Nonresponder anorectic patients after 6 months of multimodal treatment: predictors of outcome

Eur Psychiatry 2001 ; 16 : 466-73 © 2001 Éditions scientifiques et médicales Elsevier SAS. All rights reserved S0924933801006083/FLA

ORIGINAL ARTICLE

Nonresponder anorectic patients after 6 months of multimodal treatment: predictors of outcome S. Fassino*, G. Abbate Daga, F. Amianto, P. Leombruni, L. Garzaro, G.G. Rovera Department of Neurosciences, Psychiatry Section, Service for Eating Disorders, Turin University, V. Cherasco 11, 10126, Turin, Italy (Received 20 January 2000; revised 20 July 2001; accepted 12 September 2001)

Summary – Currently the therapy of anorexia nervosa is a relevant clinical problem. The percentage of patients who respond to short-term pharmacotherapy and psychotherapy is still low and the condition often leads to chronic pathology or death. The present study aims to determine outcome predictors beyond personality traits, eating psychopathology, or particular clinical features. Forty patients with restricter type anorexia nervosa were tested, at T0 and after 180 days, with psychometric tests and clinical evaluation instruments. Patients were then divided into two groups. One group included patients who showed relevant clinical improvement; the other included not-yet-improved patients. A lower Novelty Seeking, higher levels of Ascetism and Maturity Fears characterised the not-yet-improved group. Correlation showed evidence of diverse bonds between personality and psychopathology in the improved and not-yet-improved groups. The psychopathology of non-yet-improved patients seemed to be more linked to their temperamental features, whereas improved patients seemed to be more influenced by their character. Different levels of psychological functioning can be expressed. The present data suggest focusing pharmacotherapy and psychotherapy, even family counseling, with a progression more strictly related to the current personality functioning level and psychopathology of each patient. © 2001 Éditions scientifiques et médicales Elsevier SAS anorexia nervosa / outcome / personality / predictors / psychopathology

INTRODUCTION The etiopathogenesis of eating disorders (EDs) is situated at a ‘crossroads’ between individual psychopathology, the body and its biologic and relational aspects, and family and societal inter-reaction [1]. Treatment should include psychotherapeutic measures, individual and family counseling, psychopharmacologic treatment, and nutritional rehabilitation [2, 11, 15]. Anorexia nervosa generally responds to

*Correspondence and reprints. E-mail address: [email protected] (S. Fassino).

these treatments [11, 29]. Nonetheless, some patients are at high risk of becoming chronically ill or dying [18]. Furthermore, long-term follow-up studies show that approximately one-third of patients either meet the criteria of diagnosis or suffer from other EDs such as bulimia, binge eating disorders, and the like [16, 29]. Thus, in view of the difficulties of prognosis and its protracted course, anorexia is considered a serious psychiatric disturbance with a high possibility of co-morbidity [30].

Predictors of outcome in anorexia

It is important to identify some predictive indexes that would allow 1) a more precise prognosis; 2) therapeutic strategies aimed ‘ad hoc’ at patients who can be foreseen to be ‘resistant’ from the beginning of the treatment programme; and 3) the modification of therapy already underway in patients who do not show the expected improvement after a certain period. In outcome studies [16, 18, 23, 26, 28, 29, 30], many different variables have been considered: sociodemographic elements (age, social class, schooling, etc.), anamnestic (psychic state and body weight before the onset of the disorder), family relationship factors (family conflicts, level of emotional expression, family medical history), clinical factors (body mass index [BMI] at the beginning of treatment, serum albumin levels, frequency of vomiting, number of hospitalisations). Currently, nonetheless, indexes for prediction are scarce, controversial, and virtually unusable for ongoing management. Nor are there tried and tested guidelines regarding treatment and interventions. It is not yet possible to define whether anticipatory intervention can improve the prognosis [26], and in general, as reported by Garfinkel and Dorian [13], “our level of knowledge linking specific interventions [in eating disorders] with predictors of outcome is quite weak.” In any case, the personality of the patient is presently the crucial area for planning and developing treatment, determining compliance, and assessing the quality of the treatment course and its results. However, EDs do not seem to be linked to a specific personality profile but result from a range of diverse psychopathologic structures [3]. A diagnosis of Axis II can also often be found [17, 24]; a parallel personality disorder often influences the course of the ED, particularly if borderline traits are diagnosed [21, 24]. An in-depth study of the complex relationship between the personality, clinical symptoms, and results of treatment is thus required in clinical practice. Evaluation of the personality may be useful for the development of more effective interventions and variations in therapeutic strategies in the primary stages of treatment. This may be helpful in avoiding unfavourable outcomes. In this study, we examined the demographic features, personality characteristics, and psychopathologic and symptomatic traits of anorectic outpatients. The aim was to highlight, among these features, possible predictors of outcome after a short-term follow-up period. On the basis of a correlation between clinical, psychoEur Psychiatry 2001 ; 16 : 466–73

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pathologic, and personality features we hoped to determine the possible dynamics underlying resistance and improvement mechanisms. Considering these specific traits and mechanisms, clinicians may adapt clinical protocols to the features of each patient either at the beginning of therapy or after a short follow-up period. It is thus hoped that the short-term prognosis will become adaptable in relationship to the variations in the therapeutic strategies. Subsequent research and clinical practice will evaluate if such traits may be possible predictors of outcome also after longer follow-up periods. In consideration of the methodological complexity of research into EDs (selection of probands, control groups, different therapeutic contexts, etc.) a 6-month follow-up study has been carried out on 40 anorectic patients treated according to the ‘network model’ [10, 11, 20, 25]. SUBJECTS AND METHODS Subjects This study involved the observation of 40 patients afflicted with anorexia nervosa restricter type [2]. The subjects recruited were then consecutively admitted to the Centre for Eating Disorders of the Psychiatric Clinic of the University of Turin between 1 October 1997 and 1 October 1998. There were two reasons for choosing to include only anorexia nervosa restricter type patients: 1) as reported in other studies these patients show different personality characteristics compared with binge-purging patients [4]; and 2) restricter symptoms have been described as being more persistent [16]. The patients included in the study were all unmarried, between 17 and 30 years of age, and clearly within the DSM-IV diagnostic criteria of anorexia nervosa restricter [2]. Thirty-three patients suffering from anorexia binge-purging, NAS ED diagnosed with APA criteria, or a lifetime diagnosis of psychosis or other disorders diagnosable in Axis I were excluded. The personal and medical histories of the patients are shown in table I. Methods The initial evaluation included the application of psychometric tests, the registration of principal clinical data (height, weight, minor psychiatric symptoms), and determination of the BMI.

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Table I. Anorectics’ clinical, socio-demographic data, and pharmacotherapy. IG (22)

NIG (18)

Mean and SD

Mean and SD

t-test

P

Age Age at clinical onset Years of disease Years of school Initial BMI

21.6 ± 3.7 17.8 ± 2.9 3.8 ± 2.2 12.4 ± 2.4 14.6 ± 1.6

22.1 ± 3.7 18.1 ± 3.9 3.9 ± 3.9 12.4 ± 2.6 15.3 ± 1.4

–0.425 0.279 0.102 0.000 –1.455

0.673 0.782 0.919 1.000 0.154

Symptom

Number of patients

Number of patients

χ2

P

Minor depression Mild anxiety Pharmacotherapy

4.5% (1) 18% (4) 45% (10)

5.5% (1) 32% (7) 32% (7)

Variable

Statistics

0.340 0.560 1.217 0.270 0.009 0.923

Rush data represent the measure of years for first five variables and frequencies for the last one. Each value is provided with standard deviation. The t-test was used to compare personal data between groups. Freedom degrees 38. The χ2 test was used to compare minor psychiatric symptoms and pharmacotherapy between groups of. Freedom degrees: 1. IG = improved group; NIG = not improved group.

The tests carried out consisted of the Temperament and Character Inventory (TCI) [7], a questionnaire for the dimensional study of the personality, and the Eating Disorder Inventory 2 (EDI2) [14], a questionnaire on eating psychopathology. The TCI was used to diagnose personality disorder (PD). The TCI dimensional approach to personality was chosen because it has been demonstrated that categorical diagnosis of PD in subjects with EDs is still controversial [9] and unhelpful in focusing therapeutic strategy. This instrument can also permit interesting inferences in the neurobiological aspects of temperament [7]. It demonstrated good agreement with the DSM classification of PD [6, 31] and has been widely used in the study of EDs with interesting inferences on prognostic factors [4, 5]. As proposed by Svrakic [31], all patients under the fifteenth percentile of normal distribution were considered afflicted by personality disorders [7]. We thus evaluated the corresponding categories through the dimensions of temperament [7, 31]. Successively, each personality dimension was compared with the indexes of clinical and psychopathologic progression. The EDI2 was used to evaluate the progression of the most important psychopathologic traits of our patients

and correlate them with personal data, initial BMI, and TCI dimensions. After 180 days (T180) the EDI2 was applied and the clinical symptoms were recorded. The relatively short period of follow-up (6 months) was chosen because of the needs of our public service in which it is not possible to have a longer period of intensive care for each patient. A longer period of follow-up ‘after multimodal therapy’ has been programmed. In the period between T0 and T180 all patients underwent ‘network’ multimodal therapy [10, 20]. It consists of brief adlerian psychotherapy (15 weekly sessions) [22] associated if necessary with pharmacotherapy. Sessions are combined with monthly visits for dietary interventions and eventual nutritional care. A therapist, different from the one who takes care of the patient, also offers familial counseling to one or both parents. This kind of multimodal therapy may be applied either with an inpatient or outpatient regimen. All patients recruited in the present study were outpatients. Pharmacologic therapy was added as an adjunct to psychotherapy for 17 patients (45%). Only benzodiazepines were administered to those patients who showed a rise in anxiety in response to the diet therapy. A standardised protocol for pharmacologic treatment was not adopted. Dietary treatment, essential for the continuation of the psychotherapeutic process [15], was carried out through periodic medical examinations or a dietary regimen [15], the frequency of which (bimonthly or monthly) was correlated to clinical severity. Our patients were subdivided into two groups according to their response to the treatment: the improved group (IG) and not-improved group (NIG). Two indicators of improvement were used: the BMI and the Morgan Russell Outcome Assessment Schedule (MROAS) [21]. At T180 the patients who were considered improved were those who had recovered at least 50% of their BMI under the threshold (BMI threshold = 17.5, DSM-IV; e.g., if a patient had a BMI of 15.5, she must have reached a BMI of at least 16.5) and whose score had improved to at least 30% of the difference between the theoretical maximum MROAS score and the MROAS score at T0. Improved patients had to fulfill both improvement criteria; those who fulfilled just one were included in NIG. Eur Psychiatry 2001 ; 16 : 466–73

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Statistical analysis

Table II. Clinical course indexes: body mass index (BMI) and the Morgan-Russell Outcome Assessment Schedule (MROAS).

All the statistical analyses were carried out using the Statistical Package for the Social Sciences [27]. The descriptive statistic was calculated for each variable. The t-test for independent samples was used to compare the socio-demographic data and the psychometric test scores of the IG with those of the NIG. The t-test for paired data was used to evaluate the significance of the values of the various EDI2 scales on retesting after 180 days of follow-up, and also to assess the significance of changes in the clinical indexes. The parametric variables were compared between the two groups with the χ2 test. Pearson’s correlation was used to analyse the reciprocal correlation between the single dimensions of TCI and EDI2 and the BMI and the socio-demographic data of the patients. The same procedure was adopted for Total Group (TG), IG, and NIG data. A level of significance of α ≤ 0.05 was considered acceptable. Stepwise logistical multiple regression was carried out using the clinical characteristics at T0 and the psychometric instrument scores were used as predictors of the response to treatment.

Variable: BMI

T0

T180

t-test

P

IG (N = 22) NIG (N = 18) t-test P

14.6 ± 1.6 15.3 ± 1.4 –1.455 0.154

16.3 ± 1.8 15.9 ± 1.7 0.717 0.478

–3.311 –1.156

0.002* 0.256

T0

T180

t-test

P

14.0 ± 5.2 12.3 ± 3.2 1.154 0.256

19.0 ± 7.2 14.9 ± 4.5 2.101 0.042*

–2.641 –1.998

0.012* 0.054

RESULTS Clinical and socio-demographic data at T0 Table I shows the socio-demographic and clinical data of the selected patients. Thirty-two patients (80%) are currently students. Anorectic patients showed minor depressive (5%) symptoms and anxiety (28%) symptoms but there was no significant difference between the two groups of patients). Clinical parameters and variations after 6 months of treatment Table II shows the clinical data of the BMI recorded at T0 and T180. Twenty-two patients (55%) improved according to the criteria described. Thus these subjects were included in the group of ‘clinically improved’ patients (IG). The NIG includes 18 patients (45%). TCI profile and diagnosis of PD The TCI dimensional personality profile of the anorectic patients at T0 was compiled (table III). The two Eur Psychiatry 2001 ; 16 : 466–73

Variable: MROAS IG (N = 22) NIG (N = 18) t-test P

Lines: t-test was performed to compare for each group’s data collected at T0 and T180. Columns: t-test was performed to compare between-group data collected at each stage. IG = improved group; NIG = not improved group; * indicates significant P < 0.05.

groups, IG and NIG, differed significantly only in Novelty Seeking (NS), which is higher in the group of improved patients (P < 0.05 ). In this sample of subjects 53% of the anorectics (55% of those improved and 50% of those not improved) show one or more PDs at different levels of severity. There is no single personality profile although diagnoses of Obsessive (33%), Passive-Dependent (25%), and Explosive (23%) personality disorders are prevalent [24]. There are no statistically significant differences in the distribution of PDs between the two subgroups IG and NIG. EDI2 at the beginning and the end of the cycle The clinical evolution of the patients after 180 days of therapy and clinical follow-up is shown through several significant changes in the EDI2 score. At T0 (table III) the two groups differed in the dimensions of Maturity Fears and Ascetism, which are higher in the NIG group (P < 0.05). The whole group of anorectic patients (TG) showed a significant reduction from T0 and T180 in the dimensions: Drive for Thinness (t-test = 3.479; P = 0.001), Body Dissatisfaction (t-test=2.166; P = 0.033), Ascetism (t-test = 0.550; P = 0.006) and Social Insecurity (t-test = 3.279; P = 0.002).

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Table III. TCI and EDI2 profiles at T0 among improved and not improved anorectics.

DISCUSSION

TCI

Outcome and PDs

Novelty Seeking Harm Avoidance Reward Dependence Persistence Self-Directedness Cooperativeness SelfTranscendence EDI2 at T0 Drive for Thinness Bulimia Body Dissatisfaction Ineffectiveness Perfectionism Interpersonal Distrust Enteroceptive Awareness Maturity Fears Asceticism Impulse Regulation Social Insecurity

IG (22)

NIG (18)

t-test

P

17.7 ± 6.7 22.5 ± 8.3 15.3 ± 3.8

13.5 ± 6.2 25.3 ±6.6 15.1 ±3.4

–2.04 –1.16 0.17

0.048* 0.253 0.863

5.4 ± 2.2 20.6 ± 7.1 31.0 ± 5.3 14.0 ± 7.1

5.1 ± 1.7 19.7 ± 7.6 28.5 ± 9.4 13.2 ± 9.1

0.47 0.39 1.06 0.31

0.638 0.701 0.296 0.756

14.2 ± 5.1

14.27 ± 5.5

–0.06

0.953

2.4 ± 2.0 11.5 ± 6.2

1.4 ± 1.5 12.6 ±6.1

1.00 –0.56

0.577

9.7 ± 6.7 5.0 ± 3.1 8.6 ± 4.1

12.5 ± 6.4 5.3 ±3.4 9.5 ± 4.7

–1.34 –0.29 –0.65

0.188 0.772 0.522

8.5 ± 4.9

9.7 ± 6.8

–0.65

0.521

4.6 ± 3.2 6.6 ± 3.5 5.5 ± 3.3

6.7 ± 3.1 9.3 ± 4.8 7.8 ± 6.3

–2.09 –2.56 –1.48

0.043* 0.047* 0.146

8.1 ± 4.4

10.1 ± 3.5

–1.56

0.126

Table reports rush scores and standard deviation of TCI dimensions and EDI2 scales. The t-test was performed to compare data between groups. Freedom degrees: 38. IG = improved group; NIG= not improved group; *indicates significant P < 0.05.

Linear correlation To determine the type of link between eating psychopathology and personality, the linear correlation between the baseline psychometric measurements was calculated. A summary framework of the data is shown in table IV. Logistical regression Only one variable entered and remained in the final regression equation: the Maturity Fears score at T0 (estimate parameter = –0.5; χ2 = 10.236; P < 0.01). The equation indicates that higher Maturity Fears scores predict a worse prognosis at 6 months.

In our sample group the diagnosis of PD was present in approximately 50% of the subjects. This did not seem to affect the progress made in the first 6 months of therapy. In fact, the rate of responders (about 50%) was good in comparison with results reported in the literature [12, 19] and did not correlate with the rate of PDs (Self-Directedness [SD]). The discordance with other observations [16] may derive from either the particular nature of the instrument used to diagnose the PD, or from insensitive use of this instrument (the choice of discarding 15% of the SD). A multimodal therapy approach may also protect against negative interreactions of a PD on the therapy. It is possible that a long-term follow-up will show a lower response rate to therapy because of the interruption, after 6 months, of its protective effects from PDs. However, low SD could constitute an index of seriousness: low SD scores indicate immaturity and incapacity of self-projection [7, 8]. In fact, SD correlates with two important EDI2 subscales: Interoceptive Awareness and Impulsiveness. Temperamental and psychopathologic differences between responders and not-yet responders Some aspects of temperament and alimentary psychopathology seem to have a particular influence on clinical progress after 6 months of therapy. Lower Novelty Seeking (TCI) (table III) of the NIG patients corresponds with low exploratory activity, poor initiative, insecurity, and unresponsiveness to novelty and change. This indicates low levels of dopamine in the prefrontal cortex [7, 8] and was indicated by Strober et al. [29] as being one of the temperamental characteristics of anorexia. A high level of Maturity Fears denotes fear of growth as a peculiar feature of NIG patients. This trait correlates with low SD and is an important index of patients’ resistance against modifying eating habits and facing problems of mental health, self-image, and interpersonal relationships. As far as multiple regression is concerned, and supporting results of previous studies on anorexia nervosa restricter [32], it appears to be the most precise indicator of an unfavourable prognosis. A high level of Ascetism in NIG patients indicates their attitude toward self-limitation and denial; on the Eur Psychiatry 2001 ; 16 : 466–73

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Predictors of outcome in anorexia Table IV. Correlations between psychometric measures and clinical parameters. TCI

EDI2

NS HA

Bulimia Positive Inadequacy Interpersonal Positive Distrust Maturity Fears Impulsiveness Social Insecurity Ascetism Enteroceptive Awareness

Bulimia BMI Increase Impulsiveness Social Insecurity Interpersonal Distrust P Perfectionism Drive for Thinness Age of onset Social Insecurity SD Enteroceptive Awareness Impulsiveness ST BMI Increase EDI2 Clinical parameters Asceticism T0 BMI Age of onset Perfectionism Age of onset Age BMI increase

RD

Drive for Thinness Body Dissatisfaction

Correlation

Negative Positive Negative Positive Negative Negative

TG P = 0.017 P = 0.001 P = 0.012 P = 0.024 P = 0.007 P = 0.010 P = 0.026

IG r = 0.37 r = 0.49 r = 0.39 r = 0.35 r = 0.42 r = 0.40 r = 0.35

P = 0.015

r = –0.38

P = 0.004 P = 0.042 P = 0.021 P = 0.050 P = 0.028

r = 0.44 r = 0.32 r = 0.36 r = –0.31 r = –0.34

P = 0.031 P = 0.013

P = 0.058 P = 0.036 r = –0.45

NIG r = 0.46 r = 0.52

T0 BMI

Negative

Years of illness

Negative

P = 0.020 P = 0.024

r = 0.36 r = 0.35

P = 0.024 P = 0.015 P = 0.026 P = 0.052 P = 0.028

r = 0.49 r = 0.59 r = 0.50 r = 0.47

P = 0.046 P = 0.009 P = 0.008 P = 0.017 P = 0.041 P = 0.002 P = 0.041

r = -0.47 r = 0.60 r = –0.60 r = –0.55 r = –0.48 r = 0.68 r = 0.48

P = 0.042

r = 0.48

P = 0.053

r = –0.46

r = –0.41 P = 0.001 r = –0.65

Positive Positive Positive

P = 0.038 P = 0.010 P = 0.034 P = 0.048

r = 0.48 r = 0.51 r = 0.47 r = 0.41 r = –0.48

NS = Novelty Seeking; HA = Harm Avoidance; RD = Reward Dependence; P = Persistence; SD = Self-Directedness; C = Cooperativeness; ST = Self-transcendence. TG = Total Group; IG = Improved Group; NIG = Not Improved Group. All P-values are < 0.05. All group-specific values are shown.

other hand, it implies a higher tendency to direct the pain brought on by the disorder into the inner self, thus inhibiting elaboration on a psychical level. Correlation between personality, psychopathology, and clinical features in the total group The wide correlation between Harm Avoidance (HA), a typical temperamental characteristic of anorectics [7, 11], and EDI2 subscales leads us to the conclusion that it is a valid indicator of seriousness. Reward Dependence (RD) seems to be a temperamental factor limiting Impulsiveness of such patients. Persistence is an ambivalent prognostic factor. Patients with more Persistence and higher Perfectionism show less Social Insecurity, thus delaying the appearance of symptoms. Higher initial Persistence also correlates with lower initial BMI. A more significant improvement in the patients with a lower initial BMI is Eur Psychiatry 2001 ; 16 : 466–73

not easy to interpret. It may indicate a recruitment error (a lower BMI at T0 correlates with some items of the EDI2) or result from the greater effort that the medical team expends on the most seriously ill patients. Despite this, a highly persistent self-starvation may hide greater weakness of personality; in fact, once these patients have overcome their very strong initial resistance, they are more likely to cooperate with the therapeutic team. Specific correlations of the IG patients Five significant correlations between TCI and EDI2 characterise the IG group. HA, Persistence, and SD are the relevant TCI dimensions in this group. The IG patients who show higher levels of anxiety in potentially harmful situations tend to demonstrate more impulsive (or compulsive) behaviour. This reaffirms the importance for improved anorectics of a hypofunction

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ing of the serotoninergic system, which is responsible for both impulsive behaviour and high HA [7, 8]. Nonetheless, the absence of such a correlation in the NIG group seems to imply that only patients who have begun to detach themselves from the symptoms of anorexia express impulsiveness as a reaction to fear. Similarly to what happens in the TG, the ‘protective’ social role of the symptomatology of these anorectics is confirmed by correlation of Persistence with Social Insecurity [15]. There is, however, a link between level of maturity (SD) of IG and their ability to respond appropriately and not impulsively to emotional states and visceral perception. The SD in fact measures the capacity to respond to environmental stimulus in a non-impulsive way. This is not the case for the NIG group in which SD seems to be a less relevant factor. Among correlations between psychopathology and clinical features, the tendency to suppress oral needs (Ascetism) seems to delay onset of ED and the Perfectionism reaffirms itself as a protective symptom only in the IG group. Lastly, it seems apparent that the IG patients who show a stronger Drive for Thinness also have a lower BMI at T0. The prevalence of foreseeable correlation results in the IG patients, as well as their frequent concurrence with the TG, seem to suggest that such patients can be distinguished from the NIG patients through a more definable correspondence between symptoms and the better known psychopathologic characteristics of anorexia nervosa. Specific correlations of the NIG patients The temperamental dimensions correlated with psychopathology and eating symptoms are much more numerous in the NIG than in the IG. This suggests that resistance in the NIG is presumably higher at the temperamental level. The HA of NIG correlates positively with five of the EDI2 subscales connected mostly to the social and interpersonal sphere [15]. This may explain the difficulty in initiating or maintaining relationships with these patients and their lack of sufficient cooperation with therapy. These elements may perhaps be relevant factors that lead to an unfavourable prognosis. In NIG patients the bulimic tendencies that brought about a drop in anorectic defences against food (or against the deep need for relationships) are a conse-

quence of a temporary reduction of HA and not a consequence of emerging Impulsiveness. The positive correlation with a BMI increase and multiple negative correlations of RD seem to indicate that the therapeutic improvement of the NIG, although poor, results principally from the ability to build relationships of emotional dependence, albeit minimal, with therapists, or at least to recognise the desire for this relationship. A psychopathologic nucleus, specific to the most resistant anorectics, is connected to the rigid and persistent determination to lose weight. Here the prognostic role of Persistence seems to be more unfavourable than in the IG patients. Among character traits of NIG patients, only SelfTranscendence (ST), a mechanism for coping with an inevitably painful reality, may be a positive factor for prognosis. Finally, the negative correlation of the NIG body dissatisfaction with duration of illness highlights how the explicit acceptance of the patient’s own body is a negative prognostic factor over the long course of illness. CONCLUSIONS The peculiarity of the most significant dimensions correlated to the psychopathologic and eating situations in NIG (RD, ST, HA), in comparison to those of the IG (SD), seems to suggest a distinction between the levels of psychological functioning in the two subgroups. In consideration of this evidence a ‘steps’ approach could be proposed [10]. The NIG patients need pharmacologic therapy and psychotherapy to overcome their difficulties in relationships (low RD), the fear of being damaged by relationships (high HA), and the poor search for gratification (low NS) [7]. Because RD correlates with norepinephrine, HA with serotonin, and NS with dopamine [8], selective drugs affecting these neurotransmitters may be used to overcome temperamental resistances. From the psychotherapy aspect, it seems that specific goals may be encouraged using the resources of ST [7, 22]. Psychotherapy of improved patients should focus primarily on the ability to direct their own lives toward freely chosen objectives (SD) [7, 22]. A constant factor in both groups should be attention to Persistence as an ambivalent index of prognosis. Larger samples and longer follow-up studies are needed to test if prognostic factors at 6 months of follow-up are still relevant after interruption of multi Eur Psychiatry 2001 ; 16 : 466–73

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