Resistance to treatment and change in anorexia nervosa [corrected]: a clinical overview

Psychological Meanings of Eating Disorders and Their Association With Symptoms, Motivation Toward Treatment, and Clinical Evolution Among Outpatients

Unlike patients suffering from egodystonic disorders, people with eating disorders sometimes attribute positive meanings to their symptoms, and this attribution process contributes to the maintenance of the disorder. This study aims at exploring psychological meanings of eating disorders and their associations with symptoms, motivation toward treatment, and clinical evolution. Eighty-one adults with an eating disorder (anorexia nervosa, n = 46 and bulimia nervosa, n = 35) treated in a day-hospital program were asked, each week over an 8-week period, to identify the psychological meanings they ascribed to their eating disorder. Avoidance was the most frequently identified meaning, followed by mental strength, security, death, confidence, identity, care, and communication. Avoidance was more frequently mentioned by participants with bulimia than in cases of anorexia. Security and mental strength were associated with less motivation toward treatment. Death was associated with more depressive and anxious symptoms. An exploratory factor analysis showed that these meanings formed three main dimensions: Avoidance, Intrapsychic, and Relational. Findings suggest that psychological meanings associated with eating disorders can be assessed and used as a clinical tool to increase treatment acceptability and effectiveness.

Pathways to specialist care for eating disorders: An Italian multicentre study

Two hundred forty six patients with eating disorders (EDs) recruited from eight Italian specialized treatment centres were administered with the World Health Organization "Encounter Form," a standardized schedule that makes it possible to characterize the clinical pathways that patients follow to reach specialized care. The median time from symptoms onset to specialized care was 114 weeks. Primary "points of access to care" were general practitioners (25%), psychiatrists (18%), and clinical nutritionists (17%), followed by various other carers. All patients received specific psychotherapy, whereas only 11% of them were given psychotropic drugs. EDs are characterized by complex care pathways, with low rates of direct access to specialized care. Although the role of general practitioners remains crucial, they tend to follow different clinical routes to refer ED patients. Educational programmes on EDs should be addressed to general practitioners and clinical nutritionists, in order to ease the transition of ED patients to a mental health care setting.

Evidence That Frame of Reference Effects Can Reduce Socially Prescribed Perfectionism

Socially prescribed perfectionism appears to drive disordered eating behaviour in young women, usually via messages from fellow women. Social psychological research suggests that framing effects can be manipulated to reduce the effect of unhealthy messages. This research used contrasting messages about perfectionism to reduce perfectionism among female dieters. We recruited 147 female dieters (M age = 25.11) for a between-subjects experimental study. While completing an online questionnaire, participants were exposed to one of three sets of blog posts, which varied in content and source. These three conditions always had one anti-perfectionism message from a woman. This was presented along with either a high perfection message from a man, a high perfectionism message from a woman, or both of these messages. After reading the blog posts, women were asked to fill out a scale assessing their levels of socially prescribed perfectionism. When participants were exposed to an anti-perfectionism message from a woman, paired with a high-perfectionism message from a man, participants showed lower socially prescribed perfectionism than when both high and anti-perfectionism messages came from two women. These findings imply that strategies designed to reduce socially prescribed perfectionism may benefit from including contrasting messages, as this may shift perceived perfectionism norms. Implications for social interventions are discussed.

Insidious: The relationship patients have with their eating disorders and its impact on symptoms, duration of illness, and self-image

OBJECTIVES

In published clinical and autobiographical accounts of eating disorders, patients often describe their disorder in personified ways, that is, relating to the disorder as if it were an entity, and treatment often involves techniques of externalization. By encouraging patients to think about their eating disorder as a relationship, this study aimed to examine how young female patients experience their eating disorder as acting towards them, how they react in response, and whether these interactions are associated with symptoms, illness duration, and self-image.

DESIGN

Structural Analysis of Social Behavior (SASB) was used to operationalize how patients experience the actions of their eating disorder and their own reactions to the disorder.

METHOD

The relationship between patients (N = 150) and their eating disorders was examined with respect to symptoms, duration of illness, and self-image. Patients were also compared on their tendency to react with affiliation in relation to their disorder.

RESULTS

Patients' responses on the SASB indicated that they tended to conceptualize their eating disorders as blaming and controlling, and they themselves as sulking and submitting in response. Greater experience of the eating disorder as being controlling was associated with higher levels of symptomatology. Patients reacting with more negative affiliation towards their disorder were less symptomatic.

CONCLUSIONS

When encouraging patients to think about their eating disorder as a relationship, comprehensible relationship patterns between patients and their eating disorders emerged. The idea that this alleged relationship may resemble a real-life relationship could have theoretical implications, and its exploration may be of interest in treatment.

PRACTITIONER POINTS

Patients were able to conceptualize their eating disorder as a significant other to whom they relate when encouraged to do so. Patients tended to experience their disorder as controlling and domineering. Exploring the hypothetical patient-eating disorder relationship may prove helpful in understanding dysfunctional relational patterns. Helping patients to rebel against their eating disorder could potentially aid in symptom reduction.

Contingency Contracts for Weight Gain of Patients with Anorexia Nervosa in Inpatient Therapy: Practice Styles of Specialized Centers

The treatment of patients with anorexia nervosa (AN) is often challenging, due to a high degree of ambivalence towards recovery and weight gain these patients often express. One part of the multimodal treatment is the utilization of treatment contracts (i.e., contingency contracts) that aim to motivate patients to gain weight by applying positive and negative consequences for the (non-)achievement of weight goals. The main aim of this study is to assess and analyze current standards of contingency contracts’ utilization in German eating disorder centers. n = 76 mental health professionals of twelve specialized university centers in Germany that are currently or were formerly treating patients with AN in an inpatient setting participated. Most experts use contingency contracts in their clinic with weekly weight goals ranging between 500 and 700 g. Overall effectiveness and significance of contingency contracts for the inpatient treatment of patients with AN was rated high. Typical characteristics of a contingency contract in specialized German university hospital centers, such as the most frequent consequences, are described. The survey results assist the planning of further studies aiming to improve the multimodal treatment of patients with AN. For clinical practice, using external motivators such as contingency contracts as well as targeting internal motivation (e.g., by using motivational interviewing) is proposed.

Young people's experience of individual cognitive remediation therapy (CRT) in an inpatient eating disorder service: a qualitative study

INTRODUCTION AND PURPOSE

Current literature shows promising results regarding the efficacy of Cognitive Remediation Therapy for Anorexia Nervosa (AN); however, there is a paucity of studies considering the use of CRT in Young People (YP). The aim of this study was to examine YP's experiences of individual CRT in an inpatient eating disorder unit.

METHOD

Seventy letters following a cycle of eight individual CRT sessions were analysed using thematic analysis, adopting an inductive approach. Inter-rater reliability of findings was ensured.

RESULTS

The following six higher-order themes, each with lower-order themes, were identified: engaging aspects of CRT; identifying thinking skills; relevance to real-life situations; encountering personal challenges; making sense of the rational of CRT; suggestions for further improvements. YP reported enjoying CRT and described increased learning about their thinking styles and their skills from the activities undertaken during therapy. Some participants were able to apply learning outside of therapy and less frequently to difficulties related to the illness.

CONCLUSION

Feedback from patients suggests CRT is a useful intervention for YP with AN, which could facilitate their engagement in the treatment, while tackling neuropsychological processes underlying psychological symptoms of AN. Exploring participants' experience of CRT has highlighted specific elements of the intervention perceived as beneficial by YP, and areas where adaption could be made. This will allow clinicians to further develop the intervention from a service users' perspective, tailoring the sessions to their needs.

Emerging Technologies in the Treatment of Anorexia Nervosa and Ethics: Sufferers' Accounts of Treatment Strategies and Authenticity

New neural models for anorexia nervosa (AN) are emerging as a result of increased research on the neurobiology of AN, and these offer a rationale for the development of new treatment technologies such as neuromodulation. The emergence of such treatment technologies raises new ethical questions; however these have been little discussed for AN. In this article, I take an empirical approach and explore how young women who suffer from AN perceive treatment technologies in light of the concept of authenticity. Interview data showed that participants in this study did not seem to unconditionally adhere to treatment modalities that only imply laborious self-work, such as therapy. The data also showed that they were willing to accept new treatment possibilities such as pharmacological or brain-directed treatment strategies, which they view as having potential instrumental value in coping with certain symptoms of the illness. However, such modalities can pose threats to patients' authenticity, especially with regard to self-discovery. I argue that, in a context where there is an increased interest in brain-directed treatment strategies for AN, studies should continue to explore the ethical and psychological impact of such treatment technologies on individuals.

The effectiveness of contingency management in the treatment of patients with anorexia nervosa: A systematic review

Contingency management in stipulating weight gain is routinely used in the treatment of anorexia nervosa, however, empirical investigations concerning its effectiveness have been scarce. This systematic review was conducted according to the PRISMA statement. Of N = 973 hits, 42 full-texts were included in the qualitative synthesis (11 theoretical texts, 19 case reports, 12 descriptive, cohort, and controlled trials). A central topic in the included publications concerns the enhancement of patients' autonomy through participation in the contingency management process. This heightened autonomy is achieved by using contingency contracts. Positive short-term effects on weight gain were shown, whereas follow-up results were heterogeneous. Although contingency contracts are widely used in clinical practice, our systematic review shows that empirical evidence on underlying mechanisms and efficacy is still scarce. Using an explicit treatment contract can enhance patients' motivation, compliance, and autonomy. Clinical practice should see further development including innovative motivation enhancing and conflict dissolving techniques in addressing the pronounced ambivalence often shown by patients with anorexia nervosa.

Inviting eating disorder patients to discuss the academic literature: a model program for psychoeducation

BACKGROUND

Psychoeducation initiatives in which patients read primary scientific literature have not yet been studied as a treatment intervention for eating disorders. In this paper, we discuss and evaluate the acceptability of a novel psychoeducational journal club for individuals with anorexia and bulimia nervosa in inpatient and partial hospitalization program settings. Primary literature about eating disorders is presented and discussed with patients. By presenting scientifically-supported information, our "Psychoeducational Research Group" is designed to help patients restructure disordered thoughts and encourage adherence to evidence-based treatment.

METHODS

Using a Likert scale questionnaire (0 = not at all; 5 = very much), participants provided ratings for how much they liked the group and felt that it helped them across several domains.

RESULTS

Average scores from 33 participants (26 inpatient, 7 partial hospital patients) indicated they would recommend this group to others receiving eating disorder treatment (4.8 ± 0.6). Scores also suggested patients' likeability (4.6 ± 0.8), benefit regarding challenging eating disorder thoughts (4.1 ± 1.1), improved motivation for eating behavior change (4.0 ± 1.0) and completion of prescribed nutritional plan (3.6 ± 1.0), and usefulness in working towards treatment goals (4.2 ± 0.9) associated with group participation.

CONCLUSIONS

Preliminary findings support the acceptability of this psychoeducational group and that it may serve as a useful adjunct to larger evidence-based programming across eating disorder treatment settings.

Regional decrease in gray matter volume is related to body dissatisfaction in anorexia nervosa

Anorexia nervosa (AN) is a psychiatric disorder, in which the prognosis for some patients is poor. The etiology and effective treatments for AN have not been established. We examined morphometric changes in the brain of AN and clarified how the changes were associated with symptoms and pathophysiology. We enrolled 52 participants: 7 with the restrictive type of AN, 13 with the binge-eating/purging type, 3 with eating disorder not otherwise specified, and 29 healthy controls. Participants underwent T1-weighted MRI. Group differences between patients and controls in gray matter volume (GMV) were analyzed using voxel-based morphometry. Age and body mass index (BMI) were considered covariates. Correlations between regional GMVs and drive for thinness and body dissatisfaction were examined. Patients had decreased GMV in the superior/middle temporal gyrus (STG/MTG), pulvinar, and superior frontal gyrus after correction for age and BMI, and in the STG/MTG, middle frontal gyrus, and cingulate after correction for age. A correlational group difference was detected for body dissatisfaction and GMV in the STG. Our findings suggest that decreased GMV in the STG is related to body dissatisfaction that could come from impaired visuospatial perception, together with GMV decreases in several regions, which may be involved in development of AN.

Can temporary cessation of CBT really be therapeutic? A case study

Anorexia nervosa (AN) is a notoriously costly and challenging psychiatric illness to treat. Despite an accumulating evidence base, psychological treatment fails to achieve symptom abstinence in many patients with eating disorders, a shortcoming that is likely to be further pronounced in AN. The case study reported here describes how a mutually agreed break in a course of psychotherapy following an initial lack of progress might have influenced outcome for a client with a severe eating disorder. The patient received 26 sessions of CBT and results, consistent with those of larger studies, showed significant improvement on primary symptom measures. These results are discussed in the context of relevant psychological theories and an exploration of the client's motivation. Consideration is also given to other factors that may have influenced outcome.

Affective temperaments in anorexia nervosa: The relevance of depressive and anxious traits

BACKGROUND

Affective temperaments have been so far understudied in anorexia nervosa (AN) despite the relevance of personality and both affective and anxious comorbidity with regard to vulnerability, course, and outcome of this deadly disorder.

METHODS

Ninety-eight female inpatients diagnosed with AN and 131 healthy controls (HCs) were enrolled in this study and completed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) in addition to assessments of eating psychopathology, depression, and anxiety.

RESULTS

AN patients and HCs differed in all affective temperaments. The diagnostic subtypes of AN differed as well with binge-purging individuals being more cyclothymic and anxious than those with restricting-type AN. TEMPS-A scores correlated with body mass index and eating psychopathology but not with duration of illness. Concerning comorbidity, grater scores on the depressive and lower scores on the hyperthymic temperaments were found in depressed patients. Those who had either an anxious or irritable temperament were significantly more diagnosed with an anxious disorder than those who did not show this temperament. When logistic regression was performed, high depressive/low hyperthymic and high irritable/anxious traits resulted to be associated with depressive and anxious comorbidity, respectively, independently of confounding factors.

LIMITATIONS

Cross-sectional design, some patients on medications, few baseline clinical differences between diagnostic subtypes, no other personality assessments.

CONCLUSIONS

An affective continuum strongly associated with mood and anxious comorbidity emerged in AN. Such an evaluation could have several research and clinical implications given the need of improving treatment individualization and early interventions for such a complex disorder.

How a moderated online discussion forum facilitates support for young people with eating disorders

INTRODUCTION

Young people with eating disorders are at risk of harm to their social, emotional and physical development and life chances. Although they can be reluctant to seek help, they may access social media for information, advice or support. The relationship between social media and youth well-being is an emotive subject, but not clearly understood. This qualitative study aimed to explore how young people used a youth-orientated, moderated, online, eating disorders discussion forum, run by an eating disorders charity.

METHODS

We applied a netnographic approach involving downloading and thematically analysing over 400 messages posted August-November 2012.

RESULTS

Data analysis generated five themes: Taking on the role of mentor; the online discussion forum as a safe space; Friendship within the online forum; Flexible help; and Peer support for recovery and relapse prevention. Forum moderation may have influenced the forum culture.

DISCUSSION

Our findings are consistent with literature about youth preferences for mental health self-care support. A young person's decision to use this discussion forum can be construed as pro-active self-care. A moderated online discussion forum can make a positive contribution to support for youth with eating disorders, countering negative media perceptions of online groups.

CONCLUSION

This study adds to knowledge about how young people access support via social media. Online discussion forums can be safe and acceptable spaces for youth to access help. Further research could provide insights into the impact of forum moderation.

Metasynthesis of the Views about Treatment of Anorexia Nervosa in Adolescents: Perspectives of Adolescents, Parents, and Professionals

BACKGROUND

Anorexia nervosa in adolescents can be a difficult-to-treat disease. Because qualitative research is a well-established method for deepening our understanding of subjective experiences, such as eating disorders and their treatment, we sought to perform a systematic review of qualitative studies to synthesize the views of adolescents with this disease, their parents, and their healthcare providers about its treatment.

METHODS

We performed a thematic synthesis to develop the central themes that summarize all of the topics raised in the articles included in our review. The quality of the articles was assessed by the Critical Appraisal Skills Program.

RESULTS

We included 32 articles from seven different countries. Two central themes were inductively developed from the analysis: (1) the treatment targets (i.e., symptoms and patients in context), and (2) a therapeutic tool-a relationship, specifically the core concept of the therapeutic relationship.

CONCLUSION

Our results underline the difficulty in establishing a therapeutic alliance, the barriers to it, especially the risk that professionals, adolescents, and parents will not converse about treatment; although such a dialogue appears to be an essential component in the construction of a therapeutic alliance.

Food insecurity as a driver of obesity in humans: The insurance hypothesis

Integrative explanations of why obesity is more prevalent in some sectors of the human population than others are lacking. Here, we outline and evaluate one candidate explanation, the insurance hypothesis (IH). The IH is rooted in adaptive evolutionary thinking: The function of storing fat is to provide a buffer against shortfall in the food supply. Thus, individuals should store more fat when they receive cues that access to food is uncertain. Applied to humans, this implies that an important proximate driver of obesity should be food insecurity rather than food abundance per se. We integrate several distinct lines of theory and evidence that bear on this hypothesis. We present a theoretical model that shows it is optimal to store more fat when food access is uncertain, and we review the experimental literature from non-human animals showing that fat reserves increase when access to food is restricted. We provide a meta-analysis of 125 epidemiological studies of the association between perceived food insecurity and high body weight in humans. There is a robust positive association, but it is restricted to adult women in high-income countries. We explore why this could be in light of the IH and our theoretical model. We conclude that although the IH alone cannot explain the distribution of obesity in the human population, it may represent a very important component of a pluralistic explanation. We also discuss insights it may offer into the developmental origins of obesity, dieting-induced weight gain, and anorexia nervosa.

Similarities and Differences of Neuropsychological Profiles in Children and Adolescents with Anorexia Nervosa and Healthy Controls Using Cluster and Discriminant Function Analyses

OBJECTIVE

This study aimed to identify discrete neuropsychological profiles and their relationship to clinical symptoms in 253 female children and adolescents with anorexia nervosa (AN) and 170 healthy controls (HCs) using a standardised neuropsychological assessment battery.

METHOD

Hierarchical cluster analysis was used to identify the optimum number of clusters, and participants were assigned using K-means cluster analysis. Confirmatory discriminant function analysis determined which combination of neuropsychological variables best distinguished the clusters.

RESULTS

Three distinct clusters in the AN sample emerged- AN cluster 1 (19%) - "neuropsychologically low average to average"; AN cluster 2 (33%) - "verbal/visuo-spatial discrepancy"; and AN cluster 3 (48%) - "verbally strong and neuropsychologically average to high average". Two distinct clusters in HCs were identified. HC cluster 1 (48%) demonstrated poor visuo-spatial memory scores and high verbal fluency scores, whilst HC cluster 2 (52%) scored within the average range on all neuropsychological tasks. Neuropsychological performance was associated with clinical symptoms of body mass index centile, Eating Disorder Examination subscale and global score, anxiety, depression and obsessions, and compulsions between the AN and HC groups. However, niether significant differences emerged between AN clusters only nor HC clusters only at the post-hoc level.

DISCUSSION

An underlying neuropsychological heterogeneity may exist in AN. We encourage future studies to investigate whether the identified profiles and their association with clinical characteristics are replicable. We cautiously suggest that neuropsychological profiling may have potential to both inform future research and have possible clinical benefits through individually tailored treatment strategies.

The importance of social identities in the management of and recovery from 'Diabulimia': A qualitative exploration

INTRODUCTION

A significant barrier to recovery for individuals with co-morbid eating disorders and type 1 diabetes is the way in which group members self-categorise. Nonetheless, identity issues are neglected during the recovery process. The aim of this paper is to explore how group memberships (and the associated identities) both contribute to and hinder recovery in this cohort.

METHOD

Transcripts from five online focus groups with 13 members of an online support group for individuals with 'Diabulimia' were thematically analysed.

RESULTS

Findings suggested that those with whom one shares a recovery identity can be well placed to provide psychological resources necessary for successful recovery although such connections can be damaging if group norms are not managed. Members recognised that other important relationships (including family and friends and health professionals) are also key to recovery; these other group memberships (and the associated identities) can be facilitated through the recovery identity group membership, which allows for external validation of the recovery identity, provides encouragement to disclose the illness to supportive others, and provides information to facilitate positive service interactions.

CONCLUSIONS

While clinical interventions typically focus on eliminating disordered behaviours, we suggest that these should also include strengthening important group memberships that promote recovery.

A comprehensive review of psychodynamic treatments for eating disorders

PURPOSE

To comprehensively review the existing literature on the effectiveness of psychodynamic psychotherapies in eating disorders (EDs) and to stimulate both debate and research on this topic.

METHODS

Online and hand searches were conducted to identify papers published between 1980 and 2015 on psychodynamic treatments delivered to adults with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).

RESULTS

A total of 47 studies were finally included in this review. Fifteen studies were available for AN, 9 for BN, 12 for BED, and 11 for samples with mixed diagnoses. Several methodological flaws emerged, but overall psychodynamic interventions showed promising results at the end of treatment and follow-up, when available.

CONCLUSIONS

The body of literature on psychodynamic treatments is sparse and sometimes methodologically questionable; nevertheless, current data provide support to the effectiveness of these interventions, particularly for AN. However, both a defined approach (focus, themes, and techniques) and randomized controlled trials (RCTs) are warranted to clarify the effectiveness of psychodynamic psychotherapies.

Cost-effectiveness of focal psychodynamic therapy and enhanced cognitive-behavioural therapy in out-patients with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive-behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN.

METHOD

The analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WTP) per additional recovery. Cost-utility and assumptions underlying the base case were investigated in exploratory analyses.

RESULTS

Costs of in-patient treatment and the percentage of patients who required in-patient treatment were considerably lower in both intervention groups. The unadjusted ICERs indicated FPT and CBT-E to be dominant compared with TAU-O. Moreover, FPT was dominant compared with CBT-E. CEACs showed that the probability for cost-effectiveness of FTP compared with TAU-O and CBT-E was ⩾95% if the WTP per recovery was ⩾€9825 and ⩾€24 550, respectively. Comparing CBT-E with TAU-O, the probability of being cost-effective remained <90% for all WTPs. The exploratory analyses showed similar but less pronounced trends.

CONCLUSIONS

Depending on the WTP, FPT proved cost-effective in the treatment of adult AN.

Do dysfunctional coping modes mediate the relationship between perceived parenting style and disordered eating behaviours?

BACKGROUND

Preliminary studies suggest that both childhood experiences and coping behaviours may be linked to eating disorder symptoms.

METHODS

In this study maladaptive schema coping modes were investigated as mediators in the relationship between perceived negative parenting and disordered eating. A total of 174 adults with eating and/or body image concerns completed questionnaires measuring parenting experiences, schema modes, and disordered eating behaviours.

RESULTS

Perfectionistic Overcontroller, Self-Aggrandiser, Compliant Surrenderer, Detached Protector and Detached Self-Soother coping modes partially explained the variance in the relationships between perceived negative parenting experiences and the behaviours of restricting and compensation (purging and overexercising).

CONCLUSIONS

Our findings suggest that Overcompensatory, Avoidant and Surrender coping mechanisms all appear to play a role in the maintenance of eating disorder symptoms, and that there are multiple complex relationships between these and Early Maladaptive Schemas that warrant further investigation.

Gut Microbiota in Obesity and Undernutrition

Malnutrition is the result of an inadequate balance between energy intake and energy expenditure that ultimately leads to either obesity or undernutrition. Several factors are associated with the onset and preservation of malnutrition. One of these factors is the gut microbiota, which has been recognized as an important pathophysiologic factor in the development and sustainment of malnutrition. However, to our knowledge, the extent to which the microbiota influences malnutrition has yet to be elucidated. In this review, we summarize the mechanisms via which the gut microbiota may influence energy homeostasis in relation to malnutrition. In addition, we discuss potential therapeutic modalities to ameliorate obesity or undernutrition.

Eating disorders

Twenty years have passed from the International Classification of Diseases, Tenth Revision (ICD-10) to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and, in the meanwhile, a lot of research data about eating disorders has been published. This article reviews the main modifications to the classification of eating disorders reported in the "Feeding and Eating Disorders" chapter of the DSM-5, and compares them with the ICD-10 diagnostic guidelines. Particularly, we will show that DSM-5 criteria widened the diagnoses of anorexia and bulimia nervosa to less severe forms (so decreasing the frequency of Eating Disorders, Not Otherwise Specified (EDNOS) diagnoses), introduced the new category of Binge Eating Disorder, and incorporated several feeding disorders that were first diagnosed in infancy, childhood, or adolescence. On the whole, the DSM-5 revision should allow the clinician to make more reliable and timely diagnoses for eating disorders.

A factor analysis of the meanings of anorexia nervosa: intrapsychic, relational, and avoidant dimensions and their clinical correlates

BACKGROUND

Anorexia nervosa (AN) is a difficult to treat disorder characterized by ambivalence towards recovery and high mortality. Eating symptomatology has a sort of adaptive function for those who suffer from AN but no studies have to date investigated the relationship between the reported meanings of AN and patients' clinical characteristics. Therefore, we aimed to perform a factor analysis of a new measure testing its psychometric properties in order to clarify whether subjective meanings of AN can be related to AN severity, to ascertain if some personality traits correlate with the meanings attributed to AN by patients, and finally to verify to what extent such meanings relate to patients' duration of both illness and treatment.

METHODS

Eighty-one inpatients affected by AN were recruited for this study and clinical data were recorded. Participants were asked to complete a novel instrument, the Meanings of Anorexia Nervosa Questionnaire (MANQ) focused on the measurement of values that patients attribute to AN and other measures as follows: Eating Disorders Inventory-2, Beck Depression Inventory, Temperament and Character Inventory, and Anorexia Nervosa Stages of Change Questionnaire.

RESULTS

As measured by the MANQ, body dissatisfaction, problems of adolescence, and distress at school or work mainly triggered the onset of AN. Balance and self-control were mostly reported as meanings of AN while the most frequent negative effects were: being controlled by the illness, obsessive thoughts about body shape, and feeling alone. Differences were found between diagnostic subtypes. When a factorial analysis was performed, three factors emerged: intrapsychic (e.g., balance/safety, self-control, control/power, way to be valued), relational (e.g., communication, way to be recognized), and avoidant (e.g., the avoidance of negative feelings, emotions, and experiences). These factors correlated with patients' personality and motivation to treatments but were unrelated to duration of both illness and treatments.

CONCLUSIONS

Given the ego-syntonic nature of AN, the understanding of patients' value of their disorder could be relevant in treatment; moreover, the positive value of AN resulted to be unrelated to the duration of both illness and treatments. Future research is warranted to replicate these findings and test their clinical implications.

Prognostic and prescriptive predictors of improvement in a naturalistic study on inpatient and day hospital treatment of depression

BACKGROUND

The study aimed to identify prognostic (associated with general outcome) and prescriptive (associated with differential outcome in two different settings) predictors of improvement in a naturalistic multi-center study on inpatient and day hospital treatment in major depressive disorder (MDD).

METHODS

250 inpatients and 250 day hospital patients of eight psychosomatic hospitals were assessed at admission, discharge and a 3-months follow-up. Primary outcome was defined as a reduction of depressive symptomatology from admission to discharge and from discharge to follow-up (QIDS-C, total score). Percent improvement scores at discharge and at follow-up were entered as dependent variables into two General Linear Models with a set of predictor variables and the respective interaction terms with treatment setting. The selection of predictor sets was guided by statistical methods of variable preselection (LASSO).

RESULTS

Three variables were associated with less improvement from admission to discharge: the number of additional axis-I diagnoses, axis-II co-morbidity (SCID) and lower motivation (expert assessment). Social support (F-SozU) predicted symptom course between discharge and 3-month follow-up. Patients with no absent / sick days prior to admission showed a less favorable symptom course after discharge when treated as inpatients.

CONCLUSIONS

Patients with co-morbidity show less improvement during the active treatment phase. Motivation can be considered a prerequisite for symptom reduction, whereas social support seems to be an important factor for the maintenance of treatment gains. The lack in prescriptive predictors found may point to the fact that inpatient and day hospital treatment have comparable effects for most subgroups of patients with MDD.

Nursing Care Considerations for the Hospitalized Patient with an Eating Disorder

Eating disorders are chronic psychiatric illnesses with significant medical complications, psychological distress, and psychiatric comorbidity. Although many patients are treated on an outpatient basis, inpatient care for the more severely ill hospitalized patient can be challenging given the severity of illness and concurrent issues requiring intervention. This article provides an overview of the clinical characteristics of eating disorders typically seen for inpatient care, focusing primarily on anorexia nervosa and bulimia nervosa, and the associated key areas for nursing assessment, diagnoses, and plan of care during hospitalization.

Treatment of patients with severe and enduring eating disorders

PURPOSE OF REVIEW

Severe and enduring eating disorder is a new concept to the field that has potential to aid assessment and inform treatment. The aim of this review is to report recent developments in the conceptualization and treatment of people with severe and enduring eating disorder.

RECENT FINDINGS

A systematic search identified 28 included papers. These addressed conceptualization of recovery and staging models (4 studies), clinical care, presentations and treatment experiences (7 studies), four new randomized controlled trials of treatment (9 studies), two open trials of novel approaches (2 studies) and problems of treatment resistance and involuntary care (6 studies).

SUMMARY

The staging model appears to have validity and clinical utility in anorexia nervosa, but this is less clear in other eating disorders. Most literature on treatment, including new randomised controlled trials, is on underweight individuals, and there is a small literature on emerging psychological therapies that may improve outcomes. There is an expectation that with better treatment engagement, there may also be a reduced need for involuntary interventions.

Motivation to change and perceptions of the admission process with respect to outcome in adolescent anorexia nervosa

BACKGROUND

In patients with anorexia nervosa (AN), there is evidence that readiness to change is an important predictor of outcome with respect to weight gain and improvement in eating disorder psychopathology. In particular, young patients are characterized by a low level of motivation for recovery and perceive more coercion at hospitalization. Thus, a better understanding of the variables that influence readiness to change and perception of the admission process in adolescent AN may help to support patients in initiating change and staying motivated for treatment.

METHODS

In 40 adolescent patients diagnosed with AN according to DSM-IV criteria, we assessed in a prospective clinical cohort study the motivation to change using the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) at admission to inpatient treatment, in week 9 after admission and at discharge. Additional variables were assessed, including depressive symptoms (Beck Depression Inventory, BDI), eating disorder-specific psychopathology (Eating Disorder Inventory, EDI-2), body mass index (BMI) and the percentage of expected body weight (%EBW). The patients' perceptions of the admission process and their perceived need for hospitalization were assessed using a self-report scale developed by Guarda et al. (2007).

RESULTS

Younger patients perceived more coercion than older patients did. Low %EBW and more severe eating disorder-specific psychopathology were associated with a greater perceived need for hospitalization. Moreover, low %EBW at admission and a longer duration of illness were accompanied by a greater motivation to change at admission, whereas more severe eating disorder psychopathology was associated with a low motivation to change. The motivation to change increased significantly between admission and discharge. Patients with a greater motivation to change at admission exhibited a higher weekly weight gain during treatment but did not show better outcome in eating disorder-specific psychopathology and depression.

CONCLUSIONS

Motivation to change is an important predictor of short-term outcome with respect to weight gain trajectory during treatment of adolescent AN. As patients with a higher BMI at admission and those with more severe eating disorder-specific symptoms seem to be less motivated to change, the crucial issue of motivation to change should be addressed with these patients during the therapeutic process.

Day Hospital Treatment for Anorexia Nervosa: A 12-Month Follow-up Study

Day hospitals (DHs) represent a treatment option for anorexia nervosa (AN), a mental disorder that is difficult to treat and has no evidence-based treatments available. We aimed to determine the effectiveness of a DH treatment that was specifically focused on the emotions of severe AN patients. Body mass index and eating psychopathology were the primary outcome measures. Fifty-six adult patients with AN were assessed upon admission, at the end of treatment (EOT) and at a 12-month follow-up evaluation (T18) using Eating Disorders Inventory-2, Beck Depression Inventory, Hamilton Rating Scale for Anxiety and Brief Social Phobia Scale. All participants received a multidisciplinary treatment programme that focused on psychodynamic psychotherapy. Seventy-eight per cent of participants reported positive outcomes at EOT and 68% at T18. Moreover, 82.1% and 65.4% of long-standing patients showed positive outcomes at EOT and T18, respectively. All measures of psychopathology were significantly improved at EOT and were maintained at follow-up. Our DH was effective at treating severe AN patients; however, further investigations of the processes of change are warranted.

Atypical antipsychotics as augmentation therapy in anorexia nervosa

Anorexia nervosa (AN) is a life-threatening and difficult to treat mental illness with the highest mortality rates of any psychiatric disorder. We aimed to garner preliminary data on the real-world use of olanzapine and aripiprazole as augmentation agents of Selective Serotonin Reuptake Inhibitors (SSRIs) in adult inpatients affected by AN. We retrospectively evaluated the clinical charts of patients who were hospitalized between 2012 and 2014. Patients were evaluated upon admission and discharge. We investigated eating symptomatology, and both general and eating psychopathology using: Hamilton Rating Scale for Anxiety, Hamilton Rating Scale for Depression, and Yale-Brown-Cornell Eating Disorders Scale. The charts of 75 patients were included in this study. The sample resulted equally distributed among those receiving SSRIs and either aripiprazole or olanzapine in addition to SSRIs. Notwithstanding a few baseline clinical differences, upon discharge all groups were significantly improved on all measures. Interestingly, aripiprazole showed the greatest effectiveness in reducing eating-related preoccupations and rituals with a large effect size. The body of evidence on medication management in AN is in dismal condition. Augmentation therapy is a well-established approach to a variety of mental disorders and it is often used in every-day clinical practice with patients affected by AN as well. Nevertheless, to date very little data is available on this topic. Results from our sample yielded promising results on the effectiveness of aripiprazole augmentation in reducing eating-related obsessions and compulsions. Randomized controlled trials are warranted to confirm these encouraging findings.

Futility in Chronic Anorexia Nervosa: A Concept Whose Time Has Not Yet Come

Comparatively little scholarly attention has been given to the question of futility in chronic psychiatric disorders, with the exception of a small body of work on so-called end-stage anorexia nervosa (AN). A review of this literature provides the background for a critical examination of whether the concept of futility has any clinically meaningful, ethically justifiable, and legally defensible application to AN. In this article, the arguments for and against futility judgments in AN are analyzed with special emphasis on determinations of capacity in this serious mental illness. Parallels between the futility disputes in medical and psychiatric disorders, where applicable, will be drawn to further illuminate whether or not the concept that continued psychiatric treatment for AN is ever truly futile.

Social insecurity in relation to orbitofrontal activity in patients with eating disorders: a near-infrared spectroscopy study

BACKGROUND

Functional neuroimaging techniques are widely used to elucidate changes in brain activity, and various questionnaires are used to investigate psychopathological features in patients with eating disorders (ED). It is well known that social skills and interpersonal difficulties are strongly associated with the psychopathology of patients with ED. However, few studies have examined the association between brain activity and social relationships in patients with ED, particularly in patients with extremely low body weight.

METHODS

In this study, 22-channel near-infrared spectroscopy was used to quantify regional hemodynamic changes during a letter fluency task (LFT) in 20 female patients with ED with a mean body mass index of 14.0 kg/m(2) and 31 female controls (CTLs). Symptoms were assessed using the Eating Disorder Inventory-2 and Beck Depression Inventory. We hypothesized that frontal activity in patients with ED would be lower than in CTLs and would show different correlations with psychopathological features compared with CTLs.

RESULTS

The LFT performance and score on the social insecurity subscale of the Eating Disorder Inventory-2 were significantly higher in the ED group than in the CTL group. The mean change in oxygenated hemoglobin (oxy-Hb) in bilateral frontal regions during the LFT was significantly smaller in the ED group than in the CTL group. Social insecurity score was positively correlated with the concentration of oxy-Hb in the bilateral orbitofrontal cortex in the ED group but not in the CTL group.

CONCLUSIONS

These results suggest that activity of the orbitofrontal cortex is associated with social insecurity and disturbed in patients with ED. Therefore, disturbed orbitofrontal cortex activity may underlie the lack of insight and social isolation that is characteristic of patients with ED.

Health-related quality of life in adult inpatients affected by anorexia nervosa

OBJECTIVE

Poor awareness of illness in anorexia nervosa (AN) may render the assessment of health-related quality of life (HRQoL) difficult. We aimed at evaluating severe AN patients' HRQoL at discharge using different instruments and correlating this measure with clinical variables.

METHODS

We enrolled 71 adult AN inpatients admitted through the emergency department. At admission, all participants completed the following: Medical Outcome Short Form Health Survey, Eating Disorder Inventory-2 and Temperament and Character Inventory. At admission and discharge, body mass index, EuroQoL Health Questionnaire/Visual Analogue Scale and Clinical Global Impression were evaluated.

RESULTS

The HRQoL was severely impaired at baseline, but it improved at discharge. HRQoL correlated with eating psychopathology and personality, but not with body mass index or Clinical Global Impression.

CONCLUSION

The HRQoL effectively captured patients' improvement at discharge. Given its correlations with clinical variables, this instrument may be useful in clinical practice.

The ethics of neuromodulation for anorexia nervosa: a focus on rTMS

OBJECTIVE

Recently there has been emerging clinical and research interest in the application of deep brain stimulation (DBS) and repetitive transcranial magnetic stimulation (rTMS) to the treatment of anorexia nervosa (AN). To our knowledge, few studies have discussed ethical aspects associated with the increased use of neuromodulation in AN, some of which are quite specific to AN, despite the rapid development and dissemination of these new technologies.

METHOD

We provide a brief overview of three published rTMS studies for AN and discuss ethical issues involved in the use of neuromodulation for AN.

RESULTS

In contrast to neurosurgery or DBS, rTMS is a less invasive technique, with less associated risk, and thus has greater potential to become a more widespread augmentation or add-on therapy for AN. New therapeutic procedures are promising, yet they raise ethical questions regarding informed consent and patient selection. Illness-specific issues surrounding authenticity and autonomy are important to consider, ensuring an ethical approach to treatment for patients with AN.

DISCUSSION

We argue that ethical investigations for neuromodulation techniques are timely and important, and discussions should go beyond the immediate goals of patient safety, consent, and risk and benefit, to consider broader ethical concepts such as authenticity and autonomy.

Resistance to treatment in eating disorders: a critical challenge

The Special Issue "Treatment resistance in Eating Disorders" gathers together the contributions provided by several experienced groups of researchers in the field of Eating Disorders (EDs). The main topic is addressed from multiple perspectives ranging from pathogenesis (including developmental and maintaining factors) to treatment. An explicative model of resistance in EDs is also proposed.