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摂食障害

著者: 西園マーハ文 明治学院大学心理学部心理学科

監修: 上島国利 昭和大学

著者校正済:2021/09/15
現在監修レビュー中
参考ガイドライン:
Eating disorders: recognition and treatment. NICE guideline. Published: 23 May 2017, https://www.nice.org.uk/guidance/ng69/resources/eating-disorders-recognition-and-treatment-pdf-1837582159813
患者向け説明資料

概要・推奨   

  1. 入院治療での体重増加が大きいほうがその後の予後がよい可能性がある(推奨度2
  1. ボディーイメージの障害が残っていると神経性過食症(過食症)は再発しやすい(推奨度2)
  1. 神経性やせ症(拒食症は、半数以上の症例で、数年の経過後に回復するとの報告がある。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
西園マーハ文 : 未申告[2021年]
監修:上島国利 : 原稿料(大日本住友製薬)[2021年]

改訂のポイント:
  1. 定期レビューを行い、治療のポイントと文献の追加を行った。

病態・疫学・診察

疾患情報  
  1. 摂食障害とは、極端な食事制限や過食などの食行動の問題と、心身のさまざまな症状を伴う精神疾患である。
  1. 摂食障害には、神経性やせ症(拒食症)、神経性過食症(過食症)など、種々の病態がある。
 
1888年の英国の医学誌Lancetに掲載された写真の版画(神経性無食欲症の様子)

a:Photographed April 21st,1887.
b:Photographed June 14th,1887.

 
  1. 神経性やせ症と神経性過食症では食行動が異なるが、肥満恐怖、空腹感や満腹感の読み取り障害、自己評価の低さなど、心理面では共通点が多い。
  1. DSM-5では以下が神経性やせ症/神経性無食欲症の診断基準となっている[1]
  1. A.必要量と比べてカロリー摂取を制限し、年齢、性別、成長曲線、身体的健康状態に対する有意に低い体重に至る。有意に低い体重とは、正常の下限を下回る体重で、子どもまたは青年の場合は、期待される最低体重を下回ると定義される
  1. B.有意に低い体重であるにもかかわらず、体重増加または肥満になることに対する強い恐怖、または体重増加を妨げる持続した行動がある
  1. C.自分の体重または体型の体験の仕方における障害、自己評価に対する体重や体型の不相応な影響または現在の低体重の深刻さに対する認識の持続的欠如
  1. DSM-5では以下が神経性過食症/神経性大食症の診断基準となっている[1]
  1. A.反復する過食エピソード.過食エピソードは以下の両方によって特徴づけられる
  1. 他とはっきり区別される時間帯に(例:任意の2時間の間の中で)ほとんどの人が同様の状況で同様の時間内に食べる量よりも明らかに多い食物を食べる
  1. そのエピソードの間は、食べることを抑制できないという感覚(例:食べるのをやめることができない、または、食べるものの種類や量を抑制できないという感覚)
  1. B.体重の増加を防ぐための反復する不適切な代償行動。例えば、自己誘発性嘔吐;緩下剤、利尿薬、その他の医薬品の乱用;絶食;過剰な運動など
  1. C.過食と不適切な代償行動がともに平均して3カ月間にわたって、少なくても週1回は起こっている
  1. D.自己評価が体型および体重の影響を過度に受けている
  1. E.その障害は神経性やせ症のエピソードの期間にのみ起きるものではない
  1. 診断基準を満たすのは、神経性やせ症が若年女子の1%前後、神経性過食症は数%だが、診断基準を満たさない部分症状を持つものも含めると、若年女子の約1割は、食行動の問題を持っている。
  1. 治療への抵抗が強いので、治療への動機付けは丁寧に行う。
問診・診察のポイント  
  1. 神経性やせ症の場合、かなりの低栄養でも不調を自覚していないことが多い。体重、血圧、脈拍などを測定し、本人に身体の状態を知ってもらうようにする。

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文献 

著者: D I Ben-Tovim, K Walker, P Gilchrist, R Freeman, R Kalucy, A Esterman
雑誌名: Lancet. 2001 Apr 21;357(9264):1254-7. doi: 10.1016/S0140-6736(00)04406-8.
Abstract/Text BACKGROUND: Eating disorders are disabling, unpredictable, and difficult to treat. We did a prospective 5-year investigation of a representative sample of patients with eating disorders. Our aim was to identify predictors of outcome and to assess effects of available treatments.
METHODS: We prospectively investigated 95 patients with anorexia nervosa, 88 with bulimia nervosa, and 37 with eating disorders not otherwise specified (EDNOS), who sought treatment in Adelaide, South Australia. We divided patients into those who had, and had not, received treatment in specialist units and reached a safe body weight. Individuals were then further classified dependent on intensity of any treatment received. We assessed clinical symptoms, body-related attitudes, and psychosocial function.
FINDINGS: 216 (98%) patients were available for follow-up after 5 years. Three patients with anorexia nervosa and two with EDNOS died. 65 (74%) bulimic, 29 (78%) EDNOS, and 53 (56%) anorexic patients had no diagnosable eating disorder. A small proportion of patients in every group had poor Morgan-Russell-Hayward scores at outcome. Final outcome was predicted by extent and intensity, but not duration, of initial symptoms in patients with anorexia nervosa, and by initial body-related attitudes and impaired psychosocial functioning in bulimia patients. We were unable to predict EDNOS outcome. Treatment did not affect outcome for any group.
INTERPRETATION: Deaths in the study confirm the serious nature of eating disorders. However, our results suggest that the efficacy of existing interventions is questionable.

PMID 11418150  Lancet. 2001 Apr 21;357(9264):1254-7. doi: 10.1016/S014・・・
著者: S Zipfel, B Löwe, D L Reas, H C Deter, W Herzog
雑誌名: Lancet. 2000 Feb 26;355(9205):721-2. doi: 10.1016/S0140-6736(99)05363-5.
Abstract/Text In a prospective long-term follow-up of 84 patients 21 years after first hospitalisation for anorexia nervosa, we found that 50.6% had achieved a full recovery, 10.4% still met full diagnostic criteria for anorexia nervosa, and 15.6% had died from causes related to anorexia nervosa. Predictors of outcome included physical, social, and psychological variables.

PMID 10703806  Lancet. 2000 Feb 26;355(9205):721-2. doi: 10.1016/S0140・・・
著者: B Löwe, S Zipfel, C Buchholz, Y Dupont, D L Reas, W Herzog
雑誌名: Psychol Med. 2001 Jul;31(5):881-90.
Abstract/Text BACKGROUND: Given our poor understanding of the very long-term course of anorexia nervosa. many questions remain regarding the potential for recovery and relapse. The purpose of the present study was to investigate long-term outcome and prognosis in an anorexic sample 21 years after the initial treatment.
METHOD: A multidimensional and prospective design was used to assess outcome in 84 patients 9 years after a previous follow-up and 21 years after admission. Among the 70 living patients, the follow-up rate was 90%. Causes of death for the deceased patients were obtained through the attending physician. Predictors of a poor outcome at the 21-year follow-up were selected based on the results of a previous 12-year follow-up of these patients.
RESULTS: Fifty-one per cent of the patients were found to be fully recovered at follow-up, 21% were partially recovered and 10% still met full diagnostic criteria for anorexia nervosa. Sixteen per cent were deceased, due to causes related to anorexia nervosa. The standardized mortality rate was 9.8. The three groups also showed significant differences in psychosocial outcome. A low body mass index and a greater severity of social and psychological problems were identified as predictors of a poor outcome.
CONCLUSIONS: Recovery is still possible for anorexic patients after a period of 21 years. On the other hand, patients can relapse, becoming symptomatic again despite previously achieving recovery status. Only a few patients classified as having a poor outcome were found to seek any form of treatment, therefore, it is recommended that these patients should be monitored regularly and offered treatment whenever possible.

PMID 11459385  Psychol Med. 2001 Jul;31(5):881-90.
著者: M Strober, R Freeman, W Morrell
雑誌名: Int J Eat Disord. 1997 Dec;22(4):339-60.
Abstract/Text OBJECTIVE: To assess the long-term course of recovery and relapse and predictors of outcome in anorexia nervosa.
METHOD: A naturalistic, longitudinal prospective design was used to assess recovery and relapse in patients ascertained through a university-based specialty treatment program. Patients were assessed semiannually for 5 years and annually thereafter over 10-15 years from the time of their index admission. Recovery was defined in terms of varying levels of symptom remission maintained for no fewer than 8 consecutive weeks.
RESULTS: Nearly 30% of patients had relapses following hospital discharge, prior to clinical recovery. However, most patients were weight recovered and menstruating regularly by the end of follow-up, with nearly 76% of the cohort meeting criteria for full recovery. Relapse after recovery was relatively uncommon. Of note, time to recovery was protracted, ranging from 57-79 months depending on definition of recovery. Among restrictors at intake, nearly 30% developed binge eating, occurring within 5 years of intake. A variety of predictors of chronic outcome and binge eating were identified. There were no deaths in the cohort.
CONCLUSION: The course of anorexia nervosa is protracted. Predictors of outcome are surprisingly few, but those identified are in keeping with previous accounts. The intensive treatment received by these patients may account for the lower levels of morbidity and mortality when considered in relation to other reports in the follow-up literature.

PMID 9356884  Int J Eat Disord. 1997 Dec;22(4):339-60.
著者: R J Freeman, B Beach, R Davis, L Solyom
雑誌名: J Psychiatr Res. 1985;19(2-3):349-53.
Abstract/Text Thirty-nine women successfully treated for bulimia nervosa were followed up six months after the conclusion of treatment and classified as maintaining recovery or partially or completely relapsed. Clinical and psychometric variables including body image disturbance and dissatisfaction were entered into regression equations to identify predictors of relapse. Dissatisfaction with body image at the end of treatment was the most potent predictor of relapse. The finding is interpreted as underscoring the importance of addressing issues of body image in therapy if treatment gains are to be maintained.

PMID 3862835  J Psychiatr Res. 1985;19(2-3):349-53.
著者: J C Carter, E Blackmore, K Sutandar-Pinnock, D B Woodside
雑誌名: Psychol Med. 2004 May;34(4):671-9. doi: 10.1017/S0033291703001168.
Abstract/Text BACKGROUND: Knowledge about factors that predict relapse in anorexia nervosa (AN) is needed for the development of effective relapse prevention treatments and may also advance understanding of the psychopathology of AN. The aim of the present study was to examine the rate, timing and prediction of relapse in AN following weight restoration in a specialized in-patient treatment programme.
METHOD: Fifty-one consecutive first-admission AN patients who were weight-restored following in-patient treatment participated in the study. Follow-up assessments were conducted a median of 15 months post-discharge. Relapse of AN was defined as a body mass index <17.5 for 3 consecutive months. Data were analysed using Kaplan-Meier survival analysis and Cox regression.
RESULTS: The overall rate of relapse was 35% and the mean survival time was 18 months. The highest risk period was from 6 to 17 months after discharge. Several significant predictors of relapse were identified: a history of suicide attempt; previous specialized treatment for an eating disorder; severity of obsessive-compulsive symptoms at presentation; excessive exercise immediately after discharge; and residual concern about shape and weight at discharge.
CONCLUSIONS: There continues to be a significant risk of relapse among AN patients who remain well for the first year post-discharge. Several variables were shown to be associated with an elevated risk of relapse. These findings have implications for the development of initial treatments and relapse prevention strategies for AN.

PMID 15099421  Psychol Med. 2004 May;34(4):671-9. doi: 10.1017/S003329・・・
著者: Josefina Castro, Araceli Gila, Josefa Puig, Sonia Rodriguez, Josep Toro
雑誌名: Int J Eat Disord. 2004 Jul;36(1):22-30. doi: 10.1002/eat.20009.
Abstract/Text OBJECTIVE: The current study analyzed the variables related to rehospitalization after total weight recovery in adolescents with anorexia nervosa.
METHOD: One hundred and one patients first admitted for inpatient treatment, aged 11-19 years, were followed up for 12 months after discharge.
RESULTS: Twenty-five subjects (24.8%) required readmission after complete weight recovery and 76 (75.2%) did not. Duration of disorder, weight loss, body mass index at first admission, and global body image distortion were similar in the two groups. Patients needing readmission had a lower rate of weight gain (p < .001), a lower mean age (p = . 007), a higher mean score on the Eating Attitudes Test (EAT; p = .009), and a higher percentage of hips overestimation (p = .049). In a stepwise logistic regression analysis, these three variables predicted readmission and correctly classified 77.6% of patients. Taken as discrete variables, age younger than 15 years old, EAT score above 55, and a rate of weight gain lower than 150 grams per day were associated with a higher percentage of readmissions.
DISCUSSION: The variables most clearly related to readmission were young age, abnormal eating attitudes, and a low rate of weight gain.

Copyright 2004 by Wiley Periodicals, Inc.
PMID 15185268  Int J Eat Disord. 2004 Jul;36(1):22-30. doi: 10.1002/ea・・・
著者: C G Fairburn, P A Norman, S L Welch, M E O'Connor, H A Doll, R C Peveler
雑誌名: Arch Gen Psychiatry. 1995 Apr;52(4):304-12.
Abstract/Text BACKGROUND: Little is known about the longer-term outcome of bulimia nervosa and the distal effects of treatment.
METHODS: Prospective follow-up of subjects from two randomized controlled trials, involving a comparison of cognitive behavior therapy, behavior therapy, and focal interpersonal therapy.
RESULTS: Ninety percent (89/99) underwent reassessment by interview (mean [+/- SD] length of follow-up, 5.8 +/- 2.0 years). Almost half (46%) had a DSM-IV eating disorder; 19%, bulimia nervosa; 3%, anorexia nervosa; and 24%, eating disorder not otherwise specified. There was a low rate of other psychiatric disorders. Premorbid and paternal obesity predicted a poor outcome. While the three treatments did not differ with respect to the proportion of subjects with anorexia nervosa or bulimia nervosa at follow-up, they did differ once all forms of DSM-IV eating disorder were considered together. Those who had received cognitive behavior therapy or focal interpersonal therapy were doing markedly better than those who had received behavior therapy.
CONCLUSIONS: The longer-term outcome of bulimia nervosa depends on the nature of the treatment received. Patients who receive a treatment such as behavior therapy, which only has a short-lived effect, tend to do badly, whereas those who receive treatments such as cognitive behavior therapy or focal interpersonal therapy have a better prognosis.

PMID 7702447  Arch Gen Psychiatry. 1995 Apr;52(4):304-12.
著者: J Bacaltchuk, P Hay
雑誌名: Cochrane Database Syst Rev. 2003;(4):CD003391. doi: 10.1002/14651858.CD003391.
Abstract/Text BACKGROUND: Bulimia Nervosa (BN) represents an important public health problem and is related to serious morbidity and even mortality. This review attempted to systematically evaluate the use of antidepressant medications compared with placebo for the treatment of bulimia nervosa.
OBJECTIVES: The primary objective of this review was to determine whether using antidepressant medications was clinically effective for the treatment of bulimia nervosa. The secondary objectives were:(i) to examine whether there was a differential effect for the various classes/types of antidepressants with regard to effectiveness and tolerability(ii) to test the hypothesis that the effect of antidepressants on bulimic symptoms was independent of its effect on depressive symptoms
SEARCH STRATEGY: (1) electronic searches of MEDLINE (1966 to December 2002), EMBASE (1980-December 2002), PsycINFO (to December 2002), LILACS & SCISEARCH (to 2002)(2) the Cochrane Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register - ongoing(3) inspection of the references of all identified trials(4) contact with the pharmaceutical companies and the principal investigator of included trials(5) inspection of the International Journal of Eating Disorders - ongoing
SELECTION CRITERIA:
INCLUSION CRITERIA: every randomised, placebo-controlled trial in which antidepressant medications were compared to placebo to reduce the symptoms of bulimia nervosa in patients of any age or gender.Quality criteria: reports were considered adequate if they were classified as A or B according to the Cochrane Manual. The Jadad scale, with a cut off of 2 points, was applied to check the validity of the above referred criterion but was not used as an inclusion criterion.
DATA COLLECTION AND ANALYSIS: Data were extracted independently by two reviewers for each included trial. Dichotomous data were evaluated by the relative risk with 95% confidence intervals (CI) around this measure, based on the random effects model; continuous data were evaluated by the standardised mean difference with the 95% CI. NNT was calculated using the inverse of the absolute risk reduction.
MAIN RESULTS: Currently the review includes 19 trials comparing antidepressants with placebo: 6 trials with TCAs (imipramine, desipramine and amitriptyline), 5 with SSRIs (fluoxetine), 5 with MAOIs (phenelzine, isocarboxazid, moclobemide and brofaromine) and 3 with other classes of drugs (mianserin, trazodone and bupropion). Similar results were obtained in terms of efficacy for these different groups of drugs. The pooled RR for remission of binge episodes was 0.87 (95% CI 0.81-0.93; p<0,001) favouring drugs. The NNT for a mean treatment duration of 8 weeks, taking the non-remission rate in the placebo controls of 92% as a measure of the baseline risk was 9 (95% CI 6 - 16). The RR for clinical improvement, defined as a reduction of 50% or more in binge episodes was 0.63 (95% CI 0.55-0.74) and the NNT for a mean treatment duration of 9 weeks was 4 (95% CI 3 - 6), with a non-improvement rate of 67% in the placebo group. Patients treated with antidepressants were more likely to interrupt prematurely the treatment due to adverse events. Patients treated with TCAs dropped out due to any cause more frequently that patients treated with placebo. The opposite was found for those treated with fluoxetine, suggesting it may be a more acceptable treatment. Independence between antidepressant and anti-bulimic effects could not be evaluated due to incomplete published data.
REVIEWER'S CONCLUSIONS: The use of a single antidepressant agent was clinically effective for the treatment of bulimia nervosa when compared to placebo, with an overall greater remission rate but a higher rate of dropouts. No differential effect regarding efficacy and tolerability among the various classes of antidepressants could be demonstrated.

PMID 14583971  Cochrane Database Syst Rev. 2003;(4):CD003391. doi: 10.・・・
著者: G F Russell, G I Szmukler, C Dare, I Eisler
雑誌名: Arch Gen Psychiatry. 1987 Dec;44(12):1047-56.
Abstract/Text A controlled trial comparing family therapy with individual supportive therapy in anorexia nervosa and bulimia nervosa was undertaken. Eighty patients (57 with anorexia nervosa; 23 with bulimia nervosa) were first admitted to a specialized unit to restore their weight to normal. Before discharge, they were randomly allocated to family therapy or the control treatment (individual supportive therapy). After one year of psychological treatment, they were reassessed, using body weight, menstrual function, and ratings on the Morgan and Russell scales. Family therapy was found to be more effective than individual therapy in patients whose illness was not chronic and had begun before the age of 19 years. A more tentative finding was the greater value of individual supportive therapy in older patients. To our knowledge, this is the first controlled trial of family therapy in anorexia nervosa and clarifies the specific indications for this treatment.

PMID 3318754  Arch Gen Psychiatry. 1987 Dec;44(12):1047-56.
著者: I Eisler, C Dare, M Hodes, G Russell, E Dodge, D Le Grange
雑誌名: J Child Psychol Psychiatry. 2000 Sep;41(6):727-36.
Abstract/Text This paper reports the results of a randomised treatment trial of two forms of outpatient family intervention for anorexia nervosa. Forty adolescent patients with anorexia nervosa were randomly assigned to "conjoint family therapy" (CFT) or to "separated family therapy" (SFT) using a stratified design controlling for levels of critical comments using the Expressed Emotion index. The design required therapists to undertake both forms of treatment and the distinctiveness of the two therapies was ensured by separate supervisors conducting live supervision of the treatments. Measures were undertaken on admission to the study, at 3 months, at 6 months and at the end of treatment. Considerable improvement in nutritional and psychological state occurred across both treatment groups. On global measure of outcome, the two forms of therapy were associated with equivalent end of treatment results. However, for those patients with high levels of maternal criticism towards the patient, the SFT was shown to be superior to the CFT. When individual status measures were explored, there were further differences between the treatments. Symptomatic change was more marked in the SFT whereas there was considerably more psychological change in the CFT group. There were significant changes in family measures of Expressed Emotion. Critical comments between parents and patient were significantly reduced and that between parents was also diminished. Warmth between parents increased.

PMID 11039685  J Child Psychol Psychiatry. 2000 Sep;41(6):727-36.
著者: S A Baran, T E Weltzin, W H Kaye
雑誌名: Am J Psychiatry. 1995 Jul;152(7):1070-2.
Abstract/Text OBJECTIVE: Because recent limitations in health care coverage have resulted in shorter lengths of inpatient stay, many patients with anorexia nervosa are discharged while still underweight. The authors' goal was to determine whether anorectic patients who were underweight when they were discharged had a worse outcome and a higher rate of rehospitalization than those who had achieved normal weight at discharge.
METHOD: They assessed weight and height, eating disorder symptoms, and severity of depressive and anxiety symptoms in 22 women with anorexia nervosa at hospital admission and at follow-up a mean of 29 months after discharge.
RESULTS: Anorectic patients who were discharged while severely underweight reported significantly higher rates of rehospitalization and endorsed more symptoms than those who had achieved normal weight before discharge.
CONCLUSIONS: These data suggest that brief hospitalization for severely underweight women with anorexia may not be cost effective because the majority are rehospitalized.

PMID 7793445  Am J Psychiatry. 1995 Jul;152(7):1070-2.

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