Feb. 24, 2000 (Washington) -- Hospitals, usually places of healing, can be just the opposite for teen-agers struggling with anorexia nervosa, a common and often dangerous eating disorder. A British study found that teen-agers who were hospitalized fared far worse than those who were not, and experts in the U.S. tell WebMD that inpatient care rarely benefits those with anorexia.
Anorexia nervosa may afflict up to 3% of all teen-agers. Those affected have a distorted body image, believing they are fat even though they may be thin. They often refuse to eat and have an abnormal fear of gaining weight. Over time, anorexics lose extreme amounts of weight and develop malnutrition. Some girls even stop having menstrual periods.
Although anorexia occurs in adolescents and young adults, the disorder may be lifelong. Treatment involves improving weight and nutrition as well as long-term psychological and social therapy.
Researchers at the University of Liverpool compared the cases of 40 teen-age girls who had been hospitalized for anorexia with those of four male and 31 female adolescents who had not had an inpatient stay for the disorder. The patients were 14-15 years old, on average. All were followed for two to seven years, and they and their families were interviewed. "Outcome was defined as good if weight was maintained about 85%, menstruation had resumed and social functioning was satisfactory," writes study author S.G. Gowers, a professor of adolescent psychiatry.
Good results were reported for 62% of adolescents who were never hospitalized, but that dropped to 14% for those who had been in a hospital for their illness, and two of those who had been hospitalized died. After studying different variables, the researchers concluded that being in the hospital was linked to a poorer prognosis for these teen-agers.
"The finding that inpatient treatment is associated with poor outcome in anorexia nervosa is not new, but it is good that Gowers [and others] have reopened the issue," says George Hsu, MD, director of the Eating Disorders Program at New England Medical Center and a professor of psychiatry at Tufts University, both in Boston. Hsu, who reviewed the study for WebMD, adds that his own research found that hospitalization was linked to poor outcomes at four to 10 years after the start of the illness.
"There are two possible explanations," Hsu says. "One, patients who need inpatient treatment are sicker in the first place; two, there is something in the inpatient treatment approach that makes the illness worse. I suspect that both possibilities are true. I have certainly met patients who seem more entrenched in their [behavior] after inpatient treatment. It is certainly a topic that needs further study. ... I think we should adhere to the American Psychiatric Association [APA] treatment guidelines for inpatient admission for anorexia nervosa for now and wait for someone to do the proper studies."
"This is an excellent article and long overdue," Ronald Liebman, MD, tells WebMD. Liebman recently served on a panel that revised the APA's treatment guidelines. Those [guidelines] recommend that patients be placed in one of five levels of care depending on the severity of the illness. These range from outpatient to partial hospitalization and residential care. Inpatient hospitalization is suggested only for patients who have very low heart rates, who have a plan to commit suicide, and are less than 75% of their ideal body weight.
There are number of reasons adolescents may be hospitalized for eating disorders, few of which are valid, according to Liebman, also a professor of psychiatry at Temple University and former head of psychiatry for Children's Hospital of Philadelphia. Doctors may suspect that the child has been abused, is psychotic, or is a danger to him or herself or others. Sometimes parents are the ones pushing for hospitalization, believing it will be better for the teen-ager and will provide them with a break. But that is not usually the case, according to the results of this study and to Liebman.
"What we have found is that in the hospital, [adolescents] learn bigger and better ways of being anorexic from other patients," says Liebman. "Their self-esteem and their self-confidence are obliterated. They are alienated from their school and peer group and the community. There is a tremendous burden on the parents. The parents are made to feel ineffective and impotent."
Edmund Neuhaus, PhD, director of the eating disorder program at McLean Hospital in Belmont, Mass., called the study findings "interesting but not surprising." He faulted the study for providing little detail on the type of inpatient programs the study participants were engaged in, and suggested that the lengths of stay in Britain are likely to be longer than in the U.S., which would contribute to poorer results. Neuhaus, who is also an instructor in psychology at Harvard University School of Medicine, reviewed the study for WebMD.
Neuhaus says the key to improving results for people who are hospitalized for anorexia might be to ensure that there are programs in place to support their adjustment to life outside the hospital. He agrees with Liebman and Hsu that some patients can actually worsen in a hospital setting.
"Anorexia, of all the eating disorders, is by far the hardest to treat, and [patients] have the worst outcomes," Neuhaus says. "Part of the problem is that no one has really figured out what works in treating it."