Are Diagnostic Criteria for Eating Disorders Markers of Medical Severity? Rebecka Peebles, Kristina K. Hardy, Jenny L.

Wilson and James D. Lock Pediatrics 2010;125;e1193; originally published online April 12, 2010; DOI: 10.1542/peds.2008-1777

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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pediatrics. 2010 Address correspondence to Rebecka Peebles. Hardy. Stanford University School of Medicine. patients with pAN and pBN differed significantly from each other in all outcome variables. North Carolina. California WHAT’S KNOWN ON THIS SUBJECT: Few studies have focused on any medical sequelae in adolescents with eating disorders not otherwise specified. temperature.2% of females had AN. Department of by guest on October 31. MD.4% had Pediatrics 2010. Stanford University School of Medicine. MD. 2011 e1193 .2008-1777 doi:10. CONCLUSIONS: EDNOS is a medically heterogeneous category with serious physiologic sequelae in children and adolescents. lost Ͼ25% of premorbid weight at presentation SMR—sexual maturity rating www. Stanford University School of Medicine. PhDc aDivision of Adolescent Medicine. RESULTS: A total of 25. eating disorders. Durham. Broadening AN and BN criteria in pediatric patients to include pAN and pBN may prove to be clinically useful. or EDNOS were retrospectively reviewed. 0031-4005. PEDIATRICS (ISSN Numbers: Print. and 62. patients with pBN did not differ significantly from those with BN in any primary outcome variable. Fourth Edition criteria but 1 for AN or BN. Copyright © 2010 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. Patients with pAN had significantly higher heart rates. METHODS: Medical records of 1310 females aged 8 through 19 years and treated for AN. E-mail: rpeebles@stanford. Wilson.1542/peds. and cDivision of Child and Adolescent Psychiatry. systolic blood pressure. Primary outcome variables were heart rate.a Kristina K. Online.aappublications. May 2010 Downloaded from pediatrics.b Jenny L. Fourth Edition BN— bulimia nervosa AN—anorexia nervosa pAN—partial anorexia nervosa pBN—partial bulimia nervosa ED— eating disorder MBW—median body weight BP— blood pressure pBN-binge/purge—partial bulimia nervosa that does not meet binging and purging frequency criteria pBN-binge only—partial bulimia nervosa. respectively. MD. Mountain View.a and James D. Number 5. Patients with EDNOS were subcategorized into partial AN (pAN) and partial BN (pBN) when they met all Diagnostic and Statistical Manual of Mental Disorders. adolescent medicine. BA. CA 94040.2008-1777 Accepted for publication Jan 7. Division of Adolescent Medicine. and temperatures than those with AN. binging but not purging pBN-purge only—partial bulimia nervosa.ARTICLES Are Diagnostic Criteria for Eating Disorders Markers of Medical Severity? AUTHORS: Rebecka Peebles. 1174 Castro St. California. Stanford. abstract OBJECTIVE: The objective of this study was to compare the medical severity of adolescents who had eating disorders not otherwise specified (EDNOS) with those who had anorexia nervosa (AN) and bulimia nervosa (BN). Additional physiologically significant medical complications were also reviewed. Patients with pBN and BN had longer QTc intervals and higher rates of additional medical complications reported at presentation than other groups. The medical severity of patients with EDNOS was intermediate to that of patients with AN and BN in all primary outcomes.4% had EDNOS. purging but not binging pAN-low weight/menstruating—partial anorexia nervosa that does not meet menstrual criteria pAN-low weight/not menstruating—partial anorexia nervosa that meets weight and menstrual criteria pAN-Ͻ90%—partial anorexia nervosa. child psychiatry ABBREVIATIONS EDNOS— eating disorders not otherwise specified DSM-IV—Diagnostic and Statistical Manual of Mental Disorders.1542/peds. systolic blood pressures. however. Suite 250A. Department of Psychiatry and Behavioral Sciences. Lock. KEY WORDS children and adolescents. bDepartment of Psychiatry and Behavioral Sciences. Mountain View. 12. 1098-4275). and QTc interval on electrocardiogram.125:e1193–e1201 PEDIATRICS Volume 125. PhD. WHAT THIS STUDY ADDS: This study provides evidence that serious medical complications can occur in children and adolescents with eating disorders who do not meet full DSM-IV criteria for anorexia nervosa or bulimia nervosa. 85% to 90% of median body weight pAN-25%—partial anorexia nervosa. Duke University Medical Center.

Fourth Edition (DSM-IV) as “disorders of eating that do not meet the criteria for any specific eating disorder.16–30 Numerous medical organizations. and there are no data to validate the commonly held tenet that EDNOS is associated with lower medical severity. this study was designed to answer a primary research question of how DSM-IV diagnostic criteria predict medical outcomes. METHODS Patients All 1310 female patients who were aged 8 to 19 years and had been diagnosed with AN. Because of small within-gender cell sizes that prevented adequate assessment of potential gender differences. or EDNOS in an academic pediatric ED program from January 1997 through April 2008 were identified. after diagnostic interviews with both patients and parents or guardians.8.”1 a categorization that has long troubled practitioners. or orthostasis are critically ill and require hospitalization.31. fracture rates. When indicated after this comprehensive re- Downloaded from pediatrics. agree that patients with eating disorders and severe malnutrition. Our goal is to describe a large group of pediatric patients with EDNOS and compare them with pediatric patients with e1194 PEEBLES et al FIGURE 1 Diagnostic categorizations for analyses. A waiver of informed consent and a Health Insurance Portability and Accountability Act– compliant waiver of individual authorization were granted.aappublications. BN. therefore. In addition. comparing adult patients who had partial AN (pAN) or partial BN (pBN) with patients who met full DSM-IV criteria. bradycardia. hypothermia. including the American Academy of Pediatrics. whereas pAN and pBN differ significantly from each other despite that both are subgroups of EDNOS. frequency. defined in the Diagnostic and Statistical Manual of Mental Disorders. we predicted that pAN and pBN would differ significantly from one other with respect to meeting hospitalization criteria. Patients with pAN and pBN typically have similar psychological profiles to those who meet full criteria for AN and BN. or clinical significance of EDNOS in young people. Furthermore.13–15 Studies of patients with EDNOS have focused on psychiatric features. male patients were excluded from analyses. hypotension.2–9 Although a handful of studies have examined bone density. DSM-IV criteria for EDs are guidelines and allow for latitude in their application in clinical by guest on October 31. AN and BN. Both inpatients and outpatients were included. We predicted that those with EDNOS and pAN or pBN would be less medically compromised than those with full DSM-IV syndromes. and as part of a comprehensive evaluation by a multidisciplinary team.10–12 most studies on medical sequelae of disordered eating have focused on bulimia nervosa (BN) or anorexia nervosa (AN). and little work has documented the severity. A systematic retrospective review of all medical records was conducted.According to current diagnostic criteria. or electrocardiograms of patients with EDNOS. however. 2011 . All patients initially received a clinical diagnosis from a boardcertified psychiatrist or psychologist with expertise in the assessment of children and adolescents with ED. This article reviews current diagnostic criteria and discusses their utility in predicting the medical severity of patients with eating disorders (EDs).4. as were patients who were found not to have a DSM-IV– diagnosable ED during their evaluation or treatment. we compare the medical severity of adolescents who have EDNOS with pAN or pBN with those who meet full diagnostic criteria. by 2 independent assessors and reviewed by the primary investigator to note relevant clinical parameters at presentation.32 No study has examined how DSM-IV diagnostic criteria correlate with medical severity. most pediatric patients with disordered eating receive a diagnosis of eating disorders not otherwise specified (EDNOS).4. all data collection protocols were approved by our Panel on Medical Research in Human Subjects and compliant with the Health Insurance Portability and Accountability Act of 1996.

1 we further categorized patients with EDNOS into nonoverlapping pAN and pBN categories: 1.0) Hypophosphatemia (phosphorus Ͻ3.33 although this convention was dropped for the DSM-IV. parent. temperature. the DSM-III suggested that patients with this degree of weight loss be eligible for the diagnosis of AN even if they were not Ͻ85% MBW. pAN-low weight/menstruating: patients who met weight criteria for AN but not menstrual criteria. To examine each separate criterion for AN and BN in the DSM-IV. 4.34 Primary outcomes were heart rate. by using strict DSM-IV criteria (Fig 1). Secondary outcome variables included rates of admission within 2 weeks of presentation. pAN-Ͻ90%: patients who met menstrual criteria for AN and weighed Ͼ85% median body weight (MBW) but Ͻ90%. BP. AN was diagnosed when weight and psychiatric criteria were met as per DSM-IV guidelines. pAN-low weight/not menstruating: patients who met menstrual and weight criteria for AN but did not openly acknowledge psychiatric criteria. In premenarchal females. similar to binge-eating disorder but with any level of frequency of binge eating. and standing heart rate and BP were taken after standing for 2 minutes. There were no deaths in this series during the first hospital stay. or outside health care professional) a Description Ͻ50 beats per minute Systolic BP Ͻ90 mm Hg Ͼ20-beat rise in heart rate from lying to standing Ͼ10-point drop in systolic BP from lying to standing Oral temperature Ͻ35. or 7. pBN-binge/purge: patients who binge-ate and purged (defined by self-induced vomiting only or laxative abuse) in the month before presentation but with less frequency than defined in the DSM-IV. blood pressure (BP). pAN-25%: patients who were not in other categories of pAN or pBN but had lost Ͼ25% of premorbid weight PEDIATRICS Volume 125. and BN. 2011 . and QTc interval. 6. patients were recategorized from their original clinical ED diagnosis.6°C QTc interval Ͼ440 ms Serum potassium Ͻ3.2. although exhibiting denial of the severity of their underweight along with weight and shape concerns by parental report were sufficient to diagnose a clinical eating disorder.2 Serum phosphorus Ͻ3. and complications that occurred during the first hospital stay if the hospitalization occurred within 2 weeks of presentation. 5. pBN-binge only: patients who bingeate with no purging behaviors. pBN-purge only: patients who purged with no binge-eating behaviors. 2.0) Pancreatitis Pericardial effusion QTc prolongation Ͼ450 ms Refeeding syndrome Seizure Serious arrhythmias Superior mesenteric artery syndrome Syncope Transfer to the ICU Vasopressor requirement Serious hospital complications (noted by medical team during hospital stay and recorded in the medical record) a Primary outcomes were continuous: heart rate. Heart rates (measured manually) and BPs (using a sphygmomanometer) were taken after lying supine for 5 minutes. 3. temperature. Variables and Outcomes Predictor variables for primary analyses were categorical diagnoses of EDNOS. at presentation.aappublications. AN.ARTICLES view.0 Percentage MBW Ͻ75 Arrhythmias Ascites Edema Hematemesis Hypokalemia Hypophosphatemia Pancreatitis Pericardial effusion Pneumothorax/pneumomediastinum Renal calculi Seizure Superior mesenteric artery syndrome Syncope Hematemesis Hypokalemia (potassium Ͻ3. complications that were attributed to the ED before presentation. When heart rates or BPs were low supine or when significant dizziness e1195 Downloaded from pediatrics.32. May 2010 TABLE 1 Medical Outcome Variables Variable Bradycardia Hypotensiona Orthostatic by heart rate Orthostatic by BP Hypothermiaa QTc prolongationa Hypokalemia Hypophosphatemia Severe malnutrition Serious complications before first visit (obtained from the medical record as a report from patient. and QTc by guest on October 31. Medical outcome variables are defined in Table 1 on the basis of national guidelines for acute hospitalization of adolescents with EDs. length of disease. Number 5. Severe malnutrition was not a primary outcome in this study because pAN and pBN categories were partly defined by weight.

3 52.6 4.4 MBW was calculated by using genderspecific 2000 Centers for Disease Control and Prevention BMI-for-age growth charts for children and adolescents aged 2 to 20 years (www.2 12.5 11 10. Because electrocardiograms and laboratory values were performed clinically rather than as part of a research protocol.8 32.7 68. Statistical Analysis Data were described with standard mean and frequency statistics and ane1196 PEEBLES et al TABLE 2 Demographic and Clinical Description: Overall Data Set Parameter Age. the majority of but not all patients had these tests performed (Table 2).3 17. Temperatures were obtained orally by using a digital thermometer.7 16.4 106 6.3 47. cdc.0 11.3 19.4 75. mg/dL Hypophosphatemia Met medical admission criteria Any Any except weight Status at initial evaluation/presentation Outpatient Inpatient Admitted to hospital or admission recommended within 2 wk of first presentation Length of stay if admitted.aappublications.6 0.4 18.0 6.9 5.4 28 9 12 0. The 50th percentile BMI for exact age at presentation on the Centers for Disease Control and Prevention chart was used to calculate an MBW.2 3. mmol/L Hypokalemia Phosphorus.5 25.0 Downloaded from pediatrics.5 1.3 89.5 9. multiplied by 100.0 20.4 62. When the maximum weight was the weight at presentation.2 36.2 61 25. Percentage Median Body Weight BMI was calculated by using the equation BMI ϭ weight in kg/(height in m)2.1 15 14.1 0.7 60. y Ethnicity White Asian Hispanic Black Pacific Islander Other Diagnosis AN BN EDNOS pAN pAN-low weight/menstruating pAN-low weight/not menstruating pAN-Ͻ90% MBW pAN-25% pBN pBN-binge/purge pBN-purge only pBN-binge only SMR: breasts 1 2 3 4 5 Hormonal contraception Months of disease Percentage of MBW Severe malnutrition Percentage weight loss Rate weight loss. ms QTc prolongation Potassium. mm Hg Hypotension Temperature.6 392 3.1 8.2 7.3 8.6 3 5. Total weight loss before presentation was defined as the maximum weight minus the weight at by guest on October 31. Total percentage weight loss was defined as the total weight loss divided by the maximum weight. and heights were obtained by using a stadiometer.7 3.7 0.3 5. The rate of weight loss was defined as total percentage weight loss divided by the months from the date of maximum weight to the date of presentation.2 7.9 9.9 2.5 18 37. Rate of Weight Loss Reported maximum weights were extracted from the medical record.4 5.3 15.5 17. Electrocardiograms were performed by trained staff members by using a standard 12-lead method.4 8. together with the height at presentation.8 4.5 45.0 2.0 6. as was the rate of weight loss. d Serious hospital complications if hospitalized within 2 wk of presentation Serious complications reported before presentation n 1310 1273 959 105 96 14 3 96 1310 330 162 811 408 111 130 121 46 223 79 86 58 1020 54 51 120 332 463 109 1300 1310 218 1239 1176 1310 333 1308 81 1298 46 1104 415 1104 62 1088 41 1179 26 1074 54 848 790 685 624 894 890 169 266 % Mean 15.0 64. %/mo Heart rate. 2011 .7 2.2 11. standing vital signs were not obtained. Weights were recorded in gowns with no clothing.2 3. °C Hypothermia Change in heart rate Orthostatic by heart rate Change in systolic BP Orthostatic by BP QTc interval.0 SD 2. bpm Bradycardia Systolic BP.6 17.was reported. the total weight loss was 0.

15. P Յ .9%. P Ͻ .001]) at the fastest rate (3.8 18 32. mean Rate loss. whereas those who did not meet psychiatric criteria were the youngest (15.7 [t ϭ 2.7 [t ϭ 2. and 75.0.4 26. but patients with pBN were slightly less pubertally mature than their BN counterparts (SMR breast: 4. Patients with pAN-low weight/ not menstruating had the longest QTc intervals (394 vs 393: pAN-low weight/ menstruating.3a 21.2%. P Ͻ .c 12. posthoc testing revealed that most differences in secondary outcomes were significant among all 3 diagnostic categories. Significant differences on posthoc testing between AN and BN and between EDNOS and BN. 378: pAN-25% [F ϭ 3. 16.3 81.8.4 10.c 2.7 92. and 38.5 vs 4. mean % Bradycardia Systolic BP.0 11.3 45.9a 62.7 BN 16. To guard against type I error in analysis of the primary aims. 19.9.6 106. Patients with pAN-low weight/menstruating were significantly older.7%. 386: pAN-Ͻ90%. Medical outcomes were compared between patients with pAN and AN.5 101 16.5%. 28.6 2.05]). P Յ .0%. pBN and BN.0 2.9 36. Pediatric patients with EDNOS had similar age.01]). e P Ͻ . and rate of weight loss as those with AN.4.05]).0% [F ϭ 32.9a 68.5% [␹2 ϭ 14.c 10.3a. Chicago. mean % Orthostatic by BP QTc interval. 59. All differences that were noted in primary analyses RESULTS Demographic and clinical characteristics are presented in Table 2.3 63 23.3 107 2. and pBN subgroups were compared with BN.01]) and orthostasis by heart rate (57.5% vs 2. mean % Hypothermia Change in heart rate.3 5.5a 20.3 31. 5. 2011 .7% vs 77.6a.8 8.6 393 3.0 3. 28.6 58.6a. c Significant differences among all 3 groups on posthoc testing.7 388 4. excluding weight (76.8.001]). mean % Hypotension Temperature. all relationships between primary predictor and outcome variables remained significant after controlling for age and months of disease.9.0a.5 ␹2 F 26.9a. Number 5.8 73.2 1.0 17 33.2 3.3 111 1.5 19.f 9. and 73.8 5. P Ͻ .7 45.3 14. P Ͻ .3 16.4%/mo [F ϭ 3.01. Patients with pAN did not differ from those with AN in sexual maturity rating (SMR). and 32.0 1.0 3.2a.9 36.7%: pAN-low weight/not menstruating.0.2 16.005]). mean % Severe malnutrition % Weight loss.9 2.2%: pANϽ90%.001]).8 vs 14.c 53.7%.5%.1 1.7a.6%. Table 3 outlines medical differences between DSM-IV ED categories at presentation. and analysis of variance with Tukey’s posthoc comparisons testing on SPSS 17.3 23. P Ͻ . The pAN25% group.5%.7a. d P Ͻ . 61. Student’s t testing. 2. 14.1% vs 66. despite being nearly at their MBW (97.c 159. except for those related to temperature differences between patients with pBN and BN. Patients with AN were most likely to have hypotension (16. but.7 3.4d 71.3 19 40.35 To assess further the relationships between primary predictor and outcome variables.8 2 6.4 66 9.6a. Inc. and 15.6e 14.1.4%.4 56 38.6 5.9a e and detailed in Tables 3 and 4 retained significance after the Hochberg modified Bonferroni correction was applied.6 0.2 4. P Ͻ . They also had higher rates of bradycardia (43.5%. and pAN and pBN (Table 4). 32. Differences were statistically significant for all primary outcomes. otherwise.9a. 37.001.2 16. d % Serious hospital complications % Serious previous complications a b AN 15.9 4.1 16.0: pAN-25%. we used a Hochberg modified Bonferroni procedure.4 36.c 5.ARTICLES TABLE 3 Comparison of EDNOS With AN and BN Parameter Age Months of disease % MBW. In exploratory analyses.aappublications.b 31. mean. mean % Hypophosphatemia % Met admission criteria Any Any except weight Length of stay.4 EDNOS 15.7 15.5% vs 22. 2.4%.0 3.7%: pAN-low weight/menstruating.05].b 61. Of note.8% [␹2 ϭ 18.6a. %/mo Heart rate.6. mean. IL).org by guest on October 31.8%.7 4.9 401 6.b 242.0 75.001]) than all other pAN subgroups and were more likely than all except patients with AN to meet any admission criteria. pubic hair: 4.8: pAN-Ͻ90%.1% vs 52.7%: pAN-low weight/menstruating.7 11. 87. pAN subgroups were compared with AN. mean % Hypokalemia Serum phosphorus.0 20.8 38. mean % QTc prolongation Serum potassium.3 years: pAN-low weight/not menstruating. f Significant differences between AN and BN and between AN and EDNOS. The medical severity of patients with EDNOS fell between that of patients with AN and BN in most criteria examPEDIATRICS Volume 125.8 61. and 2.5 20.5 vs 4.8%: AN [F ϭ 198.4a 38. 75.2 3. ined.0% [␹2 ϭ 11. alyzed by using ␹2 testing.8 4.c 79.0% vs 19.3 3 3.6%. and 23. May 2010 Downloaded from pediatrics.8d 1.7.5 0. mean % Orthostatic by heart rate Change in BP.0: pANe1197 P Յ . P Ͻ .2% vs 2.9 0. we added age and length of disease as covariates by using analysis of covariance.3: AN [F ϭ 9.0 13.0 software (SPSS.2 13.8.5e 2. 6. length of disease. P Ͻ .9: pAN-low weight/not menstruating.6%. demonstrated the highest percentage of weight lost (34.1 3 5.2 23.

0 3.01.TABLE 4 Comparisons of Medical Data Among Diagnostic Subgroups Parameter Age Months of disease % MBW.7b 1.6b 8. mean % Hypophosphatemia % Severe malnutrition % Met admission criteria Any Any except weight Length of stay.1 104.aappublications.4 Ϫ1.9c 2. Patients with pBN were younger.0 4.001]). 15.2 4.8 73. potassium and phosphorus levels.6 0.2a 75. patients who had EDNOS and had lost Ͼ25% of their premorbid body weight (pAN-25%) seemed more compromised than other subgroups of pAN and even more than patients with AN in some medical outcomes. There were no differences between groups in mean percentage weight loss.2 1.5 13. In addition.1 36.7 61 28.8 4.4 0.8 19. 61.7 105 5.2 2. 3.4% received a proper diagnosis of EDNOS when current DSM-IV standards were strictly applied. mean % Hypothermia Change in heart rate.5 0. b P Յ .4 vs 15.3a 14.0a 2 Ϫ1. mean % Hypotension Temperature.7 5. mean % Hypokalemia Serum phosphorus.9c 101 Ϫ5.2b 16.7 0. mean % Orthostatic by heart rate Change in BP. Despite their younger by guest on October 31.2 NA 0.1b 4. and 15.3 31.5. those with pAN-low weight/ menstruating were older. a P Յ .0 82. and 6.0 17. and complication rates.6 Ϫ2.001]) and had the lowest phosphorus levels (3.8 4.3 0.0. When patients with pAN were compared with those with AN.2 16. orthostatic hypotension.4 11. %/mo Heart rate.8 3.0 45.0 4.0.2 1. mean % Orthostatic by BP QTc interval. We proposed new groupings of patients with pAN and pBN within the EDNOS group.1 64.3 2. 62.6. however.5 47.0 0.2 Ϫ0.5 0.1 BN 16. hypokalemia. BP.5b Ϫ5.0b 16. P Ͻ .4 25.3 3.7 12.8 0.1b 5.5: pAN-25% [␹2 ϭ 26. Ͻ90%. serious hospital complications.4 Ϫ2.4 0.2 21.6 32.001]) and had disease longer than all pBN subgroups (26. mean % QTc prolongation Serum potassium. there were few differences.4 0.2 20.8 390 2.1 Ϫ1.0 3.2 4 4. Most pBN subgroups did not show significant differences from each other in medical hospitalization criteria. This is the case despite being at a significantly higher.4 38.0 3.1 0. Adolescents with pAN were younger and weighed significantly more but had lost weight more rapidly than those with AN and had a shorter disease duration.9%/month: pBN-binge only.2 19 42. however.6% of these patients with EDNOS met recommended criteria for medical hospital- Downloaded from pediatrics.5b 8.0 17 33.3b 36.1 0.6b 2.9 Ϫ0.5b Ϫ8. mean Rate loss.6 106.0 20.1 0.9 5.5 7.8 Ϫ1.3 36.4% vs 1. and 3.3 3 3.0 1.7 months [F ϭ 8. possibly indicating later recognition of the ED.8 4.7 11. orthostatic changes. mean % Bradycardia Systolic BP.1c 0.2 18.0 3 6.8 5.04 4.2 2. patients with pBN and subgroups did not differ significantly from adolescents with BN on most other medical outcomes examined.9c 7. Of pAN subgroups. they displayed similar disease duration and rates of weight loss.0b 3. reminding us that malnutrition is a complex disease with manifestations at multiple weights. and had lost weight more rapidly than their BN counterparts.2 22.7 0.6a 2.1 AN ␹2/t pBN 15.6 mo vs 19. or complications before presentation.8 years: pBN-binge/ purge. and e1198 PEEBLES et al 18.4 ization and were more compromised than patients with BN in most medical outcomes.9.001.8 [F ϭ 3.0 2. d % Serious hospital complications % Serious previous complications pAN 15.8 Ϫ0.9 pAN vs pBN Ϫ4.9 66 12. c P Ͻ .5 ␹2/t 4.5%/month: pBN-binge/ purge.4a 5.7 vs 3. P Ͻ .04 1.0 388 Ϫ0.9 0.6: pBN-binge only [F ϭ 6.9 36. Patients with pAN as a whole were less likely to have a low heart rate or BP but did not differ from patients with AN on most other medical outcomes. length of stay if hospitalized.3 2.2a 0. There were no differences noted among pAN subgroups and AN with regard to rates of hypothermia.2 18 Ϫ1. mean.3 0.8 1.005]).3 111 1. and hypokalemia as their full diagnostic counterparts.3a 15. had a shorter duration of disease.05]).4 26.0 12.5b 6.5 20.8 18.4%/month: BN [F ϭ 3. with each subgroup directly challenging 1 DSM-IV criterion for AN or BN.3 Ϫ2. Patients with pBN-purge only had lost weight faster than patients with BN (2. QTc prolongation.5b Ϫ19.5 71.8 399 4.9 401 6.0 25.0 47.3b 3.4 2.2 Ϫ0.6: pBN-purge only. P Յ .9 1.5 4. orthostasis.9.1c 22.2 0. although small cell sizes precluded meaningful analyses of some categorical outcomes.9b 1.9 Ϫ3. This is despite that they weighed significantly more than patients with AN.5.3 NA 34.3 2.1d 1.4. Patients with BN were older (16. 4.6 3.3b 38. 2011 . P Ͻ . 1.8 Ϫ3.04 0.8 Ϫ10.4 66 9. mean % Weight loss.9 Ϫ0. P Ͻ . d Did not retain significance when Hochberg modified Bonferroni correction was applied.2 0.1a 56 Ϫ4. NA indicates not applicable.8 0.1 111 1.7 45.3 23.4 0.6 13. and 1.9 Ϫ0.0 0.9b Ϫ3.7.4.7 18. near “ideal” body weight. These results do not support our initial hypothesis that EDNOS would be less medically severe than AN or BN. weighed less.05.4c 0.0 3.9 19 38. 16.7a Ϫ2. mean.4b 81.3 6. DISCUSSION These analyses reveal that in this adolescent population with ED.6b 23.

they suggest the need to delineate better the predictors of complications and medical protocols in each DSM group separately. and although it is critical PEDIATRICS Volume 125. It is also an exclusively female sample. Number 5. thereby necessitating caution in the interpretation of these variables. Although patients with AN certainly had a high rate of objective medical complications observed during their first hospital stays. 9. They provide a rationale to consider changes to the diagnostic criteria for adolescents with ED. A limitation of any study of current medical hospitalization criteria for patients with ED is that they were derived from expert consensus and not from longitudinal study. 6. with the exception of duration of illness and the QTc interval: patients with pBN had more months of disease and longer QTc intervals. and endocrine dysfunction are not currently evidence-based and thus may not be truly reflective of medical severity. outpatient treatment regimens may prove to be equally effective and safe in treating these cardiac sequelae. Limitations of this study include that it is a clinical sample from a subspecialty ED program. May 2010 FIGURE 2 DSM-IV and proposed diagnostic categories. Although additional prospective study is required to confirm these findings. hypotension.36 which makes it the most concerning complication of the ones examined here.3% of patients with “true” EDNOS remain. by guest on October 31. data may be missing for nonrandom reasons not yet identified.38 If Ͼ60% of patients have EDNOS by DSM-IV criteria. respectively. illustrating the original percentage of patients in AN.ARTICLES When pAN was compared with pBN. Bradycardia. duration of behaviors. and additional prospective study is urgently needed to delineate the most appropriate type of interventions and when they are indicated. respectively. patients with pAN had a more medically severe condition. In addition. rather than measuring each group against an AN standard.47 Our study also suggests that current criteria for medical intervention may be most appropriate for adolescents with AN but that we may miss critical opportunities for intervention and prevention in other ED groups. because patients with this diagnosis differ more from each other than they do from AN and BN. and 37– 46. respectively. and hypothermia have clearly been shown in studies to be strong indicators of a malnourished state and have therefore been adopted as indicators of medical severity in patients with EDs. These analyses reveal that adolescent patients with ED exist within a larger EDNOS group and are medically similar to patients with AN and BN. most variables were missing Ͻ10% of data. the complication profiles of other patients were hardly reassuring. as other authors have proposed. To our knowledge. Data were collected retrospectively. which limits its generalizability. 25. Downloaded from pediatrics.32 In addition. which may have introduced bias on the basis of medical severity. 4. 26. that we learn better how to treat male adolescents with EDs. cut points of weights.aappublications. 15. we do not have evidence that these findings mandate hospitalization and are not certain that hospitalization improves long-term medical outcomes. and EDNOS categories and comparing that with a new grouping in which pAN and pBN are counted as a subgroup of AN and BN. and orthostasis. this study does not inform that pursuit. which are shown in Fig 2. If patients with pAN and pBN are combined into AN and BN groups. similar to another diagnostic reclassification of adult patients with ED. This mirrors our comparison of BN with AN: patients with BN report nearly twice the duration of disease and longer mean QTc intervals. This lends credence to the idea that EDNOS is too heterogeneous a category. *Refs 3. Patients with pAN and pBN also displayed high rates of hospital complications at ϳ18% and 19%. and patients with BN and pBN reported significantly higher numbers of serious complications before presentation than their peers with AN and pAN. 2011 e1199 . Finally. then only 14.31. However. In general. clinical decisions that influenced the choice of laboratory tests had been made. Patients who have EDNOS and narrowly miss criteria for AN and BN are often medically compromised and in need of treatment. and orthostatic testing were missing for 10% to 20% of patients. hypophosphatemia. electrocardiograms. our data propose another possibility of diagnostic groupings. orthostasis.* For example. therefore. It is possible that in the future. but phosphorus levels. QTc prolongation has been shown to be a risk factor for sudden cardiac death. this is the first published comparison of reported complications among adolescents with ED from all DSM-IV diagnostic groups. Patients with pAN and pBN were similar only in rates of hypokalemia. 16.

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aappublications. tables) or in its entirety can be found online at: http://pediatrics. Hardy.e1193.full. DOI: 10. 2010.full. originally published online April by guest on October 31. PEDIATRICS is it has been published continuously since 1948.aappublications. and trademarked by the American Academy of Pediatrics. Copyright © 2010 by the American Academy of Pediatrics. 60007. All rights reserved. html#ref-list-1 Information about reproducing this article in parts (figures. A monthly publication. 2011 .2008-1777 Updated Information & Services References including high resolution figures.125. Jenny L. 6 of which can be accessed free at: http://pediatrics. Elk Grove Village. Lock Pediatrics 2010.1542/ ml Information about ordering reprints can be found online: http://pediatrics. Illinois.aappublications. Wilson and James D.Are Diagnostic Criteria for Eating Disorders Markers of Medical Severity? Rebecka Peebles. Kristina K.aappublications. Print ISSN: 141 Northwest Point Boulevard.aappublications.xhtml Permissions & Licensing Reprints PEDIATRICS is the official journal of the American Academy of Pediatrics. Downloaded from pediatrics. published. Online ISSN: 1098-4275. can be found at: http://pediatrics. html This article cites 43

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