Good Example Of Mortality In Anorexia Nervosa: Causes And Prognostic Factors Research Paper

Introduction: Problem Statement

Anorexia nervosa is a serious mental illness common in teenage girls and young women (Korndorfer et al., 2003). More research has increasingly found the disorder in men as well (Arcelus et al., 2011). Extensive research has focused on the investigation of mortality rates in anorexia nervosa, and the rates of morbidity and mortality in patients with anorexia nervosa and other (related) eating disorders are believed to be high. However, the exact rates remain elusive. To show this, Korndorfer et al. (2003) note that reported standardized mortality ratios (SMRs) related to the mental disorder vary substantially between 0 to 17.8 percent. The Royal Australian and New Zealand College of Psychiatrists (2009), on its part, places the range between 10 and 20 percent, which only goes to show just how varied the SMRs are. Part of the difficulty in citing the exact rates has to do with the fact that the causes of death equally vary. While many patients do die of natural causes as a result of the disorder, many others commit suicide. In this case emerges the question of psychiatric comorbidity in anorexia. Although several studies have investigated psychiatric morbidity in anorexia, many have not answered the question of the extent to which it affects mortality. This paper investigates both the natural and unnatural causes of deaths in patients with anorexia nervosa. At a secondary level, albeit implicitly, this study will also investigate potential prognostic factors that could lead to fatal outcomes of anorexia.

Literature Review

Anorexia nervosa is a chronic mental illness that manifests itself in the form of an eating disorder, and can lead to severe loss of weight, growth retardation, chronic physical disabilities (including osteoporosis), infertility, impaired thinking and concentration, as well as “major disruptions to emotional, social and educational development” (The Royal Australian and New Zealand College of Psychiatrists, 2009, p.4). In other words, anorexia is a mental illness that expresses itself in the form of significant physical complications. In this regard, the illness can be characterized by intense anxiety as well as preoccupation with one’s body weight and shape and control of eating and weight. Also common in people with anorexia are mental illnesses such as depression, anxiety disorders and obsessional thinking, perfectionism and low self-esteem (The Royal Australian and New Zealand College of Psychiatrists, 2009).
Today, eating disorders are increasingly recognized as major causes of morbidity and mortality in young people. The problem is known to be common among women. For example, according to estimates, the lifetime risk of suffering from anorexia nervosa among women is about 0.3 percent to 1 percent. More and more of these have bulimia nervosa (Hoek, 2003; Preti et al., 2009). Bulimia nervosa manifested in episodes of binge eating among other forms of unhealthy compensatory behaviors. ‘Eating disorder’ as a general description refers to any other eating disorder that does not fit the description of anorexia nervosa or bulivia nervosa. Although the general eating disorders are a common area of focus for services aimed at addressing eating disorders, there are relatively fewer published data on mortality rates of those decided to be suffering from this illness (Fairburn et al., 2007). Yet, anorexia nervosa remains a serious illness among young people often with poor outcomes. For instance, according to the Royal Australian and New Zealand College of Psychiatrists (2009), the disease is said to have one of the highest death rates among mental illnesses (between 10 and 20 percent in 20 years). A study by Steinhausen (2009) showed that only 46 percent of anorexia nervosa patients recover fully, only about 34 percent of them show improvement with residual or partial features, and 20 percent remain chronically ill for a long time. The main predictors of poor outcome of anorexia nervosa that have been identified include low body mass index (BMI), more severe psychological and social problems, purgative abuse and self-induced vomit (Keel et al., 2003).
Most of the research on mortality in eating disorders has focused on anorexia nervosa. Many authors believe that this so, and does make sense because the mortality risk for bulivia nervosa is low (Herzog et al., 2000). This conclusion is surprising, considering the medical complications that have been found to be related to laxative abuse, self-induced vomiting, among other purging behavior.
Regardless, anorexia-related deaths come from two areas: physical (natural) causes and suicide related to the associated mental problems. In fact, suicide has been found to be a very common cause of death among people with anorexia nervosa (Pompili et al., 2004). Muir and Palmer (2004) believe that official death certification may not provide a true picture of suicide death in anorexia. This, to them, might explain the wide variations of SMRs for general eating disorders, this partly having to do with the length of follow up. Some follow-ups go up to 9 to 10 years and others up to 20 to 36 years. Regardless of these SMRs variations, there are general predictors of higher mortality in anorexia, including age, severity of case and study period, and also whether the physician evaluated separately other recorded eating disorders with lower rates of mortality.

Theoretical Framework

This study is based on the theory of social cognition. This theory is based on the premise that people have the ability to construct mental representations about oneself vis-à-vis others, and use such representations in their daily lives (Adolphs 2001; Adolphs 2003). In this case, anorexia nervosa is a psychological problem in which a person makes mental representations about the body weight and size expected in the society and worry about getting it. In this case, such mental representations work against the individual. Most importantly, the premise of social cognition creates room for comorbidity, which essentially has to do with individual (of those with anorexia nervosa) to cope.

Hypotheses and Research Questions

The hypothesis in this study is that the wide variation in SMRs has to do with the lack of conclusive data on the causes of death among anorexia nervosa patients. To either affirm or dispute this hypothesis, this study will seek to answer the following questions:

What is the mortality rate among people with anorexia nervosa?

What are the causes of mortality among anorexia nervosa?
Design
As the research questions show, this is an exploratory study. In this regard, it does not just seek to find what the mortality rate in anorexia is, but also why it is as it is, including short-terms follow-ups, among others. On the same note, therefore, this is a qualitative study.
As an ethical step, the researcher(s) obtained a written informed consent from all the participants. For the under-18 participants, the researcher(s) sought written parental participation.

Generally, this paper uses the data of a previous study by Papadopoulos Ekborn, Brandt and Ekselius.

Sample
Papadopoulos et al.’s study included 6009 females who had been admitted for anorexia nervosa at least once in the three-decade period between 1973 and 2003. Of these, nearly 90 percent had been diagnosed with anorexia nervosa as the main problem. Of the other 10 percent, anorexia nervosa was only secondary, with 56 percent being mainly diagnosed with somatic and psychiatric disorders during the period of follow-up, somatic diagnosis alone being the main diagnosis for 30 percent of the same 10 percent and 10 percent diagnose with psychiatric disorder alone. Of this population for which anorexia was only a secondary diagnoses (i.e. those with somatic or psychiatric problems alone), 27 percent had attempted suicide.
The initial mean age of the participants was 19.4 years. The hospitalization period ranged between 0 days and 3 years. The follow-up period fell within the range of 0 to 31 years. The number of anorexia nervosa admissions was between 1 and 66 patient and that of somatic or psychiatric illness alone ranging between 0 and 123 patients.

Data Collection

In collecting data, the study recorded observed deaths among the 90 percent (diagnosed with anorexia nervosa as the main illness) and also deaths across the other related variables (that is, those with somatic or psychiatric disorders alone).

Data Analysis

Causes of Death
The study observed a total of 265 deaths. Of these, 126 (i.e. about 47.55 percent) resulted from unnatural causes and 53 (i.e. 20 percent) were as a result of mental diseases. Suicide was the most frequent main cause of death (n=84) and anorexia nervous came second (n:39), followed by cancer (n=29). The study found anorexia nervosa to be a secondary cause of death in 30 individuals who were registered as natural main cause of death cases (and anorexia nervosa was registered as the main cause of death in 24 of these). Anorexia nervosa was also registered as the secondary cause of death in the 5 individuals registered as having died of unnatural causes. Ultimately, anorexia nervosa was either the main or secondary cause of death in 50 of the 265 cases (that is, 19 percent).

Standardized Mortality Ratios

The researchers calculated the SMRs for unnatural causes of death on the basis of 80 388 person-years of follow-up. For the natural causes, follow-up time was 74 523.
For all causes of death, the SMR was 6.2. When focus turned to all groups of natural and unnatural causes of death, the SMR increased significantly. For example, anorexia nervosa as the main cause of death had the highest SMR (that is, 650.0). At second was psychoactive substance use with 18.9, followed by suicide at 13.6.
For the patients who died in the first year of hospital admission, SMR for unnatural causes of death was 19.3. This SMR in this case stayed high for at least the next 20 years. For natural causes of death the second year of admission (that is, the first year of follow-up), the SMR was 12.1, which also stayed high for at least the next 20 years. For those who had no admission for psychiatric diagnoses besides anorexia nervosa, the overall SMR was 3.6.

Analysis of Findings: Discussion

There has been extensive study of mortality in anorexia. However, there still remains a difficulty in making conclusive decisions regarding SMR. One of the factors that can explain these variations is methodological imitations, including heterogeneity of study population (such as using general population versus hospitalized patients) and inclusion criteria, diversity of sample size and length of mean time for follow-up, as well as differences in the methods of standardization, among others.
These findings show that people with anorexia nervosa have a six-fold higher mortality than the general population. But even more, the SMR remained high (regardless of whether it was about natural or unnatural death) remained high for the next 20 years after the first hospital admission for anorexia. Indeed, anorexia had the highest SMR, being the main or secondary cause of death in about 20 percent of the cases. This is only logical considering the high mortality rates associated with anorexia soon after it is presented, as well as the fact that nearly 20 percent of anorexia patients end up chronically ill.
Psychoactive substances had the second highest SMR. This mainly had to do with alcoholism and related diseases (and not necessarily illicit drug abuse). In this respect, alcohol-related deaths accounted for 10 out of the 13 cases of psychoactive substance abuse. Indeed, alcohol abuse has been registered as one of the key predictors of fatal outcome of anorexia nervosa. Moreover, indirect effects of alcohol could cause gastrointestinal diseases that may increase mortality five-fold. Indeed, four of the six deaths that were found to have resulted from indirect effects of alcohol were found to have liver cirrhosis. Most importantly, the abuse of alcohol seems to start with anorexia, especially in women.
The study also found suicide to account for between 20 to 30 percent of deaths related to anorexia nervosa. Suicide SMR (at 13.6) was lower than in many other cases, ranging between 23.1 and 56.9. However, it is important to note that suicide is also dependent on other factors. For example, suicide was found t be higher the alcoholics than those who are not. Moreover, women who had alcohol problems were also found to show higher risks of respiratory and urogenital systems diseases.

Conclusion, Implications & Recommendations

In conclusion, this paper sought to show what causes of mortality in people with anorexia nervosa. This investigation was driven by the premise that anorexia nervosa does not necessarily lead to death on its own, but in relation to certain risk factors. For example, anorexia nervosa is itself a psychological problem that is related to depression and anxiety, among others. These can in turn lead to suicide and alcoholism, which increase the mortality risk. In other words, mortality in anorexia nervosa is related to other factors. This knowledge is very important as it offers insight into how to go about designing interventions for people with anorexia nervosa, at least to reduce mortality rates. In this regard, it is important to include thorough assessment and treatment of alcohol-related disorders in prevention strategies. In other words, instead of tackling the anorexia nervosa itself, the intervention should focus on the related factors as well. By solving these problems, such as alcohol issues, the risk for anorexia-related mortality is also reduced.

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