.) Patient has restored some weight and is at least 90% of ideal body weight (as defined in criterion a under full remission)
c.) Patient is medically healthy
d.) If patient has a history of bingeing, purging, laxatives, or diet pills, the frequency of these behaviors has been reduced to once per week or less.
4. Patient is classified as having made some progress if:
a.) Patient has improved dietary habits since intake, but needs more improvement
b.) Patient has restored some weight but remains more than 10% below target weight (as defined in criterion a under physical remission).
c.) Patient is a female age 14 or older but is not menstruating
d.) If patient has a history of bingeing, purging, laxatives, or diet pills, he/she has reduced the frequency of these behaviors since intake but still engages in them more than once per week.
5. Patient is classified as having made no progress if he/she has not improved dietary habits, has not restored any weight, and/or has not reduced the frequency of bingeing or compensatory behaviors.
6. Patient is classified as regressed if he/she meets ANY of the following criteria:
a.) Patient has lost weight since starting treatment
b.) Patient has been eating less since intake (in terms of frequency, quantity, and variety)
c.) Frequency of bingeing or compensatory behaviors has increased since intake
d.) Patient has become medically unstable
Fifty-seven percent of patients (n = 17) completed treatment and will be referred to as “treatment completers.” Treatment completers ranged in age from 10 – 24 at intake, with a median age of 14. Duration of treatment for treatment completers ranged from 2 months to 48 months (median duration = 15.5 months).
Ninety-four percent of treatment completers (n = 16) met criteria for full remission at end of treatment. The remaining 6% (n = 1) met criteria for physical remission at end of treatment. For the treatment completers, weight restoration was achieved in an average of 3 months (range = 1 – 7 months). Two of the treatment completers were fully weight-restored (though not in full remission) at the start of treatment with me, having already been in eating disorder treatment elsewhere.
Forty-three percent of patients (n = 13) did not complete treatment and will be referred to as “treatment non-completers.” Treatment non-completers ranged in age from 10 – 37, with a median age of 20. Duration of treatment for the non-completers ranged from one week to six months (median duration = 3 months). Of the treatment non-completers, I referred 23% (n = 3) to other providers because they required something I could not provide (e.g., residential treatment) or my treatment approach was not helping them. Fifteen percent of non-completers (n = 2) moved to other parts of the country during their treatment and thus were referred to other providers near their new homes. Sixty-two percent of treatment non-completers (n = 8) dropped out of treatment prematurely.
Of the treatment non-completers, 46% (n = 6) had made significant progress by their last session with me. Fifteen percent had made some progress, 23% (n = 3) had made no progress, and 15% (n = 2) had regressed.
Stay tuned for my next blog post, in which I will examine and interpret the differences between treatment completers and treatment non-completers.