Denial and minimization in adolescents with anorexia nervosa

Etiological role of childhood emotional trauma and neglect in adolescent anorexia nervosa: a cross-sectional questionnaire analysis

BACKGROUND

Most studies on the relationship between childhood trauma and anorexia nervosa (AN) have focused on the role of childhood sexual and physical trauma in adult patients. Little is known about the role of emotional trauma and eating disorders. The aim of the present study was to examine childhood sexual, physical, and emotional traumatization in adolescents with anorexia nervosa restricting type (AN-R) in comparison to those with anorexia nervosa binge-eating/purging type (AN-BP) and a healthy control group.

SAMPLING AND METHODS

The sample included 50 patients with AN-R (mean age = 15.8 ± 1.6 years), 27 with AN-BP (mean age = 16.1 ± 1.1 years), and 44 healthy female control participants (mean age = 15.7 ± 1.3 years). AN diagnosis was confirmed by the Structured Inventory for Anorexic and Bulimic Syndromes (SIAB-EX). Childhood sexual, physical, and emotional traumatization was assessed by a self-report questionnaire (Childhood Trauma Questionnaire; CTQ).

RESULTS

The results indicated higher rates of sexual, physical, and emotional abuse and physical and emotional neglect in patients with AN-BP than in patients with AN-R and healthy control participants. No significant differences in childhood traumatization were found between patients with AN-R and control participants.

CONCLUSIONS

Our results underline the importance of detecting the full range of possible childhood traumatic experiences in adolescents with AN, rather than focusing simply on childhood sexual traumatization. Sexual, physical, and emotional childhood traumatization are particularly important in the history of adolescent patients with AN-BP, in contrast to patients with AN-R, and should be screened for in the diagnosis and therapy of eating disorders.

Eating disorders in youth: diagnostic variability and predictive validity

OBJECTIVE

The primary aim was to examine the utility of DSM-IV criteria in predicting treatment outcome in a sample of adolescents with eating disorders.

METHOD

We (a) descriptively compared the baseline rates of anorexia nervosa (AN) and bulimia nervosa (BN) across multiple reference points for diagnostic criteria, (b) using ROC curve analyses, assessed the sensitivity and specificity of each diagnostic criterion in predicting clinical outcome, and (c) with logistic regression analyses, examined the incremental predictive value of each criterion.

RESULTS

Results show a high degree of variability in the baseline diagnostic profiles as a function of the information used to inform each DSM-IV criterion. For AN, Criterion A yielded the best predictive validity, with Criteria B-D providing no significant incremental value. For BN, none of the measures had a significant AUC, and results from logistic regression analyses showed that none of the indicators were robust in predicting outcome.

DISCUSSION

For AN, the existing Criterion A is appropriate for children and adolescents, and is sufficient to predict outcome in the context of active refusal to maintain a normal weight as well as multiple informants and behavioral indicators of the psychological aspects of AN. For BN, predictive validity could not be established.

Adolescent-adult discrepancies on the eating disorder examination: a function of developmental stage or severity of illness?

OBJECTIVE

Across studies, adolescents score lower on measures of eating disorder pathology than adults, but it is unclear whether such findings reflect discrepancies inherent to site/study or true developmental differences. The aim of this study was to determine whether age predicts subscale and diagnostic scores of the Eating Disorder Examination (EDE) in adolescents and adults with anorexia nervosa (AN) admitted to a single research center within the same period of time.

METHOD

The sample consisted of 16 adolescent and 20 adult consecutive admissions to parallel, age-specific, research-based AN treatment programs. Participants completed a baseline evaluation at admission that included the EDE, depression measures, and global assessment of functioning scales.

RESULTS

Age significantly predicted EDE scores in univariate regression analyses. However, in multivariate models that included severity indices of general and specific psychopathology as covariates, age was no longer a significant predictor of severity of eating disorder symptoms.

DISCUSSION

This study adds to the growing body of data showing lower scores on the EDE for adolescents with AN relative to their adult counterparts, while eliminating potential site confounds. Results indicate that the higher adult scores may be carried in part by a more overall severe and chronic general clinical profile.

Insight in eating disorders: clinical and cognitive correlates

BACKGROUND

The aim of this study was to explore the extent of lack of insight and its components in eating disorders (EDs) and to investigate the relationship between insight and clinical and cognitive characteristics in this group.

METHOD

Seventy-five participants were enrolled in the study: 25 with anorexia nervosa (AN), 15 with bulimia nervosa (BN) and 35 healthy controls (HC). Insight was assessed with a modified version of the Schedule for the Assessment of Insight for EDs (SAI-ED) and multi-dimensional scaling (MDS) analysis was used to clarify the internal structure of the scale. Neuropsychological tests included the Trail Making Test (TMT), the Brixton Test and a Verbal Fluency Task.

RESULTS

Only a subgroup of AN patients (24%) had severe impairment of insight. Patients with the restricting type of AN (AN-R) had poorer overall insight than patients with the binge-purge type of the disorder (AN-B/P). More of the ED patients displayed a deliberate denial of illness rather than a lack of awareness of the illness. A regression model revealed that only performance in part B of the TMT (TMT-B) was a moderate predictor of insight level. No association was found between insight and other cognitive or clinical variables.

CONCLUSIONS

Impaired insight is a significant feature of some ED patients. Insight in EDs seems to be partially dependent on intact mental flexibility.

Changes in patient measures as predictors of therapists' ratings of treatment collaboration and change in eating disorder subgroups

This study examined how implicit and explicit changes following integrative inpatient treatment of adolescents with eating disorder (ED) may predict the posttreatment ratings of psychodynamic therapists of their patients' openness to therapeutic processes and their change (Therapist Evaluation Inventory). The relative contribution of inpatients' ego functions was compared with that of their mental distress and ED symptoms in two subgroups: restricting type anorexia (AN-R) and binging/purging type EDs (B/P). Data indicated that the implicit personality variable of elevated ability to modulate affects was the best predictor of therapist-rated global outcome among patients with B/P symptoms, whereas in patients with AN-R, evolving openness to implicit negative affects and a reduction in reported distress were best predictors. In patients with AN-R, attenuated affect control was also significantly correlated with therapist posttreatment ratings. These data point that in addition to addressing behavioral/symptomatic aspects, personality variables should be addressed in the psychological treatment of EDs.

Assessment Measures for Child and Adolescent Eating Disorders: A Review

BACKGROUND

  Several diagnostic and screening instruments are available for child and adolescent eating disorders. However, limitations have been identified in many of these.

METHOD

  We review the most frequently used assessment measures for eating disorders in children and adolescents.

RESULTS

  Several of the available instruments have significant limitations, although relevant strengths are identified.

CONCLUSIONS

  Limitations in the current available instruments for child and adolescent eating disorders should be addressed in order to improve recognition and treatment.

Stiff-person syndrome presenting as eating disorder: a case report

OBJECTIVE

To report a case of a 35-year-old female initially treated for anorexia nervosa who was found to have Stiff-Person Syndrome (SPS).

METHOD

Case report.

RESULTS

The patient reported panic attacks at meal times that were found to consist of tetanic contractions of the axial musculature. Swallowing initiated reflexive painful muscle spasms that consequently resulted in cibophobia and significant weight loss. Her serum tested positive for anti-glutamic acid decarboxylase antibodies, and she subsequently improved with appropriate treatment for SPS.

DISCUSSION

SPS has not been previously reported in the context of eating disorders, although it has been linked to other psychiatric disorders. Often the psychiatrist may be the first physician to diagnose SPS. We present this case to alert practitioners to the potential co-morbidity and symptom overlap between SPS and eating disorders, to aid in early recognition and appropriate treatment of this rare illness.

How do eating disorder specialist clinicians apply DSM-IV diagnostic criteria in routine clinical practice? Implications for enhancing clinical utility in DSM-5

The clinical utility of the DSM-IV eating disorder (ED) diagnostic criteria among practicing clinicians has not been formally evaluated, despite the considerable diagnostic challenges these disorders present. This study evaluated inter-rater reliability between research and clinical diagnoses, identified discrepantly rated diagnostic criteria, and evaluated ED subtype use in a naturalistic treatment setting. Seventy-six adolescent and young adult female patients consecutively admitted to a residential ED program were evaluated independently by clinicians (unstructured clinical interview) and research assessors (Structured Clinical Interview for DSM-IV). Clinicians and research assessors conferred concordant ED diagnoses in 80.3% of cases (kappa=0.70), thus highlighting the clinical utility of the extant DSM-IV diagnostic scheme in this specialty ED treatment setting. All but two discordant cases included a diagnosis of ED not otherwise specified (EDNOS). Clinicians applied ED subtypes in just 20.4% of eligible cases, and were significantly more likely to apply subtypes to major depressive disorder. Although clinical and research interviews yielded substantial reliability, EDNOS had the lowest reliability among the ED diagnoses. Moreover, infrequent subtype application on this specialty unit raises questions about the clinical utility of DSM-IV anorexia nervosa and bulimia nervosa subtypes, even in the context of clinically useful overarching categories.

Persönlichkeitsstörungen bei jugendlichen Patientinnen mit Anorexia und Bulimia nervosa

Zielsetzung: Ziel der vorliegenden Untersuchung war es, das Auftreten von Persönlichkeitsstörungen bei jugendlichen Patientinnen mit Anorexia (AN) und Bulimia nervosa (BN) anhand des Strukturierten Klinischen Interviews für DSM-IV (SKID-II) zu überprüfen. Methodik: 99 konsekutiv erfasste Patientinnen (MAlter = 16.3 ± 1.6) wurden mittels SKID-II im Hinblick auf PS untersucht. Des Weiteren wurde der Einfluss von Alter, Achse-I-Komorbiditäten und Behandlungsart auf die Ausbildung einer PS getestet. Ergebnisse: 30.3 % der untersuchten Patientinnen erhielten nach SKID-II die Diagnose einer Persönlichkeitsstörung (PS). Patientinnen mit einer AN-binge-purging Typus wiesen gegenüber den beiden anderen Essstörungsgruppen eine höhere Prävalenzrate bezüglich Persönlichkeitsstörungen und ebenso höhere Werte der dimensionalen Scores auf. Zudem zeigen unsere Ergebnisse, dass Alter und Achse-I-Komorbiditäten mit der Entwicklung von Persönlichkeitsstörungen assoziiert sind. Schlussfolgerung: Zwischen den drei Essstörungsgruppen bestehen deutliche Unterschiede hinsichtlich des Auftretens von Persönlichkeitsstörungen. Patientinnen mit einer AN-binge-purging Typus sind stärker betroffen als Patientinnen mit einer BN oder restriktiven AN. Dies und ebenso der Einfluss von Alter und Achse-I-Komorbiditäten sollten bei der Therapie von Essstörungspatientinnen berücksichtigt werden.

Should non-fat-phobic anorexia nervosa be included in DSM-V?

OBJECTIVE

Cross-cultural data suggest that rationales for food refusal vary in anorexia nervosa (AN), and a variant, termed non-fat-phobic AN (NFP-AN), has been described. This review evaluates whether data support modification of the requirement for intense fear of weight gain to meet AN criterion B in DSM-V.

METHOD

We performed a systematic search of the Medline and PsychInfo literature and evaluated the relevant publications by Robins and Guze's (Am J Psychiatry 126, 983-987, 1970) criteria as a standard for diagnostic validity. We also performed a meta-analysis comparing the severity of eating pathology in AN to (a) NFP-AN and (b) AN with low drive for thinness (low-DT-AN).

RESULTS

A modest literature indicates that NFP-AN has wide geographic distribution and occurs in both Western and non-Western populations alongside cases of typical AN. Aggregating across eligible studies, patients with NFP-AN or low-DT-AN score at least 2/3 of a standard deviation lower on measures of eating pathology than patients with conventional AN. Transcultural comparison of drive for thinness suggests significantly lower norms in non-Western cultures.

DISCUSSION

NFP-AN occurs with wide distribution. Further research is necessary on the course and outcomes of NFP-AN to characterize its congruence with, or distinction from, conventional AN. We discuss several options for including a description of NFP-AN in DSM-V.

Clarifying criteria for cognitive signs and symptoms for eating disorders in DSM-V

OBJECTIVE

This article reviews literature relevant to challenges in clinical ascertainment of cognitively-based diagnostic criteria of anorexia nervosa (AN) and bulimia nervosa (BN) to examine whether revision might enhance their clinical utility.

METHOD

We performed a systematic literature search to identify publications relevant to clinical evaluation of cognitive symptoms of AN and BN.

RESULTS

The literature supports several reasons that individuals with an eating disorder may not endorse cognitive symptoms, despite their presence. These include limited insight, minimization, or denial, as well as intentional concealment related to perceived stigma, social desirability, or investment in maintaining behavioral symptoms. We also identified reasons that the word "refusal" in AN criterion A may render its application problematic.

DISCUSSION

We conclude that specific guidance for ascertainment of cognitive signs for AN and BN in the absence of patient disclosure or endorsement, longitudinal evaluation, and/or collateral data may improve clinical utility of these diagnostic criteria.

Family-based treatment of a 17-year-old twin presenting with emerging anorexia nervosa: a case study using the "Maudsley method"

This article describes the successful application of family-based treatment (FBT) for a 17-year-old identical twin presenting with a 4-month history of clinically significant symptoms of anorexia nervosa (AN). FBT is a manualized treatment that has been studied in randomized controlled trials for adolescents with AN. This case study illustrates the administration of this evidence-based intervention in a clinical setting, highlighting how the best available research was used to make clinical decisions at each stage of treatment delivery.

Aromatic amino acids in weight-recovered females with anorexia nervosa

OBJECTIVE

Most previous studies investigating amino acid levels in anorexia nervosa (AN) have focused on acutely underweight patients. The present study assessed the availability of aromatic amino acids in the plasma of weight-recovered outpatients with AN (recAN) in comparison to acutely underweight AN patients (acAN) and healthy control woman (HCW).

METHOD

Plasma tryptophan (TRP), tyrosine (TYR), and phenylalanine (PHEN) as well as leptin concentration were determined in 32 recAN, 32 acAN, and 32 HCW.

RESULTS

Both recAN and acAN patients showed significantly lower levels of TRP and PHEN when compared to HCW. TYR was reduced in acAN patients only.

DISCUSSION

Normal weight and normal leptin levels but lower availability of TRP and PHEN in recAN patients might indicate that outside a tightly controlled setting these patients still engage in abnormal eating patterns. Reduced peripheral availability of these precursor amino acids could impact on 5-HT and catecholamine functioning in the brain.

Underweight eating disorder without over-evaluation of shape and weight: Atypical anorexia nervosa?

OBJECTIVE

Underweight patients with eating disorder not otherwise specified without the over-evaluation of shape and weight (EDNOS-W) represent a diagnostic challenge. We aimed to evaluate their clinical characteristics and treatment outcome, compared with anorexia nervosa (AN) cases.

METHOD

Eighty-eight consecutive patients (81 females; age range 13-50 years, 71 AN, and 17 EDNOS-W) were studied. The differential diagnosis of AN and EDNOS-W was based on the eating disorder examination.

RESULTS

Compared with AN, EDNOS-W cases had a milder eating disorder psychopathology, but no differences in anthropometric and clinical data. The response to inpatient cognitive behavioral treatment was good and similar between groups, and no differences in the dropout rate or time-to-dropout were observed. The normalization of body weight in EDNOS-W cases was not associated with the appearance of the over-evaluation of shape and weight.

CONCLUSION

The data gives preliminary support to the proposal to include EDNOS-W in the diagnosis of AN.

Diagnosing eating disorders in adolescents: a comparison of the eating disorder examination and the development and well-being assessment

OBJECTIVE

To compare the diagnostic properties of the Eating Disorder Examination (EDE) and the online version of the Development and Well-Being Assessment (DAWBA).

METHOD

Fifty-Seven adolescents (mean age 15.7 years) who attended consecutive assessments at a specialist eating disorders clinic completed the DAWBA, the EDE, and a standard clinical assessment with a multidisciplinary team. Cohen's Kappas were used to make pairwise comparisons between the diagnoses generated by the three assessments.

RESULTS

Participants had anorexia nervosa (n = 30), eating disorders NOS (n = 21) or no eating disorder (n = 6) according to the clinical diagnosis. Agreement between the clinical and DAWBA diagnoses was moderate (kappa = 0.59), agreement between the DAWBA and EDE diagnoses was fair (kappa = 0.21), and agreement between the clinical and EDE diagnoses was poor (kappa = 0.10). The EDE did not identify an eating disorder in 20 participants (35% of the sample) who were clinically assessed as cases.

CONCLUSION

Computerized measures using multiple informants may be more suitable for assessing clinical samples of adolescents with anorexia nervosa or eating disorders NOS than individual interviews with young people.

Compulsive exercise to control shape or weight in eating disorders: prevalence, associated features, and treatment outcome

OBJECTIVE

The study was aimed at assessing the prevalence of compulsive exercising to control shape and weight in eating disorders (EDs) and its relationship with treatment outcome.

METHOD

Compulsive exercising to control shape and weight, defined according to a modified version of the Intense Exercising to Control Shape or Weight section of the Eating Disorder Examination (EDE), was assessed in 165 consecutive ED inpatients entering a protocol based on the transdiagnostic cognitive behavior theory and treatment of EDs. Baseline assessment also included anthropometry, the global EDE interview, the Beck Depression Inventory, the State-Trait Anxiety Inventory (STAI), the Eating Disorders Inventory-Perfectionism Scale, and the Temperament and Character Inventory.

RESULTS

Of the patients, 45.5% were classified as compulsive exercisers, the prevalence being highest (80%) in restricting-type anorexia nervosa (AN), lowest in EDs not otherwise specified (31.9%), and intermediate in binge/purging AN (43.3%) and in purging-type bulimia nervosa (39.3%). Compulsive exercising to control shape and weight was independently predicted by the EDE restraint score (odds ratio, 1.32; 95% confidence interval, 1.06-1.64; P = .014) after adjustment for ED; the total amount of exercise was associated with EDE restraint, as well as with the Temperament and Character Inventory reward dependence. At follow-up, an improved EDE global score was predicted by lower baseline values, higher baseline STAI and STAI improvement, and lower amount of exercise in the last 4 weeks. Voluntary treatment discontinuation was not predicted by baseline exercise.

DISCUSSION

Compulsive exercising to control shape and weight is a behavioral feature of restricting-type AN, associated with restraint and temperament dimensions, with influence on treatment outcome.

Amenorrhea as a diagnostic criterion for anorexia nervosa: a review of the evidence and implications for practice

Amenorrhea is currently a criterion in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text rev. [DSM-IV-TR]) for the diagnosis of anorexia nervosa (AN). Recently, there has been increased interest in examining the utility of this criterion. This article reviews the historical rationale for inclusion of amenorrhea in the DSM criteria for AN, clinical evidence evaluating amenorrhea as a diagnostic criterion for AN, and the nursing practice implications of amenorrhea as a diagnostic criterion for AN. Data suggest there is limited support for amenorrhea as a diagnostic criterion for AN. J Am Psychiatr Nurses Assoc, 2008; 14(3), 209-215. DOI: 10.1177/1078390308320288.

Eating disorder not otherwise specified in adolescents

OBJECTIVE

To examine the frequency, type, and clinical severity of eating disorder not otherwise specified (EDNOS) in adolescents seeking treatment through an outpatient eating disorders service.

METHOD

Two hundred eighty-one consecutive referrals to an eating disorders program were assessed using the Eating Disorder Examination (EDE) and self-report measures of depression and self-esteem.

RESULTS

The majority of adolescents presented with EDNOS (59.1%; n = 166) relative to anorexia nervosa (AN; 20.3%; n = 57) and bulimia nervosa (BN; 20.6%; n = 58). Most EDNOS youths could be described as subthreshold AN (SAN; 27.7%; n = 46), subthreshold BN (SBN; 19.9%; n = 33), EDNOS purging (27.7%; n = 46), or EDNOS bingeing (6.0%; n = 10); yet 31 (18.7%) could not be categorized as such (EDNOS "other"). Overall differences in eating disorder pathology, depressive symptoms, and self-esteem emerged between the EDNOS types, wherein adolescents with EDNOS bulimic variants (SBN, EDNOS purging, and EDNOS bingeing) had more pathology than youths with SAN or EDNOS "other." There were no differences in these variables between AN and SAN; in contrast, compared with BN, youths with EDNOS bulimic variants reported lower EDE scores and higher self-esteem, although there were no between-group differences in depression.

CONCLUSIONS

As in adults with eating disorders, EDNOS predominates and is heterogeneous with regard to eating disorder pathology and associated features in an adolescent clinical sample. Lack of differences between AN and SAN suggests that the strict criteria for AN could be relaxed; differences between BN and EDNOS bulimic variants do not support their combination.

Linguistic analyses of natural written language: unobtrusive assessment of cognitive style in eating disorders

OBJECTIVE

Linguistic style analysis is introduced as a method of nonreactive measurement of cognitive style in individuals with eating disorders (ED).

METHOD

A journaling exercise was implemented on an ED inpatient unit. Thirty-four written essays collected from an unselected sample of 11 patients were analysed with the Linguistic Inquiry and Word Count, with regard to predefined text categories. At each session, self-report of participant well-being and session impact were assessed.

RESULTS

Compared to essays from a student control group, and message-board entries of individuals who had recovered from an anorexia nervosa (AN), the inpatient journals displayed the highest rates of self-related words, negative emotion words, and the lowest rate of positive emotion words. Inpatients used more anxiety words and fewer words that refer to social processes and eating concerns than individuals who had recovered from an AN. Associations were found between linguistic categories, prewriting well-being, and postwriting evaluation.

CONCLUSION

Linguistic style analysis offers insights into cognitive styles, and provides a promising approach for their unobtrusive measurement in ED.

Weight overestimation as an indicator of disordered eating behaviors among young women in the United States

OBJECTIVE

This paper examines the association between weight overestimation and symptoms of disordered eating behaviors using a nationally representative sample of young women.

METHOD

We use data from Wave III of the National Longitudinal Study of Adolescent Health to compare self-reported weight (in pounds) to measure weight obtained by interviewers using a scale. Focusing on normal weight women between the ages of 18 and 24 (n = 2,805) we compare the discrepancy in self-reported and measured weight among women with and without any disordered eating behaviors.

RESULTS

Women who over report their weight by at least five percent are significantly more likely than those who either under report or accurately report their weights to exhibit disordered eating behaviors. These results persist despite controlling for distorted body image.

CONCLUSION

Our findings support both motivational and perceptual bias explanations for overestimating weight among those who exhibit disordered eating behaviors. We argue that weight over-estimation, together with other important information regarding women's nutrition, exercise, mental health, and health-related behaviors, should be treated as a potential indicator for the diagnosis of an eating disorder among young normal weight women.

The addition of a parent and clinician component to the eating disorder examination for children and adolescents

OBJECTIVE

Our goal was to evaluate the addition of parent and clinician reports to the eating disorder examination (EDE) when used with children and adolescents.

METHOD

The EDE was completed with 117 children and adolescents with eating disorders (mean age 14.95 +/- 1.91 years). A slightly modified version of the EDE was completed with parents, and clinician summary scores were assigned. Repeated measures analysis was used to compare child, parent, and clinician scores.

RESULTS

In those 70 participants with anorexia nervosa (AN) or eating disorder not otherwise specified with a restrictive pattern (EDNOS-R), child scores were significantly lower than parent scores and clinician scores on restraint and weight concerns. On eating concerns and shape concerns, child scores were lower than clinician scores. Participants with bulimia nervosa (BN) or eating disorder not otherwise specified with binge eating or purging (EDNOS-BP), reported more restraint and shape concerns than parents (n = 47), but their scores did not differ from clinician ratings. No differences were seen in this group on weight concerns or eating concerns.

CONCLUSION

Parent and clinician reports are particularly important when assessing children and adolescents with AN or EDNOS-R, but may be less critical for those with BN or EDNOS-BP.

Open trial of family-based treatment for full and partial anorexia nervosa in adolescence: evidence of successful dissemination

OBJECTIVE

There is a paucity of evidence-based interventions for anorexia nervosa (AN). An innovative family-based treatment (FBT), developed at the Maudsley Hospital and recently put in manual form, has shown great promise for adolescents with AN. Unlike traditional treatment approaches, which promote sustained autonomy around food, FBT temporarily places the parents in charge of weight restoration. This aim of this open trial was to investigate the feasibility and effectiveness of delivering FBT at a site beyond the treatment's origin and manualization.

METHOD

Twenty adolescents (ages 12-17) with AN or subthreshold AN were treated with up to 1 year of FBT using the published treatment manual. Outcome indices included the percentage of ideal body weight, menstrual status, the Eating Disorder Examination (EDE) subscales scores, and the Children's Depression Rating Scale-Revised score.

RESULTS

Of the 20 patients recruited, 15 (75%) completed a full course of treatment. Intent-to-treat analyses showed significant improvement over time in the percentage of ideal body weight (t = -4.46, p =.000), menstrual status (p =.002), EDE Restraint (z = -3.02, p =.003), EDE Eating Concern (z = -2.10, p =.04), but not in EDE Shape Concern or Weight Concern subscales or Children's Depression Rating Scale-Revised score.

CONCLUSIONS

This open trial provides evidence that FBT can be successfully disseminated, replicating the high retention rates and significant improvement in the psychopathology of adolescent AN seen at the original sites.

Control and disordered eating in type 1 diabetes

Control is a major topic associated with the management of diabetes due to the importance placed on maintaining healthy blood glucose levels in this condition. Such an outcome can be influenced by individuals' sense of mastery over the disease, and more generally over their environment. In response to a diagnosis of diabetes, the self-management requirements accompanying it, and/or difficulties in other areas of life, patients may decide to undertake behaviours that are detrimental to their well-being. For instance, they may adopt fixated attitudes towards their intake and weight. This paper explores the relationship between disordered eating habits, control and diabetes in those who are insulin dependent.

Anorexia nervosa in Asian-American adolescents: do they differ from their non-Asian peers

OBJECTIVE

This study reports on the clinical characteristics and phenomenology of anorexia nervosa (AN) in Asian-American adolescents, and compares them with a non-Asian sample.

METHOD

Data were obtained from a family therapy trial for adolescents with AN. Demographic details were collected and participants assessed on a series of structured interviews. Data from Asian participants were compared with that from non-Asians.

RESULTS

Asians scored lower on all the Eating Disorder Examination (EDE) subscales, significantly on the restraint subscale (1.48 vs. 2.80, p = 0.016) and weight concerns subscale (1.35 vs. 2.30, p = 0.026). They also scored higher on the Family Environment Scale achievement orientation subscale (6.50 vs. 4.81, p = 0.011).

CONCLUSION

Asians are demographically similar to their non-Asian peers but tend to come from higher-income families who were more achievement oriented. EDE scores suggest Asians tend to report fewer symptoms. The apparent lack of fat-phobia among Asians could be related to this overall under-reporting of symptoms.

Early identification and treatment of eating disorders: prodrome to syndrome

The onset of eating disorder psychopathology is most common in the adolescent age group. Acute psychopathology or subsyndromal eating disorders are perhaps less intractable in these young patients. Subsyndromal eating disorders in children and adolescents are not only clinically significant in their present state, but may represent legitimate candidates for preventive efforts in light of: (i) a risk of progression from subthreshold anorexia nervosa (SAN) to AN or subthreshold bulimia nervosa (SBN) to BN; (ii) the detrimental effects on outcome of delaying treatment; and (iii) the refractory, severe nature of eating disorders once the diagnostic threshold is crossed. Moreover, children and adolescents with SAN and SBN may in fact be exhibiting early 'caseness' of these disorders. Given that AN is notoriously difficult to treat, and there are limited efficacy data for adolescent BN, attempts to disrupt these disorders in what is arguably their early phases is an important goal in preventing more chronic and treatment-resistant forms of these disorders. Future research should address whether the best interventions for SAN and SBN should be derived from the prevention or intervention fields.

Effect of response format on endorsement of eating disordered attitudes and behaviors

OBJECTIVE

The present study was designed to compare response rates on a standard self-report questionnaire that was nominally anonymous to an unmatched count questionnaire that allowed for true anonymity in responding.

METHOD

Four hundred and fifty-four college students were asked about several topics, including attitudes towards weight and shape, dieting, and eating disordered behavior using one of two response formats; either a standard questionnaire in true-false format or an unmatched count questionnaire that did not require participants to directly answer sensitive questions.

RESULTS

Both males and females had significantly different rates of endorsement between the two methods of assessment on the majority of the eating-related questions.

CONCLUSION

Response format and degree of anonymity affect endorsement of eating-related thoughts and behaviors. Understanding response bias is critical to determining accurate rates of eating disordered thoughts and behaviors.

Role of therapeutic alliance in family therapy for adolescent anorexia nervosa

OBJECTIVE

The purpose of this study is to examine the role of therapeutic alliance in predicting treatment dropout, response and outcome in a cohort of adolescents with anorexia nervosa (AN) and their families who were treated using a manualized form of family-based therapy (FBT).

METHOD

Independent assessors scored early and late therapeutic alliances for patients and parents using the Working Alliance Inventory-Observer (WAIo). Outcomes were weights and scores on the subscales of the Eating Disorder Examination at the end of 12 months of FBT.

RESULTS

Therapeutic alliance throughout treatment was strong both for adolescents and for their parents. A strong early alliance with adolescents was associated with early treatment response in terms of weight gain. A strong early alliance with parents prevented dropout, whereas a strong late parental alliance predicted their child's total weight gain at the end of treatment.

CONCLUSION

Therapeutic alliance in both patients and parents treated with FBT is generally strong and likely contributes to treatment retention and treatment outcome.