Norexia Nervosa Binge Purging type. BMI: Body Mass Index; SD: Standard Deviation. + FFMI and FMI are obtained for 146 patients. doi:10.1371/journal.pone.0049380.tMean D AN-BP (N = 80) 14.861.6 13.4661.68 20.6363.05 2.2161.25 12.6460.p 0.001 0.000 0.03 0.001 0.14.0161.16 12.661.25 19.4963.34 1.6160.91 12.4360.Anorexia NervosaTable 4. Correlations between age, duration of illness and BMI, body composition components and psychological scores.Age Age r p Duration of illness r p .668* .000Inclusion BMI (kg/m2) 2.002 .980 .002 .Duration of illness .668* .000FFMI 2.239* .004 2.238* .FMI 2.239* 25033180 .004 2.238* .HAD anxiety .173* .033 .174* .HAD depression .195* .0016 .236* .BDI .155* .055 .212* .LSAS .210* .009 .250* .MOCI 2.008* .919 .034* .BDI : Beck Depression Inventory, HAD: Hospital Anxiety and Depression scale, MOCI : Maudsley Obsessive-Compulsive Inventory, LSAS: Liebowitz social anxiety scale; BMI: Body Mass Index; SD: Standard Deviation; + FFMI and FMI are obtained for 146 patients. doi:10.1371/journal.pone.0049380.twith levels of malnutrition. There may be a nutrition threshold, whereby psychological state is only affected when a certain degree of nutritional deficiency has been reached. Second, we evaluated nutritional status in more comprehensive manner and in a larger sample compared to previous studies, and we used relatively a large set of indicators. However, body composition was measured using the BIA which is not a reference PD168393 method (such as Dual-emission X-ray absorptiometry (DXA) or measurements using 4 compartment models). The severely malnourished status of the patients did not enable transfer to DXA centres for the measures to be performed. Also, the severity of 478-01-3 web malnutrition was measured by a rough estimation of the difference between the highest lifetime BMI and BMI at inclusion, thus considering weight loss to be linear, and not accounting for duration of illness and weight 
fluctuations. A more precise measure of these variations should be performed to provide information on this subject. Third, as hypothesised by certain authors [36,37] depression in AN, rather than having a single aetiology, is likely to be the consequence of various factors; depressive and anxiety symptoms in severely malnourished AN patients could therefore be mainly due to factors other than malnutrition, such as depressive symptoms linked to exhaustion, chronic illness or in some cases premorbid depression. An interesting yet worrying observation from our study was the frequent use of psychotropic drugs in the treatment 24786787 of very malnourished patients. More than 36 percent of AN patients admitted were receiving antidepressants. This is unusual, especially in severely malnourished subjects: it is well established that antidepressants are not effective on patients with low BMI [2]. These treatments have usually been prescribed before inpatient admission, generally by non-specialized physicians, and they are generally stopped after admission, because they are ineffective. Despite these elements, it is interesting to see that the higher the anxiety or depressive scores, the more likely patients are to be receiving anti-depressants (AD). How can we understand the link between psychological symptoms and malnutrition in the light of our data and the literature? In the first stages of the illness, patients report that starvation provides relief from pre-existing anxiety and depressive symptoms. However, in a second stage, these symptoms tend to increase and reg.Norexia Nervosa Binge Purging type. BMI: Body Mass Index; SD: Standard Deviation. + FFMI and FMI are obtained for 146 patients. doi:10.1371/journal.pone.0049380.tMean D AN-BP (N = 80) 14.861.6 13.4661.68 20.6363.05 2.2161.25 12.6460.p 0.001 0.000 0.03 0.001 0.14.0161.16 12.661.25 19.4963.34 1.6160.91 12.4360.Anorexia NervosaTable 4. Correlations between age, duration of illness and BMI, body composition components and psychological scores.Age Age r p Duration of illness r p .668* .000Inclusion BMI (kg/m2) 2.002 .980 .002 .Duration of illness .668* .000FFMI 2.239* .004 2.238* .FMI 2.239* 25033180 .004 2.238* .HAD anxiety .173* .033 .174* .HAD depression .195* .0016 .236* .BDI .155* .055 .212* .LSAS .210* .009 .250* .MOCI 2.008* .919 .034* .BDI : Beck Depression Inventory, HAD: Hospital Anxiety and Depression scale, MOCI : Maudsley Obsessive-Compulsive Inventory, LSAS: Liebowitz social anxiety scale; BMI: Body Mass Index; SD: Standard Deviation; + FFMI and FMI are obtained for 146 patients. doi:10.1371/journal.pone.0049380.twith levels of malnutrition. There may be a nutrition threshold, whereby psychological state is only affected when a certain degree of nutritional deficiency has been reached. Second, we evaluated nutritional status in more comprehensive manner and in a larger sample compared to previous studies, and we used relatively a large set of indicators. However, body composition was measured using the BIA which is not a reference method (such as Dual-emission X-ray absorptiometry (DXA) or measurements using 4 compartment models). The severely malnourished status of the patients did not enable transfer to DXA centres for the 
measures to be performed. Also, the severity of malnutrition was measured by a rough estimation of the difference between the highest lifetime BMI and BMI at inclusion, thus considering weight loss to be linear, and not accounting for duration of illness and weight fluctuations. A more precise measure of these variations should be performed to provide information on this subject. Third, as hypothesised by certain authors [36,37] depression in AN, rather than having a single aetiology, is likely to be the consequence of various factors; depressive and anxiety symptoms in severely malnourished AN patients could therefore be mainly due to factors other than malnutrition, such as depressive symptoms linked to exhaustion, chronic illness or in some cases premorbid depression. An interesting yet worrying observation from our study was the frequent use of psychotropic drugs in the treatment 24786787 of very malnourished patients. More than 36 percent of AN patients admitted were receiving antidepressants. This is unusual, especially in severely malnourished subjects: it is well established that antidepressants are not effective on patients with low BMI [2]. These treatments have usually been prescribed before inpatient admission, generally by non-specialized physicians, and they are generally stopped after admission, because they are ineffective. Despite these elements, it is interesting to see that the higher the anxiety or depressive scores, the more likely patients are to be receiving anti-depressants (AD). How can we understand the link between psychological symptoms and malnutrition in the light of our data and the literature? In the first stages of the illness, patients report that starvation provides relief from pre-existing anxiety and depressive symptoms. However, in a second stage, these symptoms tend to increase and reg.