What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa

Abstract

Background: Relapse after treatment for anorexia nervosa (AN) is a significant clinical problem. Given the level of chronicity, morbidity, and mortality experienced by this population, it is imperative to understand the driving forces behind apparently high relapse rates. However, there is a lack of consensus in the field on an operational definition of relapse, which hinders precise and reliable estimates of the severity of this issue. The primary goal of this paper was to review prior studies of AN addressing definitions of relapse, as well as relapse rates.

Methods: Data sources included PubMed and PsychINFO through March 19th, 2016. A systematic review was performed following the PRISMA guidelines. A total of (N = 27) peer-reviewed English language studies addressing relapse, remission, and recovery in AN were included.

Results: Definitions of relapse in AN as well as definitions of remission or recovery, on which relapse is predicated, varied substantially in the literature. Reported relapse rates ranged between 9 and 52%, and tended to increase with increasing duration of follow-up. There was consensus that risk for relapse in persons with AN is especially high within the first year following treatment.

Discussion: Standardized definitions of relapse, as well as remission and recovery, are needed in AN to accelerate clinical and research progress. This should improve the ability of future longitudinal studies to identify clinical, demographic, and biological characteristics in AN that predict relapse versus resilience, and to comparatively evaluate relapse prevention strategies. We propose standardized criteria for relapse, remission, and recovery, for further consideration.

Keywords: Anorexia nervosa; Bulimia nervosa; Eating disorder; Outcome; Prevention; Recovery; Relapse; Remission; Treatment.

Fig. 1

Prisma diagram

Fig. 2

Proposed standardized definitions of relapse, remission, and recovery. These standardized definitions were synthesized from the different criteria for relapse, remission, and recovery in individual studies identified by our systematic review. We include a graphical representation of these definitions as a useful heuristic tool for conceptualizing the major transition points (relapse in red, remission in yellow, recovery in green) while at the same time underscoring the continuum of pathology existing within each stage. Note 1: since weight and height normally increase until age 20 in pediatric and adolescent populations, age- and gender- adjusted BMI percentiles for determining expected body weight (EBW) are more appropriate in these subgroups, as demonstrated by [52]. Note 2: determination of ideal body weight is complex, and subject to consideration of racial, ethnic, demographic, and cultural factors [53]. Note 3: Symptoms and behaviors are discrete variables, which are rated/ascertained by the clinician based on all available clinical information

Fig. 3

Illness trajectories across a 2 year time period for three hypothetical individuals with AN exhibiting different illness courses. One individual with an uncomplicated course shows a consistent transition from full relapse to full remission to full recovery. Another individual shows a complicated course marked by partial remission, partial relapse, and partial recovery, followed by a decline to full remission. A third individual shows a complicated course with no recovery marked by intermittent bouts of full relapse punctuated by partial relapse and partial remission. For an analogous depiction of illness trajectory based on actual patients, see Kordy et al., [10]