Which occurs more frequently in anorexia nervosa, depression or anxiety?

Anxiety Occurs More Frequently Than Depression in Anorexia Nervosa

Anxiety disorders occur more frequently than depression in patients with anorexia nervosa, with approximately 39% experiencing anxiety symptoms compared to 29% experiencing depressive symptoms. 1

Prevalence of Psychiatric Comorbidities in Anorexia Nervosa

Anorexia nervosa is frequently accompanied by various psychiatric comorbidities that significantly impact treatment outcomes and quality of life. The evidence shows:

• Anxiety symptoms affect approximately 39% of anorexia nervosa patients 1
• Depressive symptoms affect approximately 29% of anorexia nervosa patients 1
• Diagnosed anxiety disorders occur in about 23% of these patients 1

Relationship Between Symptoms and Nutritional Status

The severity of both anxiety and depressive symptoms is influenced by nutritional status:

• Symptoms of depression, anxiety, and obsessionality are most elevated in the underweight state 2
• These symptoms improve with weight restoration but do not completely normalize 2, 3
• Even after long-term weight restoration (3+ years), patients continue to show higher levels of:
  • Depressive features (p=0.002)
  • Anxious features (p=0.006)
  • Obsessive-compulsive features (p=0.015) 4

Types of Anxiety in Anorexia Nervosa

Several specific anxiety disorders commonly co-occur with anorexia nervosa:

• Obsessive-compulsive disorder (OCD) - particularly common and may share underlying neurobiological mechanisms 1
• Social phobia
• Generalized anxiety disorder
• Panic disorder 5

Clinical Implications

The higher prevalence of anxiety compared to depression in anorexia nervosa has important implications:

1. Screening and Assessment: Comprehensive evaluation should include specific screening for anxiety disorders, particularly OCD, social anxiety, and generalized anxiety disorder.

2. Treatment Planning:

   • Address anxiety symptoms early in treatment
   • Consider that some anxiety symptoms may be exacerbated by malnutrition but will not completely resolve with weight restoration alone 2
   • Family-based treatment is recommended for adolescents with anorexia nervosa 6

3. Medication Considerations:

   • Selective serotonin reuptake inhibitors (SSRIs) may be beneficial for treating comorbid anxiety disorders
   • However, SSRIs have limited evidence for weight restoration or preventing relapse in anorexia nervosa 1

4. Technology-Based Interventions:

   • Guided computer and internet-based interventions show promise for addressing both eating disorder symptoms and associated anxiety 1
   • Videoconferencing and mobile interventions may provide additional support 1

Monitoring and Follow-up

Given that anxiety symptoms often persist even after weight restoration, long-term monitoring is essential:

• Regular assessment of anxiety symptoms throughout treatment and recovery
• Continued psychological support even after weight restoration
• Attention to obsessive-compulsive features which may be particularly persistent 4, 2

Pitfalls to Avoid

1. Attributing all anxiety symptoms to malnutrition: While nutritional rehabilitation improves symptoms, evidence suggests that anxiety traits may predate the eating disorder and persist after recovery 4, 2

2. Focusing only on weight restoration: While essential, weight restoration alone is insufficient for addressing persistent anxiety symptoms

3. Overlooking specific anxiety disorders: Different anxiety disorders (OCD, social phobia, generalized anxiety) may require specific treatment approaches 5

4. Neglecting long-term follow-up: Given the persistence of anxiety symptoms even after weight restoration, ongoing monitoring and support are crucial

In conclusion, while both anxiety and depression are common in anorexia nervosa, anxiety disorders occur more frequently and may represent underlying traits that persist even after recovery from the eating disorder.