This article is a review article. The aim is to examine the evidence for using a staging model for eating disorders, especially for anorexia nervosa. The main idea is to support that the diagnosis follows a trajectory during the life course. Can prodromal symptoms and high risks markers in childhood or adolescence transition to the full manifestation of the disease? And is there the possibility that the illness evolves to a more severe and enduring syndrome?
First of all, the authors underline the limitations in using the Diagnostic and Statistical Manual of Mental Disorders (DSM) for diagnostic procedures. Indeed, it provides a categorization with symptoms that are present only in later stages of the illness, when it is already consolidated. This can hamper the development of treatment for early stages and increased the risk of its development towards more treatment-resistant forms.
The aim of this article is to make people able to distinguish different stages, from high-risks markers, prodromal features, subsyndromal disorders to full manifestation of the illness, and to provide early intervention strategies or in any cases, adapted strategies for stages. We also have to keep in mind that remission can occur at each stage.
- Developmental epidemiological studies of prodromal features and a longitudinal trajectory of illness
A number of potential risk factors have been identified: childhood adversity, maternal levels of vitamin D, maternal anxiety and obstetric complications, individual traits such as social problems, obsessive compulsive, perfectionistic and autistic spectrum features. In adolescence we can include body dissatisfaction and weight over-evaluation.
Regarding the course of illness following onset, authors highlights that patients with early partial anorexia nervosa have a greater risk of developing full-blown disorders or continuing with subsyndromal syndromes. Thus, the disorders seems to start in milder forms in the mid-teenage years with slower progression to more severe disorders in early adulthood. It can take some years before clinical presentation appear. However, most of partial syndromes seem to resolve spontaneously. We can wonder which individual are more “at risk”? The authors notice in adolescents with subsyndromal eating disorders (who are more likely to progress to full-blown syndrome) some comorbid symptoms: depression, anxiety and substance misuse, and less favourable psychosocial adjustment in early adulthood.
Thus, we can say that the illness evolves in patients who present vulnerability traits in childhood and adolescence: higher levels of premorbid obsessive–compulsive personality disorder or autistic spectrum traits for example.
This study also report that a greater risk of mortality and attempted suicide are associated with a longer duration of illness.
To conclude, developmental epidemiological studies suggest that prodromal and illness features can impact on the longitudinal trajectory of anorexia nervosa.
- Neurobiological progression
It has been proved that antecedent features and the form of symptoms can impact on the neuroprogression of the illness. For example, social problems and obsessive compulsive traits during childhood are associated with food restriction and a persistent form of anorexia nervosa. Starvation, abnormalities in the composition of diet and the induced deficiencies can impact on brain plasticity, structure and cognitive function. We can observe a shrinkage of grey matter and poor cognitive performance (cognitive inflexibility, decreased set-shifting ability, attentional bias). They are also associated with the development of depressive symptoms and may impact comorbidity.
A correlation has been found between the duration of anorexia nervosa and social and emotional function: a lack of positive facial expression and to aspects of the sense of self.
Otherwise, symptoms in the early phase of the disease, nutritional sequelae and secondary social effects of isolation impact on brain plasticity. The more the illness lasts, the more it becomes severe and enduring.
However, the evidence for a neuroprogression is still weak. Set that the duration of the illness is a proxy marker of the accumulation of starvation effects may be incorrect. Potentially, these markers may be antecedents predicting a poor prognosis and becoming more prevalent in more chronic conditions.
- The erosion of social capital
A longer duration of the illness can lead to social impairments because a lot of patience and energy in needed to cope with a relative facing anorexia nervosa. It can deplete the patience and resources of family, friends, and relatives. Studies shows that a longer duration of the disease is associated with high levels of carers’ negative expressed emotion, like criticism and over involvement. This can in turn increase and strengthen symptoms: we enter in a vicious circle.
- Treatment
For high-risk features of anorexia nervosa (AN): we can suggest preventive programmes for adolescents considered at high risk with “psychoprotective” interventions: cognitive dissonance approaches, psychoeducation focused on healthy eating. These have positive effects by reducing body dissatisfaction, unhealthy weight control efforts, extreme diet and eating disorders symptoms.
For prodromal phase of AN: family-based program and internet-facilited interventions can be used to modify risk factors. Supporting peers are essential in this case.
Interventions for the early phase of AN (duration: less than three years): Family-based therapy based on the Maudsley model has more positive result than an individual therapy for young patients (below 18 years old). Studies show that this strategy can modify the trajectory and prevent the illness from becoming more severe.
Interventions for the middle phase of AN: There is no treatment approaches that have been tailored for young adults with several years of AN, no treatment strategy has been found more efficient to another. Thus, pharmacotherapy and psychotherapy have limited outcome.
Interventions for the severe enduring phase of AN (duration: more than seven years): patients are resistant to treatment: we observe poor reduction in symptomatology with inpatient care, psychotherapy and medication. Currently, the aim in the treatment in chronic AN is to maintain the best quality of life for the patient and his family and minimize discomfort.
To conclude, we can say that the results of this review article clearly support the idea of identifying the stages of the illness to match treatment to stage. There is evidence for the effectiveness of intervention tailored for each stage.
Words that we learned :
- prodromal symptoms : symptômes avant-coureurs
- hamper : entraver
- subsyndromal syndrome : syndrome subclinique
- a shrinkage : une diminution, un rétrécissement
- set-shifting ability : capacité de flexibilité mentale
Laureen GUEGUEN