Eating disorders

A Plea for Diversity in Eating Disorders Research

Eating disorders (EDs) are often stereotyped as affecting the SWAG, that is, as affecting mostly skinny, White, affluent girls. Over the last decade, however, significant progress has been made toward increasing diversity in ED research. There is consensus that EDs affect individuals of all genders, ages, sexual orientations, ethnic, and socio-economic backgrounds, with recent studies exploring social determinants of ED etiology, ED presentation, and developing diversity-affirming ED assessments. This article provides a brief summary of current developments related to diversity as a research theme, and proposes different perspectives toward further improving diversity in ED research. Specifically, we argue for exploring the role of diversity in ED treatment settings and outcomes, for pursuing diversity-oriented research pro-actively rather than as a reaction to issues of under-representation, and for integrating diversity across different areas of medical education and trainings in psychotherapy. Limitations with respect to the paucity of research, and the link between diversity as a research theme and ED-related workforce diversity are discussed.

Disordered eating and self-harm as risk factors for poorer mental health during the COVID-19 pandemic: a UK-based birth cohort study

BACKGROUND

Young adults and especially those with pre-existing mental health conditions, such as disordered eating and self-harm, appear to be at greater risk of developing metal health problems during the COVID-19 pandemic. However, it is unclear whether this increased risk is affected by any changes in lockdown restrictions, and whether any lifestyle changes could moderate this increased risk.

METHODS

In a longitudinal UK-based birth cohort (The Avon Longitudinal Study of Parents and Children, ALSPAC) we assessed the relationship between pre-pandemic measures of disordered eating and self-harm and mental health during the COVID-19 pandemic in 2657 young adults. Regression models examined the relationship between self-reported disordered eating, self-harm, and both disordered eating and self-harm at age 25 years and depressive symptoms, anxiety symptoms and mental wellbeing during a period of eased restrictions in the COVID-19 pandemic (May-July 2020) when participants were aged 27-29 years. Analyses were adjusted for sex, questionnaire completion date, pre-pandemic socioeconomic disadvantage and pre-pandemic mental health and wellbeing. We also examined whether lifestyle changes (sleep, exercise, alcohol, visiting green space, eating, talking with family/friends, hobbies, relaxation) in the initial UK lockdown (April-May 2020) moderated these associations.

RESULTS

Pre-existing disordered eating, self-harm and comorbid disordered eating and self-harm were all associated with the reporting of a higher frequency of depressive symptoms and anxiety symptoms, and poorer mental wellbeing during the pandemic compared to individuals without disordered eating and self-harm. Associations remained when adjusting for pre-pandemic mental health measures. There was little evidence that interactions between disordered eating and self-harm exposures and lifestyle change moderators affected pandemic mental health and wellbeing.

CONCLUSIONS

Young adults with pre-pandemic disordered eating, self-harm and comorbid disordered eating and self-harm were at increased risk for developing symptoms of depression, anxiety and poor mental wellbeing during the COVID-19 pandemic, even when accounting for pre-pandemic mental health. Lifestyle changes during the pandemic do not appear to alter this risk. A greater focus on rapid and responsive service provision is essential to reduce the impact of the pandemic on the mental health of these already vulnerable individuals. The aim of this project was to explore the mental health of young adults with disordered eating behaviours (such as fasting, vomiting/taking laxatives, binge-eating and excessive exercise) and self-harm during the COVID-19 pandemic. We analysed data from an established study that has followed children from birth (in 1991 and 1992) up to present day, including during the pandemic when participants were 28 years old. We looked at the relationship between disordered eating and/or self-harm behaviours from before the pandemic and mental health problems (symptoms of depression and anxiety) and mental wellbeing during the pandemic. We also explored whether there were any lifestyle changes (such as changes in sleep, exercise, visiting green space) that might be linked to better mental health and wellbeing in young adults with disordered eating and self-harm. We found that young adults with prior disordered eating and/or self-harm had more symptoms of depression and anxiety, and worse mental wellbeing than individuals without prior disordered eating or self-harm. However, lifestyle changes did not appear to affect mental health and wellbeing in these young adults. Our findings suggest that people with a history of disordered eating and/or self-harm were at high risk for developing mental health problems during the pandemic, and they will need help from mental health services.

Depression and eating disorders in early adolescence: A network analysis approach

OBJECTIVE

Eating disorders (EDs) and depression are among the most debilitating and pervasive mental illnesses. Although they often co-occur, the relationship between EDs and depression remains poorly understood. This study used network analysis to explore the symptom-level relationship between EDs and depression among a sample of Australian adolescents completing their first year of secondary school.

METHOD

Adolescents (N = 4,421) aged between 10 and 15 years completed the Centre for Epidemiological Depression Scale and the Eating Disorder Examination-Questionnaire. Network structure was estimated using the Gaussian graphical model and node centrality was assessed using one-step expected influence (EI) and bridge EI.

RESULTS

"Depressed," "lonely," and "low energy" were identified as core symptoms of depression. "Shape and weight dissatisfaction," "desire to lose weight," and "preoccupation with shape or weight" were identified as core ED symptoms. "Irritable," "social eating," and "depressed" were identified as the most important nodes connecting (i.e., bridging) symptoms of depression and EDs.

DISCUSSION

This study provides an important symptom-level conceptualization of the association between depression and ED symptoms in a community sample of adolescents. This preliminary evidence may guide the development of public health prevention and early intervention programs. Future research should be conducted to address the study limitations (e.g., cross-sectional design).

Disordered Eating Behaviors in Young Individuals With Idiopathic Intracranial Hypertension

BACKGROUND

The objective of this study was to assess the prevalence of disordered eating behaviors (DEBs) in young individuals with idiopathic intracranial hypertension (IIH) and to identify predictors of DEBs in this population.

METHODS

Individuals with IIH aged eight to 25 years and their matched controls responded to a self-rating survey comprised of the Eating Attitude Test-26 for assessing the presence of DEBs and the Depression, Anxiety and Stress Scale.

RESULTS

Fifty-three subjects with IIH and 106 healthy controls were included. DEBs were significantly more prevalent in individuals with IIH (P < 0.001). Individuals with IIH and DEBs were more likely to have longer periods of treatment [odds ratio: 1.07, 95% CI: 1.02-1.41), P = 0.008] and to have lost a significant amount of weight during the course of treatment [odds ratio: 9.06 (95% CI: 1.30-62.9), P = 0.026]. Depression, anxiety, and stress were more prevalent in the IIH group than in the controls (P = 0.004) and were associated with DEBs in these individuals (P = 0.01).

CONCLUSIONS

There is an increased prevalence of DEBs among young individuals with IIH, which persists even after disease resolution, and is associated with higher reported rates of depression, anxiety, and stress. Medical caregivers should have heightened awareness to DEBs in individuals with IIH with the aim of early identification and intervention.

Obesity and Eating Disorders in Children and Adolescents: The Bidirectional Link

Obesity, eating disorders and unhealthy dieting practices among children and adolescents are alarming health concerns due to their high prevalence and adverse effects on physical and psychosocial health. We present the evidence that eating disorders and obesity can be managed or prevented using the same interventions in the pediatric age. In the presence of obesity in the pediatric age, disordered eating behaviors are highly prevalent, increasing the risk of developing eating disorders. The most frequently observed in subjects with obesity are bulimia nervosa and binge-eating disorders, both of which are characterized by abnormal eating or weight-control behaviors. Various are the mechanisms overlying the interaction including environmental and individual ones, and different are the approaches to reduce the consequences. Evidence-based treatments for obesity and eating disorders in childhood include as first line approaches weight loss with nutritional management and lifestyle modification via behavioral psychotherapy, as well as treatment of psychiatric comorbidities if those are not a consequence of the eating disorder. Drugs and bariatric surgery need to be used in extreme cases. Future research is necessary for early detection of risk factors for prevention, more precise elucidation of the mechanisms that underpin these problems and, finally, in the cases requiring therapeutic intervention, to provide tailored and timely treatment. Collective efforts between the fields are crucial for reducing the factors of health disparity and improving public health.

Mental Health Problems Due to Social Isolation During the COVID-19 Pandemic in a Mexican Population

Introduction: Social isolation due to the COVID-19 pandemic has been identified as a risk factor of several mental disorders. Therefore, the present work aimed to evaluate the effect of social isolation experienced during the COVID-19 pandemic on the mental health of a Mexican population. Materials and Methods: A cross-sectional online survey was conducted in individuals of 18 years of age and over. The questioner was structured to identify onset or worsening of psychiatric symptoms due to social isolation by COVID-19. The survey included changes in eating habits, changes in personal hygiene habits, the starting the use or increased the use of psychoactive substances, symptoms of depression or post-traumatic stress. Results: A total of 1,011 individuals were included in the analysis. The majority were women (68.84%). Changes in eating habits were reported in 38.51% of the participants, 67.80% reported having their physical self-perception distorted or having started a low-calorie diet. Regarding symptoms of depression, 46.10% participants indicated to have at least one depressive symptom, and 4.46% reported suicidal ideation during social isolation. Interestingly, 6.09% of individuals reported that they used to have depressive symptoms prior the COVID-19 pandemic and those symptoms decreased due to social isolation. Additionally, 2.27% of individuals presented symptoms of post-traumatic stress due to the possibility of getting COVID-19. Conclusions: In this work we identified how social isolation has impacted the mental health of the Mexican population. We observed that practically all the symptoms evaluated were affected during isolation, such as personal hygiene and eating habits. Depression and suicidal ideation were the ones that increased the most in the general population, while in individuals who had symptoms of depression before isolation, these symptoms decreased during social isolation.

Disordered eating and self-harm as risk factors for poorer mental health during the COVID-19 pandemic: A UK-based birth cohort study

BACKGROUND

Young adults and especially those with pre-existing mental health conditions, such as disordered eating and self-harm, appear to be at greater risk of developing metal health problems during the COVID-19 pandemic. However, it is unclear whether this increased risk is affected by any changes in lockdown restrictions, and whether any lifestyle changes could moderate this increased risk.

METHODS

In a longitudinal UK-based birth cohort (The Avon Longitudinal Study of Parents and Children, ALSPAC) we assessed the relationship between pre-pandemic measures of disordered eating and self-harm and mental health during the COVID-19 pandemic in 2,657 young adults. Regression models examined the relationship between self-reported disordered eating, self-harm, and both disordered eating and self-harm at age 25 years and depressive symptoms, anxiety symptoms and mental wellbeing during a period of eased restrictions in the COVID-19 pandemic (May-July 2020) when participants were aged 27-29 years. Analyses were adjusted for sex, questionnaire completion date, pre-pandemic socioeconomic disadvantage and pre-pandemic mental health and wellbeing. We also examined whether lifestyle changes (sleep, exercise, alcohol, visiting green space, eating, talking with family/friends, hobbies, relaxation) in the initial UK lockdown (April-May 2020) moderated these associations.

RESULTS

Pre-existing disordered eating, self-harm and comorbid disordered eating and self-harm were all associated with the reporting of a higher frequency of depressive symptoms and anxiety symptoms, and poorer mental wellbeing during the pandemic compared to individuals without disordered eating and self-harm. Associations remained when adjusting for pre-pandemic mental health measures. There was little evidence that interactions between disordered eating and self-harm exposures and lifestyle change moderators affected pandemic mental health and wellbeing.

CONCLUSIONS

Young adults with pre-pandemic disordered eating, self-harm and comorbid disordered eating and self-harm were at increased risk for developing symptoms of depression, anxiety and poor mental wellbeing during the COVID-19 pandemic, even when accounting for pre-pandemic mental health. Lifestyle changes during the pandemic do not appear to alter this risk. A greater focus on rapid and responsive service provision is essential to reduce the impact of the pandemic on the mental health of these already vulnerable individuals.

The Impact of Alcohol and Other Substance Use Disorders on Mortality in Patients With Eating Disorders: A Nationwide Register-Based Retrospective Cohort Study

OBJECTIVE

Research is lacking on the contribution of different types of substance use disorders (SUDs) to excess mortality across the full spectrum of eating disorders. The authors assessed the association of alcohol use disorders and other SUDs with mortality in anorexia nervosa, bulimia nervosa, and unspecified eating disorder compared with matched control subjects.

METHODS

A retrospective cohort study was conducted using Danish nationwide registers. The study included 20,759 patients with eating disorders and 83,036 matched control subjects. Hazard ratios were calculated to compare all-cause mortality risk between eating disorder patients and control subjects both with and without a lifetime SUD diagnosis (abuse or dependence of alcohol, cannabis, or hard drugs).

RESULTS

For patients with each type of eating disorder, a higher risk of all-cause mortality was observed relative to control subjects without SUDs among those who abused alcohol and/or cannabis (adjusted hazard ratios for the anorexia nervosa, bulimia nervosa, and unspecified eating disorder patients, respectively, were 11.28 [95% CI=7.01, 18.16], 5.86 [95% CI=3.37, 10.1], and 10.86 [95% CI=6.74, 17.50]), or hard drugs alone or in combination with alcohol and/or cannabis (adjusted hazard ratios, respectively, were 22.34 [95% CI=15.13, 33.00], 11.43 [95% CI=7.14, 18.28], and 15.53 [95% CI=10.15, 23.78]), than in those without SUDs (adjusted hazard ratios, respectively, were 3.21 [95% CI=2.43, 4.23], 1.24 [95% CI=0.88, 1.77], and 4.75 [95% CI=3.57, 6.31]). Control subjects with SUDs also exhibited an elevated risk of all-cause mortality relative to control subjects without SUDs, although to a much lesser extent than eating disorder patients with SUDs.

CONCLUSIONS

SUDs have an additive effect on excess mortality in patients with eating disorders. The prevention and treatment of SUDs in this patient group is thus imperative to reduce mortality.

Prevalence and early risk factors for bulimia nervosa symptoms in inner-city youth: gender and ethnicity perspectives

BACKGROUND

Research on risk factors associated with bulimia nervosa symptoms (BN) in ethnic minorities has been limited. This study adds to the existing literature by providing the ethnicity- and gender-specific prevalence of BN in US inner-city youth and by exploring the longitudinal associations between a clinical level of BN and early risk factors assessed one year previously.

METHODS

The study was conducted on a representative sample of predominantly ethnic minority youth (N = 2794; 54.1% female; age 11-16 years old (M(SD) = 12.77(1.29)); 60.0% African-American, 26.1% Hispanic American, 13.9% White). Self-reported information was obtained on BN and early risk factors (e.g., depressive and anxiety symptoms, posttraumatic stress, somatic complaints). Multivariate analysis of covariance was used to examine the longitudinal associations.

RESULTS

The 3-month BN prevalence was higher in girls (5.1%) than in boys (2.3%) (ratio 2.22:1). Significant differences in BN rates were found between White and African American students (higher in Whites), whereas Hispanic-Americans did not differ significantly from either group. Individuals with BN had significantly higher levels of early risk factors one year prior.

CONCLUSIONS

Timely recognition of BN and associated early risk factors is important for early prevention and intervention strategies.

Emerging Comorbidities in Inflammatory Bowel Disease: Eating Disorders, Alcohol and Narcotics Misuse

Inflammatory bowel disease (IBD) is a chronic and potentially devastating condition of the digestive tract which is exemplified by increasing prevalence worldwide, byzantine pathogenesis with a poorly defined role of the environmental factors, and complex clinical demonstration. As a systemic disease, IBD may progress with a wide spectrum of extraintestinal manifestations (EMs) and comorbidities affecting different organs and systems, from anaemia, undernutrition, and cancer to those which are often neglected like anxiety and depression. Evolving IBD epidemiology and changing environment are reflected by an expanding list of IBD-related comorbidities. In contrast to the well-established role of smoking the connection between alcohol and IBD is still debatable on many levels, from pathogenesis to complications. Furthermore, little is known about narcotics use in IBD patients, even if there are obvious factors that may predispose them to narcotics as well as alcohol misuse. Last but not least, the question arises what is the prevalence of eating disorders in IBD. In our paper, we aimed to discuss the current knowledge on alcohol and drugs misuse and eating disorders as emerging extraintestinal comorbidities in IBD.

Recovery from anorexia nervosa: the influence of women's sociocultural milieux

OBJECTIVE

Young women living in industrialised westernised societies have a higher prevalence of anorexia nervosa, partly due to a cultural emphasis on thinness as a beauty ideal. Sociocultural milieux might promote recovery from anorexia nervosa amongst young women. The current article is a commentary about the social influences on recovery from anorexia nervosa - based on social anthropology, narratives of people with lived experience, and clinical studies.

CONCLUSION

Anorexia nervosa increases social withdrawal, and recovery leads to re-engagement with meaningful relationships. Recovery also empowers women as 'cultural critics' who challenge assumptions about the thinness beauty ideal and gender roles. The gradual process of full or partial recovery often occurs during emerging adulthood (aged 20-29). In this life stage, adolescent friendship groups are dissolving as women move from education to work, reducing the danger of weight-based teasing by peers, which is an environmental risk factor for disordered eating. Women recovering from anorexia nervosa may connect with those aspirations of peers and mentors that eschew a focus on weight and shape, but relate to the life-stage tasks of starting careers, beginning new friendships, selecting life partners and family formation - that is, a broader role in larger relationship networks.

Network intervention analysis to assess the trajectory of change and treatment effects associated with the use of online guided self-help for anorexia nervosa

AIM

The aim of this study was to use the innovative technique of Network Intervention Analysis (NIA) to examine the trajectory of symptom change associated with the use of a digital guided self-help intervention (RecoveryMANTRA) to augment treatment as usual in adult anorexia nervosa.

METHODS

Self-reported eating disorder symptoms and mood (stress, anxiety and depression), work and social adjustment, motivation and treatment (Treatment as usual + RecoveryMANTRAand Treatment as usual) were included as nodes in the network and examined using NIA. Networks were computed at baseline (n = 88, 99), at end of treatment (6 weeks, n = 71, 75) and at 6- (n = 58, 63) and 12-month (n = 52, 63) follow-up.

RESULTS

RecoveryMANTRA was associated with a direct effect on anxiety, shape concern and restraint at the end of the intervention. This effect was not maintained at follow-up. There were no direct effects of RecoveryMANTRA on motivation, stress and depression.

CONCLUSIONS

These findings indicate that RecoveryMANTRA exerts a direct effect on eating disorder symptoms and anxiety. NIA is a promising method to evaluate trajectories of clinical change and direct and indirect effects of a therapeutic intervention compared to a control condition.

Tertiary eating disorder services: is it time to integrate specialty care across the life span?

OBJECTIVE

Australian tertiary eating disorder services (EDS) have a divided model of care, where child and adolescent mental health services (CAMHS) support patients until the age of 18 years, and thereafter, adult mental health services (AMHS) provide care. Consumers and carers have criticised this divided model because the age boundary occurs during the peak period of onset and acuity for eating disorders. Most CAMHS patients are lost to specialty follow-up around age 18, increasing the risks of relapse and premature mortality from eating disorders, since young women (aged 15-24) have the highest hospitalisation rates from anorexia nervosa. The current article is a commentary on the transition gap and possible service designs.

CONCLUSIONS

Eating disorders require access to specialty treatment across the life span. The Australian Federal Government has expanded all-age care through the 2019 Medicare Benefit Schedule (MBS) eating disorder plans. Some new MBS patients require a rapid step-up in care intensity to a tertiary EDS, thereby increasing demand on the public sector. State/Territory Governments should strengthen EDS using the 'youth reach-down' model, where AMHS extend EDS to age 12. Vertical service integration from 12 to 64+ facilitates continuity of care for the duration of an eating disorder.

The impact of maternal eating disorders on breastfeeding practices: a systematic review

Breastfeeding is an effective way to protect and promote the health of the infant and mother. Cultural, social, economic, medical, or psychological factors might interfere with successful breastfeeding. Therefore, maternal eating disorders (EDs) may have detrimental effects on the decision of breastfeeding initiation and on its continuation. There is limited knowledge about the breastfeeding practices of mothers with EDs. We performed a systematic review to generate more evidence in this area. A search was conducted in PubMed and PsycINFO, and several journals were hand searched for relevant publications. Of N = 3904 hits, 13 full texts were included in the qualitative analysis. The findings on total duration of BF between mothers with and without EDs were mixed, but women with EDs showed more negative experiences and emotional problems during BF. There was not enough evidence to conclude on breastfeeding initiation, or on the duration of exclusive breastfeeding. Maternal EDs might have a negative impact on BF practices with possible negative effects on the maternal-child feeding environment. Further studies with comparable data and information on the women's partners' attitudes about breastfeeding are needed.

Open science practices for eating disorders research

This editorial seeks to encourage the increased application of three open science practices in eating disorders research: Preregistration, Registered Reports, and the sharing of materials, data, and code. For each of these practices, we introduce updated International Journal of Eating Disorders author and reviewer guidance. Updates include the introduction of open science badges; specific instructions about how to improve transparency; and the introduction of Registered Reports of systematic or meta-analytical reviews. The editorial also seeks to encourage the study of open science practices. Open science practices pose considerable time and other resource burdens. Therefore, research is needed to help determine the value of these added burdens and to identify efficient strategies for implementing open science practices.

The neurostructural and neurocognitive effects of physical activity: A potential benefit to promote eating disorder recovery

Accumulating evidence suggests that supervised and adapted physical activity provides cognitive benefits for individuals with eating disorders (EDs). The mechanisms underlying the benefits of physical activity are poorly understood. Addressing this knowledge gap may inform the appropriate integration of structured physical activity into eating disorders treatment and recovery. We draw attention to recent findings in the study of the impact of physical activity on the brain, and we describe the neurostructural and neurocognitive changes associated with physical activity observed in various clinical and nonclinical populations. Considering the identified impairment in brain volume- and/or neurocognitive function in various EDs, we propose that positive effects of physical activity may play a meaningful role in successful ED treatment. Accordingly, we outline research steps for closing the knowledge gap on how physical activity may aid in ED recovery, and emphasize the need to combine measures of cognitive and behavioral responses to physical activity, with technology capable of measuring changes in brain structure and/or function.

Clinicians as a critical link: Understanding health professionals' beliefs and attitudes toward anorexia nervosa, bulimia nervosa, and binge eating disorder

Understanding the perspectives of health professionals remains an understudied issue, yet may help bridge research-practice gaps and pinpoint important areas for education, training, and research. This study investigated attitudes toward anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) among Nordic health professionals specialized within the eating disorder (ED) field. Participants (n = 144) completed a modified ED-version of the Illness Perception Questionnaire which assessed attitudes and beliefs toward perceived symptom controllability, severity, treatment effectiveness, and views on the prognosis of AN, BN, and BED. Personal enjoyment and level of comfort working with AN, BN, and BED were also assessed. The majority agreed or strongly agreed that patients with AN, BN, and BED were not responsible for their illness, and viewed the illnesses as psychological rather than medical in etiology. AN was viewed as the most severe and enduring, followed by BN, then BED. Treatment for BN was viewed as being more highly effective than treatments for either AN or BED. Professionals rated significantly less enjoyment and less confidence working with BED. To conclude, both commonalities and differences in attitudes toward AN, BN and BED were found in terms of perceived symptom controllability, views on severity, treatment effectiveness, and anticipated prognosis. In particular, findings emphasized the need for additional training in the management of BED among Nordic healthcare professionals.

Clinical Features of Gambling Disorder Patients with and Without Food Addiction: Gender-Related Considerations

Although food addiction (FA) is a debated condition and it is not currently recognized as a formal diagnosis, it shares features with other addictions, such as gambling disorder (GD). However, the prevalence of FA in GD and the clinical correlates are incompletely understood, especially within women versus men. To investigate FA in patients presenting with GD. The sample included 867 patients diagnosed with GD (798 males and 69 females) attending a specialized behavioral addictions unit. FA was observed in 8.3% of GD patients (18.8% of women, 7.4% of men). More psychopathology and harm avoidance, greater body mass indices and less self-directedness and cooperativeness were associated with FA. In women, FA was associated with a longer GD duration. In men, FA was associated with earlier GD onset, greater GD and problematic alcohol use severities. Among patients with GD, FA was associated with more psychopathology and gambling patterns suggestive of more protracted or severe GD. Screening for and addressing FA condition in patients with GD may help optimize preventive and therapeutic approaches. Future studies should consider testing guidelines to improve healthy eating habits, increase physical exercise and better manage stress and other negative emotions in order to target FA in GD.

Toward a Biological, Psychological and Familial Approach of Eating Disorders at Onset: Case-Control ANOBAS Study

Eating disorders (ED) are considered as heterogeneous disorders with a complex multifactor etiology that involves biological and environmental interaction. Objective: The aim was to identify specific ED bio-psychological-familial correlates at illness onset. Methods: A case-control (1:1) design was applied, which studied 50 adolescents diagnosed with ED at onset (12-17 years old) and their families, paired by age and parents' socio-educational level with three control samples (40 with an affective disorder, 40 with asthma, and 50 with no pathology) and their respective families. Biological, psychological, and familial correlates were assessed using interviews, standardized questionnaires, and a blood test. Results: After performing conditional logistic regression models for each type of variable, those correlates that showed to be specific for ED were included in a global exploratory model (R 2 = 0.44). The specific correlates identified associated to the onset of an ED were triiodothyronine (T3) as the main specific biological correlate; patients' drive for thinness, perfectionism and anxiety as the main psychological correlates; and fathers' emotional over-involvement and depression, and mothers' anxiety as the main familial correlates. Conclusion: To our knowledge, this is the first study to use three specific control groups assessed through standardized interviews, and to collect a wide variety of data at the illness onset. This study design has allowed to explore which correlates, among those measured, were specific to EDs; finding that perfectionism and family emotional over-involvement, as well as the T3 hormone were relevant to discern ED cases at the illness onset from other adolescents with or without a concurrent pathology.

Dissociation and Suicidality in Eating Disorders: The Mediating Function of Body Image Disturbances, and the Moderating Role of Depression and Anxiety

In patients with eating disorders (EDs), elevated dissociation may increase the risk of suicide. Bodily related disturbances, depression, and anxiety may intervene in the association between dissociation and suicidality. In this study we aimed to examine the influence of bodily related disturbances, depression, anxiety, severity of ED symptoms, body mass index (BMI), and type and duration of the ED on the relationship between elevated dissociation and elevated suicidality. The study included 172 inpatients: 65 with anorexia nervosa restricting type, 60 with anorexia nervosa binge/purge type, and 37 with bulimia nervosa. Participants were assessed using self-rating questionnaires for dissociation, suicidality, bodily related parameters, and severity of ED symptomatology, depression, and anxiety. We found that dissociation and suicidality were directly associated. In addition, depression and anxiety moderated the mediating role of body image parameters in the association between increased dissociation and increased suicidality. Thus, only in inpatients with high depression and anxiety, i.e., above the median range, body image disturbances were found to mediate the association between dissociation and suicidality. ED-related parameters did not moderate these relationships. Our study demonstrates that in inpatients with EDs, increased dissociation may be significantly associated with increased suicidality, both directly and via the intervening influence of body image, depression, and anxiety.

Bone mineral density at extremely low weight in patients with anorexia nervosa

OBJECTIVE

Low bone mineral density (BMD) is a frequent and invalidating consequence of chronic undernourishment in patients with anorexia nervosa (AN). The aim of this study was to assess prevalence and clinic-biological correlates of low BMD and fractures in extremely undernourished inpatients with AN.

DESIGN

Retrospective cohort study.

PATIENTS AND MEASUREMENTS

This study included 97 extremely malnourished female inpatients with AN consecutively admitted over 2 years. Clinical-biological variables, history of fractures and BMD by dual-energy X-ray absorptiometry (DXA) were examined to find predictors of low BMD and fractures.

RESULTS

The prevalence of low BMD was of 51% for lumbar spine and 38% for femoral neck. Z-scores were lower at lumbar spine (-2.2 ± 1.2 SD) than at femoral neck (-1.9 ± 0.9 SD) (P<.01). Fragility fractures were reported by 10% of patients. BMD was mainly predicted by FFM, illness duration, age at onset and restricting AN (P<.05). Fractures were predicted by sodium concentrations, femoral neck Z-score and illness duration (P<.03).

CONCLUSION

Extremely severe patients with AN have high prevalence of low BMD, predicted by severity and chronicity of malnutrition.

Challenging rigidity in Anorexia (treatment, training and supervision): questioning manual adherence in the face of complexity

BACKGROUND

Anorexia Nervosa is a debilitating illness. While there have been many advancements to treatment protocols and outcomes for people with eating disorders, the field acknowledges there remains considerable room for improvement. This timely Special Edition of the Journal of Eating Disorders has invited those of us in the field to consider a range of topics in aid of this task, including potential modifications and implementation of evidence-based practice, specific and common psychotherapy factors, treatment manuals, adherence and individualising treatment approaches for individuals and families. BODY: In this paper, we briefly outline the key manualised treatments currently available to treat children, adolescents and adults with Anorexia Nervosa, considering the benefits, potential reasons for adaptations and limitations. We then review the current evidence for training strict adherence to treatment manuals which is often a key focus in training and supervision, questioning the association of increased treatment adherence with improved therapeutic outcome. We then summarise some key evidence behind other therapeutic factors which have been demonstrated to affect outcome regardless of which manual is implemented, such as readiness to change and therapeutic alliance.

CONCLUSION

The paper concludes with implications and considerations for future research, clinical guidelines, training and supervision, highlighting the need to consider the therapeutic relationship and processes alongside manual content to conduct best evidence-informed practice.

Towards a Comprehensive Understanding of Body Image: Integrating Positive Body Image, Embodiment and Self-Compassion

Body image (BI) disturbance is a relevant factor in the etiology and treatment of eating disorders (ED). Although progress has been made in recent decades in understanding BI and its relationship with ED, the efficacy of BI disturbance prevention and intervention programs is still limited. In order to reach deeper understanding of BI disturbance and clarify the interactions between some protective and risk factors related to this construct, we carried out a literature review on some specific BI-related factors that so far have been analyzed independently. We specifically examined positive and negative BI; embodiment and its role in the development of positive and negative BI; and self-compassion as a protective factor that promotes positive embodiment (vs. disembodiment) and protection against body shame. We conclude that integrating the available evidence on these factors into BI models may be used to enhance our understanding of BI and improve the efficacy of prevention and intervention programs to help fight negative BI (by reducing body shame and disembodiment) and promote positive BI (by increasing self-compassion and positive embodiment).

Perceived parental bonding and cortisol awakening response in people with eating disorders

It is widely acknowledged that early life experiences may have an impact on hypothalamic-pituitary-adrenal (HPA) axis functioning in eating disorders (EDs). Parental bonding is defined as the parental contribution of care and control to parent-child relationships. We evaluated whether perceived care and protection of parental bonding in childhood and adolescence were associated with HPA axis functioning in adult patients with EDs. Sixty-four women with EDs participated in the study, 37 with anorexia nervosa and 27 with bulimia nervosa. Parental care and control (separately for the mother and father) were evaluated by the Parental Bonding Instrument. The activity of the HPA axis was assessed by measuring the salivary cortisol awakening response (CAR). Parental care and control did not differ significantly between the two diagnostic groups. High and low maternal care were associated with significantly different time patterns of CAR without any significant difference in the overall post-awakening production of cortisol. Maternal control, paternal care and paternal control were not associated with any difference in the CAR. Our results showed for the first time an association of perceived maternal care with the time pattern of CAR in female patients with EDs, while perceived parental control was not associated with any CAR feature. These findings support the idea that perceived characteristics of parental bonding in childhood and adolescence may influence the HPA axis activity in adults with EDs.

Socio-cognitive processing in people with eating disorders: Computerized tests of mentalizing, empathy and imitation skills

OBJECTIVE

Eating disorders are psychiatric illnesses characterized by extreme eating behaviors, such as sustained food restriction or loss of control over eating. Symptoms are thought to be maintained by a variety of mechanisms, one of which may be the socio-cognitive impairments associated with eating disorders. While some previous work has addressed socio-cognitive impairments in eating disorders, this work has relied mostly on self-report data.

METHOD

Here we employed computerized tests of (a) mentalizing (ability to infer the mental states of others); (b) empathy (the degree to which the emotional states of others can be identified and the degree to which the states of others impact one's own emotional state); and (c) imitation (the degree to which observation of another's actions prompts the performance of those actions); in a group of 78 women with an eating disorder and a matched control group of 66 healthy women.

RESULTS

People with eating disorders showed both hyper- and hypo-mentalizing and reduced accuracy of emotional and cognitive mental state inference. They displayed less imitation of observed actions, but no differences in empathy compared to healthy controls. Although anxiety and depressive symptoms had significant effects on mentalizing, most of the observed inter-group differences persisted.

DISCUSSION

Women with eating disorders have difficulties mentalizing and imitating observed actions despite intact non-social automatic imitation, compared to healthy controls. These findings provide an indication that intervention modules to strengthen specific areas of social cognition might be helpful to improve patients' social skills.

Executive functions in binge spectrum eating disorders with comorbid compulsive buying

OBJECTIVE

The aims were to explore if bulimic spectrum disorders (BSD) patients, who also present comorbid compulsive buying (CB), could represent a specific subtype considering its neuropsychological performance; to present a descriptive analysis of different clinical features; and to explore how these variables could influence treatment outcome. It was hypothesised that the comorbid group will present worse neuropsychological performance that will lead to a worse treatment outcome.

METHOD

The study has a longitudinal design. Women (N = 75) diagnosed with BSD, BSD + CB and Healthy Controls (HC); completed an evaluation of: cognitive flexibility, decision making, eating disorder (ED) symptomatology, psychopathological state and personality traits.

RESULTS

BSD + CB was the group with the most severe clinical profile, worst treatment outcome and higher neuropsychological impairment, than other groups. Path-analysis evidenced that deficits in decision making were associated with bad treatment outcome, while deficits in flexibility with the presence of the comorbidity. Self-directedness and novelty seeking were associated with the neuropsychological performance and the comorbidity.

CONCLUSION

BSD + CB exhibit a worse clinical and neuropsychological profile that seems to be related with the treatment outcome, which should be taken into account for the establishment of specific treatment approaches.

Short-Term Outcome of Inpatient Treatment for Adolescents with Anorexia Nervosa Using DSM-5 Remission Criteria

This study evaluated the short-term outcome of a multimodal inpatient treatment concept for adolescents with anorexia nervosa (AN). In this prospective observational study, a cohort of 126 female adolescents with AN (age range: 11–17, mean age: 14.83) was longitudinally followed from admission to discharge (average duration of stay: 77 days). We used gold-standard clinical interviews and self-report data, as well as DSM-5 remission criteria, to evaluate the treatment outcome. From admission to discharge, body-mass-index (BMI) significantly improved by 2.6 kg/m². Data from clinical interviews and self-reports yielded similar improvements in restraint eating and eating concerns (large effects). Lower effects were observed for variables assessing weight/shape concerns and drive for thinness. At discharge, 23.2% of patients showed full remission of AN, 31.3% partial remission, and 45.5% no remission according to DSM-5 criteria. Differences in remission groups were found regarding AN severity, age at admission, and use of antidepressant medication. Living with both parents, longer duration of inpatient treatment and the use of antipsychotic medication were significantly associated with higher BMI change. The findings provide evidence for the short-term effectiveness of our inpatient treatment concept. We recommend using DSM-5 based remission criteria to evaluate the treatment outcome to improve the comparability of studies.

Implementation of mentalization-based treatment in a day hospital program for eating disorders-A pilot study

OBJECTIVE

Aim of the pilot study was to evaluate the effectiveness of a day hospital program for eating disorders (EDs) after implementation of mentalization-based treatment (MBT), including a comparison to a historical matched control group.

METHOD

All consecutively admitted patients with an ED were included in a prospective, observational study over a period of 2 years. Main outcome criteria were eating and overall psychopathology. Furthermore, changes in the capacity to mentalize (reflective functioning [RF]), difficulties with affect regulation and interpersonal problems were assessed at admission, discharge and a three months follow-up.

RESULTS

Thirty-eight out of fourty patients could be included. The program led to significant reductions in eating and general pathology. There was significant improvement in RF, difficulties in emotion regulation and interpersonal functioning. However, there was no advantage in comparison to a matched control group (main outcomes). ED symptoms showed a slight renewed increase after discharge, while body mass index further increased. RF change was predictive of change in overall psychopathology, but not ED symptoms. Drop-out rate was 13.2%.

CONCLUSION

The program showed no advantage in comparison to a historical control group concerning a reduction in eating and overall psychopathology. However, it was associated with low drop-out rates, and changes which MBT targets: An increase in RF and a reduction of interpersonal problems as well as difficulties in emotion regulation.

A pilot study exploring the effect of repetitive transcranial magnetic stimulation (rTMS) treatment on cerebral blood flow and its relation to clinical outcomes in severe enduring anorexia nervosa

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a novel treatment option for people with severe enduring anorexia nervosa (SE-AN), but associated neurobiological changes are poorly understood. This study investigated the effect of rTMS treatment on regional cerebral blood flow (CBF) and whether any observed changes in CBF are associated with changes in clinical outcomes in people with SE-AN.

METHODS

As part of a randomised sham-controlled feasibility trial of 20 sessions of high-frequency rTMS to the left dorsolateral prefrontal cortex, 26 of 34 trial participants completed arterial spin labelling (ASL) functional magnetic resonance imaging (fMRI) to quantify regional and global resting state CBF before (pre-randomisation baseline) and after real or sham treatment (1-month post-randomisation). A group of healthy females (n = 30) were recruited for baseline comparison. Clinical outcomes, including BMI, and depression and anxiety symptoms, were assessed at baseline, 1-, 4-, and 18-months post-randomisation.

RESULTS

No group differences in regional CBF were identified between the SE-AN and healthy comparison participants. A significant treatment-by-time interaction in a medial temporal lobe cluster with the maximal peak in the right amygdala was identified, reflecting a greater reduction in amygdala CBF following real rTMS compared to sham. Participants with the greatest rTMS-related reduction in amygdala CBF (i.e., between baseline and 1-month post-randomisation) showed the greatest sustained weight gain at 18-months post-randomisation. Higher baseline CBF in the insula predicted greater weight gain between baseline and 1-month post-randomisation and between baseline and 4-months post-randomisation.

CONCLUSIONS

This exploratory pilot study identified rTMS treatment related changes in CBF in adults with SE-AN and these were associated with changes in weight. Our preliminary findings also suggest that CBF (as measured by ASL fMRI) may be a marker of rTMS treatment response in this patient group. Future rTMS studies in AN should employ longitudinal neuroimaging to further explore the neurobiological changes related to rTMS treatment.

TRIAL REGISTRATION

ISRCTN14329415 , registered 23rd July 2015.

Could acne be a risk factor for developing eating disorders? Acne vulgaris and eating disorders

INTRODUCTION

Skin findings such as acne, hypertrichosis, and hyperpigmentation may be a clue for the diagnosis of eating disorders. There are studies on skin findings in eating disorders, but there is no study evaluating eating disorders in acne patients. We aimed to investigate eating disorders in acne patients and evaluate the effect of acne severity, quality of life, and body mass index (BMI) on eating disorders.

METHODS

Two hundred thirty-two acne patients and 314 healthy controls were enrolled. Acne severity was detected according to Grading Acne Severity Scale (GAGS) by the dermatologists. Eating Attitude Test-40 (EAT) and Acne Quality of Life Scale (AQLS) were filled out by patients. The controls filled out EAT. Individuals scoring EAT≥30 points were considered at risk for eating disorders.

RESULTS

The median EAT score (15 vs. 13) and the number of patients scoring EAT ≥30 (14.2% vs. 2.2%) were found to be significantly higher in the patients' group compared with control group (p: 0.005, p < 0.001). There was a significant positive correlation between EAT score and AQLS score but no significant relationship between acne severity and EAT score. A significant positive correlation was found between EAT scores and BMI.

CONCLUSION

Eating disorders and acne are mostly seen in adolescence, and both have high biopsychosocial morbidity. Also eating disorders can even be mortal sometimes. There are common psychopathological mechanisms in eating disorders and acne.

Caloric Restriction and Cardiovascular Health: the Good, the Bad, and the Renin-Angiotensin System

Much excitement exists over the cardioprotective and life-extending effects of caloric restriction (CR). This review integrates population studies with experimental animal research to address the positive and negative impact of mild and severe CR on cardiovascular physiology and pathophysiology, with a particular focus on the renin-angiotensin system (RAS). We also highlight the gaps in knowledge and areas ripe for future physiological research.

Brief early adolescent multi-family therapy (BEAM) trial for anorexia nervosa: a feasibility randomized controlled trial protocol

INTRODUCTION

Multi-family therapy (MFT) is a recommended treatment for adolescent anorexia nervosa internationally. Despite recent significant advances in single-family therapy, the evidence base for MFT remains relatively small. Several individual and family factors have been associated with poorer outcomes in single-family therapy, many of which may be addressed or ameliorated by MFT if delivered early in treatment. This trial aims to determine the feasibility and acceptability of adding a five-day multi-family therapy group to the early stages of family therapy for anorexia nervosa. Secondary objectives are to explore effect size changes in key individual and family factors across treatment.

METHODS

This feasibility trial will use a randomised controlled design. Sixty adolescents (age 10-17 inclusive) with anorexia nervosa or atypical anorexia nervosa and their parents will be recruited from a community-based specialist eating disorder service in London, UK. Participants will be randomly allocated to receive six months of eating disorder focussed family therapy with a five-day MFT group (experimental group) or without (control group). Block randomisation will be conducted by the King's Clinical Trials Unit and researchers will be blind to participants' intervention allocation. Feasibility, acceptability and secondary outcomes measures will be collected at baseline, post-MFT, end of treatment, six-month and 12-month follow-up. Feasibility and acceptability will be assessed according to trial sign-up rates, retention, measure completion rates and satisfaction. Secondary outcomes include physical health improvements, changes in psychiatric symptoms, emotion regulation and reflective function capacity, expressed emotion, parental difficulties and therapeutic alliance. Descriptive data and exploration analysis of trends and effect sizes will be reported upon at trial completion.

DISCUSSION

The five-day MFT program developed for this study is novel, brief and more accessible than previous MFT models. The inclusion of a data collection point during treatment and follow-up will allow for an investigation of trends during and after treatment. This will allow exploration and comparison of future potential mediators and moderators of MFT and FT-AN outcomes and how these may differ between treatments.

TRIAL REGISTRATION

ISRCTN registry; ISRCTN93437752 , on 27 January 2021.

Risk factors for eating disorders: an umbrella review of published meta-analyses

Objective:

To grade the evidence about risk factors for eating disorders (anorexia nervosa, bulimia nervosa, and binge eating disorder) with an umbrella review approach.

Methods:

This was a systematic review of observational studies on risk factors for eating disorders published in PubMed/PsycInfo/Embase until December 11th, 2019. We recalculated random-effect meta-analyses, heterogeneity, small-study effect, excess significance bias and 95% prediction intervals, grading significant evidence (p < 0.05) from convincing to weak according to established criteria. Quality was assessed with the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) tool.

Results:

Of 2,197 meta-analyses, nine were included, providing evidence on 50 risk factors, 29,272 subjects with eating disorders, and 1,679,385 controls. Although no association was supported by convincing evidence, highly suggestive evidence supported the association between childhood sexual abuse and bulimia nervosa (k = 29, 1,103 cases with eating disorders, 8,496 controls, OR, 2.73, 95%CI 1.96-3.79, p = 2.1 x 10-9, AMSTAR-2 moderate quality) and between appearance-related teasing victimization and any eating disorder (k = 10, 1,341 cases with eating disorders, 3,295 controls, OR 2.91, 95%CI 2.05-4.12, p = 1.8x10-9, AMSTAR-2 moderate quality). Suggestive, weak, or no evidence supported 11, 29, and 8 associations, respectively.

Conclusions:

The most credible evidence indicates that early traumatic and stressful events are risk factors for eating disorders. Larger collaborative prospective cohort studies are needed to identify risk factors for eating disorders, particularly anorexia nervosa.

Eating Disorders in Children and Adolescents: A Practical Review and Update for Pediatric Gynecologists

Eating disorders (EDs) are common among female adolescents and young adults and can have serious and diverse health consequences. Pediatric gynecology providers have the opportunity to play a vital role in the recognition of EDs in this population. Early medical detection and referral for appropriate evidence-based treatment can lead to better health outcomes for youth. In this article we aim to increase the awareness of the pediatric gynecologist of typical and subtle presentations of EDs, provide guidance for screening, discuss common and serious medical complications, and review treatment considerations for gynecologic issues in patients with EDs.

Neurobiological and Psychological Maintenance Mechanisms Associated with Anticipatory Reward in Bulimia Nervosa

The purpose of this investigation is to identify the anticipatory reward mechanisms that maintain binge eating and purging in bulimia nervosa. Emerging data indicate the importance of reward and anticipatory processes as maintenance mechanisms of bulimia nervosa that can be targeted in treatment. The proposed research will identify neurobiological and psychological anticipatory mechanisms of binge eating and purging using functional magnetic resonance imaging (fMRI), and ecological momentary assessment (EMA) in the natural environment. In this investigation, 60 adults (30 with bulimia nervosa and 30 matched comparison participants) will undergo negative and positive mood inductions followed by an fMRI food selection task (and a comparison shopping task) to examine neurobiological and affective responses to food and non-food reward anticipation. Participants with bulimia nervosa will complete two weeks of EMA examining real-time affect changes in relation to the anticipation of binge eating and purging. These methods will facilitate rigorous assessment of the links between neurobiological (fMRI) and naturalistic (EMA) data in anticipatory reward processes. Findings from this investigation will inform the conceptualization and treatment of bulimia nervosa by identifying the role of reward anticipation in symptom maintenance, providing a crucial framework for targeting these anticipatory processes in existing and novel interventions.

Epidemiology and determinants of obesity in China

Obesity has become a major public health issue in China. Overweight and obesity have increased rapidly in the past four decades, and the latest national prevalence estimates for 2015-19, based on Chinese criteria, were 6·8% for overweight and 3·6% for obesity in children younger than 6 years, 11·1% for overweight and 7·9% for obesity in children and adolescents aged 6-17 years, and 34·3% for overweight and 16·4% for obesity in adults (≥18 years). Prevalence differed by sex, age group, and geographical location, but was substantial in all subpopulations. Strong evidence from prospective cohort studies has linked overweight and obesity to increased risks of major non-communicable diseases and premature mortality in Chinese populations. The growing burden of overweight and obesity could be driven by economic developments, sociocultural norms, and policies that have shaped individual-level risk factors for obesity through urbanisation, urban planning and built environments, and food systems and environments. Substantial changes in dietary patterns have occurred in China, with increased consumption of animal-source foods, refined grains, and highly processed, high-sugar, and high-fat foods, while physical activity levels in all major domains have decreased with increasing sedentary behaviours. The effects of dietary factors and physical inactivity intersect with other individual-level risk factors such as genetic susceptibility, psychosocial factors, obesogens, and in-utero and early-life exposures. In view of the scarcity of research around the individual and collective roles of these upstream and downstream factors, multidisciplinary and transdisciplinary studies are urgently needed to identify systemic approaches that target both the population-level determinants and individual-level risk factors for obesity in China.

Detection, treatment, and course of eating disorders in Finland: A population-based study of adolescent and young adult females and males

Objective:

We assessed the detection, treatment and outcomes of DSM-5 eating disorders in a nationwide community setting.

Method:

The FinnTwin12 cohort comprises twins born in 1983–1987 in Finland (n = 5,600), with follow-up starting at age 12. We outline treatment and outcomes of the 127 females and 15 males diagnosed with a lifetime DSM-5 eating disorder in interviews conducted for a subsample (n = 1,347) in their early 20s.

Results:

Only 45 (32%) of those diagnosed with eating disorder in the interviews had their condition detected in healthcare, and even fewer received treatment (30% of females, 13% of males). Anorexia nervosa (AN), bulimia nervosa, and atypical AN were detected and treated more often than other eating disorders. Five years after disease onset, 41% of those diagnosed had recovered. There were no statistically significant differences in the course of different eating disorders (log-rank p = 0.66) but the outcome was more favourable among males (log-rank p = 0.008). The likelihood of 5-year recovery did not differ between those who had and who had not received treatment (41.1% vs. 40.5%, log-rank p = 0.66).

Conclusion:

Although eating disorders are common and symptoms are persistent for many, they remain under-diagnosed and under-treated. In real-world settings, effectiveness of provided treatments may be limited.

Foam Rubber Pica and Cautopyreiophagia in a Highly Educated Woman: A Clinical Case Study

Pica, the developmentally and culturally-inappropriate eating of non-nutritive and non-food substances, is most often documented in people with developmental disabilities and children, frequently in institutional and residential settings. To date, there are no randomized clinical trials on pica-specific treatments, and very little literature is available regarding the characteristics or treatment of pica in adults with no intellectual or social deficits, and co-morbid disorders. This case study addresses this gap, and involves a highly educated 30 year-old American woman with foam rubber pica and burned match consumption (cautopyreiophagia) behaviors, along with co-morbid depressive, anxiety, and obsessive-compulsive symptoms, who received treatment in a general intensive outpatient program for adults in a large urban community psychiatry setting. The case study describes how the Biosocial Theory and Transtheoretical Model of Health Behavior Change were used to conceptualize this woman’s symptoms and guide a treatment team of clinicians who did not specialize in pica. Providers in non-specialty clinic settings would benefit from reflecting on ways to adapt evidence-based techniques to the treatment of uncommon symptoms.

A systematic review of network analysis studies in eating disorders: Is time to broaden the core psychopathology to non specific symptoms

Objective

Network theory considers mental disorders as the product of symptom interaction. A growing number of studies employing this methodology has been conducted in eating disorders (EDs). We aimed to review those studies to provide evidence and limitations for a novel conceptualisation of EDs.

Methods

According to PRISMA guidelines and PICOS criteria, studies eligible for inclusion were those employing network analysis in people with a clinically defined diagnosis of ED. Twenty‐five studies were included and were analysed in relation to diagnosis, comorbidity, and treatment outcome.

Results

Despite the central role of overvaluation of body shape and weight and cognitive restraint across ED diagnoses, ineffectiveness, interoceptive awareness and affective problems appear central symptoms. Ineffectiveness and interoceptive awareness emerge as bridge symptoms promoting comorbidity in people with anorexia nervosa and in mixed ED samples. Although few studies assessed treatment outcome, there is evidence supporting the predictive role of central network nodes.

Conclusions

Ineffectiveness, interoceptive ability and affective problems may be included in the core ED psychopathology, in addition to ED‐specific symptoms. Network analysis is a promising method to reconceptualize comorbidity. Future studies are recommended to include general psychopathology in ED networks, to assess connections with the external field and clinical meaning of network connectivity.

Overvaluation of body shape and weight and cognitive restraint appear as central nodes across eating disorder diagnoses and ages.

In addition to specific symptoms, ineffectiveness, low interoceptive ability and affective problems also emerge as central nodes in eating disorders.

There is some evidence to point to ineffectiveness and low interoceptive ability as bridge nodes promoting psychiatric comorbidity.

Only few studies assessed treatment outcome through the network analysis approach

Eating disorders and the risk of developing cancer: a systematic review

PURPOSE

Evidence concerning eating disorders as risk toward developing cancer is sparse. Energy restriction might be cancer protective, while malnutrition, vomiting, laxative and substance use might stimulate cancer development. We examined whether individuals with an eating disorder (not restricted to anorexia nervosa) had a different risk of developing cancer.

METHODS

A systematic search on Medline and Embase until 28th April 2020 identified relevant human original research publications, including all populations and all cancer types.

RESULTS

From 990 records, 6 case reports and 9 cohorts were included. Some cohorts found a decreased breast (3/5 studies) or cervical (1/2) cancer risk, while an increased esophageal (2/3), liver (1/1), brain (1/1 in men) and respiratory (2/4) cancer risk, but other cancer risks were non-significant, and an increased mortality overall (1/2), from breast (1/1), female genital (1/1) and skin (1/1) cancer in eating disorder patients. The case reports further described esophageal cancer and leukemia. No clear statistical differences in cancer risk were found depending on eating disorder type, perhaps due to the small sample size (n = 1783 for other than anorexia nervosa).

CONCLUSIONS

The literature on eating disorders and cancer risk is sparse with many gaps. Hormonal changes, sexual activity, nutritional status, vomiting and concomitant tobacco/alcohol abuse may explain increased/decreased cancer risk. Future large studies (now 1-366 cancer cases) that also include men (now 4.7%), bulimia nervosa (now 3.8%) and several cancer sites (now mainly breast cancer) are needed and should foresee longer follow-up time (now 5.4-15.2 years) and extensive confounder adjustment (now only age and sex).

LEVEL OF EVIDENCE

Level I, systematic review.

Association of 5-HTR2A -1438A/G polymorphism with anorexia nervosa and bulimia nervosa: A meta-analysis

Although a number of studies have been conducted on the association of -1438A/G polymorphism in serotonin 2A receptor (5-HTR2A) gene with anorexia nervosa (AN) and bulimia nervosa (BN), the results remained inconsistent. We thus performed a meta-analysis to clarify the effects of -1438A/G polymorphism on the risk of AN and BN. PubMed, Embase, the Cochrane Library, CNKI, Weipu and Wanfang databases were searched for eligible studies. Pooled odds ratio (OR) and 95 % confidence interval (CI) were calculated to estimate the strength of the association. Subgroup analysis was also performed by ethnicity. In total, 17 studies were included for the meta-analysis, of which 15 studies containing 2028 cases and 2725 controls were used for AN analysis and 7 studies containing 505 cases and 1129 controls for BN analysis. The results showed -1438A/G polymorphism was significantly associated with the risk of AN in four genetic models (allele model, A vs. G: OR = 1.31, 95 % CI = 1.11-1.64, P = 0.003; recessive model, AA vs. GA + GG: OR = 1.69, 95 % CI = 1.28-2.23, P = 0.000; dominant model, AA + GA vs. GG: OR = 1.35, 95 % CI = 1.02-1.79, P = 0.037; co-dominant model, AA vs. GG: OR = 1.94, 95 % CI = 1.29-2.92, P = 0.002) in Caucasians, but not in Asians. We failed to observe a significant association between -1438A/G polymorphism and the risk of BN either in overall or in Caucasian population. The present meta-analysis indicated that A allele and AA genotype of 5-HTR2A -1438A/G polymorphism may contribute to higher risk of AN, especially in Caucasians. However, this polymorphism was not associated with the susceptibility to BN.

Does a Skills Intervention for Parents Have a Positive Impact on Adolescents' Anorexia Nervosa Outcome? Answers from a Quasi-Randomised Feasibility Trial of SUCCEAT

Skills trainings for caregivers of patients with anorexia nervosa (AN) have been proven to be effective in improving caregiver skills and reducing caregivers’ psychopathology. The effects on patients, especially adolescents, are largely unknown. The aim of this study was to evaluate the effectiveness of a caregivers’ skills training program (Supporting Carers of Children and Adolescents with Eating Disorders in Austria, SUCCEAT, workshop or online version) on adolescents with AN delivered as workshops (WS) or online (ONL). Outcomes are Body-Mass-Index (BMI) percentile, eating psychopathology (Eating Disorder Examination, EDE), attitudinal and behavioural dimensions of eating disorders (Eating Disorder Inventory-2), motivation to change (AN Stages of Change Questionnaire), emotional and behavioural problems (Youth Self-Report) and quality of life (KINDL). All outcome variables significantly improved across both SUCCEAT groups (WS and ONL) and were sustained at 12-month follow-up. The online and workshop delivery of SUCCEAT were equally effective. Most effect sizes were in the medium-to-high range. Full or partial remission was observed in 72% (WS) and 87% (ONL) of patients. Caregiver skills trainings, either delivered as workshops or online modules, are highly recommended to complement treatment as usual.

Parental eating disorders: A systematic review of parenting attitudes, behaviours, and parent-child interactions

A substantial proportion of adults with eating disorders are parents. Studies suggest these parents may experience a range of parenting challenges, and their children may be at an increased risk for the development of eating disorders themselves. With parenting practices being one potential environmental mechanism for the intergenerational transmission of eating disorders, we systematically searched Scopus, Web of Science, PubMed, MEDLINE, PsychINFO, and PsychArticles for controlled studies in which parenting attitudes, behaviours, and parent-child interactions were examined for parents with and without probable eating disorders. 26,512 abstracts were screened, and 167 full-text manuscripts were retrieved, with 33 studies meeting the review inclusion criteria. Studies suggest that parents with eating disorders experience higher levels of parenting stress than control parents, and may on average be more intrusive, less sensitive, and provide less structuring/facilitation in non-feeding interactions with their children. These parents also appear, on average, to experience increased concern about their children's weight, and parent-child mealtime interactions may be problematic and characterised by high levels of conflict. Suggestions for future research are made with a view to enhancing understandings of the intergenerational transmission of eating disorders, which may lead to the identification of intervention targets for parents with eating disorders and their children.

Resting-state functional network connectivity underlying eating disorder symptoms in healthy young adults

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This study examined the resting-state functional network connectivity underlying eating disorder symptoms in a large sample of healthy young adults (n = 693).

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Individuals with higher levels of eating disorder symptoms displayed weaker intra-network connectivity of the executive control network and basal ganglia network, as well as weaker inter-network connectivity in the three examined networks (i.e., the executive control network, basal ganglia network, and default mode network).

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The findings suggest that these neural circuits may play a key role in symptoms of disordered eating in healthy adults. They further reveal that the less efficient information exchange within and between intrinsic networks associated with self-referential thinking, inhibitory control, and reward sensitivity are strongly related to eating disorder symptoms.

Previous neuroimaging research of eating disorders such as anorexia nervosa and bulimia nervosa has mainly focused on clinical patients, indicating the crucial role of intrinsic connectivity networks involved in aberrant behavioral control (i.e., executive control network), reward reactivity (i.e., basal ganglia network), and excessive self-focused and body-focused ruminations (i.e., default mode network) in the onset and maintenance of eating disturbances. However, examinations of large-scale resting-state networks that support the role of cognitive control, reward sensitivity, and self-directed thinking in disordered eating have rarely involved non-clinical samples from the general population. This study, involving a total of 693 healthy young adults (68.69% females; mean age, 18.37 years), investigated these issues by using pre-defined functional regions of interest from the executive control network, basal ganglia network, default mode network, and a seed-based region of interest-to-region of interest approach. After statistically controlling for differences in age, sex, body mass index, and head motion, we observed significant associations of higher levels of eating disorder symptoms, especially bulimia-type eating (i.e., binge eating and a combination of binge eating and compensatory behaviors, such as purging via self-induced vomiting or laxative use, and compulsive exercise), with weaker intra-network and inter-network functional synchrony. These results remained significant after excluding underweight, overweight, and obese participants. These findings suggest that these neural circuits may play a key role in the symptoms of disordered eating in healthy adults. They further reveal that the less efficient information exchange within and between intrinsic networks associated with self-referential thinking, inhibitory control, and reward sensitivity are strongly related to eating disorder symptoms.