Psychiatry and Clinical Neurosciences (2001), 55, 389–396

Regular Article

Outcome of severe anorexia nervosa patients receivinginpatient treatment in Japan:An 8-year follow-up study

HIDEKI TANAKA, md, NOBUO KIRIIKE, md, TOSHIHIKO NAGATA, md AND KEISEN RIKU, mdDepartment of Neuropsychiatry, Osaka City University Medical School, Osaka, Japan

Abstract Sixty-one subjects with anorexia nervosa (AN) were followed for a minimum of 4 years after dis-charge (mean 8.3 years). They were evaluated using the Morgan-Russell Outcome AssessmentScale. Thirty-one (51%) were categorized as having good outcome, eight (13%) as intermediate,15 (25%) as poor, and seven (11%) had died. As predictors of outcome, later onset (after 20 years of age) and low minimum body mass index were associated with poor prognosis. Theoutcome of AN in Japan is relatively similar to those in Western countries, irrespective of differ-ent sociocultural backgrounds and health systems.

Key words anorexia nervosa, eating disorder, Japan, outcome, prognosis.

INTRODUCTION

Recently, patients with anorexia nervosa (AN) andbulimia nervosa (BN) have increased among youngfemales in Japan as well as in Western countries. Theestimated prevalence is 0.004–0.024% for AN and1–3% for BN.1 Most patients with AN are treatedwith combined therapy such as individual psycho-therapy, behavioral therapy with or without cogni-tive therapy and somatic therapy depending on thepatients’ needs. Although there have been manystudies of the outcome of AN in Western countries,there have been few studies on the outcome andcourse of AN in Japan. In addition, these studies weremethodologically unsound because they had a cross-sectional design, short period of follow-up, smallnumber of subjects, used only self-report question-naires and/or no clear definition of outcome.2–5 InWestern countries, Hsu indicated six criteria for a‘good’ AN outcome study and reviewed five studiesthat met this criteria among numerous studies until1988.6,7 The findings of these studies showed thegeneral outcome to be good in 36–58% of subjects,intermediate in 19–36% and poor (including death) in

19–30%. Thereafter, outcome studies were performedwith due regard to this criteria. Steinhausen reviewedthese studies, which were published between 1960 and1996.8 He found that 52% of subjects had fully recov-ered, 29% showed some improvement and 19% stillhad a chronic course of disorder. The crude mortalityrate, based on a total of 918 patients, ranged from 0 to 11% with a mean of 2.2%. More recently, Pikereviewed the long-term course of AN and reportedthat approximately 50–70% of subjects achieved goodto intermediate outcome, while 15–20% were chroni-cally symptomatic.9

It has been generally suggested that the course andoutcome of AN varies widely and depends not onlyon severity of the disorders, resources, types of treat-ment, and family relationships but also on sociocul-tural backgrounds and health systems. However, therehas been no study on the intermediate- and long-termoutcome of AN in Japan, which is one of the non-Western countries using standard methods practicedin Western countries. Our department (Osaka CityUniversity Hospital, Osaka, Japan) has been engagedin the treatment of eating disorders since 1980, andwe have the opportunity to study the intermediate-and long-term outcome of eating disorders in Japan.Therefore, we investigated (i) the intermediate-termoutcome of AN patients who received inpatient treat-ment and for whom at least 4 years had elapsed since discharge from our hospital, and (ii) prognosticfactors associated with later outcome.

Correspondence address: Hideki Tanaka, Department of Neuropsy-chiatry, Osaka City University Medical School, 1-4-3 Asahimachi,Abeno-ku, Osaka 545-8585, Japan. Email: hideki-t@gc4.so-net.ne.jp

Received 13 November 2000; revised 22 January 2001; accepted30 January 2001.

390 H. Tanaka et al.

SUBJECTS AND METHODS

Subjects

The original sample consisted of 185 patients witheating disorders who were consecutively admitted toreceive inpatient treatment at Osaka City UniversityHospital between January 1982 and December 1999.Of the 185 patients, BN subjects were excluded. Sixty-nine female patients retrospectively fulfilled DSM-IV10 criteria for AN and at least 4 years had elapsedsince discharge from our hospital. Of these patients,61 (88.4%) agreed to participate in this follow-upstudy. Seven patients could not be traced becausethey had relocated and one patient refused to partici-pate. The inpatient treatment program was a combi-nation of psychotherapy, modified behavioral therapyand somatic therapy in a non-controlled manner.

Follow-up procedure

During 1999 and 2000, the 61 patients were scheduledfor follow-up examination by face-to-face interview.All patients and/or their parents were contacted initially by telephone and were given information onthe nature of the study. After informed consent wasobtained, they were invited to participate. Thirty-onepatients were allowed to have several assessmentsand semi-structured interviews either face-to-face orby telephone with the authors. Twenty-three patientswere reluctant to have semi-structured interviews,mainly due to lack of time or lack of interest.However, they gave information about their presentstatus according to follow-up questionnaires. Thefollow-up questionnaires included various demo-graphic and clinical features such as bodyweight,menstrual status, time at return of menstrual period,regularity, eating behaviors (such as restricting, bingeeating or purging), and number and sites of hospitali-zations, information about treatments after discharge,and social functioning at the follow-up. The data were confirmed by interviewing their parents and/orspouses. The clinical characteristic of the non-participants at first referral did not differ from thoseof the participants. Seven patients had died, but relevant information on their status at death could beobtained from their parents.

Assessment

Assessment of outcome was based on the averageoutcome score and general outcome category, accord-ing to the Morgan and Russell Outcome AssessmentSchedule.11,12 The average outcome score is a compos-ite rating on a 12-point scale in which high scores

indicate a good prognosis and is based on theoutcome in five scales (eating difficulties, menstrualstate, mental state, psychosexual state, socioeconomicstate). The ratings on the five scales were based onthe 6-month period immediately preceding the inter-view and the final score for each patient represents anaverage of the ratings of these five scales. The findingsfrom the interview were used to rate outcome onthese five scales.

The general outcome category was based on thepatients’ bodyweight and menstrual function duringthe 6 months that preceded follow-up. Three cate-gories of outcome were defined: (i) good: bodyweighthad been maintained within 15% of average body-weight, appropriate for age and height and menstrua-tion was regular; (ii) intermediate: bodyweight hadbeen within 15% of average weight for age and heightbut not constantly sustained, and/or there were pres-ence of menstrual disturbances; (iii) poor: bodyweighthad remained below 15% of average and menstrua-tion was absent or near absent. However, there is alimitation in this classification in which conversionfrom anorexic to bulimic with regular menstruation iscategorized as good outcome. Therefore, we used thegeneral outcome category modified by Ratnasuriya etal.13 In this category, patients who were either bingeeating and/or vomiting weekly or were classified morein the poor-outcome group regardless of their weightor menstrual status.

To evaluate psychological and behavioral featuresrelated to eating disorders, the Japanese version ofthe Eating Disorders Inventory (EDI)14 and theJapanese version of the Eating Attitudes Test (EAT)15

were administered.

Data analysis

The statistical analyses were performed using one-way analysis of variance (ANOVA) for significant meangroup differences for parametric variables, and the c2

test and Kruskal–Wallis analysis for non-parametricvariables.

RESULT

The demographic and clinical features of 61 patientswith AN when they first presented to our hospital areshown in Table 1. The mean age at first referral to ourhospital was 22.7 years. The mean age at onset and themean duration of illness were 18.8 years and 4.1 years,respectively. ‘Onset’ was defined as the age when thesubjects began to reduce food intake leading to sub-stantial weight loss. Fifty patients (82.0%) had nevermarried. The mean height, bodyweight and body mass

index (BMI) are shown in Table 1. Twenty-seven(44.3%) patients were diagnosed as restricting type ofAN (AN-R) and the others (55.7%) were diagnosedas binge-eating/purging type (AN-BP) according toDSM-IV criteria. Twenty-four (39.3%) of the patientshad a history of attempted suicide. Forty-one patients(67.2%) had previous treatment at another hospitalwith a mean number of 1.1 times. The mean totalscore of EAT was 43.1 ± 21.4.

Table 2 shows the bodyweight and menstrual,marital and social status of the patients at admission,discharge and follow-up. The mean age at admissionand follow-up were 23.1 and 31.2 years, respectively.The mean duration of follow-up after discharge was8.3 ± 3.8 (range 4.0–17.7) years. A mean of 12.4 yearshad elapsed from the onset of illness. The mean BMIincreased from 14.2 to 15.5 during hospitalization, andthen to 18.2 at follow-up. The number of patients with a BMI greater than 17.5 increased from seven at admission to 12 at discharge and to 37 at follow-up.

Twenty-four (39%) patients were readmitted two ormore times after first discharge, with a mean durationof 84.0 days. At the time of follow-up assessment, 11patients were still receiving outpatient treatment.Since first referral, approximately 75% of the patientsreceived treatment only from our hospital. Regardingmenstrual status, 34 (63.0%) patients had normalmenstruation, three (5.6%) patients were pregnant,and five (9.3%) patients showed oligomenorrhea.Twelve (22.2%) patients still had amenorrhea.

Married subjects had increased from nine at admis-sion to 20 at follow-up. Two subjects were engaged to be married. Fourteen patients who married afterrecovery from their eating disorders had a satisfactorymarital relationship at follow-up; of the nine patientswho were married at admission, two had died and six patients were below 17.5 BMI. Only one subjectrecovered and had a child. Regarding social status, thenumber of subjects who were wage earners andhomemakers increased from admission to at follow-up as shown in Table 2.

Table 3 shows the general outcome categoryaccording to the Morgan-Russell Scale modified byRatnasuriya et al.13 and diagnosis by DSM-IV criteriaat follow-up. According to the general outcome cate-gorization, 31 patients (51%) had good outcome. Ofthese, four subjects were diagnosed as ‘eating disordernot otherwise specified’ (EDNOS) due to (i) nearlyaverage bodyweight but frequent laxative abuse forfear of weight gain, and (ii) binge eating and/or vom-iting less than once a week or for less than 3 months.Twenty-seven (44%) subjects showed normal body-weight, menstruation and normal eating habits. Eightsubjects (13%) had an intermediate outcome. Onesubject had a normal weight and ate normally, but shewas still amenorrheic. Seven patients were classifiedas EDNOS, because they had low bodyweight, below15% of the average bodyweight, but had normal men-struation or were within nearly normal weight buthad menstrual disturbances. They expressed excessiveconcerns about their bodyweight and shape andshowed some disturbances in their pattern of eating(e.g. restricting food, avoiding regular meals or main-taining a rigid diet). Of these, two were vomiting regularly. Fifteen subjects (25%) had a poor outcome.Ten subjects met the full criteria for AN: five AN-Rand five AN-BP. Four subjects had normal body-weight, but were over-eating and/or vomiting weeklyor more and were diagnosed as BN. One subject diag-nosed as EDNOS had a low bodyweight with regularmenstruation, but showed binge eating followed byvomiting almost every day. Seven (11%) subjects haddied before follow-up due to various causes such asemaciation (n = 3), suicide (n = 2), murdered (n = 1)

Severe anorexia nervosa in Japan 391

Table 1. Demographic and clinical features of 61 anorexicpatients at referral

Feature Mean ± SD Range

Age (years) 22.7 ± 6.0 13.7–37.4Age at onset (years) 18.8 ± 4.3 12.0–31.7Duration of illness (years) 4.1 ± 4.3 0.3–17.9No. admissions 1.1 ± 1.5 0–7Education (years) 12.3 ± 2.8 6–16Social status

Wage earner 17 27.9%1

Student 21 34.4%Homemaker 5 8.2%

Marital statusNever married 50 82.0%Married 8 13.1%Divorced 3 4.9%

Height (cm) 156.6 ± 5.2 146.0–168.0Body weight (kg) 34.3 ± 5.4 23.2–47.0Body mass index (BMI) 14.0 ± 2.1 9.7–17.5Premorbid BMI 20.5 ± 2.8 15.8–32.5Maximum BMI 21.9 ± 4.0 16.4–46.2Minimum BMI 12.9 ± 2.4 7.8–17.5Diagnosis

Reatricting type 27 44.3%Binge eating/purging type 34 55.7%

Suicide attempt 24 39.3%Shoplifting 20 32.8%Alcohol abuse 5 8.2%Eating Attitudes Test score 43.1 ± 21.4

1 Values are expressed as numbers (%) of the patients.

392 H. Tanaka et al.

and burned to death (n = 1). Their diagnoses at thetime of death were AN, AN-BP (n = 5), AN-R (n = 1),and BN (n = 1).

Table 4 shows comparison of the various clinicalfeatures between subjects with good, intermediateand poor outcome, and those who were deceased.Subjects in the poor-outcome group were older at

referral, admission and discharge. Subjects in thepoor-outcome group showed significantly lowerminimum bodyweight than subjects in the good-outcome group. Subjects in the deceased group wereintermediate in various clinical features between sub-jects in the intermediate and poor-outcome group.However, subjects in the deceased group tended to

Table 2. Bodyweight and menstrual, marital and social status at admission, discharge and follow-up

At admission (n = 61) At discharge (n = 61) At follow-up (n = 54)1

Age (years) 23.1 ± 6.2 23.4 ± 6.2 31.2 ± 6.6Duration after onset (years) 4.3 ± 4.1 4.6 ± 4.1 12.4 ± 5.3Duration of first admission (days) – 88.3 ± 62.2 –Duration of follow-up (years) – – 8.3 ± 3.8Height (cm) 156.6 ± 5.2 – 156.8 ± 5.0Body weight (kg) 34.8 ± 7.2 38.0 ± 5.4 44.6 ± 7.7Body Mass Index (kg/m2) 14.2 ± 2.7 15.5 ± 2.1 18.2 ± 3.4Education (years) 12.3 ± 2.8 – 13.3 ± 2.2BMI

< 17.5 54 49 17≥ 17.5 7 12 37

Menstrual statusRegular 0 0 84Oligomenorrhea 0 0 5Amenorrhea 61 61 12Pregnancy 0 0 3

Marital statusNever married 49 – 32Married 9 – 20Engaged 0 – 2Divorced 3 – 4

Social statusWage earner 17 – 29Student 21 – 4Homemaker 5 – 9No occupation 18 – 12

Values are expressed as mean ± SD.1 Seven patients deceased.

Table 3. General outcome category according to Morgan-Russell outcome scale1 and diagnosis by DSM-IV criteria atfollow-up

Good n = 31 (51%) Intermediate n = 8 (13%) Poor n = 15 (25%) Deceased n = 7 (11%)

ANRestricting 0 0 5 1Binge eating/purging 0 0 5 5

BNPurging 0 0 4 1

EDNOS 4 7 1 0No eating disorders 27 1 0 0

1 Modified by Ratnasuriya et al.

have more AN-BP subtype, and impulsive behaviorssuch as suicidal attempts, shoplifting and alcoholabuse.

Eating difficulties, menstrual state, mental state,psychosexual and social status of patients with good,intermediate and poor outcome according to theMorgan and Russell Outcome Assessment Scheduleare shown in Table 5. The poor-outcome groupshowed significantly lower scores in eating difficulties,menstrual state and mental state than the good-outcome group. The poor-outcome group also showedsignificantly lower scores in attitude towards sexualmatters and in overt sexual behavior than the good-outcome group. The poor-outcome group showed sig-nificantly lower scores in the relationship with familythan the good-outcome group. The emancipation fromfamily and social activities outside the family in thepoor-outcome group were significantly lower scoresthan the good-outcome group.

DISCUSSION

In the present study, 61 female patients with AN wereevaluated for a mean of 8.3 years after discharge fromour hospital (a mean of 12.4 years after onset of the

disorders). Thirty-one (51%) subjects were catego-rized as having good outcome, eight (13%) as inter-mediate outcome and 15 (25%) as poor outcome.Twenty-seven (44%) subjects with good outcome and one (2%) of the intermediate group were freefrom any eating disorder and were normal weight;however, the other four (7%) patients with goodoutcome and seven (11%) subjects with intermediateoutcome still had abnormal eating behaviors andwere diagnosed as EDNOS. Of the poor-outcomegroup, 10 (16%) subjects had full symptoms of ANand went through a chronic course of AN. Four sub-jects (7%) had normal weight, but were binge eatingand/or vomiting weekly or more and were diagnosedas BN. One subject (2%) had a low bodyweight withregular menstruation, but was binge eating and vomit-ing almost every day, and was diagnosed as EDNOS.

To make a comparison possible with previousstudies from Western countries, we used the modifiedMorgan-Russell general outcome category,12 althoughthis criteria has a weak index of overall status becauseit evaluates only physical aspects and not psychologi-cal symptoms. In a review of 1 to 33 year follow-upstudies of AN published by 1989, approximately 50%of the subjects had a good outcome based on global

Severe anorexia nervosa in Japan 393

Table 4. Comparisons of the clinical features of patients with good, intermediate and poor outcome, and deceased

Good (G) Intermediate (I) Poor (P) Deceased (D) Post-hoc(n = 31) (n = 8) (n = 15) (n = 7) F (P) (Scheffe)

Age at follow-up (years) 30.5 ± 6.1 30.2 ± 5.6 33.2 ± 7.8 – 1.0 (0.37)Age at onset (years) 17.5 ± 3.2 19.9 ± 3.6 20.9 ± 6.1 18.9 ± 2.9 2.5 (0.07)Age at referral (years) 20.3 ± 4.1 23.3 ± 5.7 25.9 ± 7.9 25.5 ± 5.7 4.0 (0.01) GvsPAge at admission (years) 20.6 ± 4.2 23.8 ± 5.3 26.3 ± 7.8 26.9 ± 6.8 4.6 (0.01) GvsPDuration of illness 2.8 ± 3.0 3.2 ± 3.3 5.9 ± 5.9 6.7 ± 4.6 3.1 (0.03)

at referral (years)BMI at first referral (kg/m2) 14.4 ± 1.9 13.9 ± 2.4 13.4 ± 2.6 13.8 ± 1.9 0.7 (0.54)BMI at first admission (kg/m2) 14.5 ± 2.4 14.2 ± 3.1 13.6 ± 2.4 14.0 ± 2.7 0.3 (0.83)BMI at first discharge (kg/m2) 15.8 ± 2.0 15.4 ± 1.4 15.2 ± 2.3 14.9 ± 2.4 0.5 (0.70)BMI at follow-up (kg/m2) 20.2 ± 1.9 16.6 ± 0.7 15.0 ± 3.7 – 25.6 (< 0.001) GvsI, GvsPPremorbid BMI (kg/m2) 21.0 ± 3.1 19.3 ± 2.6 20.0 ± 2.5 21.0 ± 2.0 1.0 (0.40)Maximum BMI (kg/m2) 22.8 ± 5.1 20.4 ± 2.3 21.0 ± 2.1 22.3 ± 2.2 1.0 (0.41)Minimum BMI (kg/m2) 13.9 ± 2.0 12.6 ± 2.5 11.4 ± 2.3 11.9 ± 2.6 4.8 (0.005) GvsPNo. admissions 0.8 ± 1.4 0.5 ± 0.8 1.1 ± 1.0 3.1 ± 2.4 6.0 (0.001) GvsD, IvsD

PvsDDiagnosis at referral

Restricting type 14 (45%) 5 (63%) 7 (47%) 1 (14%)Binge-eating/purging type 17 (55%) 3 (38%) 8 (53%) 6 (86%)

c2 (P)Suicide attempt 11 (35%) 2 (25%) 6 (40%) 5 (71%) 3.91 (0.27)Shoplifting 9 (29%) 1 (13%) 4 (27%) 6 (86%) 10.81 (0.01)Alcohol abuse 0 (0%) 0 (0%) 1 (7%) 4 (57%) 25.81 (< 0.001)

1 chi-square.

394 H. Tanaka et al.

general outcome categories, approximately 30% ofthe subjects had an intermediate outcome, and fewerthan 20% remained chronically ill.16 In a study ofshort- and intermediate-term outcome in adolescenteating disorders, Steinhausen17 found that 26 anorexicpatients had poorer outcome at short-term follow-up(up to 38 months) than at intermediate-term follow-up (4–6 years). Gowers et al. reported that 45% of 75adolescent AN patients showed a good outcome at2–7 years follow-up.18 Casper and Jabine reported that64% of 73 subjects had a good outcome in a mean of 8-year follow-up study.19 Herpertz-Dahlmann et al.found that 58% of the 34 subjects had a goodoutcome.20 Fichter and Quadflieg studied the 6-yearcourse and outcome of AN in a large sample of 103DSM-IV AN patients.21 They found that 35% showeda good outcome, 39% an intermediate outcome, 21%a poor outcome and six patients (6%) were deceased.Herzog et al. reported that approximately 34% of the136 anorexic patients achieved full recovery in a 7.5-year follow-up study according to their definition ofoutcome, in which full recovery was defined as theabsence of symptoms or the presence of only residualsymptoms for at least 8 consecutive weeks.22 In 10–15 year follow-up studies, 24–76% of the subjectsshowed a good outcome, 11–41% an intermediateoutcome and 10–37% a poor outcome.23–27 Withrespect to these findings, the present findings are com-patible with those of intermediate term (6–10 years)follow-up studies irrespective of different health

systems and sociocultural backgrounds from those of Western countries. The mortality rate for AN hasbeen reported to be 0–9.6% in 5–10 year follow-upstudies.19–21,23,25,28 and as 0–18% in long-term (> 10years) follow-up studies.13,24,26,27 In the present study,seven patients died prior to follow-up. The crude mor-tality rate was 11%. This figure is slightly higher thanthose of previous studies. Several factors must be considered to explain this. All patients in this studyshowed severe clinical features. Many had previousinpatient treatments at other hospitals. Our inpatienttreatment could not markedly increase their body-weight at discharge. The deceased patients had shownmore impulsive behaviors such as suicide attempts,shoplifting and/or alcohol abuse. In previous studies,the cause of death in patients with AN has beenreported as the physical complications of emaciation,suicide and from accidents. In the present study, thecauses of death were mainly emaciation and suicide.These showed similar tendencies with those reportedpreviously.

There are several reports from intermediate-termand long-term outcome studies on an associationbetween age at onset and outcome. Findings fromthese studies indicate that childhood- and adolescent-onset AN is associated with variable outcomes, whilenumerous studies suggested that later onset was asso-ciated with poor outcome.9,16,29 In the present study,there was a significant difference in age at onsetamong the three outcome groups, except the deceased

Table 5. The findings of Morgan-Russell outcome assessment schedule

Post-hocGood (G) Intermediate (I) Poor (P) F (P) (Scheffe)

Eating difficultiesFood intake 11.1 ± 2.1 7.1 ± 4.2 4.2 ± 5.1 21.1 (< 0.001) GvsI, GvsPConcern at body image 9.8 ± 3.2 6.0 ± 4.6 5.5 ± 3.7 7.7 (0.002) GvsPBody weight 12.0 ± 0.0 5.4 ± 4.3 2.7 ± 4.5 46.7 (< 0.001) GvsI, GvsP

Menstrual state 12.0 ± 0.0 8.5 ± 4.5 2.4 ± 4.5 56.1 (< 0.001) GvsI, GvsP, IvsPMental state 11.1 ± 2.0 7.5 ± 3.3 5.9 ± 3.3 21.8 (< 0.001) GvsI, GvsPPsychosexual state

Attitude towards sexual matters 10.3 ± 3.4 7.2 ± 3.4 4.4 ± 5.1 7.7 (0.002) GvsPAims in sexual matters 9.9 ± 4.2 5.6 ± 6.1 7.5 ± 5.4 2.2 (0.12)Overt sexual behavior 9.9 ± 4.1 4.8 ± 5.0 2.0 ± 4.2 12.7 (< 0.001) GvsPAttitude to menstruation 10.7 ± 3.6 8.8 ± 3.4 9.8 ± 4.1 0.6 (0.53)

Socioeconomic stateRelationship with family 9.9 ± 2.9 7.0 ± 5.1 4.3 ± 2.7 12.5 (< 0.001) GvsPEmancipation from family 10.4 ± 2.9 6.5 ± 3.7 5.1 ± 4.4 13.0 (< 0.001) GvsI, GvsPSocial contacts outside family 9.1 ± 3.6 7.3 ± 3.4 6.0 ± 3.9 3.8 (0.03) GvsPSocial activities outside family 10.7 ± 2.6 8.5 ± 2.6 6.9 ± 3.2 9.8 (< 0.001) GvsPEmployment record 10.1 ± 4.0 6.9 ± 5.5 6.9 ± 4.7 3.3 (0.05)

Values are expressed as mean ± SD.

group (F = 3.6, P = 0.03). The proportion of patientsolder than 20-year-old was higher in the poor andintermediate outcome groups than in the good-outcome group (53% and 50% vs 23%). Furthermore,the poor-outcome group showed significantly olderage at referral and admission. This indicated that our patients with poor outcome took more time from the onset of illness to referral. A number ofstudies have suggested that a large interval betweenthe time of onset and first admission for treatmentmay be negatively related to the outcome of treat-ment.29–31 These findings suggest that patients olderthan 20 years at onset and with a longer time fromthe onset to referral may be associated with pooroutcome.

With regard to weight, many studies indicate thatlow bodyweight or BMI is a reliable predictor of pooroutcome.19,32,33 In the present study, there was no dif-ference among BMI at referral, admission and dis-charge. However, patients with poor outcome showedsignificantly lower minimum BMI than patients withgood outcome. These findings are consistent withthose in which extensive weight loss is a predictor ofunfavorable outcome.

In the present study, deceased patients had signifi-cantly higher numbers of admissions prior to admis-sion to our hospital and showed more AN-BP,compulsive behaviors and alcohol abuse. This suggeststhat the deceased patients might have been moretreatment-resistant and had more intractable naturesirrespective of treatment methods.

There are some factors that might limit the general-izability of the present findings. First, although themean duration of follow-up was 8.3 years since dis-charge, the duration of follow-up was widely distrib-uted (4.0–17.7 years) and patients had varying ages atonset and at the time of study. This would probably beof prognostic relevance. As both Theander34 and Ratnasuriya et al.13 have indicated, a longer follow-upperiod might have given greater chance for recovery,although longer follow-up periods also showincreased mortality rates. Second, it was not possibleto evaluate treatment effects due to the uncontrollednature of the treatments. Third, AN is a difficult disor-der from which to obtain accurate information over along period. Some patients or parents did not wish tobe reminded of their earlier problems and others didnot have sufficient time to provide the data. There-fore, we could not obtain full information from allpatients by face-to-face interview and half the inter-views were conducted over the telephone. The infor-mation about deceased subjects was obtained fromtheir parents, who were hesitant to discuss the details.Therefore, information is very limited.

In summary, the outcome of severe AN patientswith inpatient treatment in our hospital is similar to those of intermediate-term follow-up studies inWestern countries with regard to the main features ofthe disorders irrespective of different socioculturalbackgrounds and health systems. As predictors ofoutcome, later onset (older than 20 years), lowminimum BMI, and impulsive behaviors are associ-ated with unfavorable outcome.

REFERENCES

1. Kiriike N, Nagata T. Cross-cultural studies. In: JimersonD, Kaye W (eds). Bailliere’s Clinical Psychiatry, Vol3/No 2 Eating Disorders. Bailliere Tindall, London,1997; 339–354.

2. Suematsu H, Kuboki T, Itoh T. Statistical studies on theprognosis of anorexia nervosa. Psychother. Psychosom.1985; 43: 104–112.

3. Suzuki S, Takeda T, Yashiro R, Kondoh C, Hasegawa K, Yamaoka M. Intermediate-term social outcome ofanorexia nervosa treated in psychiatric facilities. Jpn. J.Clin. Psychiatry 1994; 23: 323–335 (in Japanese).

4. Kaneko M, Kumashiro H, Aono T. Psychosocial factorsand their reference to middle- and long-term course ineating disorders. Shinshin-Igaku 1990; 30: 383–388 (inJapanese).

5. Ide M, Kuboki T, Suematsu H. Long-term outcome ineating disorders. Shinshin-Igaku 1990; 30: 409–413 (inJapanese).

6. Hsu LKG. Outcome and treatment effects. In:Beaumont PJ, Burrows J, Casper RC (eds). Handbookof Eating Disorders, Part I. Elsevier Science Publishers,London, 1987.

7. Hsu LKG. The outcome of anorexia nervosa: A reap-praisal. Psychol. Med. 1988; 18: 807–812.

8. Steinhausen HC. Annotation: Outcome of anorexianervosa in the younger patient. J. Child Psychol. Psy-chiat. 1997; 38: 271–276.

9. Pike KM. Long-term course of anorexia nervosa:Response, relapse, remission, and recovery. Clin.Psychol. Rev. 1998; 18: 447–475.

10. American Psychiatric Association. Diagnostic and Sta-tistical Manual of Mental Disorders, 4th edn. AmericanPsychiatric Association, Washington DC, 1994.

11. Morgan H, Russell G. Value of family background andclinical features as predictors of long-term outcome inanorexia nervosa: 4 year follow-up study of 41 patients.Psychol. Med. 1975; 5: 355–371.

12. Morgan HG, Hayward AE. Clinical assessment ofanorexia nervosa. The Morgan-Russell outcome assess-ment schedule. Br. J. Psychiat. 1988; 152: 367–371.

13. Ratnasuriya RH, Eisler I, Szmukler GI, Russell GFM. Anorexia nervosa: Outcome and prognosticfactors after 20 years. Br. J. Psychiat. 1991; 158: 495–502.

14. Garner DM, Olmstead MP, Polivy J. Development andvalidation of a multidimensional eating disorder inven-

Severe anorexia nervosa in Japan 395

396 H. Tanaka et al.

tory for anorexia nervosa and bulimia. Int. J. Eat.Disord. 1983; 2: 15–34.

15. Garner DM, Garfinkel PE. The eating attitudes test: Anindex of the symptoms of anorexia nervosa. Psychol.Med. 1979; 9: 273–279.

16. Steinhausen HC, Rauss-Mason C, Seidel R. Follow-upstudies of anorexia nervosa: A review of four decades ofoutcome research. Psychol. Med. 1991; 21: 447–454.

17. Steinhausen HC, Seidel R. Short-term and intermedi-ate-term outcome in adolescent eating disorders. ActaPsychiat. Scand. 1993; 88: 169–173.

18. Gowers SG, Weetman J, Shore A, Hossain F, Elvins R.Impact of hospitalization on the outcome of adolescentanorexia nervosa. Br. J. Psychiat. 2000; 176: 138–141.

19. Casper RC, Jabine LN. An eight-year follow-up:Outcome from adolescent compared to adult onsetanorexia nervosa. J. Youth Adolescence 1996; 25:499–517.

20. Herpertz-Dahlmann BM, Wewetzer C, Schulz E,Remschmidt H. Course and outcome in adolescentanorexia nervosa. Int. J. Eat. Disord. 1996; 19: 335–345.

21. Fichter M, Quadflieg N. Six-year course and outcome ofanorexia nervosa. Int. J. Eat. Disord. 1999; 26: 359–385.

22. Herzog DB, Dorer DJ, Keel PK et al. Recovery andrelapse in anorexia and bulimia nervosa: A 7.5-yearfollow-up study. J. Am. Acad. Child Adolesc. Psychiatry1999; 38: 829–837.

23. Schork EJ, Eckert ED, Halmi KA. The relationshipbetween psychopathology, eating disorder diagnosis,and clinical outcome at 10-year follow-up in anorexianervosa. Compr. Psychiat. 1994; 35: 113–123.

24. Deter HC, Herzog W. Anorexia nervosa in a long-termperspective: Results of the Heidelberg-Mannheim study.Psychosom. Med. 1994; 56: 20–27.

25. Eckert ED, Halmi KA, Marchi P, Grove W, Crosby R.Ten-year follow-up of anorexia nervosa: Clinical courseand outcome. Psychol. Med. 1995; 25: 143–156.

26. Strober M, Freeman R, Morrell W. The long-termcourse of severe anorexia nervosa in adolescents: Sur-vival analysis of recovery, relapse, and outcome predic-tors over 10–15 years in a prospective study. Int. J. Eat.Disord. 1997; 22: 339–60.

27. Sullivan PF, Bulik CM, Fear JL, Pickering A. Outcomeof anorexia nervosa: A case-control study. Am. J. Psy-chiat. 1998; 155: 939–946.

28. Santonastaso P, Pantano M, Panarotto L, Silvestri A. Afollow-up study on anorexia nervosa: Clinical featuresand diagnostic outcome. Eur. Psychiat. 1991; 6: 177–185.

29. Herzog DB, Keller MB, Sacks NR, Yeh CJ, Lavori PW.Psychiatric comorbidity in tratment-seeking anorexicsand bulimics. J. Am. Acad. Child Adolesc. Psychiatry1992; 31: 810–818.

30. Jones LM, Halford WK, Dooley RT. Long termoutcome of anorexia nervosa. Behav. Change 1993; 10:93–102.

31. Schoemaker C. Does early intervention improve theprognosis in anorexia nervosa? A systematic review of the treatment-outcome literture. Int. J. Eat. Disord.1997; 21: 1–15.

32. Jarman FC, Rickards WS, Hudson IL. Late adolescentoutcome of early onset anorexia nervosa. J. Paediatr.Child Health 1991; 27: 221–227.

33. Steinhausen HC, Seidel R. Outcome in adolescenteating disorders. Int. J. Eat. Disord. 1993; 14: 487–496.

34. Theander S. Outcome and prognosis in anorexianervosa and bulimia: Some results of previous investiga-tions, compared with those of a Swedish long-termstudy. J. Psychiatr. Res. 1985; 19: 493–508.