Differentiating anorexia nervosa and atypical anorexia nervosa with absolute weight cut‐offs results in a skewed distribution for premorbid weight among youth

Author:

Matthews Abigail1ORCID,Lin Jessica234ORCID,Jhe Grace45,Peters Triinu67ORCID,Sim Leslie1ORCID,Hebebrand Johannes67ORCID

Affiliation:

1. Department of Psychiatry and Psychology Mayo Clinic Rochester Minnesota USA

2. Division of Adolescent and Transition Medicine Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA

3. Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio USA

4. Division of Adolescent and Young Adult Medicine Boston Children's Hospital Boston Massachusetts USA

5. Department of Psychiatry Harvard Medical School Boston Massachusetts USA

6. Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Essen University of Duisburg‐Essen Essen Germany

7. Center for Translational Neuro‐ and Behavioral Sciences, University Hospital Essen University of Duisburg‐Essen Essen Germany

Abstract

AbstractObjectiveAnorexia nervosa (AN) and atypical AN are conceptualized as distinct illnesses, despite similar characteristics and sequelae. Whereas DSM‐5 differentiates youth with AN and atypical AN by the presence of clinical ‘underweight’ (i.e., 5th BMI percentile for age‐and‐sex (BMI%)), we hypothesized that using this weight cut‐off to discern diagnoses creates a skewed distribution for premorbid weight.MethodParticipants included hospitalized youth with AN (n = 165, 43.1%) and atypical AN (n = 218, 56.9%). Frequency analyses and chi‐square tests assessed the distribution of premorbid BMI z‐scores (BMIz) for diagnosis. Non‐parametric Spearman correlations and Stepwise Linear regressions examined relationships between premorbid BMIz, admission BMIz, and weight loss in kg.ResultsPremorbid BMIz distributions differed significantly for diagnosis (p < .001), with an underrepresentation of ‘overweight/obesity’ (i.e., BMI% ≥ 85th) in AN. Despite commensurate weight loss in AN and atypical AN, patients with premorbid ‘overweight/obesity’ were 8.31 times more likely to have atypical AN than patients with premorbid BMI% < 85th. Premorbid BMIz explained 57% and 39% of the variance in admission BMIz and weight loss, respectively.DiscussionFindings support a homogenous model of AN and atypical AN, with weight loss predicted by premorbid BMI in both illnesses. Accordingly, premorbid BMI and weight loss (versus presenting BMI) may better denote the presence of an AN‐like phenotype across the weight spectrum. Findings also suggest that differentiating diagnoses with BMI% < 5th requires that youth with higher BMIs lose disproportionately more weight for an AN diagnosis. This is problematic given unique treatment barriers experienced in atypical AN.Public significanceAnorexia nervosa (AN) and atypical AN are considered distinct conditions in youth, with differential diagnosis hinging upon a presenting weight status of ‘underweight’ (i.e., BMI percentile for age‐and‐sex (BMI%) < 5th). In our study, youth with premorbid ‘overweight/obesity’ (BMI% ≥ 85th) disproportionately remained above this threshold, despite similar weight loss. Coupled with prior evidence for commensurate characteristics and sequelae in both diagnoses, we propose that DSM‐5 differentiation of AN and atypical AN inadvertently reinforces weight stigma and may contribute to treatment disparities in atypical AN.

Publisher

Wiley

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