روندهای موجود در علائم اختلال تغذیه ای در درمانگاه: 1988-1998

Eating disorders treatment has been altered by changes in the health care system. In addition, there has been a major emphasis on prevention in recent years. Yet, there are few investigations of the effects of these changes on the severity of patients' symptomatology at intake. This study examined differences in symptoms among women who presented to an outpatient clinic between 1988 and 1998. Patients were divided into Cohort 1 (1988–1992) and Cohort 2 (1993–1998). Patients with anorexia nervosa (AN) in Cohort 2 had significantly lower body mass indices (BMIs) at intake. Moreover, a greater number of patients with AN in Cohort 2 had BMIs≤15, suggesting severe malnourishment. Cohort 2 patients with bulimia nervosa obtained higher scores on the Interpersonal Distrust, Interoceptive Awareness, and Maturity Fears subscales of the Eating Disorder Inventory. There were no cohort differences in eating disorder duration, exercising, laxative or diuretic use, or self-induced vomiting. These results provide some evidence that the severity of eating symptomatology has increased in recent years.

Anorexia nervosa (AN) and bulimia nervosa (BN) are complex and often chronic disorders that typically require lengthy, multidisciplinary treatment Bravender et al., 1999, Hill and Maloney, 1997 and Kaye et al., 1996. Recent changes in the health care delivery system have had a substantial impact on eating disorders treatment (e.g., Andersen, 1998, Bravender et al., 1999, Franko and Erb, 1998, Garvin and Striegel-Moore, 2001, Kaye et al., 1996, Ortmeyer, 2001 and Wiseman et al., 2001). For example, Wiseman et al. (2001) evaluated changes in the average length of inpatient psychiatric hospitalization for a patient with AN treated at their hospital between 1984 and 1998 and found that the average stay decreased from 149.5 days in 1984 to 23.7 days in 1998. In addition, readmissions increased dramatically over the same period (from 1 in 1984 to 53 in 1998). These data suggest that the average patient presenting in a clinical setting today might manifest more severe symptomatology than the average patient did in the past, as shorter lengths of stay may be less effective in treating these often chronic disorders. On the other hand, there has been an increased emphasis, particularly within the last decade, on the prevention and early detection of eating problems (e.g., Mussell et al., 2000 and Pawluck and Gorey, 1998). For example, because of programs such as National Eating Disorders Screening Day (National Eating Disorders Screening Program, 2000), public awareness of eating disorders has increased. Thus, eating problems might be recognized more quickly, and affected individuals may be referred to appropriate treatment at an earlier stage in their illness. These prevention and outreach interventions might, therefore, be associated with a trend toward less severe symptomatology among individuals seeking treatment. Nonetheless, despite anecdotal reports of changes in the initial clinical presentation of patients with eating disorders, there have been relatively few empirical investigations of trends in patient characteristics and symptomatology. Perhaps the most comprehensive study of trends in eating disorder symptomatology was conducted by Ash and Piazza (1995) who reviewed charts of patients admitted to the inpatient psychosomatic/psychiatric unit of a children's hospital in the 1970s (n=32), 1980s (n=31), and 1990s (n=31). In contrast to their expectations, these researchers found no differences in patients' age at admission, age at eating disorder onset, socioeconomic status, sex, or race across the 3 decades. However, there was a significant difference in the duration of patients' eating disorders across groups: mean duration increased from 8 months in the 1970s to 22.3 months in the 1990s. Patients from the 1990s were also more likely to have a previous psychiatric hospitalization compared to patients from earlier decades. Interestingly, patients' weight at admission (as well as their previous lowest weight) increased significantly from the 1970s to the 1990s. Although the authors do not directly address this issue, these results could be attributable to the fact that patients were less likely to be diagnosed with AN (and more likely to be diagnosed with BN) in the 1990s compared to the 1970s or 1980s. In addition, Ash and Piazza (1995) found that patients' weight phobia and desire to attain extreme thinness increased significantly over time. Patients from the 1990s also manifested more comorbid psychiatric symptoms compared to those from the earlier decades, including depression and personality disorders. Based on these results, the authors concluded that eating disorders have become more diagnostically heterogeneous [i.e., BN and Eating Disorder Not Otherwise Specified (EDNOS), diagnoses have increased], and chronic in the last 3 decades. Bravender et al. (1999) conducted a similar study with an outpatient sample who presented to an eating disorders clinic in either 1991 (n=67) or 1996 (n=63). They found no differences in patient demographics across eating disorder diagnostic categories (including age at intake, race, and sex). However, patients with a diagnosis of BN were younger, on average, in 1996 compared to those initially seen in 1991. In contrast to the results of Ash and Piazza (1995), Bravender et al. found no differences in the duration of patients' eating disorder symptoms between the 1991 and 1996 groups. Their results also differ from Ash and Piazza's in that bulimic symptomatology decreased from 1991 to 1996. With respect to symptom severity, Bravender et al. found some indications that patients with AN manifested more severe symptomatology in 1996 than in 1991. Specifically, their average recumbent heart rate was lower, and they were more likely to have been previously admitted for medical stabilization. However, symptom severity remained stable over the study period among patients with diagnoses of BN or EDNOS. Eagles, Easton, Nicoll, Johnston, and Millar (1999) investigated changes in the duration and severity of AN symptoms among 287 patients referred to treatment in Scotland between 1965 and 1991. This study offers an interesting contrast to the research reviewed above because the changes in the healthcare delivery system that have affected eating disorders treatment in the United States have not influenced healthcare in Europe. These authors found no differences over time in either eating disorder duration or patients' age at intake. In addition, there were no differences across time in the number of patients who were severely underweight (defined by the authors as BMI≤15). These studies each provide insight into changes in symptomatology of patients with eating disorders over the last few decades. However, their results are somewhat difficult to compare directly due to the fact that they each used different types of samples (e.g., inpatient vs. outpatient), and studied somewhat diverse time periods. In addition, two of the studies Ash and Piazza, 1995 and Bravender et al., 1999 involved relatively small samples, which might have made it difficult to detect true group differences. Consequently, in the current study, we investigated differences in patient characteristics and symptom patterns in a larger group of patients who presented for intake at an outpatient clinic between 1988 and 1998. Outpatient treatment of eating disorders is increasingly becoming the norm (e.g., Striegel-Moore et al., 2000 and Wiseman et al., 2001). Consequently, we hoped that this descriptive study could expand our understanding of the needs of the typical outpatient. Enhanced understanding of patients' symptoms is particularly vital in the current healthcare climate, where both treatment length and options are becoming increasingly limited (Bravender et al., 1999).