Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions

Mixture Modeling to Characterize Anorexia Nervosa: Integrating Personality and Eating Disorder Psychopathology

BACKGROUND: Efforts to examine alternative classifications (e.g., personality) of anorexia nervosa (AN) using empirical techniques are crucial to elucidate diverse symptom presentations, personality traits, and psychiatric comorbidities. AIMS: The purpose of this study was to use an empirical approach (mixture modeling) to test an alternative classification of AN as categorical, dimensional, or hybrid categorical-dimensional construct based on the co-occurrence of personality psychopathology and eating disorder clinical presentation. METHODS: Patients with AN (N = 194) completed interviews and questionnaires at treatment admission and 3-month follow-up. Mixture modeling was used to test whether indicators best classified AN as categorical, dimensional, or hybrid. RESULTS: A four-latent class, one-latent dimension mixture model that was variant across groups provided the best fit to the data. Results suggest that all classes were characterized by low self-esteem and self-harming and suicidality tendencies. Individuals assigned to Latent Class 2 (LC2; n = 21) had a greater tendency toward being impulsive and easily angered and having difficulties controlling anger compared with those in LC1 (n = 84) and LC3 (n = 66). Moreover, individuals assigned to LC1 and LC3 were more likely to have a poor outcome from intensive treatment compared with those in LC4 (n = 21). Findings indicate that the dimensional aspect within each class measured frequency of specific eating disorder behaviors but did not predict treatment outcomes. CONCLUSIONS: These results emphasize the complexity of AN and the importance of considering how facets of clinical presentation beyond eating disorder behaviors may have different treatment and prognostic implications.

Increased cognitive flexibility mediates the improvement of eating disorders symptoms, depressive symptoms and level of daily life functioning in patients with anorexia nervosa treated in specialised centres

OBJECTIVE

Poor cognitive flexibility has been highlighted in patients with anorexia nervosa (AN), contributing to the development and maintenance of symptoms. The aim of the present study is to investigate how enhanced cognitive flexibility is involved in treatment outcomes in patients with AN.

METHOD

One hundred thirty female out-patients treated for AN have been assessed at baseline and after 4 months of treatment. Path analyses were used to investigate the mediating role of cognitive flexibility, measured through the Brixton test, on a wide range of outcomes: body mass index, eating disorder symptoms, daily life functioning, anxiety, depression, emotions, self-rated silhouette.

RESULTS

Cognitive flexibility was improved during treatment, and enhanced cognitive flexibility explains a significant part of level of the improvement in daily life functioning (26%), reduction of eating disorder symptoms (18%) and reduction of depressive symptoms (17%). Others outcomes were also improved, but these improvements were not mediated by cognitive flexibility.

CONCLUSIONS

Results suggest that enhancing cognitive flexibility could help reduce rigid cognitive and behavioural patterns involved in AN, thus improving everyday functioning and clinical severity. Further studies combining different types of cognitive flexibility evaluation as well as neuroimaging may be necessary to better establish which of its aspects are involved in patients' improvement.

Last word: a call to view temperamental traits as dual vulnerabilities and strengths in anorexia nervosa

Research suggests that individuals with anorexia nervosa (AN) have certain temperamental traits (e.g. perfectionism, anxiety, harm avoidance), which often onset prior to the eating disorder (ED), and may persist following recovery. Although these traits are often represented as vulnerabilities to developing an ED, there is reason to believe that within certain contexts, these traits may serve as assets. We propose that traits can be harnessed within or outside of treatment to promote long-term success, and possibly relate to recovery. To do so, the current paper will: (1) outline literature on traits viewed as strengths; (2) review precedents for strengths-based interventions drawing from other areas of research; (3) propose a framework for future research to assess these strengths in AN; and (4) discuss the implications of the proposed research for the destigmatization of EDs. This last word calls for a shift to a dual consideration of traits as vulnerabilities and strengths.

Autonomic Nervous System Response to Psychosocial Stress in Anorexia Nervosa: A Cross-Sectional and Controlled Study

To foster understanding in the psychopathology of patients with anorexia nervosa (P_AN) at the psychological and physiological level, standardized experimental studies on reliable biomarkers are needed, especially due to the lack of disorder-specific samples. To this end, the autonomic nervous system (ANS) response to a psychosocial stressor was investigated in n = 19 P_AN (BMI: 18.7 ± 3.3 kg/m²), age, and gender-matched to n = 19 healthy controls (HC; BMI: 24.23 ± 3.0 kg/m²). For this purpose, heart rate (HR) and heart rate variability (HRV) parameters were assessed in a cross-sectional study design under two experimental conditions: (1) rest and (2) stress (Trier Social Stress Test). In addition, psychological indicators of stress were assessed. An 2 × 2 × 8 ANOVA demonstrated similar HR and HRV patterns (except LF-HRV) between P_AN and HC at rest. Under stress, P_AN (vs. HC) demonstrated a blunted HR [condition^*time^*group: F_{(2.91, 104.98)} = 9.326, p = 0.000, η² = 0.206] and an attenuated HRV response (reduced SNS/PNS reactivity). Significant effects of stress appraisal (SA) and BMI on HRV-reactivity were revealed. SA on SDNN = Condition^*time^*SA = F_{(4.12, 140.15)} = 2.676, p = 0.033, η² = 0.073. BMI on LF/HF-Ratio = Condition^*time^*BMI = F_{(3.53, 60.16)} = 3.339, p = 0.019, η² = 0.164. Psychological indices suggested higher levels of chronic and appraised stress in P_AN relative to HC. Additional analyses demonstrated that ED-symptoms are highly correlated with the latter constructs, as well as with psychological burden, but not with weight. Further, it was shown that abnormalities in reactivity persisted despite normalized ANS activity. Overall, we suggested that besides weight recovery, improvement in stress appraisal could be beneficial for cardiac health. In this light, a combination of therapy (e.g., development and activation of coping skills, cognitive reappraisal) and biofeedback training may improve treatment outcomes and regulate stress reactivity.

Sharing and connecting with others - patient experiences of radically open dialectical behavior therapy for anorexia nervosa and overcontrol: a qualitative study

BACKGROUND

Recovery rates after psychological treatments for anorexia nervosa are low to moderate, and in adults, no treatment outperforms any other. The aim of this study was to evaluate patient experiences of Radically open dialectical behavior therapy (RO DBT), a treatment developed for disorders related to maladaptive overcontrol.

METHODS

Eleven female patients with anorexia nervosa were interviewed after either treatment completion (eight patients) or drop-out (three patients) from RO DBT. Interviews were transcribed and analyzed with inductive thematic analysis.

RESULTS

The analysis yielded five main themes: 1) a comprehensive treatment, 2) the benefits of sharing and connecting with others, 3) growing trust, 4) moving toward valued goals - but some remain, and 5) doing well in treatment.

CONCLUSION

Patients appreciated what they described as a comprehensive treatment and holistic view of their problems, which helped them reduce both maladaptive overcontrol and eating disorder symptoms. Gradually sharing personal experiences both in- and outside therapy was described as essential and led to enhanced social connectedness.

TRIAL REGISTRATION

The intervention study (Isaksson M, et al. J Behav Ther Exp Psychiatry. 71, 2021) that preceded this interview study was performed by the first, second, third, and fifth author, preregistered in the ISRCTN registry (no: ISRCTN47156042 ).

Implementation of a positive psychology group program in an inpatient eating disorders service: a pilot study

CONTEXT

Eating disorders (ED) are very difficult conditions to treat. Therefore, interventions in this field are shifting their main target towards the disorder's impact in quality of life, rather than ED symptomatology in itself. In this sense, a focus in the promotion of positive emotions and well-being is emerging to ameliorate the harmful effects caused by ED. However, evidence of the potential benefits of this type of interventions is still scarce.

PURPOSE

This study introduces a 4-week positive psychology group program specifically designed for ED patients' needs and to present data about feasibility and acceptability.

METHOD

Seven female inpatients of an eating disorder service aged from 13 to 38 years old attended the group. Measures of affect and optimistic thinking were taken before the program and after each session.

RESULTS

The program was very well rated by participants, and there was no attrition. Furthermore, possible benefits were found in terms of optimistic thinking at the end of the group program, and these benefits were noticeable, but non-significant, in the case of affect.

CONCLUSIONS

This study opens the door to conduct larger and controlled studies for testing interventions aimed at promoting positive emotions and well-being in ED populations. Thus, these interventions could support the efficacy of current treatments in order to improve patients' quality of life.

LEVEL OF EVIDENCE

Level IV, multiple time series analysis, with the intervention.

Effectiveness of treatment for adolescents and adults with anorexia nervosa in a routine residential setting

Residential treatment is a necessary element of treatment in some cases of anorexia nervosa, where it is used prior to transitioning to complete the treatment in a less intensive setting. This study tests how effective residential treatment is at helping adolescent and adult patients to reduce their eating pathology to levels that can be managed in outpatient settings. Ninety-eight patients with anorexia nervosa started treatment in a routine residential setting (83 completers). The adolescent and adult groups showed comparable levels of benefit, showing gains in weight and reductions in eating pathology, compatible with transitioning to less intensive treatment. Change was particularly substantial over the first 6 weeks. This effectiveness study has shown that an appropriate period of residential treatment can be used to prepare patients to be able to benefit from a less intensive treatment, regardless of age group.

Lifetime Weight Characteristics of Adult Inpatients With Severe Anorexia Nervosa: Maximal Lifetime BMI Predicts Treatment Outcome

Background: The body mass index is a key predictor of treatment outcome in patients with anorexia nervosa. In adolescents, higher premorbid BMI is a strong predictor of a favorable treatment outcome. It is unclear whether this relationship holds true for adults with anorexia nervosa. Here, we examine adult patients with AN and investigate the lowest and highest lifetime BMI and weight suppression as predisposing factors for treatment outcome. Methods: We included 107 patients aged 17-56 with anorexia nervosa and tracked their BMI from admission to inpatient treatment, through discharge, to follow-up at 1-6 years. Illness history, including lowest and highest lifetime BMI were assessed prior to admission. We used multiple linear regression models with minimal or maximal lifetime BMI or weight suppression at admission as independent variables to predict BMI at admission, discharge and follow-up, while controlling for patients' age, sex, and duration of illness. Results: Low minimal BMI had a negative influence on the weight at admission, which in turn resulted in a lower BMI at discharge. Higher maximal BMI had a substantial positive influence on BMI at discharge and follow-up. Weight suppression was highly correlated with maximal BMI and showed similar effects to maximal BMI. Conclusion: Our findings strongly support a relationship between low minimal lifetime BMI and lower BMI at admission, and between higher maximal lifetime BMI or weight suppression and a positive treatment outcome, even years after discharge. Overall, maximal BMI emerged as the most important factor in predicting the weight course in adults with AN.

The relationship between premorbid intelligence and symptoms of severe anorexia nervosa restricting type

The purposes of this study were as follows: to compare premorbid IQ with present IQ in patients with more severe anorexia nervosa restricting type (AN-R) and to investigate the relationship between decreasing IQ and symptoms in patients with severe AN-R. Twenty-two participants were recruited (12 were AN-R patients; 10 were healthy controls). The average BMI in AN-R patients and healthy controls was 12.65 and 19.82, respectively. We assessed the outcomes using the Wechsler Adult Intelligence Scale-Third Edition (WAIS-III), the Japanese Adult Reading Test, The Eating Disorders Inventory-2 (EDI-2), Beck Depression Scale-2 (BDI-2) and State-Trait Anxiety Index. In two-way ANOVA, there were significant interactions for the FIQ and PIQ. Only in the AN-R group, a significant single main effect of time was evidenced for the FIQ and PIQ. In the AN-R group, a significantly high positive correlation was found between changes in the PIQ and the body dissatisfaction subscale of the EDI-2. These findings raise the possibility that in patients with severe AN-R, an excessive decrease in body weight induces decreased PIQ; as a result, they have worse dissatisfaction with their body shape.

Current Therapeutic Approaches to Anorexia Nervosa: State of the Art

Anorexia nervosa (AN) is a devastating psychiatric disorder characterized by extreme restriction of food intake and low body weight, both associated with significant medical and psychological morbidity. The clinical severity of AN has prompted the consideration and study of behavioral and pharmacological treatments in efforts to establish empirically based methods to reduce the burden of the disorder. Among adolescents, family-based treatment is considered a first-line behavioral treatment. Research continues to explore the efficacy of family-based treatment and predictors of treatment response to further improve outcomes. Several behavioral treatments for adults also exist, including cognitive-behavioral therapy, exposure and response prevention, third-wave acceptance-based treatments, and supportive psychotherapy, all of which help to improve symptoms and promote modest weight gain. Despite this, no one treatment is considered superior, and all existing behavioral approaches leave a proportion of adults symptomatic or at a high risk of relapse. As such, among adults, there is continued need for development of novel, mechanism-based approaches to better target the core symptoms of AN. Although antidepressants impart little benefit on weight or symptoms, the second-generation antipsychotic olanzapine has shown ability to promote modest weight gain in outpatients with AN. Most recently, the field's evolving conceptualization of AN as a biologically based disorder coupled with technological advancements has led to consideration of varying neuromodulation strategies as a potential therapeutic approach that remains under investigation.

Psychotropic medication use in treatment-seeking youth with eating disorders

OBJECTIVE

Psychotropic medication use in youth with eating disorders (EDs) is poorly understood despite high co-occurrence of psychiatric disorders. This study examined characteristics associated with medication use in treatment-seeking youth with EDs.

METHOD

Youth up to age 18 reported on medication use when presenting to an academic medical center outpatient ED service in the United States. Data presented were collected between 1998-2015.

RESULTS

The sample (N = 604) was predominantly female (90.6%) with a mean age of 15.3 years (SD = 2.3). Approximately one-third (30%, n = 173) were taking psychotropic medications (40%, n = 70, were taking multiple medications). Antidepressant use was most common (26%, n = 152), followed by atypical antipsychotics (8%, n = 43). Adjusting for co-occurring psychiatric disorders, non-Hispanic Whites who had received prior treatment (psychotherapy, hospitalization) were significantly more likely to be using medication. Longer illness duration and prior treatment were associated with greater antidepressant use. For atypical antipsychotics, prior hospitalization was associated with greater use.

CONCLUSIONS

Findings confirm moderate psychotropic medication use among young patients with EDs despite a lack of clarity regarding optimally effective pharmacologic interventions in this population. Pharmacological trials examining the efficacy of medications for young patients with EDs are warranted to inform future prescribing practice.

Treating Eating: A Dynamical Systems Model of Eating Disorders

Mainstream forms of psychiatric talk therapy and cognitive behavioral therapy (CBT) do not reliably generate lasting recovery for eating disorders. We discuss widespread assumptions regarding the nature of eating disorders as fundamentally psychological disorders and highlight the problems that underlie these notions, as well as related practical problems in the implementation of mainstream treatments. We then offer a theoretical and practical alternative: a dynamical systems model of eating disorders in which behavioral interventions are foregrounded as powerful mediators between psychological and physical states. We go on to present empirical evidence for behavioral modification specifically of eating speed in the treatment of eating disorders, and a hypothesis accounting for the etiology and progression, as well as the effective treatment, of the full spectrum of eating problems. A dynamical systems approach mandates that in any dietary and lifestyle change as profound as recovery from an eating disorder, acknowledgment must be made of the full range of pragmatic (psychological, cultural, social, etc.) factors involved. However, normalizing eating speed may be necessary if not sufficient for the development of a reliable treatment for the full spectrum of eating disorders, in its role as a mediator in the complex feedback loops that connect the biology and the psychology with the behaviors of eating.

Molecular neuroanatomy of anorexia nervosa

Anorexia nervosa is a complex eating disorder with genetic, metabolic, and psychosocial underpinnings. Using genome-wide methods, recent studies have associated many genes with the disorder. We characterized these genes by projecting them into reference transcriptomic atlases of the prenatal and adult human brain to determine where these genes are expressed in fine detail. We found that genes from an induced stem cell study of anorexia nervosa cases are expressed at higher levels in the lateral parabrachial nucleus. Although weaker, expression enrichment of the adult lateral parabrachial is also found with genes from independent genetic studies. Candidate causal genes from the largest genetic study of anorexia nervosa to date were enriched for expression in the arcuate nucleus of the hypothalamus. We also found an enrichment of anorexia nervosa associated genes in the adult and fetal raphe and ventral tegmental areas. Motivated by enrichment of these feeding circuits, we tested if these genes respond to fasting in mice hypothalami, which highlighted the differential expression of Rps26 and Dalrd3. This work improves our understanding of the neurobiology of anorexia nervosa by suggesting disturbances in subcortical appetitive circuits.

Eating disorders, embodiment, and yoga: a conceptual overview

Yoga and its relation to embodiment and disordered eating has only recently received research attention. Nevertheless, early research indicates that yoga is an effective tool in the prevention and treatment of eating disorders. It is assumed that yoga ameliorates eating disorder symptoms and facilitates a shift from negative towards positive body image and well-being by cultivating positive embodiment (i.e., the ability to feel a sense of connection between mind and body). In order to provide the context of the constructs of disordered eating, embodiment, and yoga, this article presents a brief overview and conceptualization of these constructs. The three major eating disorders and current treatment methods are described. Further, the philosophical roots and theoretical models of embodiment are delineated and their communal core features are outlined. Lastly, the origin, basic principles, and modern interpretations of yoga are discussed.

Mental health dished up-the use of iPSC models in neuropsychiatric research

Genetic and molecular mechanisms that play a causal role in mental illnesses are challenging to elucidate, particularly as there is a lack of relevant in vitro and in vivo models. However, the advent of induced pluripotent stem cell (iPSC) technology has provided researchers with a novel toolbox. We conducted a systematic review using the PRISMA statement. A PubMed and Web of Science online search was performed (studies published between 2006–2020) using the following search strategy: hiPSC OR iPSC OR iPS OR stem cells AND schizophrenia disorder OR personality disorder OR antisocial personality disorder OR psychopathy OR bipolar disorder OR major depressive disorder OR obsessive compulsive disorder OR anxiety disorder OR substance use disorder OR alcohol use disorder OR nicotine use disorder OR opioid use disorder OR eating disorder OR anorexia nervosa OR attention-deficit/hyperactivity disorder OR gaming disorder. Using the above search criteria, a total of 3515 studies were found. After screening, a final total of 56 studies were deemed eligible for inclusion in our study. Using iPSC technology, psychiatric disease can be studied in the context of a patient’s own unique genetic background. This has allowed great strides to be made into uncovering the etiology of psychiatric disease, as well as providing a unique paradigm for drug testing. However, there is a lack of data for certain psychiatric disorders and several limitations to present iPSC-based studies, leading us to discuss how this field may progress in the next years to increase its utility in the battle to understand psychiatric disease.

Is it time to review NICE guidelines on family therapy for anorexia in young people?

Family therapy is recommended by the National Institute for Health and Care Excellence (NICE) for the management of anorexia nervosa in children and young people, but there is limited evidence to back this recommendation. The Cochrane Review under consideration evaluates the efficacy of different family therapy approaches compared with other treatments for anorexia nervosa, and this commentary puts the findings into clinical perspective.

The Explanation of Eating Disorders: A Critical Analysis

Eating disorders (EDs) are one of the most severe and complex mental health problems facing researchers and clinicians today. The effective prevention and treatment of these conditions is therefore of paramount importance. However, at present our treatments fall short: generally demonstrating only poor to moderate efficacy, and often completely ineffective for severe or chronic cases. A possible reason for this is that the current theories underlying these treatments are flawed. In this paper, we review and evaluate several prominent theoretical explanations associated with current frontline and promising treatments for ED. In doing so, we identify fundamental problems within the construction of current ED explanations and their implications for treatment. In response to these findings, we propose several strategies for the construction of future ED explanations which we believe have the power to ameliorate these problems and potentially help to develop more efficacious treatment downstream.

Combining day treatment and outpatient treatment for eating disorders: findings from a naturalistic setting

BACKGROUND

Day treatment programs for individuals with eating disorders (ED) have been the subject of research and are promoted as an alternative to inpatient treatment due to their therapeutic and economic advantages, but have not regularly been implemented in regular care.

PURPOSE

We investigated the long-term effectiveness of a transdiagnostic combined eating disorder treatment program which consisted of an 8-week day treatment phase followed by an average of 19 sessions of outpatient treatment over an average of 39 weeks in a naturalistic setting.

METHODS

We accepted 148 patients with different diagnoses of eating disorders into our combined treatment program. We assessed weight, behavioral eating disorder symptoms and eating disorder related cognitions and attitudes at the beginning and the end of the day treatment phase and after 6, 12 and 26 months.

RESULTS

Over the course of the 8-week day treatment phase, patients with initial binge eating, purging and/or fasting behavior reduced these symptoms by 91%, 90% and, 86%. Patients who were underweight at baseline gained on average 1.05 BMI points (d = 0.76). In addition, eating disorder related cognitions and attitudes of all patients significantly improved with large effect sizes (d = 1.12). On average, all improvements remained stable during the follow-up period.

CONCLUSIONS

Our findings add to the existing studies on day treatment and support previously found encouraging effects of treatment programs that combine day treatment and consecutive outpatient treatment for eating disorders.

LEVEL OF EVIDENCE

Level III, longitudinal cohort study.

Development and validation of a progress monitoring tool tailored for use in intensive eating disorder treatment

OBJECTIVE

Despite calls for routine use of progress and outcome monitoring in private and intensive treatment centres for eating disorders (EDs), existing measures have limited relevance to these supervised treatment settings. This study sought to develop and validate the progress monitoring tool for eating disorders, a multidimensional measure for progress monitoring in the context of intensive ED treatment.

METHOD

Thirty-seven items were generated by a team of content experts, clinicians, and administrative staff from the target treatment setting. Adolescent and adult females (N = 531) seeking residential ED treatment completed the items at admission as part of the clinic's routine assessment battery; 83% were retained for repeat assessment at discharge. Exploratory factor analysis was conducted for preliminary measure development.

RESULTS

Results yielded a five-factor, 26-item structure explaining 50% of total variance. Final construct domains included weight and shape concern, ED behaviours and urges, emotion avoidance, adaptive coping, and relational connection. The measure demonstrated adequate internal consistency, sensitivity to change during treatment, and convergence with validated assessment measures.

CONCLUSIONS

Preliminary data support the progress monitoring tool for eating disorders as a novel and valid multidimensional measure of treatment-relevant constructs. This measure may have utility in measuring treatment progress for patients receiving intensive treatment for EDs.

Deep brain stimulation of the nucleus accumbens for treatment-refractory anorexia nervosa: A long-term follow-up study

BACKGROUND

Given that anorexia nervosa (AN) is a life-threatening mental disorder and has poor clinical outcomes, novel effective treatments are warranted, especially for severe and persistent cases.

OBJECTIVE

To investigate the safety, feasibility, and clinical outcomes of using deep brain stimulation (DBS) of the nucleus accumbens (NAcc) in treatment-refractory AN patients.

METHODS

A total of 28 women with refractory AN underwent NAcc-DBS and completed this 2-year follow-up study. The clinical outcomes, including body mass index (BMI) and mood, anxiety, and obsessive symptoms, were assessed using a series of psychiatric scales at 6 and 24 months post operation.

RESULTS

While no fatalities were reported during this study, 1 patient showed device rejection. The most common short-term side effect observed was varying degrees of pain at the incision sites (n = 22), which usually disappeared 3-4 days following the operation. No severe surgical adverse events were observed. Compared to presurgical levels, significant increases in BMI and improvement in psychiatric scale scores were noted during the 6-month follow-up and were maintained at the 2-year review. Finally, a post-hoc analysis revealed that the NAcc-DBS was less effective for weight restoration in patients with the binge-eating/purge subtype of AN than in those with the restricting subtype (R-AN).

CONCLUSION

Our long-term follow-up study suggests that NAcc-DBS is safe and effective for improving the BMI and psychiatric symptoms of patients with refractory AN. Although NAcc-DBS appears to be more suitable for patients with R-AN, strict inclusion criteria must be applied considering surgery-related complications.

Radically Open Dialectical Behavior Therapy: Social Signaling, Transdiagnostic Utility and Current Evidence

At the core of an overcontrolled personality and coping style is a tendency to have too much self-control, exhibiting as behavioral and cognitive inflexibility, high inhibition of emotion, high detail-focused processing and perfectionism, and a lack of social connectedness. Overcontrol underlies a wide variety of psychiatric illnesses and as such, an innovative transdiagnostic therapy called Radically Open Dialectical Behavior Therapy (RO DBT) has been developed to treat disorders characterized by overcontrol. RO DBT targets maladaptive social signaling in order to help individuals "rejoin the tribe," hypothesizing that increasing social connectedness by means of targeting social signaling is the central mechanism of change in treatment. Because RO DBT is used for individuals with an overcontrolled personality style, rather than individual disordered symptoms, it can be used transdiagnostically across a range of comorbid disorders, including treatment-resistant depression and anxiety, anorexia nervosa, and personality disorders such as obsessive-compulsive personality disorder. The current article introduces this novel treatment approach and discusses its emphasis on social signaling and its transdiagnostic nature. We then provide the first review of existing literature testing the efficacy of RO DBT across clinical populations, discuss issues related to assessment of overcontrol, and speculate on future directions for this novel therapy.

Registration, reporting, and replication in clinical trials: The case of anorexia nervosa

OBJECTIVE

Treatment outcomes for anorexia nervosa (AN) remain modest, and recent research suggests that clinical trials may be of limited methodological quality. With increasing evidence illustrating the irreproducibility of psychological research, no research to date has systematically examined the cumulative effect of bias in research relating to the treatment of AN.

METHOD

We identified all AN trials listed on ClinicalTrials.gov between 2000 and 2018 and examined rates of (a) the noncompletion of clinical trials, the (b) nonpublication of trials once listed as completed, (c) the nonprospective registration of clinical trials, and (d) the nonreplication of findings.

RESULTS

We note that of 201 trials listed on ClinicalTrials.gov, only 101 have been completed, and of those, only 41 have been published. Moreover, of these 41 published trials, only eight demonstrated evidence of prospective trial registration, and only seven have had their primary findings replicated in other studies.

DISCUSSION

These results illustrate the profound cumulative effect of methodological bias in registered trials for AN, which may have a significant impact both on what appears in the current evidence base, and on the reproducibility of studies comprising this evidence base.

Eating Disorders on College Campuses in the United States: Current Insight on Screening, Prevention, and Treatment

BACKGROUND

Eating disorders are prevalent on college campuses and pose significant risks to student health, well-being, and academic performance. However, few students receive access to evidence-based prevention and treatment.

OBJECTIVE

The present review synthesizes the recent literature on ED screening, prevention, and treatment approaches on college campuses in the United States. We provide an overview of ED screening efforts on college campuses, including relevant screening tools, summarize the extant literature on prevention programming, as well psychological and pharmacological treatment approaches, and outline limitations of current programming and provide future directions for research.

CONCLUSION

Recent advances in ED screening, prevention, and treatment efforts highlight the importance of early detection and intervention. Innovative approaches to screening and dissemination of evidence-based prevention and treatment programs on college campuses are warranted. Implications for future research are discussed.

Updates in the treatment of eating disorders in 2019: a year in review in Eating Disorders: The Journal of Treatment & Prevention

Empirical evidence continues to suggest that the majority of patients with eating disorders will not fully recover during treatment, and that treatment gains are vulnerable to relapse in the longer term. The urgent need for improved treatment options for those with eating disorders cannot be overstated. This review article provides an overview of treatment-related research findings published in Eating Disorders: The Journal of Treatment & Prevention during 2019. Importantly, this review encapsulates research (i) outlining guidelines in managing the medical risk inherent to the treatment of eating disorders, (ii) examining the treatment of eating disorders in cross-cultural contexts, (iii) expanding treatment research to novel and atypical eating disorder populations, and (iv) augmenting existing treatment approaches for anorexia nervosa and bulimia nervosa in novel contexts. These articles represent important contributions to the ongoing evolution of the treatment of eating disorders. However, further work is needed in precisely identifying the mechanisms of eating disorder psychopathology, such that emerging treatment efforts may be mapped onto specific targets.

Intolerance of uncertainty and eating disorder behaviour: Piloting a consumption task in a non-clinical sample

BACKGROUND AND OBJECTIVES

Intolerance of uncertainty (IU) is a transdiagnostic process contributing to the maintenance of anxiety disorders, and is a potential target for treatment. Recent literature has investigated IU as a cognitive process underpinning pathological fear and anxiety in Anorexia Nervosa (AN). The current study was designed to examine trait and state IU, and their relationship to restrictive eating disorder symptoms, anxiety, worry, cognitive rigidity and eating behaviour.

METHODS

A sample of undergraduate women (N = 85) completed measures of eating disorder symptoms, IU, cognitive rigidity and worry. Participants were randomised to complete an eating task under one of two conditions: the "certain" condition received a high-calorie meal and nutritional information, while the "uncertain" condition received the meal alone. During the meal, state IU and state anxiety were examined at three time-points (baseline, pre-eating, post-eating).

RESULTS

Trait IU was correlated with cognitive rigidity, worry, global eating disorder symptoms, and, in particular, dietary restraint. No differences emerged between conditions with respect to eating-related anxiety, or amount of food eaten. Controlling for condition and eating disorder symptoms, state IU predicted pre-eating anxiety. Beyond the contribution of condition, BMI and eating disorder symptoms, state IU predicted consumption, specifically greater dietary restriction.

LIMITATIONS

The study employed a non-clinical sample.

CONCLUSIONS

IU may be implicated in a rigid cognitive style, the anxiety response to energy-dense food, and restrictive eating behaviour. Should these findings be replicated in a clinical sample, then IU might emerge as an adjunctive treatment target for AN.

The promise of neurobiological research in anorexia nervosa

PURPOSE OF REVIEW

This article reviews new research in the context of existing literature to identify approaches that will advance understanding of the persistence of anorexia nervosa.

RECENT FINDINGS

Neuroscience research in anorexia nervosa has yielded disparate findings: no definitive neural mechanism underlying illness vulnerability or persistence has been identified and no clear neural target for intervention has emerged. Recent advances using structural and functional neuroimaging research, as well as new techniques for applying and combining these approaches, have led to a refined understanding of changes in neural architecture among individuals who are acutely ill, have undergone renourishment, or are in recovery/remission. In particular, advances have come from the incorporation of computational and translational approaches, as well as efforts to link experimental paradigms with illness-relevant behavior. Recent findings converge to suggest abnormalities in systems involved in reward learning and processing among individuals with anorexia nervosa.

SUMMARY

Anorexia nervosa is associated with neurobiological abnormalities. Aberrant learning and reward processing may contribute to the persistence of illness. To better utilize new techniques to understand the neural mechanisms of persistent anorexia nervosa, it may help to distinguish stages of illness and to link neurobiology with maladaptive behavior.

Delayed Puberty-Phenotypic Diversity, Molecular Genetic Mechanisms, and Recent Discoveries

This review presents a comprehensive discussion of the clinical condition of delayed puberty, a common presentation to the pediatric endocrinologist, which may present both diagnostic and prognostic challenges. Our understanding of the genetic control of pubertal timing has advanced thanks to active investigation in this field over the last two decades, but it remains in large part a fascinating and mysterious conundrum. The phenotype of delayed puberty is associated with adult health risks and common etiologies, and there is evidence for polygenic control of pubertal timing in the general population, sex-specificity, and epigenetic modulation. Moreover, much has been learned from comprehension of monogenic and digenic etiologies of pubertal delay and associated disorders and, in recent years, knowledge of oligogenic inheritance in conditions of GnRH deficiency. Recently there have been several novel discoveries in the field of self-limited delayed puberty, encompassing exciting developments linking this condition to both GnRH neuronal biology and metabolism and body mass. These data together highlight the fascinating heterogeneity of disorders underlying this phenotype and point to areas of future research where impactful developments can be made.

Gut-Brain Interactions: Implications for a Role of the Gut Microbiota in the Treatment and Prognosis of Anorexia Nervosa and Comparison to Type I Diabetes

Anorexia nervosa has poor prognosis and treatment outcomes and is influenced by genetic, metabolic, and psychological factors. Gut microbes interact with gut physiology to influence metabolism and neurobiology, although potential therapeutic benefits remain unknown. Type 1 diabetes is linked to anorexia nervosa through energy dysregulation, which in both disease states is related to the gut microbiota, disordered eating, and genetics.

A randomized controlled trial of group cognitive remediation therapy for anorexia nervosa: Effects on set-shifting tasks for inpatient adults and adolescents

OBJECTIVE

The aim of this randomized controlled trial with a parallel design was to evaluate the effect of brief, cognitive remediation therapy (CRT) for anorexia nervosa (AN) on set-shifting.

METHOD

Two hundred seventy-five inpatient adults and adolescents with AN (mean age = 23.1; SD = 12.7) were randomly assigned (using simple randomization procedures) to either a CRT or control condition. All participants received treatment as usual; however, the CRT condition completed five CRT group sessions in lieu of other group therapies provided on the unit. Set-shifting abilities were evaluated by: (a) neuropsychological measures and (b) experimental cognitive behavior therapy thought records. Blinding of group assignment occurred during baseline assessment and ended following group commencement.

RESULTS

Data from 135 CRT and 140 control condition participants were analyzed. On all neuropsychological measures, results revealed no between group condition effects, but did show statistically significant time effects, with medium to large effect sizes. Thought record analysis revealed a significant condition by age interaction effect where adults in the CRT condition generated significantly more alternative thoughts and had stronger believability of alternative thoughts than children, a trend that was not found in the control condition. This yielded moderate to large effect sizes of.0.56 and 0.72, respectively.

DISCUSSION

Based on traditional neuropsychological measures, these findings do not suggest a differential effect of CRT for AN in the format applied. However, results suggest that CRT may have some increased beneficial cognitive effect for adults, as compared to children, based on thought record analysis.

The posited effect of positive affect in anorexia nervosa: Advocating for a forgotten piece of a puzzling disease

Anorexia nervosa (AN) is a complex and life-threatening eating disorder. Current models of AN onset and maintenance have largely focused on the role of negative affect, while fewer models have described the role of positive affect (PA). Given that these theoretical models have informed current treatment approaches, and that treatment remains minimally effective for adults with AN, we advocate that targeting PA is one avenue for advancing maintenance models and by extension, treatment. We specifically propose that AN may arise and be chronically and pervasively maintained as a function of dysregulated PA in response to weight loss and weight loss behaviors (e.g., restriction, excessive exercise), to a degree that is not accounted for in existing models of AN. We present evidence from multiple domains, including biological, behavioral, and self-report, supporting the hypothesis that PA dysregulation in AN contributes to the maintenance of the disorder. We conclude with several specific avenues for treatment development research as well as a call for future work elucidating the biological correlates of PA.

Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa

Characterized primarily by a low body-mass index, anorexia nervosa is a complex and serious illness1, affecting 0.9-4% of women and 0.3% of men2-4, with twin-based heritability estimates of 50-60%5. Mortality rates are higher than those in other psychiatric disorders6, and outcomes are unacceptably poor7. Here we combine data from the Anorexia Nervosa Genetics Initiative (ANGI)8,9 and the Eating Disorders Working Group of the Psychiatric Genomics Consortium (PGC-ED) and conduct a genome-wide association study of 16,992 cases of anorexia nervosa and 55,525 controls, identifying eight significant loci. The genetic architecture of anorexia nervosa mirrors its clinical presentation, showing significant genetic correlations with psychiatric disorders, physical activity, and metabolic (including glycemic), lipid and anthropometric traits, independent of the effects of common variants associated with body-mass index. These results further encourage a reconceptualization of anorexia nervosa as a metabo-psychiatric disorder. Elucidating the metabolic component is a critical direction for future research, and paying attention to both psychiatric and metabolic components may be key to improving outcomes.

Women's recovery from anorexia nervosa: a systematic review and meta-synthesis of qualitative research

Anorexia nervosa (AN) is a complex and challenging condition and recovery can be a slow and difficult process. Predicting factors remain largely unknown. This paper aims to systematically review qualitative studies which have investigated female service users' experiences of recovering from AN and carry out a meta-synthesis of the themes they identified. Meta-ethnography was used to select and synthesize the studies. Articles published between 2002 and 2017 were searched in PsycInfo, EMBASE, CINAHL and Medline. Studies were included if they explored recovery from AN using a qualitative methodology. The methodological quality of the studies was systematically and critically appraised. Fourteen studies were selected for inclusion. Common themes reported by participants describe the process of recovery from AN as dealing with a fragmented sense of self, a turning point where insight and commitment to recovery is developed, and, in recovery, a reclamation of self through meaningful relationships, rebuilding identity and self-acceptance. Recovery from AN is experienced as a complex psychological process with many contributing factors. Findings highlight the need to reconsider clinical practice and treatment provision to incorporate the psychological components of self-identity into recovery programs.

Feasibility of conducting a randomized clinical trial using family-based treatment for avoidant/restrictive food intake disorder

Treatments for avoidant/restrictive food intake disorder (ARFID) lack strong empirical support. There is a critical need to conduct adequately powered studies to identify effective treatments for ARFID. As a first step, the primary aim of this study was to assess the feasibility of conducting a randomized clinical trial (RCT) comparing Family-based Treatment for ARFID (FBT-ARFID) to usual care (UC). The primary outcomes were recruitment, attrition, suitability, and expectancy rates. The secondary aim was to assess changes in percent estimated body weight, eating related psychopathology, and parental self-efficacy from baseline to end of treatment/UC period in both groups. Recruitment rates were 1.87 per month; 28 children with ARFID and their families were randomized and attrition rate was 21%. Therapeutic suitability and expectancy rating suggested that FBT-ARFID was acceptable to families. Effect size (ES) differences on measures of weight and clinical severity were moderate to large, favoring FBT-ARFID over UC. Parental self-efficacy improvement also demonstrated a large ES favoring FBT-ARFID, which was correlated with improvements in ARFID symptoms. There is a research gap between our knowledge base on how to treat children with ARFID and clinical need. The data presented suggest that an RCT comparing FBT-ARFID and UC is feasible to conduct.

Anorexia Nervosa and a Lost Emotional Self: A Psychological Formulation of the Development, Maintenance, and Treatment of Anorexia Nervosa

In this paper, we argue that Anorexia Nervosa (AN) can be explained as arising from a 'lost sense of emotional self.' We begin by briefly reviewing evidence accumulated to date supporting the consensus that a complex range of genetic, biological, psychological, and socio-environmental risk and maintenance factors contribute to the development and maintenance of AN. We consider how current interventions seek to tackle these factors in psychotherapy and potential limitations. We then propose our theory that many risk and maintenance factors may be unified by an underpinning explanation of emotional processing difficulties leading to a lost sense of 'emotional self.' Further, we discuss how, once established, AN becomes 'self-perpetuating' and the 'lost sense of emotional self' relentlessly deepens. We outline these arguments in detail, drawing on empirical and neuroscientific data, before discussing the implications of this model for understanding AN and informing clinical intervention. We argue that experiential models of therapy (e.g., emotion-focused therapy; schema therapy) be employed to achieve emergence and integration of an 'emotional self' which can be flexibly and adaptively used to direct an individual's needs and relationships. Furthermore, we assert that this should be a primary goal of therapy for adults with established AN.

Treatment outcomes for anorexia nervosa: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

To determine the impact of specialized treatments, relative to comparator treatments, upon the weight and psychological symptoms of anorexia nervosa (AN) at end-of-treatment (EOT) and follow-up.

METHODS

Randomized controlled trials (RCTs) between January 1980 and December 2017 that reported the effects of at least two treatments on AN were screened. Weight and psychological symptoms were analyzed separately for each study. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, and studies were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) criteria and Cochrane risk of bias tool.

RESULTS

We identified 35 eligible RCTs, comprising data from 2524 patients. Meta-analyses revealed a significant treatment effect on weight outcomes at EOT [g = 0.16, 95% CI (0.05-0.28), p = 0.006], but not at follow-up [g = 0.11, 95% CI (-0.04 to 0.27), p = 0.15]. There was no significant treatment effect on psychological outcomes at either EOT [g = -0.03, 95% CI (-0.14 to 0.08), p = 0.63], or follow-up [g = -0.001, 95% CI (-0.11 to 0.11), p = 0.98]. There was no strong evidence of publication bias or significant moderator effects for illness duration, mean age, year of publication, comparator group category, or risk of bias (all p values > 0.05).

CONCLUSIONS

Current specialized treatments are more adept than comparator interventions at imparting change in weight-based AN symptoms at EOT, but not at follow-up. Specialized treatments confer no advantage over comparator interventions in terms of psychological symptoms. Future precision treatment efforts require a specific focus on the psychological symptoms of AN.

Medication in AN: A Multidisciplinary Overview of Meta-Analyses and Systematic Reviews

Drugs are widely prescribed for anorexia nervosa in the nutritional, somatic, and psychiatric fields. There is no systematic overview in the literature, which simultaneously covers all these types of medication. The main aims of this paper are (1) to offer clinicians an overview of the evidence-based data in the literature concerning the medication (psychotropic drugs and medication for somatic and nutritional complications) in the field of anorexia nervosa since the 1960s, (2) to draw practical conclusions for everyday practise and future research. Searches were performed on three online databases, namely MEDLINE, Epistemonikos and Web of Science. Papers published between September 2011 and January 2019 were considered. Evidence-based data were identified from meta-analyses, if there were none, from systematic reviews, and otherwise from trials (randomized or if not open-label studies). Evidence-based results are scarce. No psychotropic medication has proved efficacious in terms of weight gain, and there is only weak data suggesting it can alleviate certain psychiatric symptoms. Concerning nutritional and somatic conditions, while there is no specific, approved medication, it seems essential not to neglect the interest of innovative therapeutic strategies to treat multi-organic comorbidities. In the final section we discuss how to use these medications in the overall approach to the treatment of anorexia nervosa.

Inpatient versus outpatient care, partial hospitalisation and waiting list for people with eating disorders

BACKGROUND

Clinical guidelines recommend outpatient care for the majority of people with an eating disorder. The optimal use of inpatient treatment or combination of inpatient and partial hospital care is disputed and practice varies widely.

OBJECTIVES

To assess the effects of treatment setting (inpatient, partial hospitalisation, or outpatient) on the reduction of symptoms and increase in remission rates in people with:1. Anorexia nervosa and atypical anorexia nervosa;2. Bulimia nervosa and other eating disorders.

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 2 July 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 20 November 2015). We also searched the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (6 July 2018). We ran a forward citation search on the Web of Science to identify additional reports citing any of the included studies, and screened reference lists of included studies and relevant reviews identified during our searches.

SELECTION CRITERIA

We included randomised controlled trials that tested the efficacy of inpatient, outpatient, or partial hospital settings for treatment of eating disorder in adults, adolescents, and children, whose diagnoses were determined according to the DSM-5, or other internationally accepted diagnostic criteria. We excluded trials of treatment setting for medical or psychiatric complications or comorbidities (e.g. hypokalaemia, depression) of an eating disorder.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane procedures to select studies, extract and analyse data, and interpret and present results. We extracted data according to the DSM-5 criteria. We used the Cochrane tool to assess risk of bias. We used the mean (MD) or standardised mean difference (SMD) for continuous data outcomes, and the risk ratio (RR) for binary outcomes. We included the 95% confidence interval (CI) with each result. We presented the quality of the evidence and estimate of effect for weight or body mass index (BMI) and acceptability (number who completed treatment), in a 'Summary of findings' table for the comparison for which we had sufficient data to conduct a meta-analysis.

MAIN RESULTS

We included five trials in our review. Four trials included a total of 511 participants with anorexia nervosa, and one trial had 55 participants with bulimia nervosa. Three trials are awaiting classification, and may be included in future versions of this review. We assessed a risk of bias from lack of blinding of participants and therapists in all trials, and unclear risk for allocation concealment and randomisation in one study.We had planned four comparisons, and had data for meta-analyses for one. For anorexia nervosa, there may be little or no difference between specialist inpatient care and active outpatient or combined brief hospital and outpatient care in weight gain at 12 months after the start of treatment (standardised mean difference (SMD) -0.22, 95% CI -0.49 to 0.05; 2 trials, 232 participants; low-quality evidence). People may be more likely to complete treatment when randomised to outpatient care settings, but this finding is very uncertain (risk ratio (RR) 0.75, 95% CI 0.64 to 0.88; 3 trials, 319 participants; very low-quality evidence). We downgraded the quality of the evidence for these outcomes because of risks of bias, small numbers of participants and events, and variable level of specialist expertise and intensity of treatment.We had no data, or data from only one trial for the primary outcomes for each of the other three comparisons.No trials measured weight or acceptance of treatment for anorexia nervosa, when comparing inpatient care provided by a specialist eating disorder service and health professionals and a waiting list, no active treatment, or treatment as usual.There was no clear difference in weight gain between settings, and only slightly more acceptance for the partial hospital setting over specialist inpatient care for weight restoration in anorexia nervosa.There was no clear difference in weight gain or acceptability of treatment between specialist inpatient care and partial hospital care for bulimia nervosa, and other binge eating disorders.

AUTHORS' CONCLUSIONS

There was insufficient evidence to conclude whether any treatment setting was superior for treating people with moderately severe (or less) anorexia nervosa, or other eating disorders.More research is needed for all comparisons of inpatient care versus alternate care.

MECHANISMS IN ENDOCRINOLOGY: Anorexia nervosa and endocrinology: a clinical update

Anorexia nervosa is a syndrome, that is collections of symptoms, which is not defined by its etiology. The severe cases are intractable. The syndrome is associated with multiple, profound endocrine alterations which may be adaptive, reactive or etiologic. Adaptive changes potentially may be inappropriate in clinical settings such as inpatient intensive re-nutrition or in a setting with somatic comorbidity. Electrolyte levels must be closely monitored during the refeeding process, and the need for weight gain must be balanced against potentially fatal refeeding complications. An important focus of clinical research should be to identify biomarkers associated with different stages of weight loss and re-nutrition combined with psychometric data. Besides well-established peripheral endocrine actions, several hormones also are released directly to different brain areas, where they may exert behavioral and psychogenic actions that could offer therapeutic targets. We need reliable biomarkers for predicting outcome and to ensure safe re-nutrition, however, first of all we need them to explore the metabolism in anorexia nervosa to open new avenues with therapeutic targets. A breakthrough in our understanding and treatment of this whimsical disease remains. Considering this, the aim of the present review is to provide an updated overview of the many endocrine changes in a clinical perspective.

Updates in the treatment of eating disorders in 2018: A year in review in eating disorders: The Journal of Treatment & Prevention

Current evidence suggests that the majority of patients with eating disorders will not fully recover during treatment, and little doubt can exist around the urgent need for improved treatment outcomes across the field of eating disorders. While empirical efforts are underway to optimize outcomes, this article reviews treatment-related research findings published in Eating Disorders: The Journal of Treatment & Prevention during 2018. Importantly, this review encapsulates research addressing (i) barriers to access and the uptake of empirically supported treatments, (ii) research assessing the delivery of empirically supported treatments across the full spectrum of patient care, and (iii) research aiming to isolate treatment mechanisms and optimize treatment outcomes across a transdiagnostic array of eating disorders. Ultimately, while much ground has been covered in 2018, further research is needed to enhance the accessibility and uptake existing treatments, since only a fraction of those with eating disorders are currently engaged in treatment. Further, with the expanding scope of non-outpatient eating disorder treatment settings, further research is required to adapt and assess the implementation of empirically supported treatments in higher levels of patient care. Lastly, in aiming to optimize patient outcomes, treatment outcome research must seek to identify (i) mechanisms that underlie illness eating disorder psychopathology, and (ii) the active mechanisms of existing treatments.

Could repetitive negative thinking interfere with corrective learning? The example of anorexia nervosa

Identifying processes that may interfere with corrective learning during treatments for anorexia nervosa (AN) may help to improve the effectiveness of existing interventions. We propose that certain cognitive processes characteristic of the AN temperament may help explain previous findings in AN suggesting difficulty updating previously learned associations and learning from feedback. Specifically, we hypothesize that engagement in repetitive negative thinking (RNT), including worry and rumination, could interfere with corrective learning that is critical to the success of behavioral treatments. In doing so, we draw from existing work in anxiety and mood disorders linking RNT to the maintenance of symptoms and poorer response to cognitive-behavioral treatments. Next, we outline hypothesized mechanisms through which engagement in RNT before, during, and after exposure to aversive stimuli could interfere with learning in AN. We then provide recommendations for how these hypothesized associations could be tested in future research. Although prior work has suggested that RNT processes are common among individuals with AN, this work has been primarily descriptive in nature. We propose that extending this work through direct examination of the impact of active engagement in RNT on corrective learning could aid in identifying AN maintenance processes that could be explicitly targeted in treatment.

Predictors of outcome among young adult patients with anorexia nervosa in a randomised controlled trial

OBJECTIVE

The prognosis in cases of anorexia nervosa (AN) is unsatisfactory, and it is therefore important to examine pretreatment predictors of outcome.

METHODS

Female AN patients (N = 74) included in a randomised controlled trial receiving individual cognitive behavioural therapy (CBT) or family-based treatment (FBT) were included. Predictors of the outcome were explored using pretreatment eating disorder psychopathology.

RESULTS

In the CBT group, lower levels of emotional dysregulation and greater deficits in identifying and coping with inner states were predictors of weight increase, explaining 37.7% of the variance. In the FBT group, lower interoceptive deficits predicted an increase in weight (explaining 17.7% of the variance), whereas bulimic behaviour (32.4%) and problems with emotional regulation (23.3%) were predictors of increased diagnostic symptoms.

CONCLUSIONS

Bulimic symptoms and the ability to identify and cope with emotional states appear to be important aspects that should be addressed in the treatment of young adult patients with AN.