Anorexia nervosa treatment: a systematic review of randomized controlled trials

Aripiprazole, a partial dopamine agonist to improve adolescent anorexia nervosa-A case series

Anorexia nervosa (AN) is a severe and complex psychiatric disorder and no medication has been approved for its treatment. This case series in youth with severe, recurrent AN supports the hypothesis that dopamine receptor agonists could be helpful in supporting fear extinction during eating disorder focused psychotherapy and therefore support recovery from AN. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:529-533).

Motivational Text Message Intervention for Eating Disorders: A Single-Case Alternating Treatment Design Using Ecological Momentary Assessment

OBJECTIVE

This study tested a motivational text message treatment adjunct for individuals with eating disorders (EDs) who exhibited high dietary restraint/restriction.

METHOD

A replicated single-case alternating treatment design was used to examine (a) the feasibility of combining a brief motivational interview with subsequent text messages and (b) the influence of the text messages on eating behaviors and motivation to change in individuals with EDs (N=12). The protocol was 8weeks and the text messages were adjunctive to cognitive-behavioral therapy.

RESULTS

The intervention was well accepted (mean rating=7/10) and feasible within the context of monetary compensation (mean daily monitoring compliance =91%). Text messages did not impact behavioral outcomes: dietary restraint and kilocalorie intake. They had mixed effects on motivation to change dietary restraint, measured by the Readiness and Motivation Questionnaire (RMQ). When receiving text messages, RMQ precontemplation scores (desire to restrict) significantly increased, indicating decreased motivation; however, action scores (effort toward reducing dietary restraint) significantly increased, indicating increased motivation. These effects were moderated by weight status. Underweight individuals (n=4; body mass index [BMI]<19.0) reported increased ambivalence-that is, an increased desire to restrict and increased action toward reducing restriction-in response to the text messages. Normal weight participants (n=8; BMI>19.0) reported only increased action toward reducing restriction in response to the text messages.

DISCUSSION

These data demonstrate text messages are a potentially feasible and acceptable treatment adjunct and may be effective at increasing motivation to change for normal weight individuals, while their influence on underweight patients is more complex. These findings provide a foundation for future research in technology-based motivational interventions for EDs and offer preliminary evidence for using these methods among normal weight individuals.

Neurobiologically informed treatment for adults with anorexia nervosa: a novel approach to a chronic disorder

Anorexia nervosa (AN) is a severe and debilitating disorder with significant medical and psychological sequelae. To date, there are no effective treatments for adults, resulting in high rates of chronicity, morbidity, and mortality. Recent advances in brain imaging research have led to an improved understanding of etiology and specific neurobiological mechanisms underlying symptoms. Despite this, there are no treatments focused on targeting symptoms using this empirically supported mechanistic understanding of the illness. Updated treatment approaches focused on targeting neurobiological mechanisms underlying core AN symptomatology are necessary to improve treatment out-comes for this population. Neurobiologically Enhanced With Family Eating Disorder Trait Response Treatment (NEW FED TR) is a neurobiologically informed treatment targeting key temperament constructs associated with the illness through the delivery of psychoeducation and skills training to patients and nominated carers.

Treatment Protocols for Eating Disorders: Clinicians' Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions

There are several protocols in existence that guide clinicians in the implementation of effective, evidence-based psychological interventions for eating disorders. These have been made accessible in the form of treatment manuals. However, relatively few clinicians use those protocols, preferring to offer more eclectic or integrative approaches. Following a summary of the research that shows that these evidence-based approaches can be used successfully in routine clinical settings, this review considers why there is such poor uptake of these therapies in such settings. This review focuses on the role of service culture and on clinicians' own attitudes, beliefs and emotions. Possible means of enhancing uptake are considered, but these cannot be considered to be ideal solutions at present.

Effectiveness of psychosocial interventions in eating disorders: an overview of Cochrane systematic reviews

Eating disorders are psychiatric conditions originated from and perpetuated by individual, family and sociocultural factors. The psychosocial approach to treatment and prevention of relapse is crucial. To present an overview of the scientific evidence on effectiveness of psychosocial interventions in treatment of eating disorders. All systematic reviews published by the Cochrane Database of Systematic Reviews - Cochrane Library on the topic were included. Afterwards, as from the least recent date of these reviews (2001), an additional search was conducted at PubMed with sensitive search strategy and with the same keywords used. A total of 101 primary studies and 30 systematic reviews (5 Cochrane systematic reviews), meta-analysis, guidelines or narrative reviews of literature were included. The main outcomes were: symptomatic remission, body image, cognitive distortion, psychiatric comorbidity, psychosocial functioning and patient satisfaction. The cognitive behavioral approach was the most effective treatment, especially for bulimia nervosa, binge eating disorder and the night eating syndrome. For anorexia nervosa, the family approach showed greater effectiveness. Other effective approaches were interpersonal psychotherapy, dialectic behavioral therapy, support therapy and self-help manuals. Moreover, there was an increasing number of preventive and promotional approaches that addressed individual, family and social risk factors, being promising for the development of positive self-image and self-efficacy. Further studies are required to evaluate the impact of multidisciplinary approaches on all eating disorders, as well as the cost-effectiveness of some effective modalities, such as the cognitive behavioral therapy. RESUMO Transtornos alimentares são doenças psiquiátricas originadas de e perpetuadas por fatores individuais, familiares e socioculturais. A abordagem psicossocial é essencial para o tratamento e a prevenção de recaídas. Apresentar uma visão geral das evidências científicas sobre a efetividade das intervenções psicossociais no tratamento de transtornos alimentares. Foram incluídas todas as revisões sistemáticas publicadas no Banco de Dados de Revisões Sistemáticas da Cochrane Library. Posteriormente, a partir da data menos recente destas revisões (2001), realizou-se uma busca adicional no PubMed, com estratégia de busca sensibilizada e com os mesmos descritores utilizados antes. No total, foram incluídos 101 estudos primários e 30 revisões sistemáticas (5 revisões sistemáticas da Cochrane), metanálises, diretrizes ou revisões narrativas da literatura. Os principais desfechos foram remissão de sintomas, imagem corporal, distorção cognitiva, comorbidade psiquiátrica, funcionamento psicossocial e satisfação do paciente. A abordagem cognitivo-comportamental foi o tratamento mais efetivo, principalmente para bulimia nervosa, transtorno da compulsão alimentar periódica e síndrome do comer noturno. Para anorexia nervosa, a abordagem familiar demonstrou maior efetividade. Outras abordagens efetivas foram psicoterapia interpessoal, terapia comportamental dialética, terapia de apoio e manuais de autoajuda. Além disso, houve um número crescente de abordagens preventivas e promocionais que contemplaram fatores de risco individuais, familiares e sociais, sendo promissoras para o desenvolvimento da autoimagem positiva e autoeficácia. São necessários mais estudos que avaliem o impacto de abordagens multidisciplinares em todos transtornos alimentares, além da relação custo-efetividade de algumas modalidades efetivas, como a terapia cognitivo-comportamental.

Can an internet-based program for the prevention and early intervention in eating disorders facilitate access to conventional professional healthcare?

BACKGROUND

The majorities of individual suffering from eating disorders do not seek or receive adequate professional treatment. Internet-based approaches promise to facilitate access to conventional healthcare by providing an easy-access, low-threshold contact.

AIM

The current study investigated whether an Internet-based program for the prevention and early intervention for eating disorders (ProYouth) may contribute to the actual and intended uptake of professional care. Characteristics of individuals who seek help are explored as well as barriers to help-seeking.

METHOD

The sample included 453 ProYouth participants who were surveyed three months after registration. Actual help-seeking behavior, intended help-seeking, potential help-seeking, and barriers to help-seeking were assessed.

RESULTS

Within three months of participation, 43 individuals (9.5%) took up treatment, 32 (7.8%) intended to start treatment, and 163 (43.1%) of the remaining reported that they would seek professional help in case of need (potential help-seeking). Approximately 50% of (potential) help-seekers stated that participation in ProYouth has changed their attitude towards help-seeking. Mental health literacy and shame/stigma were the most frequently mentioned barriers.

CONCLUSIONS

This is the first study indicating that an online program for prevention and early intervention may serve as facilitator in accessing conventional healthcare.

A systematic review of the existing models of disordered eating: Do they inform the development of effective interventions?

Despite significant advances in the development of prevention and treatment interventions for eating disorders and disordered eating over the last decade, there still remains a pressing need to develop more effective interventions. In line with the 2008 Medical Research Council (MRC) evaluation framework from the United Kingdom for the development and evaluation of complex interventions to improve health, the development of sound theory is a necessary precursor to the development of effective interventions. The aim of the current review was to identify the existing models for disordered eating and to identify those models which have helped inform the development of interventions for disordered eating. In addition, we examine the variables that most commonly appear across these models, in terms of future implications for the development of interventions for disordered eating. While an extensive range of theoretical models for the development of disordered eating were identified (N=54), only ten (18.5%) had progressed beyond mere description and to the development of interventions that have been evaluated. It is recommended that future work examines whether interventions in eating disorders increase in efficacy when developed in line with theoretical considerations, that initiation of new models gives way to further development of existing models, and that there be greater utilisation of intervention studies to inform the development of theory.

Machine learning derived risk prediction of anorexia nervosa

Background

Anorexia nervosa (AN) is a complex psychiatric disease with a moderate to strong genetic contribution. In addition to conventional genome wide association (GWA) studies, researchers have been using machine learning methods in conjunction with genomic data to predict risk of diseases in which genetics play an important role.

Methods

In this study, we collected whole genome genotyping data on 3940 AN cases and 9266 controls from the Genetic Consortium for Anorexia Nervosa (GCAN), the Wellcome Trust Case Control Consortium 3 (WTCCC3), Price Foundation Collaborative Group and the Children’s Hospital of Philadelphia (CHOP), and applied machine learning methods for predicting AN disease risk. The prediction performance is measured by area under the receiver operating characteristic curve (AUC), indicating how well the model distinguishes cases from unaffected control subjects.

Results

Logistic regression model with the lasso penalty technique generated an AUC of 0.693, while Support Vector Machines and Gradient Boosted Trees reached AUC’s of 0.691 and 0.623, respectively. Using different sample sizes, our results suggest that larger datasets are required to optimize the machine learning models and achieve higher AUC values.

Conclusions

To our knowledge, this is the first attempt to assess AN risk based on genome wide genotype level data. Future integration of genomic, environmental and family-based information is likely to improve the AN risk evaluation process, eventually benefitting AN patients and families in the clinical setting.

Electronic supplementary material

The online version of this article (doi:10.1186/s12920-016-0165-x) contains supplementary material, which is available to authorized users.

Cognitive Behavioral Therapy for Anorexia Nervosa: An Update

Cognitive behavioral therapy (CBT) for anorexia nervosa (AN), based on Beck's cognitive theory, was developed in a "generic" form in the early eighties. In recent years, however, improved knowledge of the mechanisms involved in maintaining eating disorder psychopathology has led to the development of a "specific" form of CBT, termed CBT-E (E = enhanced), designed to treat all forms of eating disorders, including AN, from outpatient to inpatient settings. Although more studies are required to assess the relative effectiveness of CBT-E with respect to other available treatments, the data indicate that in outpatient settings it is both viable and promising for adults and adolescents with AN. Encouraging results are also emerging from inpatient CBT-E, particularly in adolescents, and clinical services offering CBT-E at different levels of care are now offered in several countries around the world. However, CBT-E requires dissemination in order to become widely available to patients.

Family experiences of living with an eating disorder: a narrative analysis

Families are considered important in the management and treatment of eating disorders. Yet, rarely has research focused on family experiences of living with an eating disorder. Addressing this gap, this study explores the experiences of an elite 21-year-old triathlete with an eating disorder in conjunction with the experiences of her parents. Family members attended interviews individually on three separate occasions over the course of a year. In line with the narrative approach adopted, whereby stories are considered the primary means to construct experience, interviews encouraged storytelling through an open-ended, participant-led structure. Narrative analysis involved repeated readings of the transcripts, sensitising towards issues of narrative content (key themes) and structure (overarching plot). Family difficulties arose when personal experiences strayed from culturally dominant narrative forms and when family members held contrasting narrative preferences. Suggestions are forwarded as to how an appreciation of eating disorder illness narratives might inform treatment and support.

Follow-up mortality study of compulsorily treated patients with anorexia nervosa

OBJECTIVE

In a previous study we found that compulsory inpatient treatment was associated with an increase in the number of deaths over the following 5 years when compared to non-compulsory admission. This study aimed to examine the longer term mortality of patients admitted compulsorily.

METHOD

The mortality outcome of patients with a compulsory admission (n = 81) and a comparison group (n = 81) of patients admitted to the specialized eating disorder unit at the Maudsley Hospital in the period 1983-95 was traced over two decades through the National Register held by the National Health Service (NHS) Central Register.

RESULTS

Approximately 20 years following admission there were 27 deaths in the series. The standardized mortality rate in the compulsory treatment group no longer differed significantly from that of the non-compulsory group. The suicides were not particularly linked with compulsory admission.

DISCUSSION

Although the mortality in the 5 years following a compulsory admission is higher than that seen in the non-compulsory patients, this difference is attenuated over time. The overall standardized mortality rate remains elevated.

Focus on perfectionism in female adolescent anorexia nervosa

OBJECTIVE

Maudsley Family-Based Treatment (FBT) for anorexia is successful for between 50 and 80% of adolescents. To improve this success rate, various approaches to augmenting the treatment have been proposed.

METHOD

In this study, we describe the treatment of three girls with FBTaugmented with a module focusing on perfectionism, defined as personally prescribed or socially derived irrational and rigid expectations and exceedingly high standards of self performance. Multiple times across the 1 year of treatment, girls completed the measures of perfectionism and other outcomes.

RESULTS

The results were optimistic for remission, and showed reductions in girls? perfectionism and obsessional and rigid thinking.

Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis

OBJECTIVE

Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out.

METHOD

A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor.

RESULTS

The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type.

DISCUSSION

To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types.

ESCAP Expert Paper: New developments in the diagnosis and treatment of adolescent anorexia nervosa--a European perspective

Anorexia nervosa is a potentially life-threatening disorder with a typical onset in adolescence and high rates of medical complications and psychiatric comorbidity. This article summarizes issues relating to classification in DSM-5 and presents a narrative review of key evidence-based medical and behavioral interventions for adolescent AN and subthreshold restricting eating disorders, mainly, but not exclusively published between 2012 and 2014. In addition, it systematically compares the clinical guidelines of four European countries (Germany, Spain, The Netherlands, and United Kingdom) and outlines common clinical practice, in relation to treatment settings, nutritional rehabilitation, family-oriented and individual psychotherapy, and psychopharmacological treatment. With the exception of family-based treatment, which is mainly evaluated and practiced in Anglo-American countries, the evidence base is weak, especially for medical interventions such as refeeding and pharmacological intervention. There is a need for common European research efforts, to improve the available evidence base and resulting clinical guidance.

Are There Differences in Central Coherence and Set Shifting Across the Subtypes of Anorexia Nervosa?: A Systematic Review

Anorexia nervosa (AN) has been associated with weaknesses in central coherence and set shifting. In this line, it has been proposed to directly address these neuropsychological features in treatment (e.g., cognitive remediation therapy). It is not clear, however, whether the 2 subtypes of AN, the restricting (AN-R) and bingeing/purging (AN-BP) type, have the same amount of problems in these domains. A systematic search of the literature was conducted, using the databases Web of Science and PubMed, looking for studies on the comparison of AN-R and AN-BP in performing central coherence/set-shifting tasks. Notably, very few authors describe the results of a direct comparison of the performance of patients with AN-R and AN-BP. In summary, the available indications for possible group differences are not strong enough to draw definitive conclusions.

Altered orienting of attention in anorexia nervosa

The study of cognitive processes in anorexia nervosa (AN) is largely unexplored, although recent evidence suggests the presence of impairments in both social cognition and attention processing. Here we investigated AN patients' ability to orient attention in response to social and symbolic visual stimuli. AN patients and matched controls performed a task in which gaze and pointing gestures acted as social directional cues for spatial attention. Arrows were also included as symbolic cue. On each trial, a centrally-placed cue appeared oriented rightwards or leftwards. After either 200 or 700ms, a lateralized neutral target (a letter) requiring a discrimination response appeared in a location either spatially congruent or incongruent with the directional cue. Controls showed a reliable orienting irrespective of both temporal interval and cue type. AN patients showed a reliable orienting at both temporal intervals only in response to pointing gestures. Both gaze and arrow cues failed to orient attention at the short temporal interval, that is when attention is under reflexive control, whereas a reliable orienting emerged at the long temporal interval. These results provide preliminary evidence of altered reflexive orienting of attention in AN patients that does not extend to body-related cues such as pointing gestures.

Self-reported and performance based perfectionism in mothers of individuals with Anorexia Nervosa: a pilot study

BACKGROUND

Perfectionism is implicated in the development and maintenance of Anorexia Nervosa and there is some evidence that perfectionism may be elevated in family members. However to date there are no studies investigating behavioural aspects of perfectionism in unaffected mothers.

METHODS

Forty-one participants took part in this pilot study: 21 unaffected mothers of individuals with Anorexia Nervosa and 20 healthy control mothers. Participants completed two performance based tasks assessing perfectionism-a text replication task and a bead sorting task-along with self-report measures of perfectionism.

RESULTS

No group differences were found between unaffected AN mothers and HC mothers on performance measures of perfectionism.

DISCUSSION

The findings are discussed in relation to existing studies and clinical implications explored.

Extracting body image symptom dimensions among eating disorder patients: the Profile Analysis via Multidimensional Scaling (PAMS) approach

The present study employs Profile Analysis via Multidimensional Scaling (PAMS), a procedure for extracting dimensions, in order to identify core eating disorder symptoms in a clinical sample. A large sample of patients with eating disorders (N=5193) presenting for treatment completed the Eating Disorders Inventory-2 (EDI-2; Garner, 1991), and PAMS was then employed to estimate individual profile weights that reflect the degree to which an individual's observed symptom profile approximates the pattern of the dimensions. The findings revealed three symptom dimensions: Body Thinness, Body Perfectionism, and Body Awareness. Subsequent analysis using individual level data illustrate that the PAMS profiles properly operate as prototypical profiles that encapsulate all individuals' response patterns. The implications of these dimensional findings for the assessment and diagnosis of eating disorders are discussed.

Neural correlates of eating disorders: translational potential

Eating disorders are complex and serious psychiatric illnesses whose etiology includes psychological, biological, and social factors. Treatment of eating disorders is challenging as there are few evidence-based treatments and limited understanding of the mechanisms that result in sustained recovery. In the last 20 years, we have begun to identify neural pathways that are altered in eating disorders. Consideration of how these pathways may contribute to an eating disorder can provide an understanding of expected responses to treatments. Eating disorder behaviors include restrictive eating, compulsive overeating, and purging behaviors after eating. Eating disorders are associated with changes in many neural systems. In this targeted review, we focus on three cognitive processes associated with neurocircuitry differences in subjects with eating disorders such as reward, decision-making, and social behavior. We briefly examine how each of these systems function in healthy people, using Neurosynth meta-analysis to identify key regions commonly implicated in these circuits. We review the evidence for disruptions of these regions and systems in eating disorders. Finally, we describe psychiatric and psychological treatments that are likely to function by impacting these regions.

Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa

BACKGROUND

Anorexia nervosa is a disorder with high morbidity and significant mortality. It is most common in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting, and a number of differing psychological therapies are presently used in treatment. This is an update of a Cochrane review which was last published in 2008.

OBJECTIVES

To assess the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents treated in an outpatient setting.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) (16 July 2014). This register includes relevant randomised controlled trials from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We screened reference lists of all included studies and sent letters to identified, notable researchers requesting information on unpublished or ongoing studies.

SELECTION CRITERIA

All randomised controlled trials of one or more individual outpatient psychological therapies for adults with anorexia nervosa, as defined by DSM-5 or similar international criteria.

DATA COLLECTION AND ANALYSIS

We selected a range of outcome variables, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons used the mean or standardised mean difference (MD or SMD), and binary outcome comparisons used the risk ratio (RR). Two review authors (PH and AC or ST) extracted data independently.

MAIN RESULTS

We identified 10 trials from the search, with a total of 599 anorexia nervosa participants, and included them in the review. Seven had been identified in the previous versions of this review and we now include three new trials. We now deem one previously identified ongoing trial to be ineligible, and six ongoing trials are new for this update. Two of the 10 trials included children. Trials tested diverse psychological therapies and comparability was poor. Risks of bias were mostly evident through lack of blinded outcome assessments (in 60% of studies) and incomplete data reporting (attrition bias).The results suggest that treatment as usual (TAU) when delivered by a non-eating-disorder specialist or similar may be less efficacious than focal psychodynamic therapy. This was suggested for a primary outcome of recovery by achievement of a good or intermediate outcome on the Morgan and Russell Scale (RR 0.70, 95% confidence interval (CI) 0.51 to 0.97; 1 RCT, 40 participants; very low-quality evidence). However there were no differences between cognitive analytic therapy and TAU for this outcome (RR 0.78, 95% CI 0.61 to 1.00; 2 RCTs, 71 participants; very low-quality evidence), nor for body mass index (BMI). There were no differences in overall dropout rates between individual psychological therapies and TAU.Two trials found a non-specific specialist therapy (Specialist Supportive Clinical Management) or an Optimised TAU delivered by therapists with eating disorder expertise was similar in outcomes to cognitive behaviour therapy (BMI MD -0.00, 95% CI -0.91 to 0.91; 197 participants, low-quality evidence). When comparing individual psychological therapies with each other, no specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non-completion rate in one trial (35 participants). None of the trials identified any adverse effects. Insufficient power was problematic for the majority of trials.

AUTHORS' CONCLUSIONS

There was a suggestion in one trial that focal psychodynamic therapy might be superior to TAU, but this is in the context of TAU performing poorly. An alternative control condition of dietary advice alone appeared to be unacceptable, but again this is based on just one trial. Owing to the risk of bias and limitations of studies, notably small sample sizes, we can draw no specific conclusions about the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents. Larger RCTs of longer treatment duration and follow-up are needed.

Could training executive function improve treatment outcomes for eating disorders?

Current gold standard treatments for eating disorders (EDs) lack satisfactory efficacy, and traditional psychological treatments do not directly address executive functioning deficits underpinning ED pathology. The goal of this paper is to explore the potential for enhancing ED treatment outcomes by improving executive functioning deficits that have been demonstrated to underlie eating pathology. To achieve our objective, we (1) review existing evidence for executive functioning deficits that underpin EDs and consider the extent to which these deficits could be targeted in neurocognitive training programs, (2) present the evidence for the one ED neurocognitive training program well-studied to date (Cognitive Remediation Therapy), (3) discuss the utility of neurocognitive training programs that have been developed for other psychiatric disorders with similar deficits, and (4) provide suggestions for the future development and research of neurocognitive training programs for EDs. Despite the fact that the body of empirical work on neurocognitive training programs for eating disorders is very small, we conclude that their potential is high given the combined evidence for the role of deficits in executive functioning in EDs, the initial promise of Cognitive Remediation Training, and the success in treating related conditions with neurocognitive training. Based on the evidence to date, it appears that the development and empirical evaluation of neurocognitive training programs for EDs is warranted.

The psychopharmacological management of eating disorders in children and adolescents

In this review we synthesised current literature on the psychopharmacological management of eating disorders (EDs) in children and adolescents (C&As). We focus specifically on anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). The treatment of EDs is determined by physical and psycho-social factors and needs. Pharmacological management should therefore be viewed and incorporated as one component of a multi-disciplinary comprehensive treatment plan for specific requirements of a patient depending on the stage of the disorder. As there is a dearth of studies evaluating the use of psychopharmacology for EDs in C&As we first review the findings from studies performed in adults and then discuss specific studies performed in C&As. We include information from reviews and treatment guidelines to assist the clinician with an approach to the use of psychopharmacological agents in the treatment of EDs in C&As.

A narrative review of schemas and schema therapy outcomes in the eating disorders

Whilst cognitive-behavioural therapy has demonstrated efficacy in the treatment of eating disorders, therapy outcomes and current conceptualizations still remain inadequate. In light of these shortcomings there has been growing interest in the utility of schema therapy applied to eating pathology. The present article first provides a narrative review of empirical literature exploring schemas and schema processes in eating disorders. Secondly, it critically evaluates outcome studies assessing schema therapy applied to eating disorders. Current evidence lends support to schema-focused conceptualizations of eating pathology and confirms that eating disorders are characterised by pronounced maladaptive schemas. Treatment outcomes also indicate that schema therapy, the schema-mode approach, and associated techniques are promising interventions for complex eating disorders. Implications for clinical practice and future directions for research are discussed.

Does anxiety improve during weight restoration in anorexia nervosa? A systematic review

Weight restoration is considered a principal outcome for treatment of Anorexia Nervosa (AN) due to the significant physiological disturbances resultant from acute states of malnutrition. Treatment outcomes for populations with AN are relatively poor, with increasing evidence suggesting that weight restoration alone is insufficient for long-term recovery. Research aimed at understanding the psychological sequaele of AN, in particular during weight restoration, nevertheless remain scarce. This systematic review aimed to evaluate existing research regarding anxiety symptoms during treatment for AN, and the relationship of anxiety symptomology and weight restoration. Twelve articles were identified from a systematic search of three electronic databases (PsycINFO, MEDLINE, and Web of Science), and were eligible for inclusion. Study methodology, results and quality were reviewed. Results regarding change in anxiety symptomology were inconsistent, though evidence did not support a relationship between anxiety change and weight restoration. Reasons for these inconsistencies and limitations of included studies were reviewed. Further research is warranted to elucidate the role of anxiety in AN and its implications for treatment and longer-term outcome.

A comparison of clinical characteristics between adolescent males and females with eating disorders

BACKGROUND

Eating disorders (ED) are serious disorders that have a negative impact on both the psychological and the physiological well-being of the afflicted. Despite the fact that ED affect both genders, males are often underrepresented in research and when included the sample sizes are often too small for separate analyses. Consequently we have an unclear and sometimes contradictory picture of the clinical characteristics of males with ED. The aim of the present study was to improve our understanding of the clinical features of adolescent males with eating disorders.

METHODS

We compared age at presentation, weight at presentation, history of significantly different premorbid weight and psychiatric (Attention Deficit Hyperactivity Disorder (ADHD)) and somatic comorbidity (celiac disease and diabetes) of 58 males to 606 females seeking medical care for eating disorders at the Children's Hospital in Uppsala, Sweden during the years 1999-2012. As all boys were diagnosed with either AN or Other Specified Feeding or Eating Disorder (OSFED) atypical AN, the age and weight comparisons were limited to those girls fulfilling the diagnostic criteria for AN or OSFED atypical AN.

RESULTS

There was no significant difference in age at presentation. Differences in weight at presentation and premorbid weight history were mixed. A significantly higher percentage of males had a history of a BMI greater than two standard deviations above the mean for their corresponding age group. As well, there was a higher prevalence of ADHD among the males whereas celiac disease and diabetes only was found among the females.

CONCLUSIONS

A better understanding of the clinical characteristics of males with ED at presentation should improve our ability to identify males with ED and thereby aid in tailoring the best treatment alternatives.

Genetics and Epigenetics of Eating Disorders

Eating disorders (EDs) are serious psychiatric conditions influenced by biological, psychological, and sociocultural factors. A better understanding of the genetics of these complex traits and the development of more sophisticated molecular biology tools have advanced our understanding of the etiology of EDs. The aim of this review is to critically evaluate the literature on the genetic research conducted on three major EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). We will first review the diagnostic criteria, clinical features, prevalence, and prognosis of AN, BN, and BED, followed by a review of family, twin, and adoption studies. We then review the history of genetic studies of EDs covering linkage analysis, candidate gene association studies, genome-wide association studies, and the study of rare variants in EDs. Our review also incorporates a translational perspective by covering animal models of ED-related phenotypes. Finally, we review the nascent field of epigenetics of EDs and a look forward to future directions for ED genetic research.

Disseminating evidence-based psychological treatments for eating disorders

The research-practice gap is of concern in the treatment of eating disorders. Despite the existence of empirically supported treatments, few receive them. The barriers to wider dissemination and implementation of evidence-based treatment include clinician attitudes towards such treatments and the lack of sufficient numbers of suitably trained therapists to provide treatment. In this review we discuss these barriers in the context of the wider issue of the dissemination and implementation of psychological treatments and review the research with regard to the treatment of eating disorders. Particular emphasis is placed on examining recent efforts to expand the availability and reach of treatments by making treatment delivery and training more scalable. We highlight promising developments and areas where further research is needed.

Pre-treatment attachment anxiety predicts change in depressive symptoms in women who complete day hospital treatment for anorexia and bulimia nervosa

OBJECTIVES

Individuals with eating disorders are prone to depressive symptoms. This study examines whether depressive symptoms can change in women who complete intensive day treatment for anorexia and bulimia nervosa (BN), and whether these changes are associated with pre-treatment attachment insecurity.

DESIGN

Participants were 141 women with anorexia nervosa restricting type (n = 24), anorexia nervosa binge purge type (n = 30), and BN (n = 87) who completed a day hospital treatment programme for eating disorders. They completed a pre-treatment self-report measure of attachment, and a pre-treatment and post-treatment self-report measure of depressive symptoms.

RESULTS

Participants experienced significant reductions in depressive symptoms at post-treatment. Eating disorder diagnosis was not related to these improvements. However, participants lower in attachment anxiety experienced significantly greater improvement in depressive symptoms than those who were higher in attachment anxiety.

CONCLUSIONS

These results suggest that clinicians may tailor eating disorders treatments to patients' attachment patterns and focus on their pre-occupation with relationships and affect regulation to improve depressive symptoms.

PRACTITIONER POINTS

That depressive symptoms can decrease in women who complete day hospital treatment for anorexia and BN. That improvements in depressive symptoms do not vary according to eating disorder diagnosis in these women. That patients who complete treatment and who have higher attachment anxiety experience less improvements in depressive symptoms compared to those lower in attachment anxiety. That clinicians may attend to aspects of attachment anxiety, such as need for approval and up-regulation of emotions, to improve depressive symptoms in female patients with eating disorders.

Acceptability and feasibility of self-help Cognitive Remediation Therapy for anorexia nervosa delivered in collaboration with carers: a qualitative preliminary evaluation study

Anorexia nervosa (AN) is an eating disorder without a recommended first-line treatment. Cognitive Remediation Therapy (CRT) is showing great promise in helping patients reduce cognitive inflexibility and excessive detail focus, thinking styles that could make engaging in psychological therapies difficult. CRT has shown to be effective, feasible and acceptable in both individual and group formats, and positive qualitative data has been gathered from both service users and clinicians. The aim of the current study was to assess the use of CRT as a self-help treatment for individuals with AN delivered in collaboration with carers. Six families underwent a six-week self-help CRT intervention. Feedback was gathered from qualitative interviews and analysed using thematic analysis. Neuropsychological outcomes were also collected. Participant feedback regarding the intervention was generally positive, with participants describing a number of benefits such as it creating a space for families to spend time together outside of the eating disorder, acting as a 'gateway' for more emotional work and helping participants to gain insight into their cognitive profiles. These preliminary findings suggest that self-help CRT delivered in collaboration with carers is an acceptable form of treatment, and adds to the growing literature supporting CRT for AN.

Focus on anorexia nervosa: modern psychological treatment and guidelines for the adolescent patient

Anorexia nervosa is a serious condition associated with high mortality. Incidence is highest for female adolescents, and prevalence data highlight a pressing unmet need for treatment. While there is evidence that adolescent-onset anorexia has relatively high rates of eventual recovery, the illness is often protracted, and even after recovery from the eating disorder there is an ongoing vulnerability to psychosocial problems in later life. Family therapy for anorexia in adolescence has evolved from a generic systemic treatment into an eating disorder-specific format (family therapy for anorexia nervosa), and this approach has been evidenced as an effective treatment. Individual treatments, including cognitive behavioral therapy, also have some evidence of effectiveness. Most adolescents can be effectively and safely managed as outpatients. Day-patient treatment holds promise as an alternative to inpatient treatment or as an intensive program following a brief medical admission. Evidence is emerging of advantages in detecting and treating adolescent anorexia nervosa in specialist community-based child and adolescent eating-disorder services accessible directly from primary care. Limitations and future directions for modern treatment are considered.

Anorexia nervosa: A fresh perspective

Anorexia nervosa is currently presented as a pathologised, psycho-medical feminine phenomenon through aetiological rationalisations and theories. Research results indicate that there have been no improvements in treatment outcomes for anorexia for over 50 years, except, possibly, with forms of family therapy for adolescents. This situation can be seen as critical and calls for alternative ways of understanding anorexia, and consequent different approaches to psychotherapy for persons in relationship with anorexia. This article critically explores these issues, and suggests that such circumstances offer opportunities for alternative post-structuralist approaches for informing different understandings of and working with anorexia in collaborative relational arrangements where the voices of persons in relationship with anorexia are honoured and heard.

The Intestinal Microbiota in Acute Anorexia Nervosa and During Renourishment: Relationship to Depression, Anxiety, and Eating Disorder Psychopathology

OBJECTIVE

The relevance of the microbe-gut-brain axis to psychopathology is of interest in anorexia nervosa (AN), as the intestinal microbiota plays a critical role in metabolic function and weight regulation.

METHODS

We characterized the composition and diversity of the intestinal microbiota in AN, using stool samples collected at inpatient admission (T1; n = 16) and discharge (T2; n = 10). At T1, participants completed the Beck Depression and Anxiety Inventories and the Eating Disorder Examination-Questionnaire. Patients with AN were compared with healthy individuals who participated in a previous study (healthy comparison group; HCG). Genomic DNA was isolated from stool samples, and bacterial composition was characterized by 454 pyrosequencing of the 16S rRNA gene. Sequencing results were processed by the Quantitative Insights Into Microbial Ecology pipeline. We compared T1 versus T2 samples, samples from both points were compared with HCG (n = 12), and associations between psychopathology and T1 samples were explored.

RESULTS

In patients with AN, significant changes emerged between T1 and T2 in taxa abundance and beta (between-sample) diversity. Patients with AN had significantly lower alpha (within-sample) diversity than did HCG at both T1 (p = .0001) and T2 (p = .016), and differences in taxa abundance were found between AN patients and HCG. Levels of depression, anxiety, and eating disorder psychopathology at T1 were associated with composition and diversity of the intestinal microbiota.

CONCLUSIONS

We provide evidence of an intestinal dysbiosis in AN and an association between mood and the enteric microbiota in this patient population. Future directions include mechanistic investigations of the microbe-gut-brain axis in animal models and association of microbial measures with metabolic changes and recovery indices.

Time to restore body weight in adults and adolescents receiving cognitive behaviour therapy for anorexia nervosa

BACKGROUND

The aim of the present study was to provide benchmark data on the duration of treatment required to restore body weight (to BMI ≥18.5 or a corresponding BMI centile) in adolescents and adults with anorexia nervosa treated with outpatient cognitive behaviour therapy.

METHODS

Ninety-five participants (46 adolescents and 49 adults) were recruited from consecutive referrals to a specialist eating disorder clinic. Each was offered 40 sessions of enhanced cognitive behaviour therapy (CBT-E) over 40 weeks, the conventional length of this treatment.

RESULTS

Twenty-nine (63.1%) of the adolescents and 32 (65.3%) of the adults completed all 40 sessions of treatment (P = 0.818). Significantly more adolescents reached the goal BMI than adults (65.3% vs. 36.5%; P = 0.003). The mean time required by the adolescents to restore body weight was about 15 weeks less than that for the adults (14.8 (SE = 1.7) weeks vs. 28.3 (SE = 2.0) weeks, log-rank = 21.5, P < 0.001).

CONCLUSIONS

The findings indicate that adolescent patients receiving CBT-E are able to regain weight more successfully than adults and at a faster rate. If these findings are replicated and extend to eating disorder psychopathology, then their treatment could be shorter than that of adults.

A Brief, Intensive Application of Multi-Family-Based Treatment for Eating Disorders

There is a continued need to improve upon the efficacy and availability of treatments for anorexia nervosa. Family-based therapy for anorexia nervosa demonstrates strong empirical evidence; however, trained treatment providers are limited and a subsample of participants receiving the treatment fail to respond. The intensive family treatment program is a brief, time-limited, multi-family program that trains families of adolescents with eating disorders to oversee their adolescents' recovery at home by providing psychoeducation, skills training, and immersive practice over the course of a 5-day period. This article provide a description of the program by summarizing underlying theoretical principles and key therapeutic components.

Eating disorder symptoms and quality of life: where should clinicians place their focus in severe and enduring anorexia nervosa?

OBJECTIVE

The aim of this study was to examine the relationship between quality of life (QoL), weight, and eating disorder symptoms across treatment in individuals with severe and enduring anorexia nervosa (SE-AN).

METHOD

Participants were 63 adult females with SE-AN presenting to an outpatient, multisite randomized clinical trial. QoL was assessed using three well-validated QoL questionnaire measures, the EDQOL, SF-12, and WSAS. Participants' weight and severity of symptoms was assessed by Eating Disorder Examination (EDE) and weekly BMI change.

RESULTS

Predictors of QoL were evaluated in the context of concurrent, prospective,1 and lagged mixed-effects models. Changes in both BMI and EDE were found to significantly affect current and future QoL ratings.

DISCUSSION

Findings suggest that improvements in QoL may be dependent on symptom change and weight gain. Treatments seeking solely to improve QoL may be unlikely to produce lasting change and clinicians should maintain a focus on weight and behavioral symptoms as much as on improvements in QoL.

Psychotherapy in anorexia nervosa: What does the absence of evidence mean?

Psychological treatment in anorexia nervosa (AN) is disheartening. Psychotherapy is the “treatment of choice” for adults though this recommendation is grounded on the absence of good quality clinical studies. This paper seeks to address the question of why improvements in the psychological treatment of AN have been thwarted, and why one of the best treatments available for adult patients is specialist supportive clinical management that has entered the stage through the backdoor of nonspecific supportive treatments originally serving as a placebo treatment assigned in randomized clinical trials to control for non-specific aspects of true psychosocial treatments. The possibility that most of the psychopathological features that characterise the AN symptoms profile could be best understood as the direct consequences of emaciation would enhance the utility of research with animal models for generating new hypothesis to improve AN treatment.

Temperament-based treatment for anorexia nervosa

Anorexia nervosa (AN) tends to be a chronic and deadly disorder with no proven treatments that reverse core symptoms in adults. New insight into neurobiological mechanisms that contribute to symptoms may support development of more effective interventions. We describe the development of a temperament-based treatment for AN on the basis of empirically supported models. It uses a systemized approach and takes into consideration an understanding of how neurobiological mechanisms are expressed through behaviour and personality and contribute to specific AN symptomatology. This model integrates the development of AN-focused constructive coping strategies with carer-focused strategies to manage temperament traits that contribute to AN symptomatology. This intervention is consistent with the recent Novel Interventions for Mental Disorders initiative mandating that treatment trials follow an experimental medicine approach by identifying underlying mechanisms that are directly targeted by the intervention to influence symptoms.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders

OBJECTIVES

This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013-2014.

METHODS

The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008-2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified.

RESULTS

In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice.

CONCLUSIONS

Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management.

EXPERT REVIEWERS

Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.

Comparison of 2 family therapies for adolescent anorexia nervosa: a randomized parallel trial

IMPORTANCE

Anorexia nervosa (AN) is a serious disorder with high rates of morbidity and mortality. Family-based treatment (FBT) is an evidence-based therapy for adolescent AN, but less than half of those who receive this approach recover. Hence, it is important to identify other approaches to prevent the development of the chronic form of AN for which there is no known evidence-based treatment.

OBJECTIVE

To compare FBT with systemic family therapy (SyFT) for the treatment of adolescent-onset AN.

DESIGN, SETTING, AND PARTICIPANTS

Research in Anorexia Nervosa (RIAN) is a 2-group (FBT and SyFT) randomized trial conducted between September 2005 and April 2012. Interviewers were blinded to the treatment condition. A total of 564 adolescents receiving care at 6 outpatient clinics experienced in the treatment of AN were screened. Of these, 262 adolescents did not meet the inclusion criteria and 138 declined to participate; hence, 164 adolescents (aged 12-18 years) of both sexes meeting the criteria for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, AN (except for amenorrhea) were enrolled. Three participants were withdrawn from FBT and 7 were withdrawn from SyFT after serious adverse events occurred.

INTERVENTIONS

Two manualized family therapies with 16 one-hour sessions during 9 months. Family-based therapy focuses on the facilitation of weight gain, whereas SyFT addresses general family processes.

MAIN OUTCOMES AND MEASURES

The primary outcomes were percentage of ideal body weight (IBW) and remission (≥95% of IBW). The a priori hypothesis was that FBT would result in faster weight gain early in treatment and at the end of treatment (EOT).

RESULTS

There were no statistically significant differences between treatment groups for the primary outcome, for eating disorder symptoms or comorbid psychiatric disorders at the EOT or follow-up. Remission rates included FBT, 33.1% at the EOT and 40.7% at follow-up and SyFT, 25.3% and 39.0%, respectively. Family-based therapy led to significantly faster weight gain early in treatment, significantly fewer days in the hospital, and lower treatment costs per patient in remission at the EOT (FBT, $8963; SyFT, $18 005). An exploratory moderator analysis found that SyFT led to greater weight gain than did FBT for participants with more severe obsessive-compulsive symptoms.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that FBT is the preferred treatment for adolescent AN because it is not significantly different from SyFT and leads to similar outcomes at a lower cost than SyFT. Adolescents with more severe obsessive-compulsive symptoms may receive more benefits with SyFT.

TRIAL REGISTRATION

clinicaltrials.gov Identifier NCT00610753.

Review of smartphone applications for the treatment of eating disorders

mHealth tools may be a feasible modality for delivering evidence-based treatments and principles (EBPs), and may enhance treatment for eating disorders (EDs). However, research on the efficacy of mHealth tools for EDs and the extent to which they include EBPs is lacking. The current study sought to (i) review existing apps for EDs, (ii) determine the extent to which available treatment apps utilize EBPs, and (iii) assess the degree to which existing smartphone apps utilize recent advances in smartphone technology. Overall, existing ED intervention apps contained minimal EBPs and failed to incorporate smartphone capabilities. For smartphone apps to be a feasible and effective ED treatment modality, it may be useful for creators to begin taking utilizing the abilities that set smartphones apart from in-person treatment while incorporating EBPs. Before mHealth tools are incorporated into treatments for EDs, it is necessary that the feasibility, acceptability, and efficacy be evaluated.

A new service model for the treatment of severe anorexia nervosa in the community: the Anorexia Nervosa Intensive Treatment Team

Aims and method A community intensive treatment service for severe anorexia nervosa is described. The service is multidisciplinary but driven by a focus on psychological formulation. Psychological and dietetic interventions are grounded in a process of active risk management. Evaluations of safety, cost and acceptability of the service are described. Results Patients are highly satisfied with their care. A relatively low mortality rate for such a high-risk population was observed. In-patient bed use and costs were substantially reduced. Clinical implications There is a case for greater use of intensive community care for patients with severe anorexia nervosa, as it can be acceptable to patients, relatively safe and cost less than admission.

A genome-wide association study of anorexia nervosa

Anorexia nervosa (AN) is a complex and heritable eating disorder characterized by dangerously low body weight. Neither candidate gene studies nor an initial genome-wide association study (GWAS) have yielded significant and replicated results. We performed a GWAS in 2907 cases with AN from 14 countries (15 sites) and 14 860 ancestrally matched controls as part of the Genetic Consortium for AN (GCAN) and the Wellcome Trust Case Control Consortium 3 (WTCCC3). Individual association analyses were conducted in each stratum and meta-analyzed across all 15 discovery data sets. Seventy-six (72 independent) single nucleotide polymorphisms were taken forward for in silico (two data sets) or de novo (13 data sets) replication genotyping in 2677 independent AN cases and 8629 European ancestry controls along with 458 AN cases and 421 controls from Japan. The final global meta-analysis across discovery and replication data sets comprised 5551 AN cases and 21 080 controls. AN subtype analyses (1606 AN restricting; 1445 AN binge-purge) were performed. No findings reached genome-wide significance. Two intronic variants were suggestively associated: rs9839776 (P=3.01 × 10(-7)) in SOX2OT and rs17030795 (P=5.84 × 10(-6)) in PPP3CA. Two additional signals were specific to Europeans: rs1523921 (P=5.76 × 10(-)(6)) between CUL3 and FAM124B and rs1886797 (P=8.05 × 10(-)(6)) near SPATA13. Comparing discovery with replication results, 76% of the effects were in the same direction, an observation highly unlikely to be due to chance (P=4 × 10(-6)), strongly suggesting that true findings exist but our sample, the largest yet reported, was underpowered for their detection. The accrual of large genotyped AN case-control samples should be an immediate priority for the field.

Characteristics and stability of empirically derived anorexia nervosa subtypes: towards the identification of homogeneous low-weight eating disorder phenotypes

Anorexia nervosa (AN) is characterized by within-group heterogeneity in symptom presentation, which poses problems for research on etiology and treatment. This study sought to identify homogeneous subtypes of AN, and examine their short-term stability, using empirical methods. A treatment-seeking sample with AN (n = 194) was assessed at baseline and 6- and 12-month follow-ups. Latent class analysis was used to identify homogeneous AN subgroups, and latent transition analysis was used to examine the stability of latent classes. Three low-weight eating disorder classes were identified: 1) fat-phobic restricting (AN-R-FP); 2) fat-phobic binge-eating/purging (AN-BP-FP); and 3) non-fat-phobic restricting (AN-R-NFP). Subtype membership was stable over follow-up, with .68 to .88 probabilities of remaining in the same class from baseline to 6 months, and .87 to 1.00 from 6 months to 12 months. The most common transition pattern was between AN-R-FP and AN-R-NFP (56.8% of transitions); the majority of these participants transitioned from AN-R-FP to AN-R-NFP (n = 20/21). Predictors of latent class membership included lifetime mood and substance use disorder comorbidities, negative temperament, illness duration, and body mass index at treatment presentation. Disinhibition (vs. constraint), history of overweight or obesity, and illness duration decreased the probability of latent transition. Findings support the presence of 3 low-weight eating disorder phenotypes that are highly stable over short-term follow-up. Identification of a stable non-fat-phobic AN phenotype is intriguing and highlights the importance of studying mechanisms that differentiate fat-phobic and non-fat-phobic eating disorders.

Clinician and practice characteristics influencing delivery and outcomes of the early part of outpatient cognitive behavioural therapy for anorexia nervosa

Cognitive-behavioural therapy (CBT) can be effective for anorexia nervosa. However, there is evidence that the delivery of treatments for the eating disorders is inconsistent. This study examined evidence that clinician characteristics and practice can influence the effective implementation of CBT. The participants were 100 qualified clinicians who routinely offered outpatient CBT to adults with anorexia nervosa. They completed a survey of their demographic characteristics, level of anxiety, clinical practice in CBT for anorexia nervosa, and beliefs about the relationship between weight gain and therapeutic alliance in the early part of such treatment. Greater reported levels of weight gain were associated with the use of manuals, early focus on weight gain as a target, structured eating, and a belief that weight gain precedes a good working alliance. Clinician anxiety and early focus on the therapeutic alliance rather than structured eating were associated with poorer outcomes. These conclusions need to be tested within clinical and research settings. However, they suggest that clinicians should be encouraged to use manual-based approaches when treating anorexia nervosa using CBT, as focusing on techniques might result in the best possible outcome in this early part of treatment.