Outcome of eating disorders

Evaluating empirically valid and clinically meaningful change in intensive residential treatment for severe eating disorders at discharge and at a 6-month follow-up

PURPOSE

The present study evaluated the statistical and clinical significance of symptomatic change at discharge and after 6 months of an intensive residential treatment for patients with eating disorders (ED), and explored the individual factors that may affect therapeutic outcomes.

METHODS

A sample of 118 female ED patients were assessed at intake and discharge on the following dimensions: BMI, ED-specific symptoms, depressive features, and overall symptomatic distress. A subsample of 59 patients filled out the same questionnaires at a 6-month follow-up after discharge.

RESULTS

Findings evidenced statistically significant changes in all outcome measures at both discharge and follow-up. Between 30.1 and 38.6% of patients at discharge and 35.2-54.2% at the 6-month follow-up showed clinically significant symptomatic change; additionally, 19.8-29.1% of patients at discharge and 22.9-38.3% at follow-up improved reliably. However, 34.9-39.8% remained unchanged and 2-4.8% worsened. At the 6-month follow-up, 21.3-25.9% showed no symptomatic change and 0-3.7% had deteriorated. Unchanged and deteriorated patients had an earlier age of ED onset and were more likely to suffer a comorbid personality pathology and to be following concurrent pharmacological treatment.

CONCLUSIONS

Results suggested that intensive and multimodal residential treatment may be effective for the majority of ED patients, and that therapeutic outcomes tend to improve over time. Prevention strategies should focus on early onset subjects and those with concurrent personality pathology.

LEVEL OF EVIDENCE

Level III, evidence obtained from a longitudinal cohort study.

Change in decision-making skills and risk for eating disorders in adolescence: A population-based study

BACKGROUND

Despite the growing interest in the involvement of decision-making under conditions of risk in the onset of eating disorders in adolescence, no studies have investigated how the development of decision-making across that period may influence such a risk. Using data from the Millennium Cohort Study this study explored whether changes in performance on the Cambridge Gambling Task (CGT) between age 11 and age 14 were associated with presence of eating disorder (ED) symptoms at age 14.

METHODS

Latent class analysis was used to identify groups with distinct profiles based on their responses to questions investigating eating and dieting at age 14. CGT change scores were used as predictors of latent class membership in a logistic regression while accounting for confounders.

RESULTS

In our sample of 11,303 participants, the best class solution was a two-class one reflecting high and low risk for ED symptoms. Higher risk-taking scores and lower quality of decision-making scores at age 11 were associated with increased odds of belonging to the high-risk group at age 14. Risk-taking was reduced from age 11 to age 14, but a smaller reduction was associated with a higher probability of being in the higher risk group at age 14. The change over time in the other CGT measures was not associated with risk for ED symptoms.

CONCLUSIONS

Atypical change in risk-taking from early to middle adolescence may be implicated in the risk of ED symptoms in middle adolescence. These results should be replicated in clinical samples.

Potential shortcomings in current studies on the effect of intranasal oxytocin in Anorexia Nervosa and healthy controls - A systematic review and meta-analysis

RATIONALE

The psychopathology of anorexia nervosa (AN) includes altered social cognition and information processing of fear and anxiety. Oxytocin, a neuromodulating hormone, may influence these functions and could be valuable for the treatment of AN.

OBJECTIVE

The current study aimed at reviewing the effect of intranasal oxytocin (IN-OT) on attentional bias (AB) and emotion recognition (ER) in AN.

METHODS

A systematic literature review was done for free-text and the MeSH-terms: anorexia nervosa, feeding and eating disorders, and oxytocin. Six publications, reporting from 4 unique clinical trials, were included in this review. A meta-analysis was conducted to examine the effects of IN-OT on AB towards food images and ER on healthy controls (HC) and patients with AN.

RESULTS

Overall, IN-OT did not influence AB towards food images (effect size = 0.20 [- 0.16, 0.57], p = 0.28) and had no effect on ER (effect size = - 0.01 [- 0.27, 0.26], p = 0.97) in patients with AN and healthy control (HC) subjects collectively. Assessing HC and AN separately in subgroup analyses did not show any significant effect on AB and ER in neither of the subgroups. All tests were done between 15 and 55 min post-administration of IN-OT, while peak concentration in the cerebrospinal fluid has been determined to be at 75 min.

CONCLUSION

The current level of evidence is moderate showing no effect of IN-OT on AB or ER in AN. However, brain exposure may not have been sufficient which future studies with IN-OT need to ensure by considering dose and dose-to-task interval.

Excessive laboratory monitoring to prevent adolescent's refeeding syndrome: opportunities for enhancement

PURPOSE

Anorexia nervosa (AN) is a complex medical condition affecting mainly adolescents and young adults. To monitor and prevent refeeding syndrome, current guidelines recommend daily laboratory testing in the first week of hospitalization and 2-3 times/week for the following 3 weeks. The aims of this study were to determine the proportion of abnormal results of the blood tests done during the first week of nutritional rehabilitation in adolescents with AN, the proportion of test having led to supplementation and the cost of all these tests.

METHOD

A retrospective chart review of admissions for eating disorders between May 2014 and May 2015 in a tertiary Pediatric University Hospital center was performed. Patients were included if they were younger than 18 years, admitted for protocol-based refeeding and met criteria for AN (DSM 5).

RESULTS

Among the 99 hospitalizations included in the study, the mean age was 14.6 years (± 1.7), with a female predominance (97%). The mean admission BMI was 15.3 ± 2 kg/m² (Z-score - 2.6 ± 1.4). The mean length of hospitalization was 40.3 days ± 21.8. Of the 1289 laboratory tests performed, only 1.5% revealed abnormal values and 0.85% led to supplementation. No critical value was identified. The total cost for the tests performed was 148,926.80 CAD$, 1504$/admitted patient, instead of 3890$/admitted patient had we followed the recommendations.

CONCLUSION

More precise criteria should be developed regarding the frequency of laboratory tests needed to monitor and prevent refeeding syndrome. At present, the recommendations could lead to unnecessary testing and expenses.

LEVEL OF EVIDENCE

Level IV: Dramatic results in uncontrolled trials.

Treating Eating: A Dynamical Systems Model of Eating Disorders

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

Prevalence and Risk Factors of Disordered Eating Attitudes and Behaviors Among High-school Girls in Al-Madinah City, Saudi Arabia

Objectives::

To determine the prevalence of disordered eating attitudes and behaviors among high-school girls in Al-Madinah City, Saudi Arabia.

Methods::

A cross-sectional descriptive study was conducted in Al-Madinah city in 2014-15. A multi- stage random sampling technique was adopted to include female students of government secondary schools. The Eating Attitudes Test (EAT-26) and socio-economical questionnaires were used in the study for assessing the prevalence of disordered eating. All data were entered and analyzed using SPSS version 20.

Results::

Overweight and obesity were reported among 11.2% and 5.6% of them, respectively, whereas 31.3% of the participants were underweight. The overall prevalence of disordered eating attitudes among female students was 42.5%. This rate was significantly higher among younger (≤16 years old) and those of the first scholastic level than others. The rate of disordered eating attitude was reported at a higher rate among obese students (59.1%) than underweight (41.5%) and normal students (42.4%). The commonest reported disordered eating behavior was self-reported binge eating behaviour (25.2%), followed by self-induced vomiting (8.7%) and the use of laxatives/ diuretics to control weight (6.1%).

Conclusion::

The findings show a high prevalence of disordered eating attitude among high school female students in Al-Madinah city. Younger girls and those of the first scholastic level showed higher disordered eating attitude.

Medical Assessment and Triage of Pediatric Patients with Anorexia Nervosa in Primary Care

OBJECTIVE

To examine the medical assessment and triage of pediatric patients with anorexia nervosa (AN) initially seen in primary care.

METHODS

A retrospective cohort study was conducted for all pediatric patients with AN who had eating/weight concerns and initially identified symptoms in primary care in a single health care system between January 1, 2010, and December 31, 2016. Information on presenting concern, medical assessment/laboratory tests, clinical diagnoses, treatment recommendations, and referrals were abstracted from the medical record.

RESULTS

Forty-one (mean age = 13.7 years; SD = 2.2) pediatric patients with AN had eating/weight concerns and initially identified symptoms in a primary care. Overall, only 5% (n = 2/41) of patients received an AN diagnosis during the index visit; a minority were assessed for electrolyte disturbance (n = 20), electrocardiogram abnormality (n = 18), hypothermia (n = 13), binge/purge behaviors (n = 13), orthostatic hypotension (n = 2), or dehydration (n = 1), and only 56% (n = 23) received triage consistent with practice recommendations. Although 61% (n = 25) met criteria for inpatient admission, inpatient hospitalization was recommended for only 2 patients. Patients who received triage consistent with practice recommendations received AN diagnosis and treatment significantly earlier than those who did not (p < 0.01 and p = 0.001, respectively).

CONCLUSION

Findings suggest that pediatric patients with AN may not be receiving medical assessment and triage per practice recommendations in the primary care setting. Understanding barriers to evidence-based care for pediatric eating disorders may inform provider education and system-wide changes to enhance outcomes in these patients.

Adolescent and Parent Experience of Care at a Family-Based Treatment Service for Eating Disorders

OBJECTIVE

Incorporating consumer perspectives is an important but often overlooked opportunity to optimize treatment engagement and outcomes for adolescents with eating disorders. This study explored the experience of care of adolescents and their parents at a multidisciplinary specialist eating disorders service providing family-based treatment (FBT) as first-line treatment.

METHOD

Eighty-five adolescents and 145 parents who completed FBT at the service between 2013 and 2015 were surveyed in 2017 about their experience of care. A study-designed survey asked respondents to rate on Likert scales their experience of service access, intake assessment, education, support, interactions with the treatment team, recovery, and the discharge process. Open-ended comments on helpful and unhelpful aspects of the service provided further context on the ratings.

RESULTS

Overall families were very positive about their experience, particularly in regard to assessment, education, interactions with the team, and achieving physical health. Although parents tended to be more satisfied, adolescents also held the service in high regard. Some areas were identified that could be improved, including treatment delays, carer support, therapeutic alliance, and preparation for discharge.

CONCLUSIONS

Surveying families about their experience of care provides an important opportunity to identify service strengths as well as services gaps. The results indicated several areas that specialist eating disorder services could focus on to ensure that the services provided, including FBT, fully meet the needs of families and optimize adolescents' treatment experiences.

Dopaminergic activity and exercise behavior in anorexia nervosa

Driven exercise (i.e., the tendency to exercise in excess to influence weight/shape or regulate emotion) is difficult to manage in the context of anorexia nervosa, and is associated with poorer treatment outcomes, and psychological and medical severity. Driven exercise is observed in a considerable number of those diagnosed with anorexia nervosa; however, to date, this hallmark symptom remains poorly understood. Dopamine signaling is implicated in motivating and maintaining appetitive behavior among patients with eating disorders; but, much less is known about the role of dopamine signaling specific to the symptom of driven exercise. An improved understanding of this biobehavioral mechanism may inform the etiology of driven exercise in anorexia nervosa, with the potential to impact future research and treatment efforts. This review describes the role that dopamine serves in maintaining symptoms in the context of anorexia nervosa, and synthesizes current relevant evidence on exercise in AN and related dopaminergic activity. Throughout, theoretical implications are discussed, along with critical directions for future research.

Anorexia nervosa: 30-year outcome

BACKGROUND

Little is known about the long-term outcome of anorexia nervosa.

AIMS

To study the 30-year outcome of adolescent-onset anorexia nervosa.

METHOD

All 4291 individuals born in 1970 and attending eighth grade in 1985 in Gothenburg, Sweden were screened for anorexia nervosa. A total of 24 individuals (age cohort for anorexia nervosa) were pooled with 27 individuals with anorexia nervosa (identified through community screening) who were born in 1969 and 1971-1974. The 51 individuals with anorexia nervosa and 51 school- and gender-matched controls were followed prospectively and examined at mean ages of 16, 21, 24, 32 and 44. Psychiatric disorders, health-related quality of life and general outcome were assessed.

RESULTS

At the 30-year follow-up 96% of participants agreed to participate. There was no mortality. Of the participants, 19% had an eating disorder diagnosis (6% anorexia nervosa, 2% binge-eating disorder, 11% other specified feeding or eating disorder); 38% had other psychiatric diagnoses; and 64% had full eating disorder symptom recovery, i.e. free of all eating disorder criteria for 6 consecutive months. During the elapsed 30 years, participants had an eating disorder for 10 years, on average, and 23% did not receive psychiatric treatment. Good outcome was predicted by later age at onset among individuals with adolescent-onset anorexia nervosa and premorbid perfectionism.

CONCLUSIONS

This long-term follow-up study reflects the course of adolescent-onset anorexia nervosa and has shown a favourable outcome regarding mortality and full symptom recovery. However, one in five had a chronic eating disorder.

Perspectives of professionals on the treatment and service delivery of eating disorders in cyprus

This paper investigates the perspectives of care professionals on the treament of eating disorders and the capacity of the existing settings in Cyprus, to treat eating disorders. Qualitative, semi-structured interviews were conducted with seven professionals, working in settings for treating patients with eating disorders. The investigation identified two themes: The first theme concerns the necessity to fulfill the complex needs of patients with eating disorders, as well as the needs of their families. In addition, it concerns the importance of adopting a holistic and multimodal approach towards treating eating disorders, in order to achieve successful treatment outcomes. The attitudes and feelings of care professionals working with patients with eating disorders, were also identified. The second theme that emerged is an acknowledgement of the necessity for a stronger collaboration between the existing settings, for coordinated monitoring of these settings, and for upgrading specialized training. These two themes are interrelated and create barriers, which may prevent effective service delivery, affect the attitudes of professionals, and hinder the process of treatment.

Basal ganglia volume and shape in anorexia nervosa

Background

Reward-centred models have proposed that anomalies in the basal ganglia circuitry that underlies reward learning and habit formation perpetuate anorexia nervosa (AN). The present study aimed to investigate the volume and shape of key basal ganglia regions, including the bilateral caudate, putamen, nucleus accumbens (NAcc), and globus pallidus in AN.

Methods

The present study combined data from two existing studies resulting in a sample size of 46 women with AN and 56 age-matched healthy comparison (HC) women. Group differences in volume and shape of the regions of interest were examined. Within the AN group, the impact of eating disorder characteristics on volume and shape of the basal ganglia regions were also explored.

Results

The shape analyses revealed inward deformations in the left caudate, right NAcc, and bilateral ventral and internus globus pallidus, and outward deformations in the right middle and posterior globus pallidus in the AN group.

Conclusions

The present findings appear to fit with the theoretical models suggesting that there are alterations in the basal ganglia regions associated with habit formation and reward processing in AN. Further investigation of structural and functional connectivity of these regions in AN as well as their role in recovery would be of interest.

Obstacles and facilitators of therapeutic alliance among adolescents with anorexia nervosa, their parents and their psychiatrists: A qualitative study

BACKGROUND

Therapeutic alliance is one of the most important aspects of treatment of adolescents with anorexia nervosa. Little is known about the facilitators and obstacles of its process in this situation. We aimed to explore the experience of therapeutic alliance in inpatient treatment among adolescents with anorexia nervosa, their parents and their psychiatrists.

METHODS

This qualitative study, using semi-structured interviews, took place in France. Data collection by purposive sampling continued until we reached theoretical sufficiency. Data analysis was thematic.

RESULTS

Forty-one participants were included, 15 teenaged girls, 18 parents and 8 psychiatrists. Analysis showed two themes: (1) what facilitates an alliance in treatment - with four facilitators: (a) human qualities, (b) an active role in the treatment, (c) taking time and (d) taking care of the entire family and (2) what impedes an alliance in treatment with four obstacles: (a) being too close or too distant, (b) focusing on weight, (c) control and constraints and (d) psychiatrization.

CONCLUSION

Collaborative work between paediatricians and psychiatrists could facilitate therapeutic alliance with parents. Definition of therapeutic alliance in this situation should be enlarged to include the adolescent-parent relationship. It is necessary to construct specific items to integrate these specific aspects to existing scales.

Eating Disorder Recovery: A Metaethnography

BACKGROUND: Eating disorders seriously affect both physical health and psychosocial functioning. Breaking the confines of an eating disorder requires engagement in a multifaceted recovery process. OBJECTIVE: This article provides a synthesis of 12 qualitative research studies with various eating disordered populations (anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder not otherwise specified, and other specified feeding and eating disorders) to elucidate the recovery process from the perspective of those who have overcome the disease. METHOD: A metasynthesis of qualitative studies was conducted using Noblit and Hare's metaethnographic methodology. RESULTS: Five overarching themes emerged from the data: (1) the eating disorder as a life jacket, (2) drowning: recognizing consequences, (3) treading the surface: contemplating recovery, (4) swimming: the path toward recovery, and (5) reaching recovery: a sense of freedom. CONCLUSIONS: Eating disorder treatment often entails a cycle of transitions before recovery occurs. Synthesizing the experiences from the perspective of individuals who have overcome an eating disorder presents a unique understanding of the treatment and recovery process.

The Use of Electroconvulsive Therapy in Eating Disorders: A Systematic Literature Review and Case Report

OBJECTIVE

The aim of this study was to determine the potential for safe and effective use of electroconvulsive therapy (ECT) in treating eating disorders (EDs) in patients with and without comorbid psychiatric disorders.

METHODS

A review of the literature pertaining to the use of ECT in patients with EDs was performed through PubMed, PsycINFO, and MEDLINE. Search terms included "Electroconvulsive Therapy," "ECT," and "Electroshock" each combined with "Anorexia Nervosa," "Bulimia Nervosa," "Binge Eating Disorder," "Eating Disorder," "EDNOS," and "OSFED." Additionally, a case in which ECT was used in treating a patient with anorexia nervosa is presented.

RESULTS

Eighty-nine articles were reviewed, and 11 were selected for inclusion. These articles detailed 14 patients with active EDs who received ECT during their course of treatment. Of these patients, 13 were noted to have shown improvement in disordered eating after receiving ECT, and no adverse medical outcomes were reported. Our case detailed an additional patient who benefitted from ECT.

CONCLUSIONS

There are limited data supporting the use of ECT in treating EDs; however, there is evidence to support that ECT is safe in this population and has been effective in cases of patients with AN with and without psychiatric comorbidities as well as binge eating disorder. More research is needed for treatment guidelines.

Adolescent males with atypical anorexia nervosa and premorbid obesity: three case reports

PURPOSE

Premorbid obesity is an identified risk factor for eating disorder (ED) development among adolescent males. However, pervasive gender- and weight-related biases about ED inhibit timely diagnosis and treatment among this demographic. This study examined the psychological and medical characteristics of three adolescent males with premorbid obesity who were not diagnosed with atypical anorexia nervosa (AAN) until medical sequelae of malnutrition warranted emergent hospitalization. Factors associated with diagnostic delays among these cases were identified to facilitate increased awareness of this at-risk demographic.

METHODS

Retrospective chart review was conducted on three adolescent males (aged 12-17) with AAN and premorbid obesity who were medically hospitalized for 13-24 days (M = 20.3, SD = 9.7). Demographic variables, psychological characteristics, and physical data were extracted.

RESULTS

Each case presented at normal or overweight BMI status (M = 22.7 kg/m², SD = 3.2) following a significant loss of weight ranging from 19 to 42% of total body mass (M = 31.7%, SD = 9.5) over 5-12 months (M = 8.3, SD = 2.9). Plausible factors associated with diagnostic delays included initial weight loss recommendations by a medical provider, with little support or oversight; limited insight that symptoms were problematic; social reinforcement of dieting behaviors; low prevalence of psychiatric comorbidity; parental obesity; and parental history of bariatric surgery.

CONCLUSIONS

These cases elucidate the importance of close follow-up of youth with obesity who are encouraged to lose weight. Further education about AAN among males with premorbid obesity is crucial for timely diagnosis and intervention.

An update on the medical consequences of anorexia nervosa

PURPOSE OF REVIEW

The diagnosis of anorexia nervosa is associated with the highest mortality rate of any psychiatric disorder, mainly caused by medical complications.The purpose of this article is to review the common medical consequences of anorexia nervosa focusing on the special considerations related to children and adolescents and recent updates on the pathophysiology of these complications and their prognosis significance.

RECENT FINDINGS

The main findings were related to the diagnostic and prognostic value of hypokalaemia, QTc prolongation, hypoglycaemia and orthostatic changes. A new modality to evaluate the heart in anorexia nervosa was explored (2DSTE) as well. Bone mineral density (BMD) loss is one of the few nonreversible consequences of anorexia nervosa. BMD loss does not seem to be significantly related to sex or to cut-off low-weight parameters in teenagers with anorexia nervosa, but rather to the amount of weight loss they have experienced. Brain volume deficits might be another irreversible complication in adolescents with anorexia nervosa.

SUMMARY

It is crucial for any healthcare provider to be informed about the medical consequences of anorexia nervosa, not only because they can be devastating, but also because they can play an essential role in motivating patients to get treated.

Characteristics of patients in an eating disorder sample who dropped out: 2-year follow-up

OBJECTIVE

This manuscript explores the characteristics of individuals diagnosed with an eating disorder who dropped out of treatment, compared with those who completed it.

METHOD

The participants were 196 patients diagnosed with eating disorders (according to DSM-IV-TR criteria) who consecutively began treatment for the first time in an eating disorders unit. They were assessed at baseline with a set of questionnaires evaluating eating habits, temperament, and general psychopathology. During the follow-up period, patients who dropped out were re-assessed via a telephone interview.

RESULTS

In the course of a 2-year follow-up, a total of 80 (40.8%) patients were labeled as dropouts, and 116 (59.2%) remaining subjects were considered completers. High TCI scores in the character dimensions of Disorderliness (NS4) (p < .01) and total Novelty Seeking (NST), along with low scores in Dependency (RD4), were significantly associated with dropout in the course of 2 years. Once the results were submitted to logistic regression analysis, dropout only remained associated with high scores in Disorderliness (NS4) and, inversely, with an initial Anorexia Nervosa (AN) diagnosis (p < .05). Reasons for dropout stated by the patients included logistic difficulties, subjective improvement of their condition, and lack of motivation.

DISCUSSION

Clinicians should handle the first therapeutic intervention with particular care in order to enhance their understanding of clients and their ability to rapidly identify those who are at risk of dropping out of treatment.

LEVEL OF EVIDENCE

Level III: Cohort Study.

Cortical morphometry in anorexia nervosa: An out-of-sample replication study

BACKGROUND

Acute anorexia nervosa (AN) is frequently accompanied by reduced global cortical volume. Investigations of local cortical alterations in AN have revealed widespread reduction in cortical thickness, gyrification, and curvature. The aim of the present study was to combine data from two previous studies to replicate previous findings.

METHODOLOGY

Magnetic resonance imaging (MRI) images from 46 adult women with AN and 54 age-matched healthy comparison (HC) women were analysed using FreeSurfer. Group differences in cortical volume and local cortical measures, including gyrification, curvature, thickness, and area, were examined controlling for dataset and age.

RESULTS

The AN group had reduced global cortical volume relative to the HC group. The AN group also had reduction in local cortical gyrification, small localised clusters of reduced cortical thickness, in the occipital and parietal cortices, and surface area in the frontal and temporal cortices. The AN group also had increased cortical thickness in the ACC relative to the HC participants.

CONCLUSIONS

The present findings replicate and validate previous findings of reduced global cortical volume and local gyrification in acute AN. The findings highlight the need for further investigation of local cortical folding, thickness, and surface area in AN to gain further insight into the biological underpinnings of AN.

Assessment of Knowledge, Attitudes, and Behaviors toward Eating Disorders among Adolescents in Italy

The objectives of this survey were to assess the knowledge, attitudes, and behaviors toward eating disorders among adolescents in Italy. The survey was undertaken between May and June 2017 among a random sample of 420 adolescents aged 14-20 years. Data were collected through a self-administered questionnaire. Only 22.8% correctly knew both the definition of anorexia and bulimia nervosa. Female, overweight or obese individuals, and who had at least one parent with a college degree or higher level of education were more likely to have this knowledge. More than one third (38.8%) had a fear of getting fat. Female, overweight or obese individuals, who did not know the definition of anorexia and bulimia nervosa, who avoided eating when they were hungry, and who always and usually were engaged in dieting behavior were more likely to have a fear of getting fat. Only 10.1% and 11.9% always and usually were engaged in dieting behavior, and 40.8% never did so. Respondents who usually/always had a strong desire to be thinner and who had a fear of getting fat were more likely to be engaged in dieting behavior. There is an urgent need to inform Italian adolescents about eating disorders, and healthcare workers may play a crucial role in distributing eating disorder-related knowledge.

Predictors of early response in conjoint and separated models of family-based treatment for adolescent anorexia nervosa

OBJECTIVE

Early response, as indicated by early weight gain, in family-based treatment (FBT) for adolescent anorexia nervosa (AN) predicts remission at end of treatment. However, little is known about what factors contribute to early response. Further, no previous studies have examined early response to separated forms of FBT.

METHOD

Data from a randomised clinical trial of conjoint FBT and separated FBT (parent-focused treatment, PFT) were analysed to examine the timing and amount of early weight gain that predicted remission and identify factors associated with early response.

RESULTS

Weight gain of at least 2.80 kg in FBT (N = 55) and 2.28 kg in PFT (N = 51), by Session 5, were the best predictors of remission at end of treatment. Early response in FBT was predicted by greater paternal therapeutic alliance and lower paternal criticism. Early response in PFT was predicted by less severe eating-disorder symptoms and negative affect at baseline, lower maternal criticism, and greater adolescent therapeutic alliance.

CONCLUSIONS

The results confirm that early weight gain is an important prognostic indicator in both conjoint FBT and PFT and suggest that addressing negative emotion, parental criticism, and therapeutic alliance early in treatment could improve remission rates.

Can Recovery From an Eating Disorder Be Measured? Toward a Standardized Questionnaire

Background: There is a clear need for a standardized definition of recovery from eating disorders (EDs) and for self-report instruments to assess where individuals with an ED are situated at a given point of time along their process of illness and recovery. It has been acknowledged that psychological and cognitive symptoms are important to recovery in addition to physical and behavioral indices. This study proposes a 28-item multidimensional questionnaire encompassing the main features of recovery from ED, derived from the endorsement of different criteria by people with a lifetime ED diagnosis, family members and ED clinicians. Methods: Participants were 213 volunteers over the age of 18 (118 people with a lifetime ED diagnosis, 58 healthy family members of people with EDs and 37 ED clinicians), who completed the ED-15 and indicated online how important they thought each of 56 criteria were for recovery from an ED. Results: Four factors were identified in an exploratory factor analysis: Lack of Symptomatic Behavior (LSB), Acceptance of Self and Body (ASB), Social and Emotional Connection (SEC), and Physical Health (PH). Confirmatory factor analysis using the seven highest loading items from each subscale confirmed the structure validity of a shortened version of this questionnaire, the Eating Disorders Recovery Endorsement Questionnaire (EDREQ), which had excellent goodness-of-fit indices. Despite a few between-group differences, there was general agreement that LSB was most salient to recovery, followed by ASB, SEC, and PH in that order. Conclusion: Despite the absence of a standardized definition of recovery from ED, there is a general consensus about its components. The EDREQ is a psychometrically sound questionnaire containing items that people with an ED history, their family members and therapists all define as important components of recovery. The inclusion of emotional and psychosocial aspects of recovery in addition to symptomatic and medical aspects is important to expand treatment goals and the concept of recovery from EDs beyond symptom relief and the absence of disease markers. As a clinical tool, the EDREQ stands to assist in setting and refining therapeutic goals throughout therapy, and in establishing standardized, comparable norms for recovery levels in research.

Evaluation of a pilot interprofessional education programme for eating disorder training in mental health services

OBJECTIVE

To evaluate the effectiveness of an Interprofessional Education (IPE) programme in eating disorders for mental health practitioners using a case-based learning approach.

METHODS

A total of 25 mental health clinicians were asked to evaluate their IPE programme as part of training for the National Clinical Programme in Eating Disorders. They completed a Readiness for Interprofessional Learning Scale (RIPLS), a learner reaction questionnaire after each session and a final open evaluation at 4 months. Non-parametric statistical analysis was employed to analyse learner attitudes and reactions, and qualitative information was coded.

RESULTS

A total of 23 (92%) clinicians from five disciplines participated. Baseline attitudes towards IPE were positive on all RIPLS subscales, and those with prior IPE experience had most positive views as to its benefits for teamwork and patient care (p=0.036). Learner reactions on content, delivery, outcome and structure indicated that individual learning experience was strongly positively endorsed. Change in clinical practice behaviour was reported in terms of communication, clinical activity, outcome evaluation and confidence. Barriers included other demands on time, organisational support, not having enough patients or co-workers to practice skills, and knowledge differentials between learners.

CONCLUSIONS

IPE using a case based learning approach is an effective and acceptable means of developing specialist training across existing service, team and professional boundaries. It has potential for positive impact on knowledge, clinical behaviour and service delivery. Recommendations include the introduction of IPE group guidelines, wider circulation of learning points and content, and the use of self-competency ratings and reflective logs.

Predictors of Complications in Anorexia Nervosa and Atypical Anorexia Nervosa: Degree of Underweight or Extent and Recency of Weight Loss?

PURPOSE

Adolescents with atypical anorexia nervosa (AAN) can experience severe physical complications despite not being underweight, posing questions about the contribution of weight loss to complications experienced in restrictive eating disorders (EDs). This study compared total weight loss and recent weight loss with admission weight as predictors of physical and psychological complications.

METHODS

Retrospective (2005-2010) and prospective (2011-2013) studies were undertaken of 12- to 19-year-old hospitalized adolescents with anorexia nervosa (AN) or AAN, defined as meeting criteria for AN except underweight (≥85% median body mass index). Predictors were total weight loss (from lifetime maximum), recent weight loss (past 3 months), and admission weight. Outcomes were hypophosphatemia, clinical, anthropometric, and psychometric markers during admission.

RESULTS

In 171 participants (AN, 118 [69%]; AAN, 53 [31%]), there was little evidence of an association between weight measures and hypophosphatemia. Greater total weight loss (regression coefficient [Coeff]: -1.70, 95% confidence interval [CI]: -2.77, -.63, p = .002) and greater recent weight loss (Coeff: -3.37, 95% CI: -5.77, -.97, p = .006), but not admission weight, were associated with a lower pulse rate nadir. Greater total weight loss (odds ratio [OR]: 1.70, 95% CI: 1.19, 2.24, p = .003) and greater recent weight loss (OR: 2.12, 95% CI: 1.11, 4.02, p = .02) were also associated with a higher incidence of bradycardia.

CONCLUSIONS

In adolescents with restrictive EDs, total weight loss and recent weight loss were better predictors than admission weight of many physical complications. This suggests that future diagnostic criteria for AN place greater emphasis on weight loss.

Enhanced cognitive behavioural therapy for patients with eating disorders: a systematic review

PURPOSE OF REVIEW

The aim of this study was to provide an update of the most recent (since January 2014) enhanced cognitive behavioural therapy (CBT-E) effectiveness studies (randomized controlled trials and open trials) on bulimia nervosa, binge eating disorder and transdiagnostic samples.

RECENT FINDINGS

Out of 451 screened studies, seven effectiveness studies (five randomized and two open trials) were included in this review: of these, three had a bulimia nervosa sample and four a transdiagnostic sample (all conducted in an outpatient setting). Substantial differences in posttreatment remission rates were found (range: 22.2-67.6%) due, in part, to differences in samples and operationalization of clinical significant change.

SUMMARY

There is robust evidence that CBT-E is an effective treatment for patients with an eating disorder. However, more studies on differential effects and working mechanisms are required to establish the specificity of CBT-E.

Therapeutic Alliance and Anorexia Nervosa Treatment Outcomes: Experiences of Young People and Their Families

Treatments for anorexia nervosa provided early in the onset of the illness lead to better outcomes. Despite the treatment approach used, the therapeutic alliance may be instrumental in successful outcomes. The aim of this study was to explore the young people and their families' experiences of the illness, and their access to and satisfaction with the services received. Of particular interest was their view of the working alliance with their therapist/s. Participants were interviewed by telephone using a semi-structured questionnaire. Family based treatment or the Maudsley was found superior to other treatments with regard to physical markers of recovery, satisfaction with the services and therapy received, as well as the strength of the therapeutic alliance. All the interviewees stressed the need for more research, education, accessibility and flexibility of services and increased support for both the young people and their families.

Exercise, diet, and the reinforcing value of food in an animal model of anorexia nervosa

Activity-based anorexia (ABA) develops when laboratory rats are subjected to a single meal per day and have access to an activity wheel for the remaining time. Here, we studied the contribution of exercise and diet to the reinforcing value of food during ABA development. Three groups of eight adult male Wistar rats were used: an ABA group with 21.5 hr (then 22 hr) of wheel access and 1 hr (then 30 min) of food access, a control group with the same time exposure to food but without exercise, and a yoked group to the ABA in terms of weight loss. Rats were daily tested on a progressive-ratio schedule to measure their motivation for food. ABA rats gradually reduced their body weight more than the food control group. Animals steadily increased their breaking points in parallel to losses in body weight, but no significant differences were found between groups. Adult rats can develop ABA, but their loss in weight neither resulted in a decrease of food intake nor in the motivation to obtain it.

The adolescent onset anorexia nervosa study (ANABEL): Design and baseline results

The anorexia nervosa adolescent longitudinal biomarker assessment study (ANABEL) is a 2-year longitudinal study.

OBJECTIVE

Evaluate several clinical, biochemical, immunological, psychological, and family variables and their interactions in adolescent onset eating disorders (EDs) patients and their 2-year clinical and biological outcome. This article illustrates the framework and the methodology behind the research questions, as well as describing general features of the sample.

METHODS

A longitudinal study of 114 adolescents with EDs seeking treatment was performed. Only adolescents were selected during 4 years (2009-2013). The variables were collected at different times: baseline, 6, 12, 18, and 24 months of the start of treatment. Diagnoses were completed through the semi-structured Kiddie-Schedule for Affective Disorders and Schizophrenia interview.

RESULTS

At baseline, the mean age was 15.11 (SD = 1.36). The mean ED duration was 10 months (SD = 5.75). The mean body mass index was 16.1 (SD = 1.8). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis at baseline for restrictive anorexia nervosa was 69.6%, 17.4% for purgative anorexia nervosa, and 24.3% for other specified feeding disorder. At 12 months, 19.4% were in partial remission, whereas at 24 months, 13.8% had fully recovered and 29.2% had partially recovered.

CONCLUSIONS

There was an acceptable physical and psychopathological improvement during the first year of treatment, with recovery being more evident during the first 6 months.

An Overview of Conceptualizations of Eating Disorder Recovery, Recent Findings, and Future Directions

PURPOSE OF REVIEW

This review delineates issues in the conceptualization and operationalization of eating disorder recovery, highlights recent findings about recovery (since 2016), and proposes future directions.

RECENT FINDINGS

A longstanding problem in the field is that there are almost as many different definitions of recovery in eating disorders as there are studies on the topic. Yet, there has been a general shift to accepting that psychological/cognitive symptoms are important to recovery in addition to physical and behavioral indices. Further, several operationalizations of recovery have been proposed over the past two decades, and some efforts to validate operationalizations exist. However, this work has had limited impact and uptake, such that the field is suffering from "broken record syndrome," where calls are made for universal definitions time and time again. It is critical that proposed operationalizations be compared empirically to help arrive at a consensus definition and that institutional/organizational support help facilitate this. Themes in recent recovery research include identifying predictors, examining biological/neuropsychological factors, and considering severe and enduring anorexia nervosa. From qualitative research, those who have experienced eating disorders highlight recovery as a journey, as well as factors such as hope, self-acceptance, and benefiting from support from others as integral to the process of recovery. The field urgently needs to implement a universal definition of recovery that is backed by evidence, that can parsimoniously be implemented in clinical practice, and that will lead to greater harmonization of scientific findings.

Ground zero: Ontology, recognition, and the elusiveness of care in American eating disorders treatment

This paper reflects upon questions of ontological contingency when the stark, visceral reality of a person's relentless self-destruction unfolds within institutional mechanisms that systematically withhold certain kinds of care. I consider these issues through the lens of "manipulation" as it is elaborated within an American eating disorders treatment center, where the notion of manipulation does particular kinds of affective and pragmatic work. Specifically, it serves to render clients as, paradoxically, both hyper-agentic and "agentically challenged" in ways that legitimate the withholding of their recognition as full subjects and therefore deserving of care. I propose that the ontological perspectives of the treatment center are ill-equipped for accounting for such dynamics and, in fact, carry certain risks when employed in the consideration of psychiatric conditions where they can even become coopted in unintended ways. This carries special importance when working with people whose ontological status is, in a very real (and not just theoretical) sense, teetering on the brink of the void.

A systematic review of studies on the faecal microbiota in anorexia nervosa: future research may need to include microbiota from the small intestine

PURPOSE

Anorexia nervosa (AN) is a poorly understood and often chronic condition. Deviations in the gut microbiota have been reported to influence the gut-brain axis in other disorders. Therefore, if present in AN, it may impact on symptoms and illness progression. A review of the gut microbiota studies in AN is presented.

METHOD

A literature search on PubMed yielded 27 articles; 14 were selected and based on relevance, 9 articles were included. The findings were interpreted in the larger context of preclinical research and clinical observations.

RESULTS

8 out of 9 included studies analysed microbiota from faeces samples, while the last analysed a protein in plasma produced by the gut. Two studies were longitudinal and included an intervention (i.e., weight restoration), five were cross-sectional, one was a case report, and the last was a case series consisting of three cases. Deviations in abundance, diversity, and microbial composition of the faecal microbiota in AN were found.

CONCLUSION

There are currently only a few studies on the gut microbiota in AN, all done on faeces samples, and not all describe the microbiota at the species level extensively. The Archaeon Methanobrevibacter smithii was increased in participants with a BMI < 25 in one study and specifically in AN patients in three studies. Methanobrevibacter smithii may, if detected, be a benchmark biomarker for future studies. We propose that microbiota samples could also be collected from the small intestine, where a major exchange of nutrients takes place and where the microbiota may have a biological impact on AN.

Are family relations connected to the quality of the outcome in adolescent anorexia nervosa? An observational study with the Lausanne Trilogue Play

The study aims to explore the connection between the family interactive patterns, investigated with a standardized observational tool based on a recorded play session, the Lausanne Trilogue Play, and the outcome of adolescent patients with anorexia nervosa after a 6 months treatment, based on the Morgan-Russel Outcome Assessment Schedule. Seventy-two parents and adolescent daughters with anorexia nervosa, consecutively referred to an adolescent neuropsychiatric service, participated in the study and underwent an integrated model of treatment, based on constant neuropsychiatric and dietary monitoring, weekly individual psychotherapy for the daughter, and parental counselling and support. A better adolescents' functioning in family relationships, in particular in the triadic ones, at first assessment, was associated with a better outcome. Data on family interactions may help predict the most appropriate intervention for the patient and his family.

Parental characteristics in association with disordered eating in 11- to 12-year-olds: A study within the Danish National Birth Cohort

We examined the association between parental characteristics and disordered eating among 11- to 12-year-olds within the Danish National Birth Cohort. Frequency of fasting, purging, and binge eating was obtained by self-report from 37,592 children and combined into a measure of disordered eating (no, monthly, and weekly). Information on parental characteristics was obtained during pregnancy, from the 7-year follow-up, and by linkage to population registers. Data were analysed using multinomial logistic regression models with robust standard errors. In total, 3.1% reported weekly and 4.1% reported monthly disordered eating. Parental young age, low educational level, and overweight/obesity were associated with disordered eating. The relative risk ratios for, respectively, weekly and monthly disordered eating according to maternal eating disorder were 1.01 [0.75, 1.37] and 1.09 [0.84, 1.42]. Disordered eating is common among children and is associated with several parental characteristics. We found social inequality in disordered eating, but our data did not support an association with maternal eating disorder.

Evaluation of the DSM-5 severity ratings for anorexia nervosa in a clinical sample

We examined the validity and utility of the DSM-5 severity ratings for anorexia nervosa (AN) in a clinical (treatment-seeking) sample (N = 273; 95.6% women). Participants classified with mild, moderate, severe, and extreme severity of AN based on their measured body mass index, differed significantly from each other in eating disorder features, putative maintenance factors, and illness-specific functional impairment (medium effect sizes). However, they were statistically indistinguishable in psychiatric-disorder comorbidity and distress, demographics, and age-of-AN onset. The implications of our findings, providing limited support for the DSM-5 severity ratings for AN, and directions for future research are outlined.

Evaluation of the DSM-5 Severity Specifier for Bulimia Nervosa in Treatment-Seeking Youth

A new severity specifier for bulimia nervosa (BN), based on the frequency of inappropriate weight compensatory behaviours (e.g., laxative misuse, self-induced vomiting, fasting, diuretic misuse, and excessive exercise), has been added to the most recent (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a means of addressing variability and heterogeneity in the severity of the disorder. While existing research provides support for the DSM-5 severity specifier for BN in adult patients, evidence for its validity and clinical utility in youth is currently lacking. To address this gap, data from 272 treatment-seeking adolescents with DSM-5 BN (94.2% female, M _age = 15.3 years, SD 1.7) were analysed to examine whether these patients, sub-grouped based on the DSM-5 severity definitions, would show meaningful differences in a broad range of clinical variables and demographic and physical characteristics. Analyses revealed that participants categorized with mild, moderate, severe, and extreme severity of BN significantly differed from each other in 15 variables regarding eating disorder pathological features and putative maintenance factors (i.e., core low self-esteem, perfectionism, social appearance anxiety, body surveillance, and mood intolerance), health-related quality of life and comorbid psychiatric (i.e., affective and anxiety) disorders (large effect sizes). Between-group differences in demographics, body mass index, or age-of-BN onset were not observed. Collectively, our findings provide support for the utility of the frequency of inappropriate weight compensatory behaviours as a severity indicator for BN and suggest that age-at-onset of BN is probably more disorder- than severity-dependent. Implications for future research are outlined.

A review of purging disorder through meta-analysis

Although a growing body of research has examined Purging Disorder (PD), there remains a lack of conclusive evidence regarding the diagnostic validity of PD. This meta-analysis compared PD to DSM-5 eating disorders (i.e., Anorexia Nervosa [AN], Bulimia Nervosa [BN], and Binge Eating Disorder [BED]) and controls. A comprehensive literature search identified 38 eligible studies. Group differences on indicators of course of illness and both general and eating psychopathology were assessed using standardized effect sizes. Results supported the conceptualization of PD as a clinically significant eating disorder, but findings were less clear regarding its distinctiveness from other eating disorder diagnoses. More specifically, PD significantly differed from BN and BED in natural course of illness (g = .40-.54), and PD significantly differed from AN in treatment outcome (g = .27), with PD characterized by a better prognosis. Overall, PD was more similar to AN and BED on many dimensional measures of general and eating-related psychopathology, though PD was less severe than BN in most of these domains. PD, BN, and BED groups also evidenced similar frequencies of subjective binge episodes (SBEs), yet PD evidenced less frequent SBEs than AN. There is a clear need for future studies of PD to assess validators that have not been reported comprehensively in the literature, such as mortality, medical morbidity, and course of illness. Additionally, empirical classification studies are needed to inform future classifications of PD, particularly with regard to categorical differences between PD and other eating disorders. (PsycINFO Database Record

Medical Considerations in Children and Adolescents with Eating Disorders

Eating disorders are a group of psychiatric disorders with potentially fatal medical complications. Early integrated care including the family as well as pediatric medicine, nutrition, psychology and psychiatry is critical for improving prognosis and limiting negative outcomes. Mental health services are a critical component of treatment; timely weight restoration maximizes efficacy. Despite being relatively common, there are many misperceptions about eating disorders, their severity, and the associated morbidity and mortality. Opportunities exist within the medical and psychiatric communities for a better understanding of the complexity of diagnosing and treating patients with eating disorders.

Feasibility Study Combining Art Therapy or Cognitive Remediation Therapy with Family-based Treatment for Adolescent Anorexia Nervosa

Adolescents with anorexia nervosa who have obsessive-compulsive (OC) features respond poorly to family-based treatment (FBT). This study evaluated the feasibility of combining FBT with either cognitive remediation therapy (CRT) or art therapy (AT) to improve treatment response in this at-risk group. Thirty adolescents with anorexia nervosa and OC features were randomized to 15 sessions of FBT + CRT or AT. Recruitment rate was 1 per month, and treatment attrition was 16.6% with no differences between groups. Suitability, expectancy and therapeutic relationships were acceptable for both combinations. Correlations between changes in OC traits and changes in cognitive inefficiencies were found for both combinations. Moderate changes in cognitive inefficiencies were found in both groups but were larger in the FBT + AT combination. This study suggests that an RCT for poor responders to FBT because of OC traits combining FBT with either CRT or AT is feasible to conduct. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Predictors of long-term recovery in anorexia nervosa and bulimia nervosa: Data from a 22-year longitudinal study

OBJECTIVE

The objective of this study was to investigate predictors of long-term recovery from eating disorders 22 years after entry into a longitudinal study.

METHOD

One hundred and seventy-six of the 228 surviving participants (77.2%) were re-interviewed 20-25 years after study entry using the Longitudinal Interval Follow-up Evaluation to assess ED recovery. The sample consisted of 100 women diagnosed with anorexia nervosa (AN) and 76 with bulimia nervosa (BN) at study entry.

RESULTS

A comorbid diagnosis of major depression at the start of the study strongly predicted having a diagnosis of AN-Restricting type at the 22-year assessment. A higher body mass index (BMI) at study intake decreased the odds of being diagnosed with AN-Binge Purge type, relative to being recovered, 22 years later. The only predictor that increased the likelihood of having a diagnosis of BN at the 22-year assessment was the length of time during the study when the diagnostic criteria for BN were met.

CONCLUSIONS

Together, these results indicate that the presence and persistence of binge eating and purging behaviors were poor prognostic indicators and that comorbidity with depression is particularly pernicious in AN. Treatment providers might pay particular attention to these issues in an effort to positively influence recovery over the long-term.

Validity and clinical utility of the DSM-5 severity specifier for bulimia nervosa: results from a multisite sample of patients who received evidence-based treatment

A new "severity specifier" for bulimia nervosa (BN), based on the frequency of inappropriate weight compensatory behaviours (IWCBs), was added to the DSM-5 as a means of documenting heterogeneity and variability in the severity of the disorder. Yet, evidence for its validity in clinical populations, including prognostic significance for treatment outcome, is currently lacking. Existing data from 281 treatment-seeking patients with DSM-5 BN, who received the best available treatment for their disorder (manual-based cognitive behavioural therapy; CBT) in an outpatient setting, were re-analysed to examine whether these patients subgrouped based on the DSM-5 severity levels would show meaningful and consistent differences on (a) a range of clinical variables assessed at pre-treatment and (b) post-treatment abstinence from IWCBs. Results highlight that the mild, moderate, severe, and extreme severity groups were statistically distinguishable on 22 variables assessed at pre-treatment regarding eating disorder pathological features, maintenance factors of BN, associated (current) and lifetime psychopathology, social maladjustment and illness-specific functional impairment, and abstinence outcome. Mood intolerance, a maintenance factor of BN but external to eating disorder pathological features (typically addressed within CBT), emerged as the primary clinical variable distinguishing the severity groups showing a differential treatment response. Overall, the findings speak to the concurrent and predictive validity of the new DSM-5 severity criterion for BN and are important because a common benchmark informing patients, clinicians, and researchers about severity of the disorder and allowing severity fluctuation and patient's progress to be tracked does not exist so far. Implications for future research are outlined.

The Science Behind the Academy for Eating Disorders' Nine Truths About Eating Disorders

OBJECTIVE

In 2015, the Academy for Eating Disorders collaborated with international patient, advocacy, and parent organizations to craft the 'Nine Truths About Eating Disorders'. This document has been translated into over 30 languages and has been distributed globally to replace outdated and erroneous stereotypes about eating disorders with factual information. In this paper, we review the state of the science supporting the 'Nine Truths'.

METHODS

The literature supporting each of the 'Nine Truths' was reviewed, summarized and richly annotated.

RESULTS

Most of the 'Nine Truths' arise from well-established foundations in the scientific literature. Additional evidence is required to further substantiate some of the assertions in the document. Future investigations are needed in all areas to deepen our understanding of eating disorders, their causes and their treatments.

CONCLUSIONS

The 'Nine Truths About Eating Disorders' is a guiding document to accelerate global dissemination of accurate and evidence-informed information about eating disorders. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Establishment of a chronic activity-based anorexia rat model

BACKGROUND

Anorexia nervosa (AN) is often a chronic eating disorder characterised by body image disturbance and low body weight often associated with starvation-induced amenorrhoea and excessive exercise. Activity-based anorexia (ABA) is an animal model representing many somatic aspects of this psychiatric illness. We systematically manipulated the extent and length of starvation and animal age to find the optimal parameters to study chronic starvation.

NEW METHODS

Wistar rats had 24h/day running wheel access and received 40% of their baseline food intake until a 20% or 25% weight reduction was reached (acute starvation). This body weight was then maintained for two weeks (chronic starvation). The rats of different ages of 4 or 8 weeks were used to represent early and late adolescent animals, respectively. The complete absence of a menstrual cycle was defined as the primary outcome parameter.

RESULTS

Acute starvation caused a disruption of the oestrous cycle in 58% of the animals. During chronic starvation, a complete loss of the oestrous cycle could be found. Furthermore, 4-week-old rats exhibited higher levels of hyperactivity and amenorrhoea than 8-week-old animals. A 20% starvation level led to 90% loss of cycle, while a 25% starvation level triggered complete loss.

COMPARISON WITH EXISTING METHODS

Most current ABA models focus on acute starvation, while most patients are chronically ill.

CONCLUSIONS

The optimal parameters to achieve complete amenorrhoea included early adolescence, chronic starvation and 25% weight loss. The new ABA model allows studying the effects of chronic AN on underlying behavioural, hormonal and brain pathobiology.

Predicting intolerance of uncertainty in individuals with eating disorder symptoms

BACKGROUND

Intolerance of Uncertainty (IU) is recognized for its contribution to various psychopathologies, in particular anxiety and depression. Studies highlight the relevance of IU for Eating Disorders (EDs) however, potential factors contributing to IU in EDs remain unstudied.

METHODS

Three hundred and forty-nine women with ED symptoms and 214 individuals without ED symptoms were recruited and compared on levels of IU, insecure (anxious and avoidant) attachment styles, extraversion and openness. Secondly, the contribution of these factors to IU were tested.

RESULTS

Compared to the non-ED group, the ED group scored higher on IU, insecure attachment, and lower on extraversion and openness. Regression analyses confirmed that higher insecure attachment, and lower extraversion predicted higher IU scores in the ED group, and that insecure attachment predicted higher IU scores in the non-ED group.

CONCLUSIONS

Results confirm the relevance of IU to ED, and demonstrate that personality traits and insecure attachment styles contribute to IU in ED. Findings add to the growing literature on IU in ED and suggest that people with EDs may benefit from clinical interventions targeting IU.

[The inpatient treatment of patients with anorexia nervosa in German clinics]

Objective

The medium- and long-term effects and side effects of inpatient treatment of patients with anorexia nervosa is still a matter of debate. The German S3-guidelines underline the importance of providing specialized and competent treatment. In this article we focus on the inpatient service structure in German child and adolescent psychiatric clinics with regard to their diagnostic and therapeutic concepts.

Methods

A self-devised questionnaire was sent to 163 German child and adolescent psychiatric clinics. The questionnaire focused on the characteristics of the respective clinic as well as its diagnostic and therapeutic strategies.

Results

All clinics with an inpatient service for patients with anorexia nervosa (N = 84) provide single-therapy, family-based interventions and psychoeducation. A target weight is defined in nearly all clinics, and the mean intended weight gain per week is 486 g (range: 200 g to 700 g/week; SD = 117). Certain diagnostic tests and therapeutic interventions are used heterogeneously.

Conclusions

This is the first study investigating the inpatient service structure for patients with anorexia nervosa in German clinics. Despite the provision of guideline-based therapy in all clinics, heterogeneous approaches were apparent with respect to specific diagnostic and therapeutic concepts.

Neuropsychological and Cognitive Correlates of Recovery in Anorexia Nervosa

OBJECTIVE

To identify clinical or cognitive measures either predictive of illness trajectory or altered with sustained weight recovery in adult women with anorexia nervosa.

METHODS

Participants were recruited from prior studies of women with anorexia nervosa (AN-C) and in weight-recovery following anorexia nervosa (AN-WR). Participants completed a neuropsychological battery at baseline and clinical assessments at both baseline and follow-up. Groups based on clinical outcome (continued eating disorder, AN-CC; newly in recovery, AN-CR; sustained weight-recovery, AN-WR) were compared by using one-way ANOVAs with Bonferroni-corrected post hoc comparisons.

RESULTS

Women with continued eating disorder had poorer neuropsychological function and self-competence at baseline than AN-CR. AN-CR showed changes in depression and externalizing bias, a measure of self-related attributions. AN-WR differed from both AN-CC and AN-CR at baseline in externalizing bias, but only from AN-CC at outcome.

DISCUSSION

Neuropsychological function when recently ill may be a prognostic factor, while externalizing bias may provide a clinical target for recovery. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Treating Eating Disorders at Higher Levels of Care: Overview and Challenges

Higher levels of care (HLC)-including inpatient hospitalization, residential treatment, partial hospitalization, and intensive outpatient treatment-are frequently utilized within routine care for eating disorders. Despite widespread use, there is limited research evaluating the efficacy of HLC, as well as clinical issues related to care in these settings. This review describes the different levels of care for eating disorders and briefly reviews the most up-to-date guidelines and research regarding how to choose a level of care. In addition, as HLC approaches for ED continue to be developed and refined, pragmatic and conceptual challenges have emerged that provide barriers to clinical efficacy and the execution of high-quality treatment research. This review includes a discussion of various issues specific to HLC, as well as a summary of recent literature addressing them.