What is remission in adolescent anorexia nervosa? A review of various conceptualizations and quantitative analysis

Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy

OBJECTIVE

To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST).

METHOD

Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ2 was used for between-group contrasts.

RESULTS

Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals.

CONCLUSION

Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA.

PLAIN LANGUAGE SUMMARY

This study examined rates of remission, recovery, relapse, and recurrence of suicide attempts (SA) and nonsuicidal self-injury (NSSI) among the participants in the CARES Study, a randomized clinical trial of 6 months of Dialectical Behavior Therapy or Individual and Group Supportive Therapy. 173 youth aged 12 to 18 years participated in the study and were followed for 6 months post treatment. Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA among participants who received Dialectical Behavioral Therapy. Across both treatments, remission and recovery rates were lower and relapse and recurrence rates were higher for NSSI than for SA. These results underscore the value of Dialectical Behavioral Therapy as a first line treatment for youth at high risk for suicide.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants.

CLINICAL TRIAL REGISTRATION INFORMATION

Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www.

CLINICALTRIALS

gov/; NCT01528020.

Assessing Psychological Remission in Adolescent Anorexia Nervosa: A Comparison of Patient and Parent Report

OBJECTIVE

The definition and assessment of remission in anorexia nervosa (AN) needs greater consensus. Particularly in adolescents, the use of patient-reported composite indices (such as the Eating Disorder Examination [EDE] Global Score) as the sole measure of psychological remission has the potential to obscure patients' true clinical status, given developmental factors and the propensity towards symptom minimization in AN.

METHOD

End of treatment (EOT) data from a randomized controlled trial comparing two formats of manualized family-based treatment for adolescents with AN (N = 106) were analyzed. Participants completed the EDE, and their parents completed a parent-as-informant version of the EDE (Parent Eating Disorder Examination; PEDE). Rates of remission were compared across indices (i.e., EDE Global Score vs. diagnostic item analysis) and informant (i.e., adolescent vs. parent), both independently and in combination with the achievement of a percent median body mass index (% mBMI) greater than or equal to 95%.

RESULTS

For both adolescent and parent reports, there were higher rates of remission when defined by Global Score than when defined by EDE or PEDE diagnostic items. There were no significant differences in remission rates based on informant.

DISCUSSION

In the assessment of remission in AN, the EDE Global Score may not detect some adolescents who continue to exhibit clinically significant psychological symptoms. This study supports a detailed, multidimensional approach to assessing remission in adolescent AN to optimize sensitivity to patients' diagnostic profile. Future research should explore whether parent-child concordance on measures of ED psychopathology varies over the course of treatment.

Clinical Intervention Strategies and Family Dynamics in Adolescent Eating Disorders: A Scoping Review for Enhancing Early Detection and Outcomes

Background: This systematic review investigated the impact of familial factors on individuals aged 10-17 who have clinical signs or symptoms of eating disorders. Simultaneously, it scrutinized the involvement of the family in therapy, as well as other forms of intervention. Methods: The PsycINFO, PubMed, and Scopus databases were used to search for research material comprehensively. After applying specific criteria, 46 articles were deemed suitable and included in the systematic review. The study comprised a cohort of 4794 adolescents who received a diagnosis of either Anorexia Nervosa (AN), Bulimia Nervosa (BN), or Binge-Eating Disorder (BED). In addition, controls were utilized for 1187 adolescents, 1563 parents, 1809 siblings, and 11 other relatives. Results: The connection between family factors and eating disorders is primarily determined by the families' level of functioning, satisfaction with the family dynamic, parents' attitudes toward their children, and the role of food within the family system. Family Therapy was the most used psychotherapeutic approach in the treatment of AN. The incidence of reports in BN closely paralleled that of Cognitive-Behavioral Therapy (CBT) models. Articles about (Enhanced) CBT were exclusively associated with BED. Conclusions: Family-based approaches are crucial in comprehending, preventing, and addressing eating disorders in adolescents. Incorporating the study of family dynamics and actively engaging families in the treatment process can significantly enhance recovery rates and decrease the occurrence of relapses.

Who Responds to an Adaptive Intervention for Adolescents With Anorexia Nervosa Being Treated With Family-Based Treatment? Outcomes From a Randomized Clinical Trial

OBJECTIVE

Anorexia nervosa (AN) is a serious psychiatric disorder with high morbidity and mortality. The current evidence supports the use of family-based treatment (FBT), but recovery rates are only about 40%. Improving treatment outcomes among adolescents with AN will save lives, improve health, and prevent chronicity. This study examined the relative efficacy of adding intensive parental coaching (IPC) to standard FBT for patients who do not respond by weight gain of 2.4 kg by session 4, a clinical predictor of outcome at the end of treatment, to improve remission rates (>94% of expected mean body mass index).

METHOD

The study recruited 107 participants and their families from across the United States; 69 participants failed to respond early and were randomly assigned to continue with standard FBT or to receive 3 sessions of IPC. Participants were adolescents (ages 12-18) meeting DSM-5 criteria for AN; 6.5% were male, and 11% were Hispanic.

RESULTS

Main outcomes were mean body mass index >94% expected for age, height, and sex. Secondary outcomes included change in eating-related cognitions. Adding IPC to early nonresponders did not improve outcomes except for participants whose parents demonstrated low parental self-efficacy at baseline (moderator). Early weight gain of 2.4 kg by session 4 was replicated as a predictor of end of treatment remission.

CONCLUSION

Parental self-efficacy moderates IPC as an adaptive treatment for adolescents with AN. Baseline parental self-efficacy assessment can be used to identify families most likely to benefit from adding IPC to FBT. Future studies should consider earlier interventions to improve early response rates.

PLAIN LANGUAGE SUMMARY

Anorexia nervosa is a serious psychiatric disorder. While family-based treatment (FBT) has the largest evidence base for adolescents with anorexia, recovery rates are only about 40%. This study investigated the addition of 3 sessions of intensive parental coaching intervention (IPC) to FBT among youth with anorexia who did not gain adequate weight early in treatment, a predictor of recovery by the end of treatment. Youth with inadequate weight gain were randomized to either receive FBT with IPC or FBT as usual. Overall, adding IPC did not improve outcomes among youth with anorexia. However among those whose parents demonstrated low parental self-efficacy at baseline, youth who received FBT with IPC had higher remission rates than youth who received FBT alone.

CLINICAL GUIDANCE

Intensive parental coaching shows promise for improving outcomes among youth with anorexia whose parents report low parental self-efficacy.

CLINICAL TRIAL REGISTRATION INFORMATION

Adaptive Treatment for Adolescent Anorexia Nervosa; https://clinicaltrials.gov/; NCT03097874.

Predictors for and duration of hospitalization among children and adolescents with eating disorders

OBJECTIVE

The objective of this study was to investigate the predictive value of sex, age, body mass index (BMI), Eating Disorder Examination (EDE) score, social risk factors, and psychiatric comorbidities for hospitalization and hospitalization duration among children and adolescents suffering from eating disorders.

METHOD

This prospective cohort study involved 522 consecutive patients who had been referred to a specialized eating disorder unit between January 1, 2009 and December 31, 2015; participants were followed up until August 1, 2016 by medical records. We used regression analyses to evaluate the prognostic value of sex, age, BMI, EDE, eating disorder diagnoses, social risk factors, and psychiatric comorbidities concerning inpatient hospitalization and hospitalization duration.

RESULTS

We found that younger age, higher EDE global score, lower BMI percentile, anorexia nervosa, a higher number of social risk factors, and the presence of diagnosed self-harm increased the odds of being hospitalized, while being female and having a comorbid autism spectrum condition increased the duration of hospitalization. No other psychiatric comorbidity was found to significantly predict hospitalization or duration of hospitalization.

DISCUSSION

The odds of being hospitalized were predicted by the severity of anorexia nervosa and indicators of social risk factors in the family, whereas the duration of hospitalization was predicted by having a comorbid autism spectrum condition, indicating a difference between the factors affecting the risk of hospitalization and the factors affecting the duration of hospitalization. This calls for further exploration of tailored treatments for eating disorders.

PUBLIC SIGNIFICANCE STATEMENT

This study finds that hospitalization for an eating disorder is predicted by the severity of the illness, self-harm, and social risk factors. Duration of hospitalization is predicted by having a comorbid autism spectrum condition. These findings indicate that the treatment of eating disorders may require different treatment approaches depending on the presentation of the individual patient to reduce both the need for hospitalization and the length of inpatient stay.

When eating disorder attitudes and cognitions persist after weight restoration: An exploratory examination of non-cognitive responders to family-based treatment for adolescent anorexia nervosa

OBJECTIVE

Family-based treatment (FBT) is a well-established intervention for adolescent anorexia nervosa (AN). Although FBT is efficacious in promoting weight gain and improvements in psychological symptoms, for some adolescents, cognitive/attitudinal recovery lags behind weight gain. This study conducted an exploratory post hoc analysis of outcomes of adolescents who achieved weight gain by the end of FBT but continued to experience elevated psychological symptoms post-treatment.

METHODS

Data were drawn from two randomised controlled trials (RCTs) testing two forms of FBT (conjoint/whole family and parent-focussed). Descriptive statistics and generalised estimating equations were used to examine differences in treatment outcomes between non-cognitive responders (NCRs) (those who regained weight but continued to experience psychological symptoms) and full responders (FRs) (those who achieved both weight and cognitive restoration by the end of treatment) (n = 80; 83.7% female, Agemean [SD] = 14.66 [1.73]).

RESULTS

By 12 months post-treatment, there were no differences in weight between NCRs and FRs. However, NCRs had a slower trajectory of weight gain than FRs and continued to have elevated levels of psychological symptoms throughout the follow-up period.

CONCLUSIONS

A subset of adolescents appear to continue to experience clinically significant levels of eating pathology up to 12 months after FBT even when weight restoration is achieved.

Evidence Based Update on Psychosocial Treatments for Eating Disorders in Children and Adolescents

Eating disorders (EDs) are life-threatening psychiatric illnesses that occur in adolescents. Unfortunately, limited randomized controlled trials exist to address EDs in this vulnerable population. The current review updates a prior Journal of Clinical Child and Adolescent Psychology review from 2015. The recommendations in this review build upon those that were previously published. This update was completed through a systematic search of three major scientific databases (PsychInfo, Pubmed, and Cochrane) from 2015 to 2022 (inclusively) from three databases, employing relevant medial subject headings. Additionally, expert colleagues were asked for additional literature to include. Thirty-one new studies were added to this review. Psychosocial treatments included family therapies, individual therapy, cognitive-behavioral therapy, interpersonal psychotherapy, cognitive training, dialectical behavioral therapy, and more recently, virtual or telehealth-based practices and guided self-help modalities for carers of youth with EDs. Using the Journal of Clinical Child and Adolescent Psychology's methodological review criteria, this update found behavioral family-based treatment modalities (FBT) for both adolescent anorexia nervosa and bulimia nervosa met well-established treatment criteria. To date, there were no well-established treatments found for child and adolescent avoidant-restrictive food intake disorder, or binge eating disorder. Internet facilitated cognitive-behavioral therapy and family-based therapy were found to be possibly efficacious for binge eating disorder. Family-based treatment was found to be possibly efficacious for avoidant restrictive food intake disorder, with other clinical trials for cognitive treatment modalities under way. Ongoing research examining treatments for eating disorders in children and adolescents broadly is needed.

Predictors of family-based treatment for adolescent eating disorders: Do family or diagnostic factors matter?

OBJECTIVE

Misconceptions around which patients will and will not benefit from family-based treatment (FBT) for adolescent eating disorders (EDs) limit referrals and access to this treatment modality. The present study explored whether common demographic and clinical factors that may prevent referral to FBT predict treatment outcomes in adolescent anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

The following predictors of treatment outcomes were assessed: baseline family and diagnostic factors (socioeconomic status, comorbidity, illness duration, parent feelings of self-efficacy, family status, prior treatment, sex and prior hospitalizations) in a combined sample of adolescents receiving FBT compared to those randomized to other treatment conditions, across six clinical trials in the United States and Canada (total n = 724, ages 12-18, 90% female across both diagnoses). AN and BN samples were examined separately.

RESULTS

Any prior ED treatment emerged as the only predictor of outcome in AN and BN, such that having no prior treatment predicted better outcomes in FBT for AN, and in both FBT and other treatment modalities for BN. No other sociodemographic or clinical variables predicted outcomes for AN or BN in FBT or in other evidence-based treatment modalities.

CONCLUSIONS

The findings of this exploratory analysis suggest that commonly assumed factors do not predict outcome in FBT. Specifically socioeconomic and demographic factors or clinical variability in families seeking treatment do not predict treatment outcomes in FBT, or other evidence-based treatment modalities, with the exception of prior treatment. Providers should consider referring to FBT even when these factors are present.

PUBLIC SIGNIFICANCE

This manuscript reports that commonly assumed family, sociodemographic and diagnostic factors do not predict outcome in FBT or other evidence-based treatment modalities, with the exception of prior treatment. This data may be helpful for providers when considering referrals to FBT in the context of variability in these variables.

Different pathways, same goals: A large-scale qualitative study of autistic and non-autistic patient-generated definitions of recovery from an eating disorder

BACKGROUND

Definitions of recovery from an eating disorder (ED) have generally been formulated around clinical conceptualisations, rather than based on the views of patients. This paper therefore asked those with lived experience of ED for their own definitions of recovery.

METHOD

Data were collected as part of an online study looking at EDs, autism and relationships. About 173 participants identified as recovered from ED and gave free-response definitions of recovery. Responses were subject to thematic analysis.

RESULTS

Seven major themes were identified: Weight restoration, lack of ED behaviours, thoughts and behaviours, cognitions, emotional responses, getting on with life, and ongoing challenges.

CONCLUSIONS

Many definitions of recovery given by those who have lived experience of ED echoed those used by clinicians and researchers. There were also points of divergence around the ongoing challenges of recovery. Our findings highlight the need for continuing support post-weight restoration to facilitate the successful long-term recovery for those with ED.

A biomarker and endophenotype for anorexia nervosa?

OBJECTIVE

Recent research has suggested that a type of atypical eye movement, called square wave jerks, together with anxiety, may distinguish individuals with anorexia nervosa from those without anorexia nervosa and may represent a biomarker and endophenotype for the illness. The aim of this study was to identify the presence of this proposed marker in individuals currently with anorexia nervosa relative to healthy controls, and to identify the state independence and heritability of this putative marker by exploring whether it also exists in individuals who are weight-restored from anorexia nervosa and first-degree relatives (i.e. sisters of people with anorexia nervosa).

METHODS

Data from 80 female participants (20/group: current anorexia nervosa, weight-restored from anorexia nervosa, sisters of people with anorexia nervosa and healthy controls) were analysed. Square wave jerk rate was acquired during a fixation task, and anxiety was measured with the State Trait Anxiety Inventory.

RESULTS

Current anorexia nervosa, weight-restored from anorexia nervosa and sisters of people with anorexia nervosa groups made significantly more square wave jerks than healthy controls, but did not differ from one another. Square wave jerk rate and anxiety were found to discriminate groups with exceptionally high accuracy (current anorexia nervosa vs healthy control = 92.5%; weight-restored from anorexia nervosa vs healthy control = 77.5%; sisters of people with anorexia nervosa vs healthy control = 77.5%; p < .001).

CONCLUSION

The combination of square wave jerk rate and anxiety was found to be a promising two-element marker for anorexia nervosa, and has the potential to be used as a biomarker or endophenotype to identify people at risk of anorexia nervosa and inform future treatments.

State or trait: the neurobiology of anorexia nervosa - contributions of a functional magnetic resonance imaging study

BACKGROUND

The understanding of the cerebral neurobiology of anorexia nervosa (AN) with respect to state- versus trait-related abnormalities is limited. There is evidence of restitution of structural brain alterations with clinical remission. However, with regard to functional brain abnormalities, this issue has not yet been clarified.

METHODS

We compared women with AN (n = 31), well-recovered female participants (REC) (n = 18) and non-patients (NP) (n = 27) cross-sectionally. Functional magnetic resonance imaging was performed to compare neural responses to food versus non-food images. Additionally, affective ratings were assessed.

RESULTS

Functional responses and affective ratings did not differ between REC and NP, even when applying lenient thresholds for the comparison of neural responses. Comparing REC and AN, the latter showed lower valence and higher arousal ratings for food stimuli, and neural responses differed with lenient thresholds in an occipital region.

CONCLUSIONS

The data are in line with some previous findings and suggest restitution of cerebral function with clinical recovery. Furthermore, affective ratings did not differ from NP. These results need to be verified in intra-individual longitudinal studies.

Depression, perceived disability and unemployment are associated with reduced life satisfaction in anorexia nervosa

Life satisfaction is a core aspect of an individual's wellbeing and describes the subjective assessment of their quality of life. Reduced life satisfaction is frequently reported in anorexia nervosa (AN),  but the factors contributing to this are still unclear. This study sought to extend previous work by examining 12 potential correlates of AN life satisfaction. One hundred and five female AN patients were administered questionnaires assessing life satisfaction, depression, anxiety, stress, employment status, marital status, body mass index, eating disorder symptomatology, perceived disability and readiness for change. A stepwise linear regression revealed that only depression, perceived disability and employment status were significantly associated with AN life satisfaction. The findings thus highlight prevailing mood and personal functioning as critical foci for clinical management strategies in people with AN. Addressing depressive symptoms and perceived disability while bettering employment prospects could facilitate improved AN life satisfaction.

An evaluation of family-based treatment for restrictive-type eating disorders, delivered as standard care in a public mental health service

BACKGROUND

Family-based treatment (FBT) has demonstrated efficacy for anorexia nervosa (AN) in youth in randomized, controlled trials. It is important to assess if it shows a similar effectiveness when implemented in standard care.

AIM

To evaluate outcomes of FBT for restrictive-type eating disorders, delivered as standard care in a public mental health service. Outcomes are remission, frequency of hospital admissions and day-patient treatment, and frequency of other adaptations within 12 months from commencement of treatment. Second, to compare the collaborative clinical decisions of successful treatment in standard care made by family therapist at the end of treatment, with more objective definitions of recovery.

METHODS

The design is a prospective, uncontrolled study of a consecutive series of patients with restrictive-type eating disorders, treated with FBT in a specialty unit at the Child and Adolescent Mental Health Centre in the Capital Region of Denmark.

RESULTS

FBT was successfully completed within 12 months by 57% of participants, and 47% completed with 20 sessions or fewer. Weight restoration was achieved by 75% within 12 months, and 46% achieved both normalisation of body weight and behavioural symptoms of AN within 12 months. A total of 20% needed intensified treatment. All aspects of remission were often not present simultaneously, and the collaborative clinical decisions of successful treatment only partly aligned with other parameters of remission.

CONCLUSION

FBT showed good results when implemented as standard care, and it can be adapted to the specifics of local service organisation without compromising effectiveness.

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.

A primary care modification of family-based treatment for adolescent restrictive eating disorders

Although eating disorders pose a significant threat to the health and well-being of children and adolescents, due to a profound scarcity of specialty providers, only a small percentage of patients receives evidence-based treatment. To improve access to care for restrictive eating disorders, we developed a modified version of Family-Based Treatment to be delivered by primary care providers (PCPs) and conducted a pilot study to evaluate the feasibility and preliminary outcomes of this intervention. Fifteen adolescents (mean age = 15.5 years) with restrictive eating disorders and their caregiver(s) were enrolled in Family-Based Treatment for Primary Care (FBT-PC), delivered by three trained PCPs. Retention for the intervention was high (n = 13, 86.7%). Over the course of 3 months, participants attended an average of 9.2 (SD = 2.8) sessions and experienced a significant increase in BMI percentile from 39.1 to 54.8 (t (13) = -6.71, p < .001; d = .61). FBT-PC appears to be feasible for implementation in the primary care setting and has the potential to improve access to treatment and yield positive outcomes for young patients with restrictive eating disorders.

Higher-Calorie Refeeding in Anorexia Nervosa: 1-Year Outcomes From a Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

We recently reported the short-term results of this trial revealing that higher-calorie refeeding (HCR) restored medical stability earlier, with no increase in safety events and significant savings associated with shorter length of stay, in comparison with lower-calorie refeeding (LCR) in hospitalized adolescents with anorexia nervosa. Here, we report the 1-year outcomes, including rates of clinical remission and rehospitalizations.

METHODS

In this multicenter, randomized controlled trial, eligible patients admitted for medical instability to 2 tertiary care eating disorder programs were randomly assigned to HCR (2000 kcals per day, increasing by 200 kcals per day) or LCR (1400 kcals per day, increasing by 200 kcals every other day) within 24 hours of admission and followed-up at 10 days and 1, 3, 6, and 12 months post discharge. Clinical remission at 12 months post discharge was defined as weight restoration (≥95% median BMI) plus psychological recovery. With generalized linear mixed effect models, we examined differences in clinical remission over time.

RESULTS

Of 120 enrollees, 111 were included in modified intent-to-treat analyses, 60 received HCR, and 51 received LCR. Clinical remission rates changed over time in both groups, with no evidence of significant group differences (P = .42). Medical rehospitalization rates within 1-year post discharge (32.8% [19 of 58] vs 35.4% [17 of 48], P = .84), number of rehospitalizations (2.4 [SD: 2.2] vs 2.0 [SD: 1.6]; P = .52), and total number of days rehospitalized (6.0 [SD: 14.8] vs 5.1 [SD: 10.3] days; P = .81) did not differ by HCR versus LCR.

CONCLUSIONS

The finding that clinical remission and medical rehospitalization did not differ over 1-year, in conjunction with the end-of-treatment outcomes, support the superior efficacy of HCR as compared with LCR.

The outcome at follow-up after inpatient eating disorder treatment: a naturalistic study

BACKGROUND

Patients with eating disorders may experience a severe and enduring course of illness. Treatment outcome for patients provided with inpatient treatment is reported as poor. Research to date has not provided consistent results for predictors of treatment outcome. The aims of the study were to investigate rates of remission at follow-up after inpatient treatment, symptom change from admission to follow-up, and predictors of treatment outcome.

METHODS

The follow-up sample consisted of 150 female adult former patients (69.4% of all eligible female patients) with eating disorders. Mean age at admission was 21.7 (SD = 4.9) years. Diagnostic distribution: 66% (n = 99) anorexia nervosa, 21.3% (n = 32) bulimia nervosa and 12.7% (n = 19) other specified feeding or eating disorder, including binge eating. Data were collected at admission, discharge and follow-up (mean 2.7 (SD = 1.9) years). Definition of remission was based on the EDE-Q Global score, body mass index and binge/purge behavior. Paired T-tests were performed to investigate change over time. Univariate and multivariate logistic regressions were estimated to investigate predictors of remission.

RESULTS

At follow-up, 35.2% of the participants were classified as in remission. Significant symptom reduction (in all patients) (p <  0.001) and significant increase in body mass index (BMI) (in underweight participants at admission) (p <  0.001) was found. Increased BMI (p <  0.05), the level of core eating disorder symptoms at admission (p <  0.01) and reduced core eating disorder symptoms (p <  0.01) during inpatient treatment were found significant predictors of outcome in the multivariate model.

CONCLUSIONS

All participants had an eating disorder requiring inpatient treatment. Approximately one-third of all participants could be classified as in remission at follow-up. However, most participants experienced significant symptom improvement during inpatient treatment and the improvements were sustained at follow-up. Increased probability of remission at follow-up was indicated by lower core ED symptoms at admission for all patients, raised BMI during admission for patients with AN, and reduced core ED symptoms during inpatient treatment for all patients. This finding contributes important information and highlights the importance of targeting these core symptoms in transdiagnostic treatment programs.

Developing consensus on the definition of remission and recovery for research

OBJECTIVE

The current research investigated whether a consensus among professional eating disorder researchers existed for definitions of remission and recovery that could be used in research.

METHOD

Membership of the Eating Disorder Research Society and attendees at the 2018 annual meeting in Sydney were invited to participate in this investigation. Two surveys were conducted with 62 and 122 respondents, respectively. The first survey used a mix of forced choice yes/no or scaled responses. The second survey was a free response to the question "which definitions of recovery do you favor?"

RESULTS

A majority consensus emerged about three issues. First, it was agreed that it was important to develop a standard definition of recovery for research purposes. Second, recovery needed to be evident over a 12-month period, with remission evident over a 3- to 12-month period. Third, recovery and remission required the absence of diagnostic criteria in addition to the presence of functional recovery.

DISCUSSION

Consensus is apparent in the field. We suggest that future research seeks to: (a) validate the most commonly researched definition of remission and recovery across different eating disorders using a standardized battery of assessments, and (b) better understand differences in self-assessed and psychometrically assessed recovery.

Early changes in depression predict outcomes of inpatient adolescent anorexia nervosa

PURPOSE

The aim of this study was to investigate the predictive value of early changes in depression levels during inpatient treatment of adolescent anorexia nervosa (AN).

METHODS

Fifty-six adolescents (88% girls) aged 10-18 years (M = 15.35, SD = 2.23) diagnosed with AN were assessed at admission and 1 month following admission to an inpatient setting. Depression levels and eating disorder symptoms were reported at both assessments. Re-hospitalization within 12 months of discharge was documented using official national records.

RESULTS

Whereas depression levels at baseline were found equivalent between subsequently re-hospitalized and non-re-hospitalized patients, at 1 month after admission patients who were later re-hospitalized had higher levels of depression compared to those who were not re-hospitalized. These differences remained significant after controlling for weight gain and anti-depressant medication intake. We additionally found that the proportion of boys in the non-re-hospitalized group was substantially larger than their proportion in the re-hospitalized group.

CONCLUSIONS

Our results suggest that depression at the point of hospital admission may not be a reliable predictor of treatment outcomes, and highlight the risk of relapse in AN patients whose depression levels do not alleviate after a month of inpatient treatment. Clinicians should consider providing more adjusted and intensive attention to such patients in their efforts to facilitate remission.

LEVEL OF EVIDENCE III

Well-designed cohort study.

Insular Cell Integrity Markers Linked to Weight Concern in Anorexia Nervosa-An MR-Spectroscopy Study

Objective: An insular involvement in the pathogenesis of anorexia nervosa (AN) has been suggested in many structural and functional neuroimaging studies. This magnetic resonance spectroscopy (MRS) study is the first to investigate metabolic signals in the anterior insular cortex in patients with AN and recovered individuals (REC). Method: The MR spectra of 32 adult women with AN, 21 REC subjects and 33 healthy controls (HC) were quantified for absolute N-acetylaspartate (NAA), glutamate + glutamine (Glx), total choline, myo-inositol, creatine concentrations (mM/L). After adjusting the metabolite concentrations for age and partial gray/white matter volume, group differences were tested using one-way multivariate analyses of variance (MANOVA). Post-hoc analyses of variance were applied to identify those metabolites that showed significant group effects. Correlations were tested for associations with psychometric measures (eating disorder examination), duration of illness, and body mass index. Results: The MANOVA exhibited a significant group effect. The NAA signal was reduced in the AN group compared to the HC group. The REC and the HC groups did not differ in metabolite concentrations. In the AN group, lower NAA and Glx signals were related to increased weight concern. Discussion: We interpret the decreased NAA availability in the anterior insula as a signal of impaired neuronal integrity or density. The association of weight concern, which is a core feature of AN, with decreased NAA and Glx indicates that disturbances of glutamatergic neurotransmission might be related to core psychopathology in AN. The absence of significant metabolic differences between the REC and HC subjects suggests that metabolic alterations in AN represent a state rather than a trait phenomenon.

Naturalistic outcomes for a day-hospital programme in a mixed diagnostic sample of adolescents with eating disorders

Despite initial data suggesting positive treatment outcomes for adolescent eating disorder day-hospital programmes (DHPs), existing studies have included limited follow-up, small samples, and a focus on restricting-type eating disorders. To address these gaps, we explored naturalistic outcomes for an adolescent eating disorders DHP. Adolescent participants (N = 265) completed measurements at treatment admission, discharge (n = 170), and various lengths of follow-up (n = 126; M_{follow up} = 278.87 days). Results from multilevel models indicated significant increases in body weight for the anorexia nervosa group throughout treatment and maintenance of increased body weight from discharge to follow-up. In bulimic spectrum disorders, binge eating and purging significantly decreased from intake to discharge and did not change from discharge to follow-up. Across the entire sample, eating disorder symptoms decreased from intake to discharge and did not change from discharge to follow-up. Further, anxiety and depression decreased over the course of treatment and continued to decrease over the follow-up period. The current investigation represents the first study to explore longitudinal DHP outcomes within adolescent bulimic spectrum eating disorders. Our findings also highlight many challenges inherent in conducting naturalistic research; it is critical that the field continue to develop solutions to the barriers inherent in conducting longitudinal research on eating disorder treatment.

Exploring Differences in the Role of Hospitalization on Weight Gain Based on Treatment Type From Randomized Clinical Trials for Adolescent Anorexia Nervosa

Background: This study explores the impact of weight gain during medical stabilization hospitalization on weight outcomes between three outpatient treatments for adolescent anorexia nervosa (AN): Adolescent Focused Therapy (AFT), Systemic Family Therapy (SyFT), and Family Based Treatment (FBT). Methods: A secondary analysis of weight gain data (N = 215) of adolescents (12-18 years) meeting DSM-IV criteria for AN (exclusive of amenorrhea criteria) who participated in two randomized clinical trials (RCTs) was conducted. Main outcomes examined were changes in weight restoration (≥95% expected body weight or EBW) and differences in weight change attributable to hospital weight gain. Results: Weight gain resulting from hospitalizations did not substantially change weight recovery rates. Hospital weight gain contributed most to overall treatment weight gain in AFT compared to FBT and SyFT. Conclusion: Brief medical stabilization weight gain does not contribute substantially to weight recovery in adolescents with AN who participated in RCTs.

Confirming the Efficacy of an Adaptive Component to Family-Based Treatment for Adolescent Anorexia Nervosa: Study Protocol for a Randomized Controlled Trial

Family-based treatment (FBT) has the largest evidence base for treating adolescents with anorexia nervosa (AN); 35-50% of cases remit at the end-of-treatment and remain remitted 3-4 years after treatment. Studies of FBT demonstrate that weight restoration by session 4 (of 2.4 kgs) predicts remission at end of treatment in 85-90% of cases. One way to improve outcomes is to tailor treatments to patients depending on successful weight restoration at session 4. Pilot data found that by adding three sessions of Intensive Parental Coaching (IPC) after session 4 improved outcomes in early non-responders. Further, data suggest that the mechanism underlying FBT is early improvements in parental self-efficacy related to re-feeding their child. This manuscript describes a study protocol to examine whether adding IPC to FBT improves outcomes in early non-responders and confirm whether change in parental self-efficacy is the mechanism by which FBT works. This two-site randomized controlled trial (RCT) will randomize 60 adolescents with a DSM-5 diagnosis of AN (30 per site) who are between the ages of 12-18 years old and do not gain 2.4 kgs by session 4 of FBT. Randomized participants will either continue standard FBT or receive the three sessions of IPC and then continue FBT as usual. Both arms include up to 18 sessions over the course of 9 months. Blinded assessments will be conducted at baseline, 3-month within-treatment, end of treatment, and at 6 and 12-month follow-up. Parental-self efficacy will be assessed using the Parent versus Anorexia Scale at all major assessment time points and at each of the first eight sessions of treatment. The primary outcome is achievement of weight remission (> 94% expected mean percent body mass index (BMI) adjusted for age, height, and gender).

CLINICAL TRIAL REGISTRATION

http://www.ClinicalTrials.gov, identifier NCT03097874.

Family-based therapy for anorexia nervosa: results from a 7-year longitudinal Singapore study

PURPOSE

To determine the effectiveness of Family-Based Therapy (FBT) as a treatment for Anorexia Nervosa (AN) in adolescents in a Singaporean cohort. FBT has proven effective in studies in the West, but no such study has been done in Asia.

METHODS

This is a retrospective analysis of a hospital-based cohort, which included all paediatric patients (≤ 18-years) with AN treated at a tertiary hospital in Singapore between 2011 and 2017 (n = 119). The patients either received manualised FBT (n = 42) or individualized adolescent focussed therapy (non-FBT) (n = 77). Patient characteristics and time to remission were abstracted from patient records. Survival analysis was used to determine median time to remission and remission-free survival rates. Hazard ratios for remission were obtained by cox regression.

RESULTS

Patients in the non-FBT group had a significantly longer time to remission compared with the FBT group after adjustment for age, gender, BMI, psychiatric comorbidity, and ethnicity (p = 0.003, HR = 2.523, 95% CI 1.37-4.64). In the FBT group, the median time to remission was 5.0 months (95% CI 3.4-6.6 months); 11 months shorter than the non-FBT group (p < 0.001, 95% CI 7.9-14.1 months). FBT group remission rates were 69% and 90% at 1 and 2 years, respectively. Non-FBT group remission rates were 30% and 57% at 1 and 2 years, respectively.

CONCLUSIONS

This study confirms that FBT is an effective treatment strategy for AN in adolescents in the Asian context. FBT can shorten the illness duration, which reduces disruption to schooling and family life at this critical life stage.

LEVEL OF EVIDENCE

Level IV, evidence obtained from retrospective review of data before and after the introduction of new intervention.

Variability in remission in family therapy for anorexia nervosa

OBJECTIVE

The evolution toward more stringent conceptualizations of remission in family therapy for adolescent anorexia nervosa (AN) has, with time, introduced variability in outcomes across randomized controlled trials (RCTs). An examination of remission across the history of research on family therapy for AN shows that earlier studies adopted lenient definitions and generally yielded higher rates of remission than studies of the past decade that have used stricter definitions of remission. In this study, we investigate the reactivity of remission rates to the application of different definitions of remission used within the family therapy for AN literature, within a single RCT data set.

METHOD

We conducted a secondary analysis of data from a single-site RCT which compared the relative efficacy of two formats of family therapy in a sample of 106 Australian adolescents with AN. Using end-of-treatment data, we compared remission rates using 11 definitions of remission that have been used in studies of family therapy for AN spanning more than three decades.

RESULTS

We found wide variability in remission rates (21.7-87.7%; Cochran's Q χ² (10, N = 106) = 303.55, p = .000], depending on which definition of remission was applied. As expected, more lenient criteria produced higher remission rates than more stringent definitions.

DISCUSSION

Applying different criteria of remission to a single data set illustrates the impact of changing how remission is defined. Failure to consider the greater stringency of remission criteria in recent studies could result in false inferences concerning the efficacy of family therapy for AN over time.

Weight gain trajectories during outpatient family-based treatment for adolescents with anorexia nervosa

OBJECTIVE

Given that weight gain patterns in adolescents receiving outpatient Family-Based Treatment (FBT) have not been characterized, the purpose of this study was to examine trajectories of weight gain in a group of adolescent patients with a restrictive eating disorder [e.g., anorexia nervosa (AN) and atypical AN] receiving FBT. This study also examined the association of patient characteristics with weight gain trajectories, including age, diagnosis, weight suppression, presenting BMI-for-age percentile, and eating pathology.

METHOD

Latent growth mixture modeling was used to identify distinct weight trajectories, as defined by change in BMI-for-age percentile, for 153 adolescents with AN or atypical AN, receiving FBT.

RESULTS

There were five distinct weight gain trajectory profiles for adolescents receiving FBT for a restrictive eating disorder. Younger age and greater weight suppression were associated with more rapid weight gain trajectories. A pattern of slow and consistent weight gain was associated with older age and less eating pathology.

DISCUSSION

There was considerable variability in weight gain trajectories in youth receiving outpatient FBT for a restrictive eating disorder. This suggests that patients' presenting information can be used to inform expectations regarding weight gain trajectories.

Short- and long-term outcome of males treated for anorexia nervosa: a review of the literature

PURPOSE

To give an overview of existing studies on the short- and long-term outcome for males treated for anorexia nervosa and to compare the outcome between adolescents and adults as well as between males and females.

METHODS

A systematic literature search was conducted in PubMed, PsycINFO and PSYNDEX and complemented by a manual search of the references from all relevant studies.

RESULTS

Out of 1064 search results, 18 studies met our inclusion criteria. A combined total of 1129 males of varying age groups were followed 0.5-27 years post-treatment. For 1009 individuals, only vital status was ascertained. Length of follow-up and outcome definitions varied considerably. Limited data-especially in adults-prevented adequate age comparisons. In both adolescents and adults outcome and mortality differed widely across studies with no firm evidence for gender differences. Outcome in mixed samples of adolescents and adults was inconsistent. Studies rarely compared the genders statistically, and when they did, the results were nonsignificant.

CONCLUSIONS

Knowledge on the outcome of males treated for anorexia nervosa is scarce. Only few studies comprising insufficient numbers of males exist. Results based on these findings are inconclusive and in part contradicting. Further research is needed, including large sample sizes of reliably diagnosed males, adequate follow-up intervals, follow-up assessments with carefully defined outcome criteria, and comparisons to matched female patient samples.

LEVEL OF EVIDENCE

Level I, Systematic review.

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Augmentative Approaches in Family-Based Treatment for Adolescents with Restrictive Eating Disorders: A Systematic Review

OBJECTIVE

To systematically review the literature reporting outcomes of augmentative family-based treatment (FBT) interventions for adolescents with restrictive eating disorders (EDs).

METHOD

Articles were identified through a systematic search of five electronic databases (PsycINFO, MEDLINE, EMBASE, CINAHL, Cochrane Database).

RESULTS

Thirty articles were included, reporting on FBT augmentations featuring adjunctive treatment components, modified treatment structure and/or content with adherence to FBT principles, and adaptations allowing FBT delivery in different settings. All reported significant improvements in weight and/or ED symptoms at end-of-treatment, although few compared augmentative and standard FBT interventions and good quality follow-up data was generally lacking.

CONCLUSIONS

There is early evidence for the effectiveness of augmentative FBT-based approaches in facilitating weight and/or ED symptom improvements for adolescents with restrictive EDs. There remains a lack of robust evidence demonstrating superior effects of such approaches over standard FBT, and further controlled studies are required to expand on the current evidence. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

The modeled cost-effectiveness of family-based and adolescent-focused treatment for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a prevalent, serious mental disorder. We aimed to evaluate the cost-effectiveness of family-based treatment (FBT) compared to adolescent-focused individual therapy (AFT) or no intervention within the Australian healthcare system.

METHOD

A Markov model was developed to estimate the cost and disability-adjusted life-year (DALY) averted of FBT relative to comparators over 6 years from the health system perspective. The target population was 11-18 year olds with AN of relatively short duration. Uncertainty and sensitivity analyses were conducted to test model assumptions. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted.

RESULTS

FBT was less costly than AFT. Relative to no intervention, the mean ICER of FBT and AFT was $5,089 (95% uncertainty interval (UI): dominant to $16,659) and $51,897 ($21,591 to $1,712,491) per DALY averted. FBT and AFT are 100% and 45% likely to be cost-effective, respectively, at a threshold of AUD$50,000 per DALY averted. Sensitivity analyses indicated that excluding hospital costs led to increases in the ICERs but the conclusion of the study did not change.

CONCLUSION

FBT is the most cost-effective among treatment arms, whereas AFT was not cost-effective compared to no intervention. Further research is required to verify this result.

Parental Expressed Emotion During Two Forms of Family-Based Treatment for Adolescent Anorexia Nervosa

High parental expressed emotion (EE), reflected by criticism or emotional over-involvement, has been related to poorer outcome in family-based treatment (FBT) for adolescent anorexia nervosa. This study assessed EE in 89 mothers and 64 fathers at baseline and end of treatment in a randomised trial comparing conjoint FBT to parent-focused FBT (PFT). Compared with conjoint FBT, PFT was associated with a decrease in maternal criticism, regardless of adolescent remission. Furthermore, an increase in maternal criticism was more likely to be observed in conjoint FBT (80%) than PFT (20%, p = 0.001). Adolescents of mothers who demonstrated an increase in EE, or remained high in EE, were less likely to remit compared with adolescents for whom EE decreased or remained low (33% and 0% vs. 43% and 50%, p = 0.03). There were no significant effects for paternal EE. The results highlight the importance of considering EE when implementing FBT for adolescents with anorexia nervosa. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Treatment of avoidant/restrictive food intake disorder in a cohort of young patients in a partial hospitalization program for eating disorders

OBJECTIVE

Avoidant/restrictive food intake disorder (ARFID) is a recently named condition to classify patients who present with restricted nutritional intake without body image distortion or fear of weight gain. We sought to compare treatment outcomes of patients with ARFID in a family-centered partial hospital program (PHP) to those with other eating disorders (ED).

METHOD

A retrospective chart review of 130 patients 7-17 years of age admitted to the program from 2008 to 2012 was performed. Intake and discharge data included: length of stay; percentage median body mass index (%MBMI); and scores on the Children's Eating Attitudes Test (ChEAT) and Revised Children's Manifest Anxiety Scale (RCMAS). Between and within group effects were measured for intake and discharge data.

RESULTS

Patients with ARFID spent significantly fewer weeks in program than those with anorexia nervosa (AN) and experienced a similar increase in %MBMI as patients with AN and other specified/unspecified feeding and eating disorders. All patients exhibited significant improvements in psychopathology over the course of treatment as measured by scores on the ChEAT and RCMAS.

DISCUSSION

Our findings suggest that patients with ARFID can be successfully treated in the same PHP as patients with other ED, with comparable improvements in weight and psychopathology over a shorter time period. Results are limited to patients with ARFID who exhibit an acute onset of severe food restriction. Future research should incorporate measures relevant to the diagnosis of ARFID and explore how patients with different ARFID subtypes may respond to various treatments.

Parental strategies used in the family meal session of family-based treatment for adolescent anorexia nervosa: Links with treatment outcomes

OBJECTIVE

Examine relationships between parental mealtime strategies used in the family meal session of family-based treatment (FBT) and adolescent outcomes at EOT (session 20).

METHOD

Eighteen families with an adolescent receiving FBT-AN participated. Parental strategies during videoed family meals were assessed using a family mealtime coding system. Change scores were calculated for both adolescent %EBW and EDE scores.

RESULTS

Increased use of parental direct and non-direct eating prompts during the family meal was associated with greater adolescent weight gain at EOT. Use of parental mealtime strategies was not associated with any significant change in adolescent eating psychopathology at EOT.

DISCUSSION

Parental verbal eating prompts during the family meal may be effective in promoting short-term weight gain. During the family meal session, parents should be encouraged to maintain a direct focus on their adolescent child's eating behaviour which may assist their child with food consumption and potential weight gain. Further research examining food-based interactions among parents and their adolescent child with AN is needed. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:433-436).

What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa

BACKGROUND

Relapse after treatment for anorexia nervosa (AN) is a significant clinical problem. Given the level of chronicity, morbidity, and mortality experienced by this population, it is imperative to understand the driving forces behind apparently high relapse rates. However, there is a lack of consensus in the field on an operational definition of relapse, which hinders precise and reliable estimates of the severity of this issue. The primary goal of this paper was to review prior studies of AN addressing definitions of relapse, as well as relapse rates.

METHODS

Data sources included PubMed and PsychINFO through March 19th, 2016. A systematic review was performed following the PRISMA guidelines. A total of (N = 27) peer-reviewed English language studies addressing relapse, remission, and recovery in AN were included.

RESULTS

Definitions of relapse in AN as well as definitions of remission or recovery, on which relapse is predicated, varied substantially in the literature. Reported relapse rates ranged between 9 and 52%, and tended to increase with increasing duration of follow-up. There was consensus that risk for relapse in persons with AN is especially high within the first year following treatment.

DISCUSSION

Standardized definitions of relapse, as well as remission and recovery, are needed in AN to accelerate clinical and research progress. This should improve the ability of future longitudinal studies to identify clinical, demographic, and biological characteristics in AN that predict relapse versus resilience, and to comparatively evaluate relapse prevention strategies. We propose standardized criteria for relapse, remission, and recovery, for further consideration.

Early Response to treatment in Eating Disorders: A Systematic Review and a Diagnostic Test Accuracy Meta-Analysis

OBJECTIVE

Early response to eating disorders treatment is thought to predict a later favourable outcome. A systematic review of the literature and meta-analyses examined the robustness of this concept.

METHOD

The criteria used across studies to define early response were summarised following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Diagnostic Test Accuracy methodology was used to estimate the size of the effect.

RESULTS

Findings from 24 studies were synthesized and data from 14 studies were included in the meta-analysis. In Anorexia Nervosa, the odds ratio of early response predicting remission was 4.85(95%CI: 2.94-8.01) and the summary Area Under the Curve (AUC) = .77. In Bulimia Nervosa, the odds ratio was 2.75(95%CI:1.24-6.09) and AUC = .67. For Binge Eating Disorder, the odds ratio was 5.01(95%CI: 3.38-7.42) and AUC = .71.

CONCLUSION

Early behaviour change accurately predicts later symptom remission for Anorexia Nervosa and Binge Eating Disorder but there is less predictive accuracy for Bulimia Nervosa. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Nasogastric Tube Feeding for Individuals With Anorexia Nervosa: An Integrative Review

BACKGROUND

The use of nasogastric (NG) feeding in individuals with anorexia nervosa (AN) is endorsed by national professional organizations; however, no guidelines currently exist.

OBJECTIVES

The objectives of this review were to identify and evaluate outcomes of NG feedings for individuals with AN and to develop recommendations for future research, policy, and practice.

DESIGN

An integrative review of the research literature was conducted.

RESULTS

Of the 19 studies reviewed, all indicated short-term weight gain following NG feeding. Four studies examined adherence; nearly 30% of subjects were nonadherent as evidenced by tube manipulation. Seven studies reported psychiatric outcomes, suggesting NG feeding reduces eating disorder behaviors but not overall symptomology.

CONCLUSIONS

NG feeding promotes short-term weight gain; however, long-term outcomes are poorly understood. Future research, using rigorous methods, is still needed to inform practice.

An Interactive, Graphical Tool for Retrospectively Assessing Symptom Frequency and Severity: An Illustration With Eating Disorder Behaviors, Body Weight, and Stress

There are few assessments that gather valid, highly detailed data on short-term (i.e., weekly) symptom frequency/severity retrospectively. In particular, methodologies that provide valid data for research investigating symptom changes are typically prospective, expensive, and burdensome. The purpose of this study was to evaluate a new interactive and graphical assessment tool for gathering detailed information about eating-related symptom frequency/severity retrospectively over a 3-month period. A mixed eating disorder sample ( N = 113) recruited from the community provided symptom data once weekly for 12 weeks and completed the Interactive, Graphical Assessment Tool (IGAT) assessing eating disorder symptoms on three occasions to determine the test-retest and concurrent validity of the IGAT. The IGAT performed marginally better than other measures for retrospective symptom frequency assessment in the eating disorders and did so at a greater level of detail than other available tools. Future research should evaluate the IGAT with other behaviors of interest.

Randomized Clinical Trial of Parent-Focused Treatment and Family-Based Treatment for Adolescent Anorexia Nervosa

OBJECTIVE

There have been few randomized clinical trials (RCTs) for adolescents with anorexia nervosa (AN). Most of these posit that involving all family members in treatment supports favorable outcomes. However, at least 2 RCTs suggest that separate parent and adolescent sessions may be just as effective as conjoint treatment. This study compared the relative efficacy of family-based treatment (FBT) and parent-focused treatment (PFT). In PFT, the therapist meets with the parents only, while a nurse monitors the patient.

METHOD

Participants (N = 107) aged 12 to 18 years and meeting DSM 4(th)Edition criteria for AN or partial AN were randomized to either FBT or PFT. Participants were assessed at baseline, end of treatment (EOT), and at 6 and 12 months posttreatment. Treatments comprised 18 outpatient sessions over 6 months. The primary outcome was remission, defined as ≥95% of median body mass index and Eating Disorder Examination Global Score within 1 SD of community norms.

RESULTS

Remission was higher in PFT than in FBT at EOT (43% versus 22%; p = .016, odds ratio [OR] = 3.03, 95% CI = 1.23-7.46), but did not differ statistically at 6-month (PFT 39% versus FBT 22%; p = .053, OR = 2.48, CI = 0.989-6.22), or 12-month (PFT 37% versus FBT 29%; p = .444, OR = 1.39, 95% CI = 0.60-3.21) follow-up. Several treatment effect moderators of primary outcome were identified.

CONCLUSION

At EOT, PFT was more efficacious than FBT in bringing about remission in adolescents with AN. However, differences in remission rates between PFT and FBT at follow-up were not statistically significant.

CLINICAL TRIAL REGISTRATION INFORMATION

A Randomised Controlled Trial of Two Forms of Family-Based Treatment and the Effect on Percent Ideal Body Weight and Eating Disorders Symptoms in Adolescent Anorexia Nervosa; http://www.anzctr.org.au/; ACTRN12610000216011.

Prevalence, incidence, and natural course of anorexia and bulimia nervosa among adolescents and young adults

We aimed to assess the prevalence, incidence, age-of-onset and diagnostic stability of threshold and subthreshold anorexia nervosa (AN) and bulimia nervosa (BN) in the community. Data come from a prospective-longitudinal community study of 3021 subjects aged 14-24 at baseline, who were followed up at three assessment waves over 10 years. Eating disorder (ED) symptomatology was assessed with the DSM-IV/M-CIDI at each wave. Diagnostic stability was defined as the proportion of individuals still affected with at least symptomatic eating disorders (EDs) at follow-ups. Baseline lifetime prevalence for any threshold ED were 2.9 % among females and 0.1 % among males. For any subthreshold ED lifetime prevalence were 2.2 % for females and 0.7 % for males. Symptomatic expressions of EDs (including core symptoms of the respective disorder) were most common with a lifetime prevalence of 11.5 % among females and 1.8 % among males. Symptomatic AN showed the earliest onset with a considerable proportion of cases emerging in childhood. 47 % of initial threshold AN cases and 42 % of initial threshold BN cases showed at least symptomatic expressions of any ED at any follow-up assessment. Stability for subthreshold EDs and symptomatic expressions was 14-36 %. While threshold EDs are rare, ED symptomatology is common particularly in female adolescents and young women. Especially threshold EDs are associated with a substantial risk for stability. A considerable degree of symptom fluctuation is characteristic especially for subthreshold EDs.

Childhood Anorexia Nervosa Compared with Low Weight Food Intake Disorder Without Weight and Shape-Related Psychopathology: A Retrospective Study of 102 Patients

Objective

To compare the clinical presentation of children with anorexia nervosa (AN group) with that of children with low‐weight food intake disorder without weight and shape‐related psychopathology (non‐AN group).

Method

Medical and psychiatric data were obtained from the case records of a consecutive series of 102 children with an eating disorder and a pronounced low weight who were below the age of 13 at the start of treatment.

Results

Fifty‐eight patients constituted the AN group, and 44 constituted the non‐AN group. The non‐AN group was younger and had a longer duration of symptoms than the AN group. The non‐AN group also had a lower maximum premorbid weight and shorter stature. There were no differences in medical severity, but the AN group had more psychiatric treatment.

Discussion

The non‐AN group seems to have a medically equally severe disorder as the AN group, but is less often detected and properly treated. Copyright © 2016 The Authors European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd

Prognostic factors and outcome in anorexia nervosa: a follow-up study

BACKGROUND AND AIMS

Anorexia nervosa is an eating disorder characterized by food restriction, irrational fear of gaining weight and consequent weight loss. High mortality rates have been reported, mostly due to suicide and malnutrition. Good outcomes largely vary between 18 and 42%. We aimed to assess outcome and prognostic factors of a large group of patients with anorexia nervosa. Moreover we aimed to identify clusters of prognostic factors related to specific outcomes.

METHODS

We retrospectively reviewed data of 100 patients diagnosed with anorexia nervosa previously hospitalized in a tertiary level structure. Then we performed follow-up structured telephone interviews.

RESULTS

We identified four dead patients, while 34% were clinically recovered. In univariate analysis, short duration of inpatient treatment (p = 0.003), short duration of disorder (p = 0.001), early age at first inpatient treatment (p = 0.025) and preserved insight (p = 0.029) were significantly associated with clinical recovery at follow-up. In multiple logistic regression analysis, duration of first inpatient treatment, duration of disorder and preserved insight maintained their association with outcome. Moreover multiple correspondence analysis and cluster analysis allowed to identify different typologies of patients with specific features. Notably, group 1 was characterized by two or more inpatient treatments, BMI ≤ 14, absence of insight, history of long-term inpatient treatments, first inpatient treatment ≥30 days. While group 4 was characterized by preserved insight, BMI ≥ 16, first inpatient treatment ≤14 days, no more than one inpatient treatment, no psychotropic drugs intake, duration of illness ≤4 years.

CONCLUSIONS

We confirmed the association between short duration of inpatient treatment, short duration of disorder, early age at first inpatient treatment, preserved insight and clinical recovery. We also differentiated patients with anorexia nervosa in well-defined outcome groups according to specific clusters of prognostic factors. Our study might help clinicians to evaluate prognosis of patients with anorexia nervosa.

Favorable effects of clearly defined interventions by parents at the start of treatment of adolescents with restrictive eating disorders

OBJECTIVE

To study the effect of clearly defined and decisive parental interventions at the start of treatment of restrictive eating disorders (ED) in adolescents.

METHOD

Forty-seven adolescents with ED (anorexia nervosa = 6, bulimia nervosa = 1, EDNOS = 40) and their families participated. Parents were advised to (1) keep the adolescent home from school, (2) eat all meals together with the adolescent, (3) prevent any form of exercise, and (4) prevent vomiting during the first week of treatment. Weight change was followed up to three months and EDE-Q administered at start of treatment and at three months.

RESULTS

Thirty (64%) of the families accomplished all four interventions during the first week of treatment. Their adolescents gained ∼ 1 kg of weight at one week, 2 kg at one month, and 4 kg at three months while adolescents in families who did not accomplish all four interventions gained only 1.4 kg up to three months. Scores on the EDE-Q decreased during treatment and in adolescents of families who accomplished all four interventions they were in the range of a reference population.

DISCUSSION

Decisive parental management of eating disturbed behaviors at the start of treatment of adolescents with ED promotes later clinical outcome. The finding supports the view that family based therapies are effective in adolescent ED. Results has to be followed up for evaluation of the long term effects of this type of intervention.

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.

Focus on perfectionism in female adolescent anorexia nervosa

OBJECTIVE

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

METHOD

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

RESULTS

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

Family-based Treatment of Child and Adolescent Eating Disorders

Best-practice guidelines for the treatment of child and adolescent eating disorders recommend the inclusion of parents. Family-based treatment (FBT) posits that families are not only important in supporting their children but are critical change agents in the recovery process. As originally developed for anorexia nervosa, parents take a central role in managing and disrupting eating disorder symptoms. The most evidence-based treatment model for adolescent anorexia nervosa, FBT has also recently been found to be useful in the treatment of adolescent bulimia nervosa. This article provides a summary of the theoretic model, evidence base, and application of FBT.

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.