Health-related quality of life and eating disorders: a review and update

Individual differences in motivation to change in individuals with eating disorders: A systematic review

OBJECTIVE

Motivation to change has been suggested to significantly impact treatment outcomes in eating disorders (EDs). This review will investigate factors associated with motivation to change in EDs with the aim of supporting clinicians to be aware and sensitive to factors that might obstruct recovery and to inform motivation-based interventions.

METHOD

Using PRISMA guidelines, this article identified 24 studies through database searches meeting eligibility criteria. Only correlates of motivation were identified, limiting the ability of this review to identify causal relationships. Factors that changed alongside changes in motivation were identified from longitudinal studies.

RESULTS

This review identified factors such as individual characteristics, co-morbid psychopathology, lack of treatment autonomy and relationships with others to be associated with motivation to change in individuals with EDs. In addition, motivation to change significantly increased alongside self-esteem and identity re-negotiation when measured longitudinally.

DISCUSSION

Motivational interviewing can typically focus on exploring ambivalence to treatment, identifying goals and values, and increasing self-efficacy. However, this review identifies individual and relational factors to be particularly significant and may obstruct recovery from an ED. As such, evidence-based targets have been identified to inform clinicians and motivation-based interventions.

PUBLIC SIGNIFICANCE

Knowledge of factors associated with motivation to change in EDs is important to understand those who may have poorer treatment outcomes. Motivation may be improved by supporting individuals' relationship with others and tailoring interventions according to temperament and personality traits. Utilizing an individual's social support as they enter ED treatment may be effective in maximizing motivation to recover.

Self-reported health related quality of life in children and adolescents with an eating disorder

BACKGROUND

Eating disorders in children and adolescents can have serious medical and psychological consequences. The objective of this retrospective quantitative study is to gain insight in self-reported Health Related Quality of Life (HRQoL) of children and adolescents with a DSM-5 diagnosis of an eating disorder.

METHOD

Collect and analyse data of patients aged 8-18 years, receiving treatment for an eating disorder. At the start and end of treatment patients completed the KIDSCREEN-52, a questionnaire measuring HRQoL.

RESULTS

Data of 140 patients were analysed. Children diagnosed with Anorexia Nervosa, Bulimia Nervosa, and Other Specified Feeding or Eating Disorder all had lower HRQoL on multiple dimensions at the start of treatment, there is no statistically significant difference between these groups. In contrast, patients with Avoidant Restrictive Food Intake Disorder only had lower HRQoL for the dimension Physical Well-Being. HRQoL showed a significant improvement in many dimensions between start and end of treatment, but did not normalize compared to normative reference values of Dutch children.

CONCLUSION

The current study showed that self-reported HRQoL is low in children with eating disorders, both at the beginning but also at the end of treatment. This confirms the importance of continuing to invest in the various HRQoL domains.

An investigation of the dual continua model of mental health in the context of eating disorder symptomatology using latent profile analysis

OBJECTIVE

The dual continua model of mental health suggests that mental well-being and mental illness are two distinct continua that are interrelated in their contributions to overall mental health. This study investigated the dual continua model in individuals with eating disorder symptoms.

METHOD

Female university students (N = 346) completed measures of mental well-being, eating disorder symptomatology, clinical impairment and psychological distress. Confirmatory factor and latent profile analyses were used to derive underlying mental health profiles.

RESULTS

Results revealed two oblique factors representing the mental well-being and eating disorder symptomatology constructs and four unique mental health profiles that were partially consistent with the dual continua model emerged: 'flourishing', 'vulnerable', 'partially symptomatic and content', and 'languishing'. The derived mental health profiles had unique characteristics described by psychological distress and clinical impairment.

CONCLUSIONS

The results did not provide conclusive evidence for the dual continua model as they could also be interpreted in a manner consistent with the unidimensional approach. While the dual continua model is a promising avenue to understand mental health in a way that looks beyond symptoms, these results caution against its rapid adoption and encourage future research to understand how eating disorder symptomatology and positive mental health assets contribute to overall mental health.

Validation of the Spanish version of the eating disorders quality of life instrument (EDQOL)

BACKGROUND

The Eating Disorders Quality of Life instrument (EDQOL) is a disease-specific health related quality of life self-report questionnaire designed for disordered eating patients. Although the EDQOL is one of the most suitable and widely used questionnaires in many countries, no prior research has addressed the psychometric properties of the Spanish adaptation of the EDQOL. Therefore, the aim of this study is to examine the psychometric properties of the Spanish version of the EDQOL among ED patients.

METHODS

141 female eating disorder patients, with a mean age of 18.06 years (SD = 6.31), completed the EDQL in addition to the Eating Disorder Examination Questionnaire (EDEQ), the Depression, Anxiety and Stress Scales (DASS-21), the Clinical Impairment Assessment (CIA 3.0) and the Health Survey (SF-12). We calculated item/scale characteristics, internal consistencies and bivariate correlations with other measures of quality of life and adjustments. We assessed the goodness-of-fit of the 4-factor model using confirmatory factors analysis and explored the sensitivity of change following skill-based interventions.

RESULTS

The fit of the 4-factor model was acceptable (Root Mean Square Error of Approximation: 0.07, Standard Root Mean Square Residual: 0.07). Cronbach's alpha was excellent for the total (.91) and acceptable for all subscales (0.78-0.91). The construct validity was found with measures of psychological distress, depression, anxiety, quality of life and clinical impairment. The psychological and physical/cognitive scales and the EDQOL global scale were responsive to change.

CONCLUSION

The Spanish EDQOL version is a useful instrument to assess quality of life in eating disorder patients and to evaluate outcomes of skills-based interventions.

Exploring the moderating role of mindfulness, mindful eating, and self-compassion on the relationship between eating-disordered quality of life and orthorexia nervosa

Orthorexia nervosa (ON) is characterised by an obsessive focus on healthy eating, following restrictive dietary practices and dietary restrictions escalating over time. The aim of this study was to explore mindfulness, mindful eating, self-compassion and quality of life in a female population. Two hundred eighty-eight participants completed Orthorexia, Self-Compassion, Mindful eating, Mindfulness and Eating Disorder Quality of Life scales. The results indicated that there was a negative relationship between ON and mindfulness, self-compassion and mindful eating. Furthermore, the present study found a positive relationship between lower quality of life and ON, while findings indicated that self-compassion and the awareness facet of mindfulness moderated the relationship between ON and QOL. The present results contribute to a better understanding of orthorexic eating behaviours in a female population, and identify the moderating capacity of self-compassion and mindfulness. Further implications and future directions are discussed.Level of evidence Level V, cross-sectional descriptive study.

Anonymous Online Survey on Disordered Eating, Drive for Muscularity, Sexual Orientation, and Satisfaction with Life in Young Swedish Males

Psychiatric conditions in general, including eating disorders, are stigmatizing conditions. The stigma of eating disorders is even more pronounced among males. We conducted an anonymous, online survey to explore the feasibility of recruiting participants for collecting sensitive information, and the relation among eating disorders, drive for muscularity, satisfaction with life, and sexual preference in males (N = 824) aged 15-30 years in Sweden. Internet survey method was a feasible way of recruiting males and obtaining sensitive information. Drive for muscularity was positively related to eating psychopathology. Interestingly, only the attitudinal aspect of the drive for muscularity was negatively related to satisfaction with life, whereas the behavioral component of the drive for muscularity was unrelated to quality of life. Drive for muscularity and disordered eating were not significantly different across participants with various sexual orientations. Our findings corroborate and extend previous research by using an anonymous Internet-based survey that may be less contaminated by social desirability or reporting bias due to the sensitivity of some of the questions.

Classification of subtypes of patients with eating disorders by correspondence analysis

BACKGROUND

Grouping eating disorders (ED) patients into subtypes could help improve the establishment of more effective diagnostic and treatment strategies.

AIM

To identify clinically meaningful subgroups among subjects with ED using multiple correspondence analysis (MCA).

METHODS

A prospective cohort study was conducted of all outpatients diagnosed for an ED at an Eating Disorders Outpatient Clinic to characterize groups of patients with ED into subtypes according to sociodemographic and psychosocial impairment data, and to validate the results using several illustrative variables. In all, 176 (72.13%) patients completed five questionnaires (clinical impairment assessment, eating attitudes test-12, ED-short form health-related quality of life, metacognitions questionnaire, Penn State Worry Questionnaire) and sociodemographic data. ED patient groups were defined using MCA and cluster analysis. Results were validated using key outcomes of subtypes of ED.

RESULTS

Four ED subgroups were identified based on the sociodemographic and psychosocial impairment data.

CONCLUSION

ED patients were differentiated into well-defined outcome groups according to specific clusters of compensating behaviours.

Is Fatty Liver Associated With Depression? A Meta-Analysis and Systematic Review on the Prevalence, Risk Factors, and Outcomes of Depression and Non-alcoholic Fatty Liver Disease

Background and Aims: Both non-alcoholic fatty liver disease (NAFLD) and depression have a high global prevalence which is projected to increase further. While studies exploring the association have been done, there are conflicting data. This study aims to assess the prevalence and association between depression and NAFLD.

Methods: Medline and Embase were searched from inception to March 3, 2020. Meta-analysis of proportions using the generalized linear mix model was conducted to analyze the pooled prevalence of depression in NAFLD patients. Risk factors for depression in NAFLD patients were evaluated in conventional pairwise meta-analysis.

Results: Ten studies involving 2,041,752 NAFLD patients were included. Pooled prevalence of depression was 18.21% (CI: 11.12–28.38%) in patients with NAFLD and 40.68% (CI: 25.11–58.37%) in patients with non-alcoholic steatohepatitis (NASH). NAFLD resulted in significantly higher risk of development of depression (OR: 1.29, CI: 1.02–1.64, p = 0.03). NASH patients had a significantly higher risk of depression compared with NAFLD patients (RR: 2.83, CI: 2.41–3.32, p < 0.001). Diabetes, body mass index (BMI), female sex, smoking, and history of pulmonary disease were significant risk factors for depression in NAFLD patients.

Conclusion: This study demonstrated a high prevalence of depression in NAFLD patients and a significant association between both conditions. Furthermore, patients with NASH had a significantly higher risk of depression compared with those with NAFLD. Diabetes, BMI, history of lung disease or smoking, and female gender were significant risk factors. Further studies investigating the pathophysiological mechanism underlying depression and NAFLD are needed.

Low satisfaction with normative life domains in adolescents with anorexia nervosa

OBJECTIVE

Low satisfaction with normative life domains might be an important factor in the persistence of anorexia nervosa (AN). Initial evidence in non-clinical samples showed that lower satisfaction with normative life domains was related to more intense eating disorder symptoms. As a critical next step, the current study examined satisfaction with normative life domains in a clinical sample. Specifically, the present study tested whether adolescents with AN reported lower satisfaction with normative life domains than adolescents without an eating disorder.

METHOD

Adolescents with AN (n = 69) and adolescents without an eating disorder matched on age, gender and educational level (n = 69) completed the Brief Multidimensional Students' Life Satisfaction Scale to assess satisfaction with five life domains (family, friendships, school, self and living location) and life in general.

RESULTS

Adolescents with AN reported significantly lower satisfaction with normative life domains than the comparison group. Subsequent analyses showed that this overall group difference was primarily driven by adolescents with AN reporting lower satisfaction with the self, school experience and life in general.

CONCLUSIONS

Findings supported the hypothesis that adolescents with AN show relatively low satisfaction with meaningful, non-AN-related life domains. This points to the potential relevance of enhancing satisfaction with specific life domains to optimize treatment effectiveness.

Health-Related Quality of Life in Spanish Women with Eating Disorders

People with eating disorders show impaired health-related quality of life (HRQoL). We aimed to investigate the relative role of physical and mental factors and stage of change as possible predictors of HRQoL in a group of Spanish women (n = 124) with eating disorders. For this purpose, initial and follow-up data were obtained after 6 months from patients attending an outpatient treatment unit for eating disorders. The determinants of the physical and mental domains of the Medical Outcomes Survey Short-form Health Survey (SF-36) questionnaire were investigated in the total sample and separately based on the eating disorder diagnosis by multiple linear regression. Lower scores in the physical component of the SF-36 questionnaire were associated with the presence of a higher body mass index (BMI) at follow-up as well as a higher score in the "action" component of the Attitudes towards Change in Eating Disorders Questionnaire (ACTA). Conversely, a higher index in the EuroQoL-5D overall quality of life questionnaire (EQ-5D) and the presence of obsessive compulsive disorder were associated with a higher score in the physical dimension. The instrument used demonstrated the ability to assess changes associated with the physical component of these patients over the period studied, and the analysis provided more information and specific data on different aspects of HRQoL, thus allowing a more detailed analysis of the information.

Factor structure and psychometric properties of the clinical impairment assessment 3.0 (CIA) in a clinical eating disorder sample

PURPOSE

The aim of this study was to investigate the psychometric properties and the factor structure of the Clinical Impairment Assessment 3.0 (CIA) utilizing a confirmatory factor analysis in a large clinical sample of ED patients.

METHODS

A total of 260 patients between the ages of 18 and 45 who completed assessments in a partial hospitalization or residential treatment program at an ED treatment facility between December 2012 and December 2016 were included in the analyses. Assessment measures included the CIA, EDE-Q, BDI-II, WHODAS, and a demographic questionnaire.

RESULTS

Results favored a bifactor model with a strong general factor and three unreliable subfactors. The CIA showed strong construct validity with other measures of ED pathology (EDE-Q) and health-related QoL (WHODAS). Furthermore, admission CIA scores were predictive of treatment outcomes.

CONCLUSIONS

The CIA assesses general psychosocial impairment, supporting the use of a total, but not subscale scores, among symptomatic ED samples in the United States.

Eating Disorders, Perfectionism, and Quality of Life: Maladaptive Perfectionism as a Mediator Between Symptoms of Disordered Eating and Quality of Life

Individuals with disordered eating behaviors exhibit significantly impaired quality of life (QoL). Maladaptive perfectionism is consistently associated with both eating disorders (EDs) and QoL, but its role in the relationship between eating pathology and QoL has remained largely unexplored. The current study investigated whether maladaptive perfectionism mediates the ED-QoL relationship. A total of 286 university students completed an online survey that consisted of self-report questionnaires assessing ED symptomology, QoL, maladaptive perfectionism, and anxiety and depression symptoms. Maladaptive perfectionism mediated the relationship between ED symptomology and QoL, but this effect did not persist when body mass index, depression, and anxiety were controlled for. The results suggest the mediatory effect of maladaptive perfectionism is masked by depression and anxiety symptomology. Recommendations for further research are proposed to clarify the role of maladaptive perfectionism in the ED-QoL relationship and to explore the mediatory role of depression and anxiety in this relationship.

Validation of the Portuguese version of the Clinical Impairment Assessment (CIA) in eating disorders' patients

PURPOSE

The purpose of the study was to assess the psychometric properties of the Portuguese version of the Clinical Impairment Assessment (CIA) in eating disorders (ED) patients.

METHOD

The CIA is a 16-item brief self-reported instrument developed to assess psychosocial impairment secondary to EDs. The CIA was administered to a clinical sample of 237 women with EDs and a college sample of 196 women. The clinical sample completed the Eating Disorders Examination Questionnaire, the Beck Depression Inventory and the Outcome-45 Questionnaire. Reliability, confirmatory factor analysis, validity, and clinically significant change were calculated.

RESULTS

Confirmatory factor analysis validated the original 3-factor structure showing an adequate model fit. CIA showed good psychometric properties with high internal consistency, good convergent validity with the EDE-Q, the OQ-45, and the BDI. For divergent validity, participants CIA scores in the clinical sample were significantly higher than in the non-clinical sample. ROC curve analysis provided a cutoff of 15. For known-groups validity participants' scoring above CIA cutoff reported significantly higher CIA scores. In addition, non-underweight participants and participants reporting the presence of dysfunctional ED behaviors had significantly higher CIA scores. Finally, for clinically significant change, a reliable change index of 5 points was obtained to consider a reliable change in the CIA global score.

CONCLUSIONS

Our findings support the validity and clinical utility of the CIA as a good self-report measure to be used in both clinical and research settings.

LEVEL OF EVIDENCE

Level V. Cross-sectional descriptive study.

Can high intensity interval training improve health outcomes among people with mental illness? A systematic review and preliminary meta-analysis of intervention studies across a range of mental illnesses

BACKGROUND

High intensity interval training (HIIT) may have beneficial effects among people with mental illnesses. The aim of this systematic review was to establish the benefits, safety and adherence of HIIT interventions across all categories of mental illness.

METHODS

Major databases were searched from inception to 18/2/2019 for intervention studies investigating HIIT among people with mental illnesses. Study quality was assessed via the PEDro scale, intervention characteristics were reported using the TIDier and CERT checklists and findings narratively summarised. A preliminary meta-analysis was undertaken where possible.

RESULTS

12 intervention studies, (including 7 RCTs), were included. Evidence suggested HIIT improved cardiorespiratory fitness (5/8 intervention studies,63%), anthropometric variables (3/4,75%), mental health outcomes (9/12, 75%), cardiovascular fitness (5/9,56%), physical fitness (1/1,100%) and motor skills (1/1,100%), compare to pre-training. The preliminary meta-analysis of pre-post changes found HIIT reduced depression severity (Standardised mean difference (SMD):-1.36 [95%CI-1.63;-1.089], p<0.0001) and possibly improved VO2max (SMD:0.18 [95%CI -0.02; 0.37], p = 0.08) in people with depression. HIIT increased High-Density-Lipoprotein (SMD:0.373 [95%CI 0.18; 0.57], p = 0.0002) and possibly reduced general psychopathology (SMD:-1.58 [95%CI -3.35; 0.18], p = 0.08) in people with schizophrenia-spectrum disorders. No acute injuries were reported, mean adherence to HIIT sessions ranged from 64-94%, and dropout ranged from 0--50%.

LIMITATIONS

Results were limited to a small number of low-to-moderate quality intervention studies.

CONCLUSION

These findings suggest HIIT may improve a range of physical and mental health outcomes among people with mental illnesses. Nonetheless, high-quality well-powered trials are needed to reaffirm these findings, and future research should address the seemingly high rate of dropout.

The General Factor of Psychopathology

An important advance in understanding and defining mental disorders has been the development of empirical approaches to mapping dimensions of dysfunction and their interrelatedness. Such empirical approaches have consistently observed intercorrelations among the many forms of psychopathology, leading to the identification of a general factor of psychopathology (the p factor). In this article, we review empirical support for p, including evidence for the stability and criterion validity of p. Further, we discuss the strong relationship between p and both the general factor of personality and the general factor of personality disorder, substantive interpretations of p, and the potential clinical utility of p. We posit that proposed substantive interpretations of p do not explain the full range of symptomatology typically included in p. The most plausible explanation is that p represents an index of impairment that has the potential to inform the duration and intensity of a client's mental health treatment.

Establishment of a multifamily therapy (MFT) service for young adults with a severe eating disorder - experience from 11 MFT groups, and from designing and implementing the model

BACKGROUND

Eating disorders are serious illnesses leading to a substantially lowered quality of life not only for the patient but also for their family. They are difficult to treat, and many patients fail to complete their treatment. At the Regional Centre for Eating Disorders (RESSP) at Nordland Hospital in Bodø, in the north of Norway, it was apparent that many young adult patients maintained an active, ongoing relationship with their family of origin, and that parents and others were often highly involved in their life and illness. It was therefore desirable to develop a treatment model involving family members; specifically a multifamily therapy (MFT) group programme.

METHODS

The aim was to establish an MFT service at RESSP for young adult patients suffering from severe eating disorders. This involved, (1) work preparatory to the establishment of the new service, (2) the development and implementation of a suitable MFT model, and (3) sharing the skills and knowledge gained from our experiences to other professionals in the field, and in other settings. This work of development and change can be understood as a process of innovation and is here described within the framework of implementation theory. The work took place in a clinically naturalistic context at the centre.

RESULTS

The MFT model description is based on experience during its development as well as its final form. The stages of this development process and of the changes made in order to establish the new service are described, together with its core components. To date, 68 patients and 198 family members have participated. Dropout rate has been 7.4% and the majority of patients have continued in treatment after completion of the MFT groups. BMI measurements show a significant weight-gain for those with an underweight at start. 32 other professionals have been trained in the model, and a similar service started in 3 other units.

CONCLUSION

The new model has been welcomed by patients and families alike. The MFT group programme has had a strikingly low dropout rate and a majority of patients have continued in treatment. BMI measurements show a significant weight-gain for those being underweight at start. Other therapists have been trained in the model, and similar services set up elsewhere. In order to document and increase the usefulness of the MFT treatment, a research project has been initiated to evaluate experience and outcomes both quantitatively and qualitatively.

Reasons for non-response and recommendations for optimal outpatient treatment of bulimia nervosa: A survey on German expert therapists' views

Objectives: Remission rates after treatment for bulimia nervosa can be considered insufficient. The study aimed to explore the perspective of expert psychotherapists on possible reasons for non-response and recommendations for an optimized treatment. Methods: Experts filled in a questionnaire that comprised questions about possible reasons for low remission rates as well as ratings of interventions suggested for different treatment phases and subgroups of patients. Results: 56 experienced therapists could be included in the survey. Ambivalence of patients, insufficient training of therapists and heterogeneity of the patient group were most often rated as possible reasons for insufficient outcomes. For optimized treatment, therapists recommended a combination of cognitive-behavioral and psychodynamic techniques, depending on treatment phase and patient characteristics. Conclusions: Further research should examine, if a more specific training of therapists, a more integrative approach and flexible adaptations of interventions to patients' characteristics are effective strategies to improve outcome.

Understanding profiles of student binge drinking and eating: The importance of motives

Binge drinking and binge eating occur frequently in undergraduates; however, the mechanism driving their co-occurrence is not well-understood. Several theories support the role of motives in driving drinking and eating behavior, especially motivations related to affect regulation (i.e., enhancement/pleasure and coping). This study used a person-centered approach to identify classes of students based on eating and drinking motives and past-month binge behavior and examined class differences in psychopathology, emotion regulation, and impulsivity. Undergraduates (N = 776) completed a drinking timeline follow-back and surveys assessing motives, binge eating, psychopathology, emotion regulation, impulsivity, and quality of life. Mixture modeling was used to group students based on presence/absence of past-month binge eating, binge drinking, and motives for eating and drinking. The analysis resulted in 4 classes: Binge Drinking (with relatively high social and enhancement drinking motives), Binge Eating (with overall high eating motives), Both Bingeing (with high drinking motives, especially coping, and high eating motives), and Low Bingeing (with low motives for both behaviors). ANOVA and post-hoc analyses suggested that the Binge Eating and Both Bingeing groups were most impaired, while the Binge Drinking class rarely differed from the Low Bingeing group across measures of psychological distress. Notably, classes with high eating/drinking motives displayed significant impairment despite not all class members endorsing binge behavior. Findings suggest that binge drinking in addition to binge eating may not imply more psychological impairment and support the importance of assessing motives for eating/drinking among undergraduates and potentially trying to challenge these motives through early intervention.

Measuring treatment outcome in patients with anxiety disorders: A comparison of the responsiveness of generic and disorder-specific instruments

BACKGROUND

For routine outcome monitoring, generic (i.e., broad-based) and disorder-specific instruments are used to monitor patient progress. While disorder-specific instruments may be more sensitive to therapeutic change, generic measures can be applied more broadly and allow for an assessment of therapeutic change, irrespective of a specific anxiety disorder. Our goal was to investigate whether disorder-specific instruments for anxiety disorders are a valuable (or even necessary) addition to generic instruments for an appropriate assessment of treatment outcome in groups of patients.

METHODS

Data were collected from 2002 to 2013 from psychiatric outpatients in treatment for Social Phobia (SP; n = 834), Generalized Anxiety Disorder (GAD; n = 661), Panic Disorder (PD; n = 944), Obsessive-Compulsive Disorder (OCD; n = 460), and Posttraumatic Stress Disorder (PTSD; n = 691). Instruments used were the generic Brief Symptom Inventory (BSI), The Mood and Anxiety Symptoms Questionnaire (MASQ), and several disorder-specific instruments (e.g., Social Interaction Anxiety Scale, Social Phobia Scale, Panic Appraisal Inventory, etc.). Responsiveness (i.e., sensitivity to therapeutic change) was examined through correlational analyses, effect sizes (ES), and analysis of variance for repeated measures.

RESULTS

The MASQ appeared generally more responsive than the BSI, except for the BSI Anxiety subscale for PD. Disorder-specific measures equaled the MASQ and BSI in responsiveness. When statistically significant differences occurred, the ES was small.

DISCUSSION/CONCLUSIONS

For most anxiety disorder groups (i.e., SP, PD and OCD), the MASQ or BSI was equally suited as disorder-specific instruments to detect change at group level. Exceptions are GAD and PTSD. These findings suggest limited incremental information value of disorder-specific instruments over the MASQ and BSI for measuring change.

Anxiety and depressive symptoms are related to core symptoms, general health outcome, and medical comorbidities in eating disorders

OBJECTIVE

The goal of this study is to identify potential factors that have a significant effect on anxiety and depression of patients with eating disorders (ED) using the beta-binomial regression (BBR) approach on a broad sample of patients.

METHOD

This cross-sectional study involved 520 ED patients. The effect of sociodemographics, core symptoms, general health outcomes, and medical comorbidities in anxiety and depression were analysed jointly using the beta-binomial mixed-effects model.

RESULTS

Two hundred fifty-five (49.4%) patients had anorexia nervosa, 173 (33.3%) patients had bulimia nervosa, and 92 (17.7%) had ED not otherwise specified. A high level of anxiety was associated, among other variables, with having a restrictive ED subtype as compared with purgative and binge ED subtypes (β = -0.2, p < 0.001, OR = 0.82 and β = -0.16, p < 0.03, OR = 0.85, respectively), with having a high level of ED symptomatology or with living not alone (β = -0.23, p = 0.002, OR = 0.80). A high level of depression was associated, among other variables, with older age (β = 0.74, p < 0.001, OR = 2.1).

CONCLUSIONS

The results of our study suggest that depressive and anxiety symptoms are related to ED symptoms, health status, ED subtype, medical comorbitidy, and educational level. In addition, another interesting finding is the inverse association between symptomatology of anxiety and living alone. Finally, BBR may be a useful approach in interpreting patient-reported outcome as odds.

Transactions among thinness expectancies, depression, and binge eating in the prediction of adolescent weight control behaviors

OBJECTIVE

Binge eating, the transdiagnostic risk associated with depression, and the eating disorder-specific risk associated with expectancies for reinforcement from thinness have been identified as risk factors for the development of weight control behaviors. The purpose of this study was to examine if these risk factors transact to further predict risk in youth.

METHOD

Binge eating, depressive symptoms, thinness expectancies, and weight control behaviors were assessed in 1,758 adolescents three times during the transitional period between middle school and high school. We tested six different possible transactional processes.

RESULTS

Mediation tests demonstrated that both 8th grade binge eating and 8th grade depressive symptoms predicted 10th grade weight control behaviors through their predictive influence on thinness expectancies in 9th grade. However, our results were not consistent with a mediational process in which 8th grade thinness expectancies predicted 9th grade depression to further predict 10th grade weight control behaviors. No interactions among binge eating, depressive symptoms, or thinness expectancies predicted weight control. Results did not differ between girls and boys.

DISCUSSION

Thinness expectancies appear to mediate the predictive influence of binge eating and depressive symptoms on risk for engaging in weight control behaviors. These results add to theoretical understanding of risk and suggests potential intervention pathways for clinicians.

Momentary predictors of binge eating: An attachment perspective

INTRODUCTION

According to attachment theory, individuals who are preoccupied with the possibility of rejection are prone to emotion dysregulation, which research has found to be related to disordered eating. The current study examined naturalistic momentary relationships between binge eating, depressive symptoms, emotion dysregulation, and attachment anxiety.

METHOD

Participants were 55 undergraduate women who owned a mobile phone and who had binge eaten at least once during the past 28 days. All participants were screened to confirm the presence of binge eating and then completed trait measures of attachment anxiety. Participants then received seven text messages per day for 14 days. Texts contained links to state measures of depressive symptoms, state emotion dysregulation, and recent binge eating.

RESULTS

Momentary depressive symptoms predicted subsequent binge eating. Aspects of emotion dysregulation (i.e., nonacceptance of emotional responses and difficulty modulating one's emotions) mediated the relationship between attachment anxiety and binge eating.

DISCUSSION

Depressed mood often triggers binge eating. Additionally, attachment anxiety seems to predict binge eating through emotion dysregulation. Interventions for binge eating should address both attachment anxiety and emotion dysregulation in order to maximize therapeutic benefit.

The role of depression, eating disorder symptoms, and exercise in young adults' quality of life

OBJECTIVE

Eating disorder (ED) symptoms are negatively associated with quality of life (QOL), while exercise is typically positively associated with QOL. Past studies have not examined the relative contribution of depression to this outcome. This study examined the influence of ED symptoms, exercise frequency, and exercise motivation on global QOL in undergraduates while accounting for the shared relationship between ED symptoms and depression.

METHOD

Students (N = 851) completed the EDE-Q, Reasons for Exercise Inventory, BDI-II, Quality of Life Inventory, and a 1-month exercise timeline followback calendar. Hierarchical regression analyses were conducted to examine the relative contributions of ED symptoms, depression, and exercise variables to QOL.

RESULTS

Shape concern and BDI-II scores accounted for significant variance in QOL scores. Depressive symptoms, however, accounted for 9.55% of the unique variance in QOL, while shape concern accounted for only 0.77%. Exercise frequency did not explain significant variance in QOL. The motivations of exercising for mood improvement and for enjoyment explained significant variance in QOL. No interactions between exercise frequency and exercise motivations were significant. In the final model, identifying as a woman was associated with decreased QOL.

DISCUSSION

Results suggest that studies examining the impact of disordered eating and exercise on QOL should account for depression due to depression's high comorbidity with EDs and its influence on exercise behavior and motivation. Additionally, results support findings that factors such as exercise motivation may better account for differences in QOL than exercise frequency.

Qualidade de Vida em Pacientes com Anorexia e Bulimia Nervosa

RESUMO Este estudo teve por objetivo avaliar a qualidade de vida relacionada à saúde (QVRS) de pacientes com transtornos alimentares (TAs). A amostra foi composta por 40 pacientes consecutivos, em sua maioria mulheres jovens e adultas, com diagnóstico de Anorexia Nervosa e em tratamento ambulatorial. A coleta de dados foi realizada por meio da aplicação de um instrumento de QVRS (SF-36) e do Teste de Atitudes Alimentares (EAT-26). Os resultados evidenciaram QVRS rebaixada, especialmente nos Componentes Mentais. Constatou-se prejuízo em seis dos oito domínios de QV avaliados naqueles pacientes com maior pontuação no EAT-26, em cinco domínios nos pacientes com idade acima de 22 anos, nos domínios Estado Geral de Saúde (p = 0,02) e Saúde Mental (p = 0,03) naqueles pacientes com menos de cinco anos de tratamento e no domínio Aspectos Físicos (p = 0,02) naqueles que receberam diagnóstico de Bulimia Nervosa.

Disordered Eating: The Young Male Side

Disordered eating (DE) is known to predominate among girls, and historically studies have focused primarily on them. This cross-sectional study aimed to investigate the characteristics of adolescent and young adult males at risk of DE. Participants (N = 2269; 15-24 years) in a study assessing their lifestyle were divided into two groups based on the SCOFF five-question screening tool: a SCOFF[+] group for participants at risk of disordered eating, and a SCOFF[-] group for everyone else. SCOFF[+] participants were more likely to be overweight and obese; have a lower socio-economic status and non-Swiss parents; experience weight issues; and report a chronic condition, poorer emotional well-being and a less positive attitude towards life. With 10% of males at risk of DE, clinicians should be aware of their specific characteristics, which should be considered red flags. DE is no longer a female-specific issue.

Testing the relative associations of different components of dietary restraint on psychological functioning in anorexia nervosa and bulimia nervosa

Although empirical evidence identifies dietary restraint as a transdiagnostic eating disorder maintaining mechanism, the distinctiveness and significance of the different behavioural and cognitive components of dietary restraint are poorly understood. The present study examined the relative associations of the purportedly distinct dietary restraint components (intention to restrict, delayed eating, food avoidance, and diet rules) with measures of psychological distress (depression, anxiety, and stress), disability, and core eating disorder symptoms (overvaluation and binge eating) in patients with anorexia nervosa (AN) and bulimia nervosa (BN). Data were analysed from a treatment-seeking sample of individuals with AN (n = 124) and BN (n = 54). Intention to restrict, food avoidance, and diet rules were strongly related to each other (all r's > 0.78), but only weakly-moderately related to delayed eating behaviours (all r's < 0.47). In subsequent moderated ridge regression analyses, delayed eating was the only restraint component to independently predict variance in measures of psychological distress. Patient diagnosis did not moderate these associations. Overall, findings indicate that delayed eating behaviours may be a distinct component from other indices of dietary restraint (e.g., intention to restrict, food avoidance, diet rules). This study highlights the potential importance of ensuring that delayed eating behaviours are screened, assessed, and targeted early in treatment for patients with AN and BN.

Eating Disorder Quality of Life Scale (EDQLS) in ethnically diverse college women: an exploratory factor analysis

Background

Extant research suggests that disordered eating is common in college women and is associated with decreased quality of life. The Eating Disorder Quality of Life Scale (EDQLS) examines impairment to disordered eating-related quality of life, but has not been validated in college women. Accordingly, the purpose of this study was to examine the reliability, validity, and factor structure of the EDQLS in a diverse sample of 971 college women.

Method

Students from a large United States university completed questionnaires examining disordered eating and the EDQLS online.

Results

The EDQLS demonstrated excellent internal consistency and good convergent validity with the Eating Disorder Examination Questionnaire (EDEQ). Contrary to the original 12-domain design of the EDQLS, principal component analyses suggested five factors that mapped onto the following constructs: (1) Positive Emotionality; (2) Body/Weight Dissatisfaction; (3) Disordered Eating Behaviors; (4) Negative Emotionality; and (5) Social Engagement. However, 15 of the 40 items loaded onto multiple factors.

Conclusions

Total scores on the EDQLS are reliable and valid when used with diverse samples of college women, but some revisions are needed to create subscales than can justifiably be used in clinical practice.

Predictors of quality of life in patients with eating disorders

BACKGROUND

The aims of this study were to analyse the quality of life (QoL) of a broad sample of patients with eating disorders (ED) and to identify potential factors that predict QoL.

METHODS

This prospective cohort study involved 528 patients diagnosed with ED and treated over a 15-year period in the Eating Disorders Outpatient Clinic. Information on sociodemographic and clinical data were gathered. Patients completed five self-administered instruments: the Eating Attitudes Test-26 (EAT-26); the Eating Disorder Diagnostic Scale (EDDS); the Hospital Anxiety and Depression Scale (HADS); the Short-Form 12 (SF-12); and the Quality of Life in ED-short form (HeRQoLED-s). Descriptive, univariate analyses and multivariate linear regression models were applied to identify factors associated with QoL.

RESULTS

Predictive variables for a low level of QoL in patients with anorexia nervosa (AN) included antidepressant treatment (P=0.009), substance abuse disorder, (P=0.03) and other organic comorbidities (P<0.0001). For patients with bulimia nervosa (BN), they included osteoporosis (P≤0.0001), obesity (P=0.0004) or being a student (P=0.04). For patients with eating disorders not otherwise specified (EDNOS), they included anxiolytic treatment (P=0.003), having circulatory disease (P=0.001), more years since start of ED treatment (P=0.03) and living alone (P<0.0001).

CONCLUSIONS

We found a significant difference in QoL between the diagnostic ED groups. With regard to the variables predicting QoL in ED patients, the findings of this study suggest that organic or psychiatric comorbidities and some data of social normality might be more relevant to QoL in ED than age, type of compensatory behaviour, BMI or number of visits to hospital emergency department.

The effects of cognitive-behavioral therapy for eating disorders on quality of life: A meta-analysis

OBJECTIVE

Meta-analyses have documented the efficacy of cognitive-behavioral therapy (CBT) for reducing symptoms of eating disorders. However, it is not known whether CBT for eating disorders can also improve quality of life (QoL). This meta-analysis therefore examined the effects of CBT for eating disorders on subjective QoL and health-related quality of life (QoL).

METHOD

Studies that assessed QoL before and after CBT for eating disorders were searched in the PsycInfo and Medline database. Thirty-four articles met inclusion criteria. Pooled within and between-groups Hedge's g were calculated at post-treatment and follow-up for treatment changes on both subjective and HRQoL using a random effects model.

RESULTS

CBT led to significant and modest improvements in subjective QoL and HRQoL from pre to post-treatment and follow-up. CBT led to greater subjective QoL improvements than inactive (i.e., wait-list) and active (i.e., a combination of bona fide therapies, psychoeducation) comparisons. CBT also led to greater HRQoL improvements than inactive, but not active, comparisons. Prepost QoL improvements were larger in studies that delivered CBT individually and by a therapist or according to the cognitive maintenance model of eating disorders (CBT-BN or CBT-E); though this was not replicated at follow-up CONCLUSIONS: Findings provide preliminary evidence that CBT for eating disorders is associated with modest improvements in QOL, and that CBT may be associated with greater improvements in QOL relative to comparison conditions.

Cost-effectiveness of achieving clinical improvement with a dissonance-based eating disorder prevention program

Using data from an effectiveness trial delivered by college clinicians, we examined the cost-effectiveness of the dissonance-based Body Project program for reducing eating disorder symptoms in women with body dissatisfaction. The outcome of interest was individual-level change; 14.9% of Body Project participants attained clinically meaningful improvement vs. 6.7% of controls. Delivering the intervention costs approximately $70 (2012 U.S. dollars) per person. Incremental cost-effectiveness was $838 for each additional at-risk person reducing eating disorder symptomology to a clinically meaningful degree. These analyses demonstrate the economic value of the Body Project for college-age women with symptoms below the eating disorder diagnosis threshold.

Does psychological well-being change following treatment? An exploratory study on outpatients with eating disorders

Psychological well-being changes following cognitive-behavioral therapy-based treatment were investigated in outpatients with eating disorders (ED). While it is known that CBT reduces symptomatology in EDs, less is known about how changes in positive functioning may ensue. One-hundred and eighty five ED outpatients were analyzed for pre-treatment and post-treatment changes in psychological well-being (PWB) by last observation carried forward - Wilcoxon signed rank tests. Significant gains in all PWB dimensions were found, with moderate effect size correlations in environmental mastery (r=-.418), personal growth (r=-.351) and self-acceptance (r=-.341). A subsample of patients in remission (n=51) was selected and compared to healthy controls in PWB post-treatment scores through Mann-Whitney U tests. Remitted patients showed significantly lower psychological well-being in two dimensions compared to controls: PWB-positive relations (r=-.360) and PWB-self-acceptance (r=-.288). However, more than 50% of ED outpatients in remission had PWB scores that fell below the 50th percentile of healthy controls in all psychological well-being dimensions, despite significant treatment response. Several mechanisms of psychological well-being change following CBT-based treatment are discussed. The assessment of treatment outcome in EDs may benefit from considering changes in positive functioning such as psychological well-being, in addition to the standard measurement of BMI, symptomatology and behavioral parameters. CBT-based treatment outcomes may be strengthened by promoting the development of optimal domains particularly in the interpersonal realm, such as building of quality and warm relationships and focusing on enhancing self-acceptance.

Cost-effectiveness of anorexia nervosa in QALYs

BACKGROUND

The costs of treating eating disorders are often considered high.

AIMS

The objective was to perform a cost-utility analysis to estimate the cost-effectiveness of treatment of anorexia nervosa (AN).

METHODS

Thirty-nine patients entering treatment of AN completed the 15D health-related quality-of-life (HRQoL) questionnaire before and 2 years after the start of treatment. Direct hospital costs were obtained. Quality-adjusted life years (QALYs) gained were calculated and cost-utility assessed.

RESULTS

Patients' baseline HRQoL was severely impaired. During follow-up, mean HRQoL improved statistically significantly. The cost per QALY gained was €5296 (best-case scenario) or €64 440 (base-case scenario) (€11 559 or €71 600 discounted 3%) depending on the assumptions used in the analysis.

CONCLUSIONS

The cost per QALY was in the same range as that of many other interventions provided in specialized medical care and within the limits usually considered acceptable, indicating that the treatment of AN is cost-effective.

The impact of suicidality on health-related quality of life: A latent growth curve analysis of community-based data

OBJECTIVE

The subjective burden of suicidality on mental and physical health-related quality of life (HRQoL) remains to be examined. Eight-year trajectories of mental and physical components of HRQoL were compared for suicidal and non-suicidal participants at baseline. The effect of poor mental and/or physical HRQoL on subsequent suicidality was also investigated.

METHOD

Randomly-selected community data (W1=7485; W2=6715; W3=6133) were analysed with multivariate latent growth curve (LGC) and logistic regression models.

RESULTS

Adjusted LGC modelling identified that baseline ideation was associated with poorer mental, but better physical HRQoL at baseline (b=-3.93, 95% CI=-4.75 to -3.12; b=1.38, 95% CI=0.53-2.23, respectively). However, ideation was associated with a declining physical HRQoL trajectory over 8 subsequent years (b=-0.88, 95% CI=-1.42 to -0.35). Poorer mental HRQoL was associated with higher odds of ideation onset (OR=0.98, 95% CI=0.96-0.99).

LIMITATIONS

Frequency of data collection was four-yearly, while suicidality was reported for the previous 12-months; analyses did not control for physical health problems at baseline, baseline depression may have influenced physical QoL; suicidality was assessed with binary measures; and, prior analyses of attrition over time showed those with poorer health were less likely to continue participating in the study.

CONCLUSIONS

Suicidality has differential longitudinal effects on mental and physical HRQoL. Findings emphasise the considerable subjective HRQoL burden upon suicidal individuals. HRQoL may be useful to compare relative social and economical impacts.

Predictors of change in psychosocial impairment secondary to an eating disorder

Eating disorders (ED) can significantly impair psychosocial health in patients. However, no published studies have so far used a standardized and specific instrument to evaluate predictive factors in ED-related psychosocial impairment. This prospective cohort study involved 177 patients receiving outpatient treatment for an ED at baseline and 115 patients at the 1-year follow-up. Patients completed three self-administered questionnaires: the Clinical Impairment Assessment (CIA), the Eating Attitudes Test-12 (EAT-12), and the Health-Related Quality of Life in ED-short form (HeRQoLED-s). Descriptive statistics, ANOVA, chi-square, and Fisher's exact test were applied to examine intervariable relationships. Multivariate linear regression was used to determine predictors of change in CIA scores. An improvement was reported by patients with restrictive anorexia nervosa (AN) compared to those with purgative AN. In the multivariate analysis, employment status, subtype of ED, and the bulimia and food preoccupation factor of the EAT-12 were significant predictors of change in the CIA scores.

Influence of negative affect on decision making in women with restrictive and binge-purge type anorexia nervosa

The present study aims to examine the influence of negative affect on decision making in women with anorexia nervosa (AN) compared to healthy control women and, secondly, to assess differences between the restrictive (ANR) and binge-purge (ANBP) subtypes. One hundred four women (32 with ANR, 32 with ANBP, and 40 healthy controls) participated. All women were asked to watch either a negative or a control film fragment, both followed by the Bechara Gambling Task (BGT). Before and after the fragments negative affect was measured. Additionally, relevant characteristics (e.g., overall depressive symptoms) were assessed. Differences in negative affect did not influence decision making performance. Independent of affective state, decision making was found to be impaired in women with ANBP (no learning effect on the BGT), but not in women with ANR. These findings highlight the importance of considering different AN subtypes when examining decision making processes. However, the role of negative affect on decision making remains uncertain. Since other affect related factors such as affect dysregulation may also play a role, future studies on decision making in AN should take the role of affect into account.

Sex differences in the effects of residential treatment on the quality of life of eating disorder patients

AIMS

This study compared the effects of residential treatment on improving health-related quality of life (HRQOL) between males and females diagnosed with eating disorders (EDs) from admission to discharge and at follow-up. This study also analyzed the association between changes in HRQOL and changes in the severity of ED pathology, depression, and trait anxiety.

METHODS

145 consecutive patients (34 males and 111 females) admitted to a residential ED unit completed a panel of surveys at admission and discharge. The survey panel included the Eating Disorders Quality of Life Survey (EDQLS), the Eating Disorder Examination Questionnaire, the Quick Inventory of Depressive Symptomatology and the State-Trait Anxiety Inventory. An online follow-up survey was also conducted for the EDQLS. Mixed-factorial ANOVA was used to examine sex differences and changes in HRQOL between admission, discharge and post-treatment follow-up. Multiple regression analysis was used to investigate the relationship between sex, change in HRQOL, and changes in all other variables studied.

RESULTS

By the end of residential treatment, both males and females had made similar statistically significant improvements in HRQOL from admission to discharge, which persisted after treatment. Greater decreases in ED pathology and trait anxiety significantly predicted greater increases in HRQOL during residential treatment while sex and changes in depression did not.

CONCLUSION

The data show that residential treatment is an effective approach to improving HRQOL in both males and females with EDs. Greater improvements in trait anxiety and ED pathology contributed to greater improvement in HRQOL in these patients.

Quantitative and Qualitative Analysis of the Quality of Life of Individuals With Eating Disorders

OBJECTIVE

To examine the quality of a broad range of life domains using both quantitative and qualitative methodologies.

METHOD

Forty-eight individuals seeking inpatient treatment for an eating disorder (mean age = 29.8 years, female = 100%, white = 96.4%) from 2007 to 2009 completed the Quality of Life Inventory (QOLI) and the Eating Disorder Examination Questionnaire; a medical chart review confirmed diagnosis and treatment history. Patients diagnosed with anorexia nervosa (n = 24) and bulimia nervosa (n = 24) were compared. Body mass index (kg/m(2)), treatment history, number of comorbid psychiatric conditions, and eating disorder severity were used to predict quality of life. Finally, an inductive content analysis was performed on qualitative QOLI responses to contextualize the quantitative findings.

RESULTS

Participants with anorexia nervosa, compared to those with bulimia nervosa, reported significantly less satisfaction with the domain of relatives (F 1,46 = 5.35; P = .025); no other significant group differences were found. The only significant predictor of QOLI global score was number of previous treatments (F 1,41 = 8.67; P = .005; R (2) = 0.175). Content analysis of qualitative data yielded complementary findings to the quantitative data; interesting group differences emerged for satisfaction with health with implications for measuring quality of life domains.

CONCLUSIONS

Across several life domains, individuals seeking treatment for anorexia nervosa and bulimia nervosa appear to have similar levels of satisfaction, as evidenced by numeric and descriptive responses. Satisfaction with relatives, however, appears to differ between groups and suggests a specific target for intervention among patients in treatment for anorexia nervosa (eg, a family-based intervention such as the Maudsley approach). The use of quantitative and qualitative assessments, such as the QOLI, provides more clinically meaningful, contextualized information about quality of life than traditional self-report assessments alone.

Bayesian prediction of treatment outcome in anorexia nervosa: a preliminary study

BACKGROUND

Knowledge of the prognostic factors predicting treatment outcome in anorexia nervosa (AN) measured with health-related quality of life (HRQoL) is limited.

AIMS

We performed a novel statistical analysis to identify factors predicting treatment outcome in AN.

METHODS

39 patients entering treatment of an ICD-10-defined AN completed the 15D HRQoL survey, the Eating Disorder Inventory (EDI) and a questionnaire evaluating self reported health status and eating habits before and 2 years after the start of treatment. The analysis was based on a Bayesian approach, which allows analyses of small data sets, and was performed using a naïve Bayes classifier.

RESULTS

An impaired follow-up HRQoL score was associated with three baseline risk factors: low self-reported vitality, high scores in eating control and a poor reported health status. Low baseline body mass index (BMI) and a high score in the eating dimension of the 15D predicted low follow-up BMI.

CONCLUSIONS

In our preliminary study, we identified a set of variables predicting poor HRQoL in AN. An effort to treat these symptoms effectively in the beginning of AN treatment may influence the outcome.

The bidirectional relationship between quality of life and eating disorder symptoms: a 9-year community-based study of Australian women

OBJECTIVE

Studies that have investigated quality of life (QoL) in eating disorders (EDs) have been focussed on the impact of the ED on QoL and little is known regarding the possible reciprocal impact of QoL on EDs. The aim of this study was to provide a first-time investigation of possible bidirectional relationships between EDs and both health-related QoL (HRQoL) and psychological distress (PD).

METHOD

Structural equation modeling was applied to longitudinal data collected from a community sample of Australian women (N = 828) surveyed at baseline, five annual follow-ups, and again after nine years. Participants reported height and weight (from which body mass index, BMI, was calculated) and completed measures of ED symptoms (Eating Disorder Examination Questionnaire), HRQoL (12-item Medical Outcomes Study Short Form), and PD (Kessler Psychological Distress Scale).

RESULTS

Overall, evidence was found for a bidirectional relationship, whereby ED symptoms predicted reduced HRQoL and greater PD over time, while lower levels of HRQoL and greater PD in turn predicted increased levels of ED symptoms. These relationships were stable, observable within 12 months, and remained observable over a time period of at least four years. However, also observed were some inconsistent findings where ED symptoms predicted a short term (one year) improvement in mental HRQoL. This short term boost was not sustained at longer follow-ups.

CONCLUSIONS

Not only do ED symptoms impact on HRQoL and PD, but perceived poor HRQoL and PD also contribute to ED symptom development or exacerbation. This supports a movement away from symptom-centric approaches whereby HRQoL is conceptualized as a passive outcome expected to be rectified by addressing ED symptoms. Improvement in QoL and PD might rather be viewed as targets to be pursued in their own right under broader approaches in the treatment of EDs.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Acceptance-based treatment and quality of life among patients with an eating disorder

This study assessed the relationship between acceptance-based constructs and quality of life (QOL) among patients with an eating disorder, as well as whether an acceptance-based treatment group could improve QOL. Patients (n = 105) at a residential treatment center received treatment as usual (TAU) or TAU plus twice-weekly acceptance and commitment therapy groups (TAU+ACT), and completed assessments at admission and discharge. Higher scores on several acceptance-related constructs at admission were associated with better psychological QOL, and pre- to post-treatment improvements in the ability to defuse from distressing internal experiences were associated with improved QOL. However, no differences in pre- to post-treatment changes in QOL were observed between treatment conditions. These results suggest that while some acceptance-related variables (e.g. defusion, impulse control, access to emotion regulation skills) may contribute to QOL, ACT does not appear to incrementally improve these variables or QOL beyond standard treatment programs. Additional research is needed to evaluate whether ACT may confer greater benefit for improving QOL in an outpatient setting where patients have more opportunity to utilize ACT skills, or when a stronger dose of treatment is administered.

Exploring health-related quality of life in eating disorders by a cross-sectional study and a comprehensive review

BACKGROUND

People with eating disorders (ED) often report poor health-related quality of life (HRQoL), which is explicitly correlated to illness' severity and its effects on cognitive performance. We aimed to analyze health-related quality of life (HRQoL) in subgroups of eating disorder (ED) patients by using the brief version of WHOQoL questionnaire (WHOQoL-BREF) before treatment administration. Moreover, in order to compare our findings with other published data, we carried out a comprehensive review of the literature on HRQoL in ED patients.

METHODS

Our review was carried out by means of an accurate data mining of PsychInfo and Medline databases and other available sources. In our cross-sectional study, eighty female ED patients (26 with bulimia nervosa, 33 with anorexia nervosa, 7 with binge eating disorder and 14 with ED not otherwise specified) completed the WHOQoL-BREF. HRQoL scores were compared among ED subgroups and clinical information (presence of previous contacts, length of illness, psychiatric comorbidity) was considered in the analysis.

RESULTS

Our review shows that with few exceptions ED patients have a poorer HRQoL than the healthy population of control and sometimes the mental component of HRQoL is the most involved dimension. Moreover, there are no differences in the HRQoL among ED groups, even if AN patients in some studies have a lower HRQoL scores. Furthermore, BED patients have a poorer HRQoL than obese patients who do not have binge episodes. Finally, all treatments were positively correlated with an improvement on general and specific QoL dimensions. In our sample, ED subgroups differed only for Psychological Health HRQoL scores (F = 4.072, df = 3; p = 0.01). No differences were found between inpatients and outpatients, treatment naïve and previously treated patients and patients with or without psychiatric comorbidity. Moreover, HRQoL scores were not correlated to length of illness within each ED subgroup.

CONCLUSIONS

The analysis of the literature adds some relevant information on HRQoL in ED and may address the future research toward the exploration of specific questions. One of these may be the prominent role of Psychological Health domain in HRQoL, since our study confirms that this component is able to differentiate eating disorders.

The meaning of (quality of) life in patients with eating disorders: a comparison of generic and disease-specific measures across diagnosis and outcome

OBJECTIVE

Compare general and disease-specific health-related quality of life (HRQoL) among female patients with an eating disorder (ED).

METHOD

Female patients (n = 221; 95.3% Caucasian; 94.0% never married) completed the Medical Outcome Short Form Health Survey (SF-36) and Eating Disorders Quality of Life (EDQoL) as part of a study of treatment outcomes. Multivariate regression models were used to compare HRQoL differences across initial ED diagnosis (85 AN-R, 19 AN-B/P, 27 BN, 90 EDNOS) and ED diagnostic classification at time of outcome assessment (140 no ED, 38 subthreshold ED, 43 full threshold ED).

RESULTS

There were no significant differences across ED diagnosis at initial assessment on either of the SF-36 Component Summary scores. However, patients with AN-B/P scored poorer on the work/school EDQoL subscales than other ED diagnoses, and on the psychological EDQoL subscale compared to AN-R and EDNOS. At outcome assessment, comparisons across full threshold, subthreshold and no ED classification indicated that those with no ED reported better HRQoL than those with full threshold ED on the SF-36 Mental Components Summary and three of four EDQoL subscales. Furthermore, those with no ED reported better psychological HRQoL than those with subthreshold ED.

DISCUSSION

Disease-specific HRQOL measures are important to use when comparing HRQoL in ED patients across treatment and outcome, and may have the sensitivity to detect meaningful differences by diagnosis more so than generic instruments. EDQoL scores from patients remitted from symptoms approach but do not reach scores for unaffected college females; thus, treatment should continue until quality of life is restored.

Pathological motivations for exercise and eating disorder specific health-related quality of life

OBJECTIVE

To examine associations among pathological motivations for exercise with eating disorder (ED) specific health-related quality of life (HRQOL).

METHOD

Survey data assessing ED severity (i.e., Eating Disorder Diagnostic Survey), ED specific HRQOL (i.e., Eating Disorders Quality of Life Instrument), and pathological motivations for exercise (i.e., Exercise Dependence Scale) were collected from female students (N = 387) at seven universities throughout the United States. Regression analyses were conducted to examine the associations among exercise dependence, ED-specific HRQOL and ED severity, and the interaction of exercise dependence and ED severity on HRQOL scores.

RESULTS

The overall model examining the impact of ED severity and exercise dependence (independent variables) on HRQOL (dependent variable) was significant and explained 16.1% of the variance in HRQOL scores. Additionally, the main effects for ED severity and exercise dependence and the interaction among ED severity and exercise dependence were significant, suggesting that the combined effects of ED severity and exercise dependence significantly impacts HRQOL.

DISCUSSION

Our results suggest that pathological motivations for exercise may exacerbate ED's detrimental impact on HRQOL. Our results offer one possible insight into why exercise may be associated with deleterious effects on ED HRQOL. Future research is needed to elucidate the relationship among psychological aspects of exercise, ED, and HRQOL.

Psychological well-being in out-patients with eating disorders: a controlled study

OBJECTIVE

Positive functioning is widely neglected in research on eating disorders (EDs). The aim of this exploratory study was to assess psychological well-being (PWB) in out-patients with ED and in controls.

METHOD

The authors assessed PWB in 245 out-patients with EDs [105 with bulimia nervosa (BN), 57 with anorexia nervosa (AN), and 83 with binge eating disorder (BED) who met DSM-IV-TR] and 60 controls. They tested whether PWB was associated with eating attitude test (EAT) scores and if such associations differed among ED groups while taking into account confounding variables.

RESULTS

Significant differences between groups in all PWB scales were found. While individuals with BN reported significantly lower scores in all PWB dimensions than healthy controls, patients with BED scored significantly lower than controls in PWB autonomy, environmental mastery, and self-acceptance scales. Patients with AN showed similar scores to controls in all PWB dimensions, except for positive relationships and self-acceptance. In all ED groups, most PWB dimensions resulted significantly and negatively associated with EAT scales, except for AN where oral control was found to positively correlate with a high sense of purpose in life. All results were maintained even after adjusting for possible confounding variables.

DISCUSSION

Patients with EDs reported an impairment in PWB. The paucity of PWB was not necessarily dependent on the presence of high levels of psychological distress and on the severity of the disorder. Such assessments may therefore yield a more comprehensive evaluation in this clinical population.