The validity of the eating disorder examination and its subscales

Relational containment: exploring the effect of family-based treatment for anorexia on familial relationships

BACKGROUND

The aim of this research was to investigate the process of familial relationship change for adolescents with anorexia nervosa and their parents, who participated in Family-Based Treatment (FBT).

METHOD

A Constructionist grounded theory design was employed with purposive sampling. Sixteen young people between 12 and 18 years with a good outcome in FBT and twenty-eight of their parents participated. Young people and their parents took part in separate interviews at the end of treatment. Each interview was transcribed and analysed to identify a unifying phenomenon across the data to elicit a theory that explained the data and then integrated into existing theory.

RESULTS

Prior to treatment families' experienced significant conflict, disconnection and isolation. The FBT structure, therapist direction, and the specialist medical setting created a process of relational containment. This enabled parents to trust the process of FBT and develop confidence in their executive role in the family. In turn this allowed the adolescent with anorexia nervosa to trust their parents, feel more secure and gradually engage in the treatment process themselves. Improvements in closeness, communication and adolescent sense of self were reported after FBT.

CONCLUSIONS

These findings illuminate a possible mechanism of change in FBT. It underscores the importance of parental management of eating disorder symptoms at the commencement of treatment to enable increased parental confidence. Meaningful changes occurred for the adolescents' that aided normal developmental and relational processes, an important aspect of recovery.

TRIAL REGISTRATION

Australian Clinical Trials Register number: ACTRN012607000009415.

How does family functioning effect the outcome of family based treatment for adolescents with severe anorexia nervosa?

BACKGROUND

The aim of this research was to investigate the relationship between family functioning, adolescent-parent attachment and remission, as well as changes in these variables over time for adolescents with severe anorexia nervosa treated with family based treatment (FBT). Understanding how families respond to treatment is important because the family will be the ongoing context for psychosocial development in the longer term. The relationship between family functioning and outcome is also an important variable because it is potentially modifiable during treatment and this may improve outcome.

METHODS

Fifty-seven female adolescents treated with FBT in a randomised controlled trial were assessed at baseline, FBT session 20 and 12-months post FBT session 20. Data on family functioning and adolescent-parent attachment was collected from patients and their parents at each time point. A series of regression analyses were used to determine the relationship between family functioning and comorbidity at baseline, and the relationship with remission status over time. Repeat measure mixed-effects models were used to assess changes in family functioning and attachment quality over time.

RESULTS

Greater adolescent perceived family functioning impairment was positively related to psychiatric comorbidity at the start of treatment. Conversely, better family functioning predicted higher self-esteem and stronger attachment quality. Adolescent's reporting better general family functioning, communication and problem solving were more likely to be remitted at session 20, but not at 12-month follow-up. There was no overall improvement in family functioning for any respondent either during treatment or at follow-up, and no significant relationship between change and remission at either session 20 or follow-up.

CONCLUSIONS

The adolescent's perspective on family functioning at the start of treatment impacts on a positive outcome. Addressing family issues earlier in FBT may be important for some patients. Further research is needed in this area to determine how these findings could be integrated into the current FBT model.

TRIAL REGISTRATION

Australian Clinical Trials Register number: ACTRN012607000009415 (www.anzctr.org.au).

Change in expressed emotion and treatment outcome in adolescent anorexia nervosa

Expressed emotion (EE) has been associated with poor outcomes in anorexia nervosa (AN); however, whether changes in EE predict superior treatment outcomes is unknown. The current study examined whether decreases in EE during an open trial of a novel family-based treatment for AN predicted symptoms at end of treatment. Forty-seven adolescents (12-18 years of age) with AN or sub-threshold AN and their parents (mothers: n = 47, fathers: n = 39) participated in 6 months of family treatment. Measures of AN symptomatology (Eating Disorder Examination completed by adolescent and end of treatment recovery status) and parental EE (Family Questionnaire completed by parents which measures two facets of EE: critical communication [CC] and emotional over-involvement [EOI]) were collected at baseline and end of treatment. Parental EOI, but not CC, significantly decreased during the course of treatment. Change in mothers', but not fathers', EE accounted for additional variance in AN symptomatology at end of treatment above baseline EE and baseline AN symptom levels. Findings suggest a greater emphasis on parent support during treatment may improve outcomes.

Physical activity, body weight, and resumption of menses in anorexia nervosa

Few data are available on long-term outcomes and increased physical activity at the end of inpatient treatment in patients with anorexia nervosa. Hence we assessed the association between physical activity, measured objectively by Sense Wear Armband (SWA), and body mass index (BMI; kg/m²) and menses resumption at one-year follow-up in 32 females with anorexia nervosa who had restored normal body weight by the end of a specialist inpatient treatment. Combined logistic regression models used to evaluate the relationship between variables at discharge, BMI and resumption of menses at one-year follow-up revealed no significant association between BMI at one-year follow-up and physical activity patterns at inpatient discharge. However, total daily steps at inpatient discharge were significantly lower in patients who had resumed menstruation, as confirmed by logistic regression analysis. A small reduction in daily steps at inpatient discharge (~1000 steps) was found to increase the probability of menses resumption at one-year follow-up by ~3%. These data provide preliminary indications as to the potential usefulness of assessing daily steps to predict the resumption of menses at one-year follow-up in patients with anorexia nervosa who restore body weight by the end of inpatient treatment, although confirmation on larger samples is urgently required.

Effectiveness of enhanced cognitive behavioral therapy (CBT-E) for eating disorders: study protocol for a randomized controlled trial

BACKGROUND

While eating disorder not otherwise specified (EDNOS) is the most common eating disorder (ED) diagnosis in routine clinical practice, no specific treatment methods for this diagnosis have yet been developed and studied. Enhanced cognitive behavioral therapy (CBT-E) has been described and put to the test as a transdiagnostic treatment protocol for all EDs, including EDNOS. Initial research in the UK suggests that CBT-E is more effective for EDs, especially bulimia nervosa (BN) and EDNOS, than the earlier version of CBT. These positive results of CBT-E have to be replicated in more detail, preferably by independent researchers in different countries. Being the first Dutch study into CBT-E, the results from this national multicenter study - on three sites specialized in EDs - will deliver important information about the effectiveness of CBT-E in several domains of ED pathology, while providing input for the upcoming update of the Dutch Multidisciplinary Guideline for the Treatment of Eating Disorders.

METHODS/DESIGN

A multicenter randomized controlled trial will be conducted. One hundred and thirty-two adult outpatients (aged 18 years and older) with an ED diagnosis and a Body Mass index (BMI) of between 17.5 and 40 will be randomly allocated to the control or the intervention group. Subjects in the control group will receive Treatment as Usual (standard outpatient treatment provided at the participating sites). Subjects in the intervention group will receive 20 sessions of CBT-E in 20 weeks. The design is a 2 (group) × 5 (time) repeated measures factorial design in which neither therapists nor patients will be blinded for treatment allocation. The primary outcome measure is recovery from the ED. Secondary outcome measures include ED psychopathology, common mental disorders, anxiety and depressive symptoms, health-related quality of life, health care use and productivity loss. Self-esteem, perfectionism and interpersonal problems will be examined as putative predictors and mediators of the effect of treatment. Also, an economic evaluation from a societal perspective will be undertaken. All relevant effects, direct and indirect costs will be included. Utility scores will measure the effects. Measurements will take place at pretreatment, 6 weeks, 20 weeks, 40 weeks and 80 weeks.

DISCUSSION

This effectiveness study into CBT-E has the aim of broadening the scope and generalizability of former studies. If CBT-E appears to be at least as effective as traditional diagnosis-specific treatments for a broad range of ED patients, training in one protocol would be sufficient for clinicians to treat patients with different kinds of EDs. It gives the opportunity to offer treatment for a severe mental disorder with fewer resources, thereby increasing the accessibility of specialized care for patients with an ED.

TRIAL REGISTRATION

Netherlands Trial Register, NTR4485 . Registered on 2 April 2014.

Cognitive remediation therapy (CRT) as a treatment enhancer of eating disorders and obsessive compulsive disorders: study protocol for a randomized controlled trial

BACKGROUND

Anorexia nervosa (AN) and Obsessive Compulsive Disorder (OCD) are among the most incapacitating and costly of mental disorders. Cognitive Behaviour Therapy (CBT), medication, and combination regimens, to which in AN personalised guidance on weight control is added, are moderately successful, leaving room for more effective treatment algorithms. An underlying deficit which the two disorders share is cognitive inflexibility, a trait that is likely to impede treatment engagement and reduce patients' ability to benefit from treatment. Cognitive remediation therapy (CRT) is an easy-to-use intervention aimed at reducing cognitive inflexibility and thereby enhancing treatment outcome, which we aim to test in a controled study.

METHODS

In a randomized-controlled multicenter clinical trial 64 adult patients with AN and 64 with OCD are randomized to 10 bi-weekly sessions with either CRT or a control condition, after which Treatment As Usual (TAU) is started. All patients are evaluated during single-blind assessments at baseline, post-CRT/control intervention, and after 6 months. Indices of treatment effect are disorder-specific symptom severity, quality of life, and cost-effectivity. Also, moderators and mediators of treatment effects will be studied.

DISCUSSION

To our knowledge, this is the first randomized controlled trial using an control condition evaluating the efficacy and effectiveness of CRT as a treatment enhancer preceding TAU for AN, and the first study to investigate CRT in OCD, moreover taking cost-effectiveness of CRT in AN and OCD into account.

TRIAL REGISTRATION

The Netherlands Trial Register NTR3865 . Registered 20 february 2013.

Binge-eating disorder and the outcome of bariatric surgery in a prospective, observational study: Two-year results

OBJECTIVE

A previous study reported that preoperative binge-eating disorder (BED) did not attenuate weight loss at 12 months after bariatric surgery. This report extends the authors' prior study by examining weight loss at 24 months.

METHODS

A modified intention-to-treat population was used to compare 24-month changes in weight among 59 participants treated with bariatric surgery, determined preoperatively to be free of a current eating disorder, with changes in 33 surgically treated participants with BED. Changes were also compared with 49 individuals with obesity and BED who sought lifestyle modification for weight loss. Analyses included all available data points and were adjusted for covariates.

RESULTS

At month 24, surgically treated patients with BED preoperatively lost 18.6% of initial weight, compared with 23.9% for those without BED (P = 0.049). (Mean losses at month 12 had been 21.5% and 24.2%, respectively; P = 0.23.) Participants with BED who received lifestyle modification lost 5.6% at 24 months, significantly less than both groups of surgically treated patients (P < 0.001).

CONCLUSIONS

These results suggest that preoperative BED attenuates long-term weight loss after bariatric surgery. We recommend that patients with this condition, as well as other eating disturbances, receive adjunctive behavioral support, the timing of which remains to be determined.

Psychological conditions in adults with diabetes

Type 1 (T1D) and Type 2 diabetes (T2D) represent a demanding set of biopsychosocial challenges for patients and their families, whether the age of disease onset occurs in childhood, adolescence, or adulthood. Psychological conditions, defined as syndromes, disorders, and diabetes-specific psychological issues affect a larger proportion of individuals with T1D and T2D compared to the general population. In this review, we summarize the prevalence, impact and psychological treatments associated with the primary categories of psychological conditions that affect adults with T1D and T2D: depressive symptoms and syndromes, anxiety disorders, eating behaviors and disorders and serious mental illness. The implications of the literature for psychologists are discussed, and priorities for future research to advance the science of psychological conditions for adults with T1D and T2D are identified. (PsycINFO Database Record

Binge-Eating Disorder in Adults: A Systematic Review and Meta-analysis

BACKGROUND

The best treatment options for binge-eating disorder are unclear.

PURPOSE

To summarize evidence about the benefits and harms of psychological and pharmacologic therapies for adults with binge-eating disorder.

DATA SOURCES

English-language publications in EMBASE, the Cochrane Library, Academic OneFile, CINAHL, and ClinicalTrials.gov through 18 November 2015, and in MEDLINE through 12 May 2016.

STUDY SELECTION

9 waitlist-controlled psychological trials and 25 placebo-controlled trials that evaluated pharmacologic (n = 19) or combination (n = 6) treatment. All were randomized trials with low or medium risk of bias.

DATA EXTRACTION

2 reviewers independently extracted trial data, assessed risk of bias, and graded strength of evidence.

DATA SYNTHESIS

Therapist-led cognitive behavioral therapy, lisdexamfetamine, and second-generation antidepressants (SGAs) decreased binge-eating frequency and increased binge-eating abstinence (relative risk, 4.95 [95% CI, 3.06 to 8.00], 2.61 [CI, 2.04 to 3.33], and 1.67 [CI, 1.24 to 2.26], respectively). Lisdexamfetamine (mean difference [MD], -6.50 [CI, -8.82 to -4.18]) and SGAs (MD, -3.84 [CI, -6.55 to -1.13]) reduced binge-eating-related obsessions and compulsions, and SGAs reduced symptoms of depression (MD, -1.97 [CI, -3.67 to -0.28]). Headache, gastrointestinal upset, sleep disturbance, and sympathetic nervous system arousal occurred more frequently with lisdexamfetamine than placebo (relative risk range, 1.63 to 4.28). Other forms of cognitive behavioral therapy and topiramate also increased abstinence and reduced binge-eating frequency and related psychopathology. Topiramate reduced weight and increased sympathetic nervous system arousal, and lisdexamfetamine reduced weight and appetite.

LIMITATIONS

Most study participants were overweight or obese white women aged 20 to 40 years. Many treatments were examined only in single studies. Outcomes were measured inconsistently across trials and rarely assessed beyond end of treatment.

CONCLUSION

Cognitive behavioral therapy, lisdexamfetamine, SGAs, and topiramate reduced binge eating and related psychopathology, and lisdexamfetamine and topiramate reduced weight in adults with binge-eating disorder.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

An open trial evaluating an attention bias modification program for overweight adults who binge eat

BACKGROUND AND OBJECTIVES

Binge eating is prevalent and is associated with significant psychiatric and medical comorbidities. To date, the most effective psychological treatments for individuals who binge eat are not effective for all patients and they do not result in significant weight loss. Dual process theories suggest that implicit factors, such as attention bias, may influence behavior, even when the behavior is in opposition to long-term goals. Attention bias modification programs have been tested in other areas of psychopathology, and could be utilized to improve outcomes for people who binge eat. Thus, the aim of this open trial was to conduct a preliminary evaluation of an attention bias modification program (ABM-Food) designed to train attention away from food cues.

METHODS

Adults who binge eat and were overweight or obese enrolled in an 8-week ABM-Food program, which consisted of one session in the lab each week and two training sessions at home. Nine participants completed the ABM-Food training program and the post-treatment assessment, and 8 completed the 3-month post-treatment assessment.

RESULTS

Results showed that the ABM-Food program is a feasible and acceptable treatment for adults who binge eat. Initial effectiveness data showed decreases in weight, eating disorder symptoms, binge eating, loss of control and responsivity to food in the environment, as well as changes in attention bias. The majority of these effects remained at the 3-month follow-up time point.

LIMITATIONS

This study is limited by the single-group open label trial, and the small sample size.

CONCLUSIONS

This open trial provides initial evidence for the feasibility, acceptability and effectiveness of ABM-Food for individuals who binge eat and are overweight or obese.

Attention bias in adults with anorexia nervosa, obsessive-compulsive disorder, and social anxiety disorder

BACKGROUND

Attention bias to threat (selective attention toward threatening stimuli) has been frequently found in anxiety disorder samples, but its distribution both within and beyond this category is unclear. Attention bias has been studied extensively in social anxiety disorder (SAD) but relatively little in obsessive compulsive disorder (OCD), historically considered an anxiety disorder, or anorexia nervosa (AN), which is often characterized by interpersonal as well as body image/eating fears.

METHODS

Medication-free adults with SAD (n = 43), OCD (n = 50), or AN (n = 30), and healthy control volunteers (HC, n = 74) were evaluated for attention bias with an established dot probe task presenting images of angry and neutral faces. Additional outcomes included attention bias variability (ABV), which summarizes fluctuation in attention between vigilance and avoidance, and has been reported to have superior reliability. We hypothesized that attention bias would be elevated in SAD and associated with SAD severity.

RESULTS

Attention bias in each disorder did not differ from HC, but within the SAD group attention bias correlated significantly with severity of social avoidance. ABV was significantly lower in OCD versus HC, and it correlated positively with severity of OCD symptoms within the OCD group.

CONCLUSIONS

Findings do not support differences from HC in attention bias to threat faces for SAD, OCD, or AN. Within the SAD sample, the association of attention bias with severity of social avoidance is consistent with evidence that attention bias moderates development of social withdrawal. The association of ABV with OCD diagnosis and severity is novel and deserves further study.

Using Cognitive-Behavioral Therapy to Treat Adolescent-Onset Bulimia Nervosa: A Case Study

This case study describes the treatment of an adolescent female, referred to as Susan, who presented for evaluation at the Eating Disorders Clinic of Child and Adolescent Psychiatry at Stanford University. Susan presented with symptoms of body image disturbance, dietary restriction, binge eating, self-inducted vomiting, and overexercise, and was diagnosed with bulimia nervosa (BN). She was treated with 20 sessions of manualized cognitive-behavioral therapy (CBT) for BN adjusted for adolescents. Susan's progress throughout treatment is detailed in this case study report. Results lend support to a scant body of case series studies attesting to the efficacy of CBT for use with adolescents with BN. Large-scale, randomized studies are needed to corroborate preliminary conclusions that have been promulgated in this case study.

Personality predicts drop-out from therapist-guided internet-based cognitive behavioural therapy for eating disorders. Results from a randomized controlled trial

Internet-based guided self-help cognitive behavioural therapy (ICBT) seems a promising way of delivering eating disorder treatment. However, treatment drop-out is a common problem and little is known about the correlates, especially in clinical settings. The study aimed to explore prediction of drop-out in the context of a randomized controlled trial within specialized eating disorder care in terms of eating disorder symptomatology, personality traits, comorbidity, and demographic characteristics. 109 outpatients diagnosed with bulimia nervosa or similar eating disorder were randomized to two types of ICBT. Participants were assessed with several clinical- and self-ratings. The average drop-out rate was 36%. Drop-out was predicted by lower scores in the personality traits Dutifulness and Assertiveness as measured by the NEO Personality Inventory Revised, and by higher scores in Self-affirm as measured by the Structural Analysis of Social Behaviour. Drop-out was also predicted by therapist factors: one therapist had significantly more drop-outs (82%) than the other three (M = 30%). Theoretical and clinical implications of the impact of the predictors are discussed.

Assessment of Eating Disorders in Women

This article reviews current eating disorder self-report and interview measures and makes recommendations for choosing assessment devices for practice and research. The authors also incorporate overviews of related measures, such as body satisfaction and restrained eating. The presentation of women with eating disorders on measures of general psychological functioning (such as the Minnesota Multiphasic Personality Inventory) is also discussed. Implications and recommendations for practice are presented, as are recommendations for future research. The lack of validation of, and urgent need for, eating disorder assessment measures with ethnic minority women is discussed throughout.

Does impulsivity predict outcome in treatment for binge eating disorder? A multimodal investigation

Multiple dimensions of impulsivity (e.g., affect-driven impulsivity, impulsive inhibition - both general and food-specific, and impulsive decision-making) are associated with binge eating pathology cross-sectionally, yet the literature on whether impulsivity predicts treatment outcome is limited. The present pilot study explored impulsivity-related predictors of 20-week outcome in a small open trial (n = 17) of a novel treatment for binge eating disorder. Overall, dimensions of impulsivity related to emotions (i.e., negative urgency) and food cues emerged as predictors of treatment outcomes (i.e., binge eating frequency and global eating pathology as measured by the Eating Disorders Examination), while more general measures of impulsivity were statistically unrelated to global eating pathology or binge frequency. Specifically, those with higher levels of negative urgency at baseline experienced slower and less pronounced benefit from treatment, and those with higher food-specific impulsivity had more severe global eating pathology at baseline that was consistent at post-treatment and follow-up. These preliminary findings suggest that patients high in negative urgency and with poor response inhibition to food cues may benefit from augmentation of existing treatments to achieve optimal outcomes. Future research will benefit from replication with a larger sample, parsing out the role of different dimensions of impulsivity in treatment outcome for eating disorders, and identifying how treatment can be improved to accommodate higher levels of baseline impulsivity.

Development and Psychometric Validation of the EDE-QS, a 12 Item Short Form of the Eating Disorder Examination Questionnaire (EDE-Q)

Objective

The aim of this study was to develop and validate a short form of the Eating Disorder Examination Questionnaire (EDE-Q) for routine, including session by session, outcome assessment.

Method

The current, 28-item version (6.0) of the EDE-Q was completed by 489 individuals aged 18–72 with various eating disorders recruited from three UK specialist eating disorder services. Rasch analysis was carried out on factors identified by means of principal component analysis, which in combination with expert ratings informed the development of an EDE-Q short form. The shortened questionnaire’s reliability, validity and sensitivity was assessed based on online data collected from students of a UK university and volunteers with a history of eating disorders recruited from a national eating disorders charity aged 18–74 (N = 559).

Results

A 12-item short form, the Eating Disorder Examination Questionnaire Short (EDE-QS) was derived. The new measure showed high internal consistency (Cronbach’s α = .913) and temporal stability (ICC = .93; p < .001). It was highly correlated with the original EDE-Q (r = .91 for people without ED; r = .82 for people with ED) and other measures of eating disorder and comorbid psychopathology. It was sufficiently sensitive to distinguish between people with and without eating disorders.

Discussion

The EDE-QS is a brief, reliable and valid measure of eating disorder symptom severity that performs similarly to the EDE-Q and that lends itself for the use of sessional outcome monitoring in treatment and research.

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.

Attention-deficit/hyperactivity disorder-specific stimulant misuse, mood, anxiety, and stress in college-age women at high risk for or with eating disorders

OBJECTIVE

To examine the misuse of attention-deficit/hyperactivity disorder (ADHD)-specific stimulants in a college population at high risk for or with clinical or subclinical eating disorders.

PARTICIPANTS

Four hundred forty-eight college-age women aged 18-25 at high risk for or with a clinical or subclinical eating disorder.

METHODS

Participants completed assessments of stimulant misuse and psychopathology from September 2009 to June 2010.

RESULTS

Greater eating disorder pathology, objective binge eating, purging, eating disorder-related clinical impairment, depressive symptoms, perceived stress, and trait anxiety were associated with an increased likelihood of stimulant misuse. Subjective binge eating, excessive exercise, and dietary restraint were not associated with stimulant misuse.

CONCLUSIONS

ADHD-specific stimulant misuse is associated with eating disorder and comorbid pathology among individuals at high risk for or with clinical or subclinical eating disorders. Screening for stimulant misuse and eating disorder pathology may improve identification of college-age women who may be engaging in maladaptive behaviors and inform prevention efforts.

Are Weight Status and Cognition Associated? An Examination of Cognitive Development in Children and Adolescents with Anorexia Nervosa 1 Year after First Hospitalisation

Objective

The aim of this study was to characterise the association between the cognitive profile and weight restoration in children and adolescents with anorexia nervosa.

Methods

The study was a longitudinal, matched case–control, multicentre study. An assessment of cognitive functions was conducted by using the Wechsler Intelligence Scale for Children–III/the Wechsler Adult Intelligence Scale–III, the Test of Memory and Learning–second edition, Trail Making Tests A and B, the Rey–Osterrieth Complex Figure Test and the Cambridge Neuropsychological Test Automated Battery.

Results

One hundred twenty individuals, 60 patients with anorexia nervosa with mean age of 14.65 (SD 1.820) years and 60 healthy controls with mean age of 14.76 (SD 1.704) years, participated. No association was found between weight recovery and cognitive functions. However, a significant increase in motor speed was found in Trail Making Test A (p = 0.004), Reaction Time (RTI) five‐choice movement time (p = 0.002) and RTI simple movement time (p = 0.011), resulting in a normalisation corresponding to that found in healthy controls. Furthermore, a significantly lower score in the perceptual organization index (p = 0.029) was found at follow‐up.

Conclusions

Weight recovery appears not to be associated with cognition. Copyright © 2016 The Authors European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd

Does Sex Matter in the Clinical Presentation of Eating Disorders in Youth?

PURPOSE

Eating disorders (EDs) impact both males and females, but little is known about sex differences in ED psychopathology and overall clinical presentation. This study compared demographic and clinical characteristics of child and adolescent males and females who presented for ED treatment.

METHODS

Participants included 619 youth (59 males and 560 females) ages 6-18 years who presented for treatment between 1999 and 2011.

RESULTS

Males presented for ED treatment at a significantly younger age (p < .001), earlier age of onset (p = .004), and were more likely to be nonwhite (p = .023). Females showed more severe ED pathology across the Eating Disorder Examination subscales (weight concern: p < .001; eating concern: p < .001; restraint: p = .001; and shape concern: p = .019) and global score (p < .001). Males were more likely to present with an ED other than anorexia nervosa or bulimia nervosa (p = .002). Females presented with significantly higher rates of mood disorders (p = .027) and had a lower average percent of expected body weight (p = .020). Males and females did not differ in duration of illness, prior hospitalization or treatment, binging and purging episodes, anxiety disorders, behavioral disorders, or self-esteem. All analyses were controlled for age.

CONCLUSIONS

Results indicate that further exploration into why the sexes present differently may be warranted. Developing ED psychopathology assessments that better capture nuances particular to males and reevaluating criteria to better categorize male ED diagnoses may allow for more targeted treatment.

A systematic review of approaches to refeeding in patients with anorexia nervosa

OBJECTIVE

Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings.

METHODS

Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic.

RESULTS

Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (≥1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown;

DISCUSSION

Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings.

Process evaluation of the MOSAIC trial: treatment experience of two psychological therapies for out-patient treatment of Anorexia Nervosa

BACKGROUND

This study is part of a series of process evaluations within the MOSAIC Trial (Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions). This randomised controlled trial (RCT) compared two psychological treatments, the Maudsley Model for Treatment of Adults with Anorexia Nervosa (MANTRA) and Specialist Supportive Clinical Management (SSCM) for adult outpatients with Anorexia Nervosa. The present process study integrates quantitative (treatment acceptability and credibility) and qualitative (written) feedback to evaluate patients' treatment experiences.

METHOD

All 142 MOSAIC participants were asked to (a) rate treatment acceptability and credibility on visual analogue scales (VAS) at six and 12 months post-randomisation, and (b) provide written feedback regarding their views on their treatment at 12 months. Transcripts were first analysed thematically and then rated according to the global valence of feedback (positive, mixed/negative).

RESULTS

114/142 (80.3 %) MOSAIC participants provided VAS data and 82 (57.7 %) provided written feedback. At 12 months, MANTRA patients gave significantly higher acceptability and credibility ratings compared to SSCM patients. A significantly higher proportion of MANTRA patients provided written feedback. MANTRA patients also tended to write in more detail and to give globally more positive feedback when compared to individuals receiving SSCM. Qualitative themes suggest that patients experienced the two treatments differently in terms of characteristics and outcomes.

CONCLUSIONS

This study highlights the benefits of incorporating qualitative and quantitative data into RCT process evaluations. MANTRA patients were more willing to express their views on treatment and generally felt more positively about this than those receiving SSCM.

Reducing eating disorder onset in a very high risk sample with significant comorbid depression: A randomized controlled trial

OBJECTIVE

Eating disorders (EDs) are serious problems among college-age women and may be preventable. An indicated online eating disorder (ED) intervention, designed to reduce ED and comorbid pathology, was evaluated.

METHOD

206 women (M age = 20 ± 1.8 years; 51% White/Caucasian, 11% African American, 10% Hispanic, 21% Asian/Asian American, 7% other) at very high risk for ED onset (i.e., with high weight/shape concerns plus a history of being teased, current or lifetime depression, and/or nonclinical levels of compensatory behaviors) were randomized to a 10-week, Internet-based, cognitive-behavioral intervention or waitlist control. Assessments included the Eating Disorder Examination (EDE, to assess ED onset), EDE-Questionnaire, Structured Clinical Interview for DSM Disorders, and Beck Depression Inventory-II.

RESULTS

ED attitudes and behaviors improved more in the intervention than control group (p = .02, d = 0.31); although ED onset rate was 27% lower, this difference was not significant (p = .28, NNT = 15). In the subgroup with highest shape concerns, ED onset rate was significantly lower in the intervention than control group (20% vs. 42%, p = .025, NNT = 5). For the 27 individuals with depression at baseline, depressive symptomatology improved more in the intervention than control group (p = .016, d = 0.96); although ED onset rate was lower in the intervention than control group, this difference was not significant (25% vs. 57%, NNT = 4).

CONCLUSIONS

An inexpensive, easily disseminated intervention might reduce ED onset among those at highest risk. Low adoption rates need to be addressed in future research.

Use of yoga in outpatient eating disorder treatment: a pilot study

BACKGROUND

Individuals with restrictive eating disorders present with co-morbid psychiatric disorders and many attempt to control symptoms using strenuous exercises that increase caloric expenditure. Yoga offers a safe avenue for the engagement in physical activity while providing an outlet for disease-associated symptoms. This study sought to examine use of yoga practice in an outpatient setting and its impact on anxiety, depression and body image disturbance in adolescents with eating disorders.

METHODS

Twenty adolescent girls were recruited from an urban eating disorders clinic who participated in weekly yoga classes at a local studio, in addition to standard multidisciplinary care. Yoga instructors underwent training regarding this patient population. Participants completed questionnaires focused on anxiety, depression and body image disturbance prior to the first class, and following completion of 6 and 12 classes.

RESULTS

In participants who completed the study, a statistically significant decrease in anxiety, depression, and body image disturbance was seen, including: Spielberger State anxiety mean scores decreased after the completion of 7-12 yoga classes [47 (95%CI 42-52) to 42 (95%CI 37-47), adj. p = 0.0316]; as did the anorexia nervosa scale [10 (95% CI 7-12) vs. 6 (95%CI 4-8), adj. p = .0004], scores on Beck depression scales [18 (95%CI 15-22) to 10 (95%CI 6-14), adj. p = .0001], and weight and shape concern scores [16 (95%CI 12-20) to 12 (95%CI 8-16), adj. p =0.0120] and [31 (95%CI 25-37) to 20 (95%CI 13-27), adj. p = 0.0034], respectively. No significant changes in body mass index were seen throughout the trial.

CONCLUSIONS

Yoga practice combined with outpatient eating disorder treatment were shown to decrease anxiety, depression, and body image disturbance without negatively impacting weight. These preliminary results suggest yoga to be a promising adjunct treatment strategy, along with standard multidisciplinary care. However, whether yoga should be endorsed as a standard component of outpatient eating disorder treatment merits further study.

The relation of weight suppression and BMIz to bulimic symptoms in youth with bulimia nervosa

BACKGROUND

Weight suppression (WS), which is the difference between a patient's highest and current weight, has been associated with bulimic symptom severity in adults with bulimia nervosa (BN). However, the impact of WS on eating disorder psychopathology in youth with BN is unknown.

METHODS

Participants included 85 youth with DSM-5 BN who presented for outpatient treatment. Current WS was calculated as the difference between highest and current body mass index z-score (BMIz), while greatest WS was the difference between highest and lowest BMIz, both assessed at participants' current height. Separate multivariable linear regressions were conducted to determine if current or greatest WS was significantly associated with frequency of binge eating, compensatory behaviors, or dietary restraint. A secondary analysis was conducted on youth ages 16 and older, given the limitation of assessing WS at current height in younger participants with greater height instability.

RESULTS

Youth with higher levels of greatest WS (but not current WS) were older, had a longer duration of illness, and reported greater weight and shape concern. When adjusting for BMIz, neither current nor greatest WS was significantly associated with bulimic behaviors or dietary restraint in the full sample. However, in the subset of youth ages 16 and older, current WS moderated the effect of BMIz on binge eating and compensatory behaviors. For youth with high WS, those with a high current BMIz engaged in more frequent binge eating than those with low current BMIz, and the negative impact of BMIz on compensatory behaviors became weaker.

CONCLUSIONS

Our findings suggest that WS is clinically relevant in the presentation of youth with BN, and that it may need to be addressed as one important factor in BN psychopathology. Future studies using growth charts to determine historically highest and lowest BMIz may help to further elucidate the link (or lack thereof) between WS and BN psychopathology in youth.

Eating disorder examination: Factor structure and norms in a clinical female pediatric eating disorder sample

OBJECTIVE

The factor structure of the eating disorder examination (EDE) has never been tested in a clinical pediatric sample, and no normative data exist.

METHOD

The factor structure of an adapted EDE was examined in a clinical sample of 665 females aged 9-17 years with anorexia nervosa spectrum (70%), bulimia nervosa spectrum (12%), purging disorder (3%), and unspecified feeding and eating disorders (15%).

RESULTS

The original four-factor model was a good fit in a confirmatory factor analysis as well a higher order model with three dimensions of restraint, eating concern, and combined weight concern/shape concern. Normative data are reported for clinicians to identify the percentiles in which their patients' score.

DISCUSSION

The findings support dimensions of restraint, eating concern, weight concern, and shape concern in a clinical pediatric sample. This supports the factorial validity of the EDE, and the norms may assist clinicians to evaluate symptoms in females under 18 years.

Focused vs. Broad enhanced cognitive behavioral therapy for bulimia nervosa with comorbid borderline personality: A randomized controlled trial

OBJECTIVE

A subset of individuals with bulimia nervosa (BN) have borderline personality disorder (BPD) symptoms, including chronic negative affect and interpersonal problems. These symptoms predict poor BN treatment outcome in some studies. The broad version of Enhanced Cognitive Behavior Therapy (CBT-E) was developed to address co-occurring problems that interfere with treatment response. The current study investigated the relative effects, predictors, and moderators of CBT-E for BN with BPD and co-occurring mood/anxiety disorders.

METHOD

Fifty patients with BN and threshold or sub-threshold BPD and current or recent Axis I mood or anxiety disorders were randomly assigned to receive focused CBT-E (CBT-Ef) or broad CBT-E (CBT-Eb) specifically including an interpersonal module and additional attention to mood intolerance.

RESULTS

Forty-two percent of the sample reported remission from binge eating and purging at termination. Significant changes across symptom domains were observed at termination and at 6-month follow-up. Though CBT-Ef predicted good outcomes in multivariate models, the severity of affective/interpersonal problems moderated treatment effects: participants with higher severity showed better ED outcomes in CBT-Eb, whereas those with lower severity showed better outcomes in CBT-Ef. Severity of affective/interpersonal BPD symptoms at baseline predicted negative outcomes overall. Follow-up BPD affective/interpersonal problems were predicted by baseline affective/interpersonal problems and by termination EDE score.

DISCUSSION

This study supports the utility of CBT-E for patients with BN and complex comorbidity. CBT-Ef appears to be more efficacious for patients with relatively less severe BPD symptoms, whereas CBT-Eb appears to be more efficacious for patients with more severe BPD symptoms.

The eating disorder examination: reliability and validity of the Italian version

OBJECTIVE

To examine the psychometric characteristics of the Italian language version of the latest edition of the eating disorder examination (EDE).

METHODS

An Italian version of the EDE (17th edition) was designed and administered to 185 in- and outpatients with eating disorders and 60 age-matched controls. Its internal consistency, inter-rater reliability, short-term (7-23 days) test-retest reliability and criterion validity were evaluated.

RESULTS

Internal consistency was high for all four original EDE subscales. Inter-rater reliability was excellent for global EDE scores and original subscales (≥0.93), and for eating disorder behaviours (≥0.89). Test-retest reliability was good for global EDE scores and original subscales (0.57-0.80), objective bulimic episodes and days, vomiting episodes, laxative and diuretic misuse episodes, and excessive exercising (≥0.82), but unsatisfactory for subjective bulimic episodes and days. Patients with eating disorders displayed significantly higher EDE scores than age-matched controls, demonstrating the good criterion validity of the instrument.

CONCLUSIONS

The Italian version of the EDE 17.0D has adequate psychometric properties and can therefore be recommended for examining Italian patients with eating disorders in clinical and research settings.

Problematic Exercise in Anorexia Nervosa: Testing Potential Risk Factors against Different Definitions

“Hyperactivity” has a wide prevalence range of 31% to 80% in the anorexia nervosa literature that could be partly due to the plethora of definitions provided by researchers in this field. The purpose of this study was two-fold: 1) To assess the variance across prevalence rates of problematic exercise encountered in patients with anorexia nervosa, in relation to seven different definitions found in the literature. 2) To examine how core eating disorder symptoms and the dimensions of emotional profile are associated with these different definitions and the impact of these definitions on the assessment of patients’ quality of life. Exercise was evaluated in terms of duration, intensity, type and compulsion using a semi-structured questionnaire administered to 180 women suffering from severe anorexia nervosa. Seven different definitions of problematic exercise were identified in the literature: three entailing a single dimension of problematic exercise (duration, compulsion or intensity) and four combining these different dimensions. Emotional profile scores, obsessive-compulsive symptoms, eating disorder symptomatology, worries and concerns about body shape, self-esteem and quality of life were assessed using several established questionnaires. The prevalence of problematic exercise varied considerably from, 5% to 54%, depending on the number of criteria used for its definition. The type and level of eating disorder symptomatology was found to be associated with several definitions of problematic exercise. Surprisingly, a better self-reported quality of life was found among problematic exercisers compared to non-problematic exercisers in three of the definitions. The different definitions of problematic exercise explain the broad prevalence ranges and the conflicting associations generally reported in the literature between problematic exercise and eating disorder-related psychological parameters. There is an urgent need for a valid consensus on the definition of problematic exercise in anorexia nervosa. This will support the development of further research on the etiology and treatment of problematic exercise.

Inpatient Treatment for Adolescents with Anorexia Nervosa: Clinical Significance and Predictors of Treatment Outcome

This study evaluated the clinical significance as well as predictors of outcome for adolescents with severe anorexia nervosa (AN) treated in an inpatient setting. Body mass index (BMI), eating disorder (ED) symptoms [Eating Disorder Inventory-2 (EDI-2)], general psychopathology and depression were assessed in 238 patients at admission and discharge. BMI increased from 14.8 + 1.2 to 17.3 + 1.4 kg/m(2). Almost a fourth (23.6%) of the patients showed reliable changes, and 44.7% showed clinically significant changes (EDI-2). BMI change did not significantly differ between those with reliable or clinically significant change or no reliable change in EDI-2. Length of stay, depression and body dissatisfaction were negative predictors of a clinically significant change. Inpatient treatment is effective in about two thirds of adolescents with AN and should be considered when outpatient treatment fails. About one third of patients showed significant weight gain, but did not improve regarding overall ED symptomatology. Future studies should focus on treatment strategies for non-responders.

An exploratory examination of patient and parental self-efficacy as predictors of weight gain in adolescents with anorexia nervosa

OBJECTIVE

To determine whether increases in adolescent or parental self-efficacy predicted subsequent weight gain in two different therapies for adolescent anorexia nervosa (AN).

METHOD

Participants were 121 adolescents with AN (M = 14.4 years, SD = 1.6), from a two-site randomized clinical trial for family-based treatment (FBT) and individual adolescent focused therapy (AFT). Both adolescent and parental self-efficacy were assessed at baseline and sessions 2, 4, 6, and 8. Adolescent self-efficacy was assessed using a generic measure of self-efficacy, while parental self-efficacy was assessed using a measure specific to the recovery of an eating disorder. Weight was assessed at baseline, sessions 1 through 8, and end of treatment. Mixed-effects models were used to evaluate the relation between patient and parent self-efficacy and subsequent weight gain, controlling for weight at the previous time point.

RESULTS

For families who received FBT, greater within-treatment increases in parental self-efficacy predicted greater subsequent adolescent weight gain compared to those who received FBT with lesser change in parental self-efficacy and those who received AFT. Interestingly, adolescent self-efficacy did not significantly predict subsequent weight gain.

DISCUSSION

Greater increases in parental self-efficacy predicted significantly greater subsequent weight gain for adolescents who received FBT, but the same was not true for adolescents who received AFT. Neither overall level nor change in adolescent self-efficacy significantly predicted subsequent weight gain in either treatment group. These findings emphasize the importance of increasing parental self-efficacy in FBT in order to impact adolescent weight outcomes.

Do executive functioning deficits underpin binge eating disorder? A comparison of overweight women with and without binge eating pathology

OBJECTIVE

Deficits in executive function (EF)-including inhibitory control, cognitive flexibility, decision-making, and working memory-may be risk or maintenance factors for binge eating disorder (BED). However, there is mixed evidence regarding EF deficits in individuals with BED. Significant methodological weaknesses (e.g., use of a single EF measure, omission of relevant covariates) in the current literature represent one reason for lack of consensus.

METHOD

This study compared EF in a sample of overweight women with (n = 31) and without (n = 43) full or subthreshold BED, with the aim of conducting a multifaceted investigation of the neurocognitive profile of BED. A neuropsychological battery of EF was administered to all participants.

RESULTS

After controlling for IQ and age, individuals with binge eating displayed significantly poorer performance on tasks of problem-solving and inhibitory control, and displayed higher prioritization of immediate versus delayed rewards, but the two groups did not appear to differ on set-shifting, working memory, and risk taking. Differences in inhibitory control were no longer statistically significant when depressive symptomology was added as a covariate and correction for multiple comparisons was applied. Exploratory analyses indicated that full and sub-threshold BED groups did not differ in EF.

DISCUSSION

Results partially support the hypothesis of relative EF deficits in individuals with BED, suggesting that binge eating may be maintained by cognitive factors distinct from those of obesity. Future research should aim to replicate with a larger sample, control for a wider range of psychiatric comorbidities, and examine whether EF deficits predict treatment outcome.

A preliminary examination of Loss of Control Eating Disorder (LOC-ED) in middle childhood

Loss of Control Eating Disorder (LOC-ED) has been proposed as a diagnostic category for children 6-12years with binge-type eating. However, characteristics of youth with LOC-ED have not been examined. We tested the hypothesis that the proposed criteria for LOC-ED would identify children with greater adiposity, more disordered eating attitudes, and greater mood disturbance than those without LOC-ED. Participants were 251 youth (10.29years±1.54, 53.8% female, 57.8% White, 35.5% Black, 2.0% Asian, 4.8% Hispanic, 53.0% overweight). Youth were interviewed regarding eating attitudes and behaviors, completed questionnaires to assess general psychopathology, and underwent measurements of body fat mass. Using previously proposed criteria for LOC-ED, children were classified as LOC-ED (n=19), LOC in the absence of the full disorder (subLOC, n=33), and youth not reporting LOC (noLOC, n=199). LOC-ED youth had higher BMIz (p=0.001) and adiposity (p=0.003) and reported greater disordered eating concerns (p<0.001) compared to noLOC youth. Compared to subLOC youth, LOC-ED youth had non-significantly higher BMIz (p=0.11), and significantly higher adiposity (p=0.04) and disordered eating attitudes (p=0.02). SubLOC youth had greater disordered eating concerns (p<0.001) and BMIz (p=0.03) but did not differ in adiposity (p=0.33) compared to noLOC youth. These preliminary data suggest that LOC-ED youth are elevated on disordered eating cognitions and anthropometric measures compared to youth without LOC-ED. Longitudinal studies are needed to determine if those with LOC-ED are at particularly increased risk for progression of disordered eating and excess weight gain.

Eating Disorders in Girls and Women With Type 1 Diabetes: A Longitudinal Study of Prevalence, Onset, Remission, and Recurrence

OBJECTIVE

Girls and women with type 1 diabetes are at increased risk for developing eating disorders (EDs), and these disorders are associated with serious diabetes-related medical complications. This study describes the longitudinal course of disturbed eating behavior (DEB) and EDs in a cohort with type 1 diabetes.

RESEARCH DESIGN AND METHODS

A total of 126 girls with type 1 diabetes receiving care for diabetes at The Hospital for Sick Children in Toronto participated in a series of seven interview-based assessments of ED behavior and psychopathology over a 14-year period, beginning in late childhood. Survival analysis was used.

RESULTS

Mean age was 11.8 ± 1.5 years at time 1 and 23.7 ± 2.1 years at time 7. At time 7, 32.4% (23/71) met the criteria for a current ED, and an additional 8.5% (6/71) had a subthreshold ED. Mean age at ED onset (full syndrome or below the threshold) was 22.6 years (95% CI 21.6-23.5), and the cumulative probability of onset was 60% by age 25 years. The average time between onset of ED and subsequent ED remission was 4.3 years (95% CI 3.1-5.5), and the cumulative probability of remission was 79% by 6 years after onset. The average time between remission of ED and subsequent recurrence was 6.5 years (95% CI 4.4-8.6), and the cumulative probability of recurrence was 53% by 6 years after remission.

CONCLUSIONS

In this longitudinal study, EDs were common and persistent, and new onset of ED was documented well into adulthood. Further research regarding prevention and treatment for this vulnerable group is urgently needed.

Family Profiles of Expressed Emotion in Adolescent Patients With Anorexia Nervosa and Their Parents

The current study examined expressed emotion (EE) among families of adolescents with anorexia nervosa (AN) participating in a treatment study. EE ratings were made from 110 adolescents toward their parents and from parents toward their children using videotaped family interviews. Participants were 92% female and 75% Caucasian with a mean age of 14.41 years. Four family profiles were created (low patient EE/low parent EE, high patient EE/high parent EE, low patient EE/high parent EE, high patient EE/low parent EE). Family EE profile was not related to full remission at end of treatment. Groups were then combined according to EE level of parent. The low parent group (defined as low on criticism, hostility, and emotional overinvolvement) had significantly lower scores on a measure of eating disorder psychopathology than the high parent group at the end of treatment. Patients with AN in low EE families do better in treatment than those patients belonging to high EE families. These findings are true regardless of the EE status of the patient.

Practice parameter for the assessment and treatment of children and adolescents with eating disorders

This Practice Parameter reviews evidence-based practices for the evaluation and treatment of eating disorders in children and adolescents. Where empirical support is limited, clinical consensus opinion is used to supplement systematic data review. The Parameter focuses on the phenomenology of eating disorders, comorbidity of eating disorders with other psychiatric and medical disorders, and treatment in children and adolescents. Because the database related to eating disorders in younger patients is limited, relevant literature drawn from adult studies is included in the discussion.

Behavioral responses to catecholamine depletion in unmedicated, remitted subjects with bulimia nervosa and healthy subjects

BACKGROUND

Bulimia nervosa (BN) has been associated with dysregulation of the central catecholaminergic system. An instructive way to investigate the relationship between catecholaminergic function and psychiatric disorder has involved behavioral responses to experimental catecholamine depletion (CD). The purpose of this study was to examine a possible catecholaminergic dysfunction in the pathogenesis of bulimia nervosa.

METHODS

CD was achieved by oral administration of alpha-methyl-para-tyrosine (AMPT) in 18 remitted female subjects with BN (rBN) and 31 healthy female control subjects. The study design consisted of a randomized, double blind, placebo-controlled crossover, single-site experimental trial. The main outcome measures were bulimic symptoms assessed by the Eating Disorder Examination-Questionnaire. Measures were assessed before and 26, 30, 54, 78, 102 hours after the first AMPT or placebo administration.

RESULTS

In the experimental environment (controlled environment with a low level of food cues) rBN subjects had a greater increase in eating disorder symptoms during CD compared with healthy control subjects (condition × diagnosis interaction, p < .05). In the experimental environment, rBN subjects experienced fewer bulimic symptoms than in the natural environment (uncontrolled environment concerning food cues) 36 hours after the first AMPT intake (environment × diagnosis interaction, p < .05). Serum prolactin levels increased significantly, and to a comparable degree across groups, after AMPT administration.

CONCLUSIONS

This study suggests that rBN is associated with vulnerability for developing eating disorder symptoms in response to reduced catecholamine neurotransmission after CD. The findings support the notion of catecholaminergic dysfunction as a possible trait abnormality in BN.

Alexithymia is not related to severity of night eating behavior: a useful distinction from other eating disorders

OBJECTIVE

Patients affected by Night Eating Syndrome (NES) complain of insomnia, mood, anxiety and overeating, which have all been linked to difficulties in dealing with emotions, but no research has examined the levels of alexithymia among NES patients. We compared the levels of alexithymia among samples of: NES patients, insomniac patients who do not eat at night, and a control group.

METHOD

The study included 153 participants: 34 with NES, 47 with insomnia, and 72 in the control group. Half of the NES group was recruited in a weight and eating disorders center in Philadelphia and the other in a sleep disorders center in Bologna, Italy. Alexithymia was evaluated through the Toronto Alexithymia Scale (TAS).

RESULTS

All groups scored in the normal range of the TAS. There was no relationship between alexithymia and the severity of NES. The insomnia participants reported the highest levels of alexithymia and NES patients the lowest. All NES patients' scores were under the clinical cut-off for alexithymia.

DISCUSSION

These data differ from the high levels of alexithymia reported by the literature among patients affected by Binge Eating Disorder (BED), suggesting that abnormal diurnal and nocturnal eating patterns, even though they may share several symptoms, are distinct syndromes having different psychopathological pathways.

Identification as overweight by medical professionals: relation to eating disorder diagnosis and risk

PURPOSE

Discussions about weight between medical professionals and young adults may increase risk of eating disorders (EDs). Clarifying the relation between screening for overweight and ED risk is needed.

METHODS

548 college-age women were classified as at-risk (n=441) or with an ED (n=107), and were assessed for disordered eating attitudes, behaviors, and relevant history, including, "Has a doctor, nurse, or other medical professional ever told you that you were overweight?" Regression analyses were used to evaluate the relations between being identified as overweight and current disordered eating behaviors, attitudes, and ED diagnosis, without and with covariates (history of weight-related teasing, history of an ED, family history of being identified as overweight, and current body mass index).

RESULTS

146 (26.6%) women reported being previously identified as overweight by a medical professional. There was no relation between being previously identified as overweight and having an ED. Those identified as overweight were more likely to have weight/shape concerns above a high-risk cutoff, but showed no difference in dietary restraint, binge eating, purging behaviors, or excessive exercise compared to those not identified.

CONCLUSIONS

Being previously identified as overweight by a medical professional was associated with increased weight/shape concerns but not with current disordered eating behaviors or ED status. Minimizing the potential negative effects of overweight screening on weight and shape concerns by providing patients with strategies to increase healthy lifestyle behaviors and long-term support for healthy weight loss goals may have a positive impact on reducing the public health problem of overweight and obesity.

The potential of technology-based psychological interventions for anorexia and bulimia nervosa: a systematic review and recommendations for future research

BACKGROUND

Previous studies have shown an unmet need in the treatment of eating disorders. In the last decade, interest in technology-based interventions (TBIs) (including computer- and Internet-based interventions [CBIs] or mobile interventions) for providing evidence-based therapies to individuals with different mental disorders has increased.

OBJECTIVE

The aim of this review was to systematically evaluate the potential of TBIs in the field of eating disorders, namely for anorexia nervosa (AN) and bulimia nervosa (BN), for both prevention and treatment, and also for carers of eating disorder patients.

METHODS

A systematic literature search was conducted using Medline and PsycINFO. Bibliographies of retrieved articles were also reviewed without date or study type restrictions.

RESULTS

Forty studies resulting in 45 publications reporting outcomes fulfilled the inclusion criteria: 22 randomized controlled trials, 2 controlled studies, and 16 uncontrolled studies. In total, 3646 patients were included. Overall, the studies provided evidence for the efficacy of guided CBIs, especially for BN patients and for compliant patients. Furthermore, videoconferencing also appeared to be a promising approach. Evaluation results of Internet-based prevention of eating disorders and Internet-based programs for carers of eating disorder patients were also encouraging. Finally, there was preliminary evidence for the efficacy of mobile interventions.

CONCLUSIONS

TBIs may be an additional way of delivering evidence-based treatments to eating disorder patients and their use is likely to increase in the near future. TBIs may also be considered for the prevention of eating disorders and to support carers of eating disorder patients. Areas of future research and important issues such as guidance, therapeutic alliance, and dissemination are discussed.

Systematic review of evidence for different treatment settings in anorexia nervosa

AIM: To compare outcomes in anorexia nervosa (AN) in different treatment settings: inpatient, partial hospitalization and outpatient.

METHODS: Completed and published in the English language, randomized controlled trials comparing treatment in two or more settings or comparing different lengths of inpatient stay, were identified by database searches using terms “anorexia nervosa” and “treatment” dated to July 2014. Trials were assessed for risk of bias and quality according to the Cochrane handbook by two authors (Madden S and Hay P) Data were extracted on trial quality, participant features and setting, main outcomes and attrition.

RESULTS: Five studies were identified, two comparing inpatient treatment to outpatient treatment, one study comparing different lengths of inpatient treatment, one comparing inpatient treatment to day patient treatment and one comparing day patient treatment with outpatient treatment. There was no difference in treatment outcomes between the different treatment settings and different lengths of inpatient treatment. Both outpatient treatment and day patient treatment were significantly cheaper than inpatient treatment. Brief inpatient treatment followed by evidence based outpatient care was also cheaper than prolonged inpatient care for weight normalization also followed by evidence based outpatient care.

CONCLUSION: There is preliminary support for AN treatment in less restrictive settings but more research is needed to identify the optimum treatment setting for anorexia nervosa.

Gender differences in clinical trials of binge eating disorder: An analysis of aggregated data

OBJECTIVE

The aim of the study was to examine gender differences in baseline and outcome variables in clinical trials for binge eating disorder (BED).

METHOD

Data from 11 randomized controlled psychosocial treatment studies were aggregated (N = 1,325: 208 male, 1,117 female). Baseline and outcome symptoms were assessed via the interview and questionnaire versions of the Eating Disorder Examination (EDE). Multilevel analyses were conducted investigating gender differences at baseline and posttreatment, defined as EDE scores, objective binge episode (OBE) reduction, and OBE remission at termination.

RESULTS

Few males from low socioeconomic status or minority groups participated in the outcome studies. Males reported significantly lower EDE global, shape, weight, and eating concerns at baseline. No main effects of gender were found in treatment outcome scores when controlling for baseline differences; however, baseline EDE global score (which showed gender differences at baseline) and OBEs directly predicted outcome for both males and females. A significant interaction between gender, treatment length, and shape/weight concerns indicated that males with lower shape/weight concerns achieved OBE remission in shorter treatments, whereas men with high shape/weight concerns and women with either high or low shape/weight concerns were more likely to achieve OBE remission in treatments of longer duration.

CONCLUSIONS

These results suggest BED treatment studies must improve their recruitment of men and appeal to men with lower shape/weight concerns. Additionally, longer term treatments, although more efficacious for women and men with more severe shape/weight concerns, may not be necessary for men with low shape/weight concerns. (PsycINFO Database Record

Factor structure of a French version of the Eating Disorder Examination-Questionnaire among women with and without binge eating disorder symptoms

The Eating Disorder Examination-Questionnaire (EDE-Q) is a self-report questionnaire that is widely used to investigate the core features of eating disorders. The EDE-Q is derived from the Eating Disorder Examination, a semi-structured interview considered as the "gold standard" in the assessment of eating disorders. To verify the factor structure of both instruments, originally composed of four subscales, factor analyses have been conducted with various samples. Heterogeneous results were found. Because no study had investigated the factor structure of the EDE-Q in individuals with binge eating disorder, the goal of our study was to fill this gap. We started with a review of the studies on the EDE and EDE-Q factor structure to decide which models to compare. Among 21 studies that were identified, three models had been replicated several times. We compared these three models-a 22-item, 3-factor model, a brief 7-item, 3-factor model and a brief 8-item, 1-factor model-in two samples of participants, one with threshold and subthreshold criteria for binge eating disorder (N = 116) and one without eating disorders (N = 161). Confirmatory factor analysis revealed a good fit for the brief 7-item, 3-factor model for both populations, whereas other solutions were not acceptable. Cronbach's alpha coefficients of the three factors were acceptable to good, ranging between 0.714 and 0.953. The group with binge eating disorder symptoms had significantly higher scores for each factor. This brief 7-item instrument might be useful for screening or short interventions.

The independent and interacting effects of hedonic hunger and executive function on binge eating

Poor executive function (EF; pre-frontal cognitive control processes governing goal-directed behavior) and elevated hedonic hunger (i.e., preoccupation with palatable foods in the absence of physiological hunger) are theoretical risk and maintenance factors for binge eating (BE) distinct from general obesity. Recent theoretical models posit that dysregulated behavior such as BE may result from a combination of elevated appetitive drive (e.g., hedonic hunger) and decreased EF (e.g., inhibitory control and delayed discounting). The present study sought to test this model in distinguishing BE from general obesity by examining the independent and interactive associations of EF and hedonic hunger with BE group status (i.e., odds of categorization in BE group versus non-BE group). Treatment-seeking overweight and obese women with BE (n = 31) and without BE (OW group; n = 43) were assessed on measures of hedonic hunger and EF (inhibitory control and delay discounting). Elevated hedonic hunger increased the likelihood of categorization in the BE group, regardless of EF. When hedonic hunger was low, poor EF increased the likelihood of categorization in the BE group. Results indicate that the interplay of increased appetitive drives and decreased cognitive function may distinguish BE from overweight/obesity. Future longitudinal investigations of the combinatory effect of hedonic hunger and EF in increasing risk for developing BE are warranted, and may inform future treatment development to target these factors.

Are poor set-shifting abilities associated with a higher frequency of body checking in anorexia nervosa?

BACKGROUND

The rigid and obsessional features of anorexia nervosa (AN) have led researchers to explore possible underlying neuropsychological difficulties. Numerous studies have demonstrated poorer set-shifting in patients with AN. However, due to a paucity of research on the connection between neuropsychological difficulties and the clinical features of AN, the link remains hypothetical. The main objective of this study was to explore the association between set-shifting and body checking.

METHODS

The sample consisted of 30 females diagnosed with AN and 45 healthy females. Set-shifting was assessed using the Wisconsin Card Sorting Test (WCST) and frequency of body checking was assessed using the Body Checking Questionnaire (BCQ).

RESULTS

The analysis showed no significant correlations between any of the WCST scores and the BCQ.

CONCLUSION

The results suggest that there is no association between set-shifting difficulties and frequency of body checking among patients with AN. An alternative explanation could be that the neuropsychological measure included in this study is not sensitive to the set-shifting difficulties observed in clinical settings. We recommend that future studies include more ecologically valid measures of set-shifting in addition to standard neuropsychological tests.

Family functioning in two treatments for adolescent anorexia nervosa

OBJECTIVE

Family functioning impairment is widely reported in the eating disorders literature, yet few studies have examined the role of family functioning in treatment for adolescent anorexia nervosa (AN). This study examined family functioning in two treatments for adolescent AN from multiple family members' perspectives.

METHOD

Participants were 121 adolescents with AN ages 12-18 from a randomized-controlled trial comparing family-based treatment (FBT) to individual adolescent-focused therapy (AFT). Multiple clinical characteristics were assessed at baseline. Family functioning from the perspective of the adolescent and both parents was assessed at baseline and after 1 year of treatment. Full remission from AN was defined as achieving both weight restoration and normalized eating disorder psychopathology.

RESULTS

In general, families dealing with AN reported some baseline impairment in family functioning, but average ratings were only slightly elevated compared to published impaired functioning cutoffs. Adolescents' perspectives on family functioning were the most impaired and were generally associated with poorer psychosocial functioning and greater clinical severity. Regardless of initial level of family functioning, improvements in several family functioning domains were uniquely related to full remission at the end of treatment in both FBT and AFT. However, FBT had a more positive impact on several specific aspects of family functioning compared to AFT.

DISCUSSION

Families seeking treatment for adolescent AN report some difficulties in family functioning, with adolescents reporting the greatest impairment. Although FBT may be effective in improving some specific aspects of family dynamics, remission from AN was associated with improved family dynamics, regardless of treatment type.

Overvaluation of shape and weight in adolescents with anorexia nervosa: does shape concern or weight concern matter more for treatment outcome?

BACKGROUND

Overvaluation of shape and weight is a key diagnostic feature of anorexia nervosa (AN); however, limited research has evaluated the clinical utility of differentiating between weight versus shape concerns. Understanding differences in these constructs may have important implications for AN treatment given the focus on weight regain. This study examined differences in treatment outcome between individuals whose primary concern was weight versus those whose primary concern was shape in a randomized controlled trial of treatment for adolescent AN.

METHODS

Data were drawn from a two-site randomized controlled trial that compared family-based treatment and adolescent focused therapy for AN. Chi-square tests and logistic regression analyses were conducted.

RESULTS

Thirty percent of participants presented with primary weight concern (n = 36; defined as endorsing higher Eating Disorder Examination (EDE) Weight Concern than Shape Concern subscale scores); 60 % presented with primary shape concern (n = 72; defined as endorsing higher EDE Shape Concern than Weight Concern scores). There were no significant differences between the two groups in remission status at the end of treatment. Treatment did not moderate the effect of group status on achieving remission.

CONCLUSIONS

Results suggest that treatment outcomes are comparable between adolescents who enter treatment for AN with greater weight concerns and those who enter treatment with greater shape concerns. Therefore, treatment need not be adjusted based on primary weight or primary shape concerns.