An integrative quantitative model of factors influencing the course of anorexia nervosa over time

A multi-modal assessment of fear conditioning in adolescent anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a pernicious psychiatric disorder which is principally characterized by a fear of weight gain. Notwithstanding the centrality of fear in the psychopathology of AN, controlled assessments of negative valence systems are lacking. Herein we assess fear conditioning in adolescent females with AN.

METHOD

Adolescent girls (Mage = 14.6 years, ±1.57) with DSM-5 diagnoses of AN (N = 25) and age-matched control girls (Mage = 14.8 years, ±1.46) with no DSM-5 diagnoses (N = 25) completed structured clinical interviews and participated in a classical three-phase Pavlovian fear conditioning paradigm. Participants with comorbid anxiety disorders were excluded. Skin conductance response (SCR) was measured, alongside self-reported fear, valence, and fear expectancy ratings.

RESULTS

Both groups demonstrated significant differential acquisition across all four measures. Regarding group comparisons, no differences emerged for self-reported fear, valence, and fear expectancy ratings during acquisition, although for SCR, those with AN demonstrated reduced physiological arousal relative to controls. Both groups demonstrated significant differential extinction for unconditioned stimuli (US) expectancy, self-report fear, and self-report valence. No statistically significant group differences were evident during extinction to the conditioned stimuli (CS)+, on any outcome measure. However, controls reported more positive valence to the CS- than those with AN.

CONCLUSIONS

Contrary to our hypotheses, our preliminary assessment did not find support for elevated fear responding among adolescent girls with AN with regards to fear acquisition or extinction. These data suggest that AN in adolescent girls may not be associated with a heightened propensity to acquire fear, but conversely, may suggest that exposure treatments for AN may be helpful, since extinction learning is intact in AN.

PUBLIC SIGNIFICANCE

AN is characterized by fear-related symptoms, including food and weight-related fear, and behavioral avoidance, yet controlled studies assessing fear learning are limited. Our preliminary assessment of adolescent AN indicates no abnormalities in fear learning among adolescents with AN. These findings may inform existing mechanistic models of AN psychopathology, and the development of exposure-based treatments for AN.

Self-perception and perceived parental perception in adolescent girls with anorexia nervosa

Negative self-perception is associated with poor outcomes in adults with anorexia nervosa (AN). Our study aimed to assess the association between the self-perception of female adolescents with AN and how these adolescents perceive the attitudes of their parents toward them on the severity and short-term outcome of their illness. For this purpose, we assessed 30 adolescent girls hospitalized with AN and 30 female controls. Self-perception and perceived parental attitudes were assessed using the Structural Analysis of Social Behavior (SASB), according to which self-perception is formed via close relations with significant others in early life. Patients with AN responded to the SASB and to questionnaires assessing eating disorder (ED) symptomatology and emotional distress at both admission and discharge. Controls were similarly assessed once. We found that patients with AN showed a more negative self-perception than controls. Negative self-perception was associated with negative perceptions of the mothers' attitudes toward the girls. There was no between-group difference in the perceived perception of the fathers' attitude to the girls. Self-perception and perceived parental attitudes were associated with the severity of ED symptoms and emotional distress. Finally, an improvement was found in self-perception and perceived maternal attitudes toward the girl from admission to discharge, alongside a decrease in the severity of ED symptoms and emotional distress. Self-perception at admission was associated with ED pathology and emotional distress at discharge. These findings suggest that self-perception and perceived parental attitudes toward the adolescent with AN may be associated with the severity of the illness and its short-term outcome.

Genetics of vegetarianism: A genome-wide association study

A substantial body of evidence points to the heritability of dietary preferences. While vegetarianism has been practiced for millennia in various societies, its practitioners remain a small minority of people worldwide, and the role of genetics in choosing a vegetarian diet is not well understood. Dietary choices involve an interplay between the physiologic effects of dietary items, their metabolism, and taste perception, all of which are strongly influenced by genetics. In this study, we used a genome-wide association study (GWAS) to identify loci associated with strict vegetarianism in UK Biobank participants. Comparing 5,324 strict vegetarians to 329,455 controls, we identified one SNP on chromosome 18 that is associated with vegetarianism at the genome-wide significant level (rs72884519, β = -0.11, P = 4.997 x 10-8), and an additional 201 suggestively significant variants. Four genes are associated with rs72884519: TMEM241, RIOK3, NPC1, and RMC1. Using the Functional Mapping and Annotation (FUMA) platform and the Multi-marker Analysis of GenoMic Annotation (MAGMA) tool, we identified 34 genes with a possible role in vegetarianism, 3 of which are GWAS-significant based on gene-level analysis: RIOK3, RMC1, and NPC1. Several of the genes associated with vegetarianism, including TMEM241, NPC1, and RMC1, have important functions in lipid metabolism and brain function, raising the possibility that differences in lipid metabolism and their effects on the brain may underlie the ability to subsist on a vegetarian diet. These results support a role for genetics in choosing a vegetarian diet and open the door to future studies aimed at further elucidating the physiologic pathways involved in vegetarianism.

Rapid refeeding does not worsen anxiety in adolescents with anorexia nervosa: a pilot study

The study aimed to describe the progression of state anxiety in adolescents with anorexia nervosa (AN) hospitalized on a high calorie refeeding (HCR) protocol. Participants, 12-21 years, admitted for malnutrition due to AN were placed on a HCR protocol in which calories were advanced by 300 kcal/day. The State-Trait Anxiety Inventory for Children (STAIC) was given to participants within 24 hours of hospitalization and the state anxiety component of the STAIC was administered daily immediately before and after breakfast until discharge. Of 22 patients enrolled, 86% were female, mean age was 14.9 ± 2.0 years, and 95% had AN-restrictive type. The median state and trait anxiety scores at time of admission were 37.0 (28-55) and 35.5 (23-51), respectively. There was no significant difference in median pre-meal state anxiety from hospital day 1 to 6 (34.0(26-55) vs. 38.5(25-55), p-value = 0.079) or in median post-meal state anxiety from hospital day 1 to 6 (35.5(29-56) vs. 37(24-56), p-value = 0.484). Similarly, we found minimal correlation between change in caloric intake and change in pre-meal S-anxiety (Spearman correlation coefficient = -0.032) or post-meal S-anxiety (Spearman correlation = 0.032). While this was a small sample observing anxiety over one week, we found no evidence that state anxiety increased with advancing calories, providing additional support for the use of more rapid refeeding protocols.

Social attention in anorexia nervosa and autism spectrum disorder: Role of social motivation

LAY ABSTRACT

Research suggests a relationship between autism and anorexia nervosa. For example, rigid and inflexible behaviour, a preference for routine and social difficulties are seen in both conditions. In this study, we examined whether people with anorexia and people with autism show similarities in social attention (where they look while engaging in social interactions or watching a scene with people interacting). This could help us understand why people with anorexia and autism experience difficulties in social situations. Participants with either anorexia or autism, as well as participants with no mental health problems watched a video of a social scene while we recorded which parts of the scene they looked at with an eye-tracker. Participants also completed questionnaires to assess characteristics of autism. We found that autistic participants looked at faces less than typically developing participants. However, participants with anorexia did not show a similar reduction in attention to faces, contrary to our predictions. Autistic features were not related to attention in either group. The results suggest that autistic people may miss important social cues (like facial expressions), potentially contributing to social difficulties. However, this mechanism does not appear explain social difficulties in people with anorexia.

Disordered eating and the meat-avoidance spectrum: a systematic review and clinical implications

PURPOSE

Meat avoidance has long been thought to be related to eating psychopathology; however, research does not necessarily support this notion. Furthermore, commonly used eating disorder scales may be picking up on normal meat-avoiding behaviours in vegetarians and vegans. As such, we systematically reviewed the association between vegetarianism, veganism, and disordered eating, and reviewed the psychometric properties of eating disorder scales for use in these populations.

METHODS

We searched electronic databases MEDLINE, PsychINFO, and CINAHL for literature published until June 2021.

RESULTS

Forty-eight studies met eligibility criteria, with no consensus as to whether meat avoidance was associated with higher rates of disordered eating. Most studies reported a significant positive association with both vegetarianism and veganism, and orthorexia nervosa. Six studies provided evidence for the use of eating disorder measures in vegetarians and vegans, reporting poor psychometric fit among all scales.

CONCLUSION

This systematic review highlights the extent to which vegetarians and vegans have been highly understudied, with limited research suggesting higher levels of orthorexia nervosa behaviours in vegetarians and vegans. Furthermore, our results provide tentative evidence that the factorial validity of commonly used eating disorder scales, such as the EDE-Q, may be poor in vegans.

LEVEL OF EVIDENCE

Level I, systematic review.

Family-based treatment for adolescents with anorexia nervosa: A long-term psychological follow-up

AIM

Family-based treatment (FBT) has the greatest evidence base for the treatment of adolescents with anorexia nervosa (AN). However, little is known about the long-term outcomes for patients who receive FBT. The current study aimed to investigate the long-term psychological health of former patients who received FBT for AN during adolescence.

METHODS

Former patients diagnosed and treated for AN at the Royal Children's Hospital and Monash Children's Hospital (N = 36) in Melbourne, Australia completed self-report questionnaires to assess eating, exercising, mood and the impact of the coronavirus (COVID-19) pandemic. Patient scores were compared to healthy controls (N = 29) and normative data.

RESULTS

The eating and exercising behaviours of the patients who formerly had AN were comparable to controls. However, the former patients experience significantly greater levels of depression, anxiety, and stress than the controls (P < 0.05). The COVID-19 pandemic appeared to impact the former patients and controls to a similar extent across quantifiable criteria.

CONCLUSIONS

This study extends previous research highlighting FBT as an effective intervention for adolescents with AN. Positive short- and long-term patient outcomes can be achieved with this form of treatment.

Further support for the validity of the social appearance anxiety scale (SAAS) in a variety of German-speaking samples

PURPOSE

Eating disorders (ED) and social anxiety disorder are highly comorbid with potentially shared symptoms like social appearance anxiety (SAA) referring to a fear of being negatively evaluated by others' because of overall appearance. SAA constitutes a risk factor for eating psychopathology and bridges between EDs and social anxiety disorder.

METHODS

The present studies examined internal consistency, factor structure, test-retest reliability, gender and age invariance, convergent validity and differences between individuals with and without an ED of a German version of the social appearance anxiety scale (SAAS) in four independent samples (n₁ = 473; n₂ = 712; n₃ = 79; n₄ = 33) including adolescents and patients with EDs.

RESULTS

Consistently, the SAAS showed excellent internal consistency (ωs ≥ 0.947) and a one-factorial structure. Convergent validity was shown via high correlations of the SAAS with social anxiety (e.g., social interaction anxiety r = 0.642; fear of negative evaluation rs ≥ 0.694), body image disturbance measures (e.g., shape concerns rs ≥ 0.654; weight concerns rs ≥ 0.607; body avoidance rs ≥ 0.612; body checking rs ≥ 0.651) and self-esteem (r = -0.557) as well as moderate correlations with general eating psychopathology (e.g., restrained rs ≥ 0.372; emotional r = 0.439; external eating r = 0.149). Additionally, the SAAS showed gender and age invariance and test-retest reliability after 4 weeks with r = 0.905 in Study 2 and was able to discriminate between individuals with and without an ED in Study 4.

CONCLUSION

Hence, the German version of the SAAS can reliably and validly assess SAA in female and male adolescents or adults with or without an ED. Additionally, the SAAS might be used in a therapeutic context to especially target patient groups suffering from EDs with comorbid social anxiety.

LEVEL OF EVIDENCE

Level III: Evidence obtained from cohort or case-control analytic studies.

Sleep Quality and Eating Disorder-Related Psychopathologies in Patients with Night Eating Syndrome and Binge Eating Disorders

Night eating syndrome (NES) is an eating disorder (ED) characterized by nocturnal ingestion (NI), evening hyperphagia, morning anorexia, as well as mood and sleep disturbances. This study compared subjective and objective sleep quality and ED-related psychopathologies in patients seeking treatment for ED. Method: The sample was composed of 170 women, aged 18–68, who were referred for an ED assessment from 2011 to 2020. The participants were divided into three subgroups: NES-NI only (n = 30), NES+ binge eating (BE) (including binge eating disorders or bulimia nervosa (n = 52), and BE-only (n = 88). The measures consisted of a psychiatric evaluation, objective sleep monitoring measured by an actigraph for 1 week, a subjective sleep self-report, and ED-related psychopathology questionnaires. Results: Objective sleep monitoring revealed significant group differences, with higher sleep efficiency in participants with BE-only and longer sleep durations for the NES-NI only group. Subjectively, the BE-only group described a significantly lower sleep quality than either the NES-NI only or the NES+BE groups. ED-related psychopathology was lower in the NES-NI-only group. A stepwise linear regression revealed that general psychopathology (the brief symptom inventory total score) was a significant predictor of subjective sleep quality. Conclusion: NES-NI-only was correlated with less psychopathology, but with more subjective and objective sleep disturbances. These results lend weight to the supposition that NES lies on a continuum of ED psychopathologies, and that NES-NI-only appears to be a separate entity from NES+BE and BE-only in terms of its psychopathology.

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

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

Differences in severity of eating disorder symptoms between adults with depression and adults with anxiety

OBJECTIVES

Anxiety and depression are both considered maintaining factors for eating disorders (ED) but it is still unclear if one is more strongly associated with ED symptoms than the other. We examined differences in severity of ED symptoms among adults with either, both, or neither depression and anxiety.

METHODS

Volunteers (N = 3,780) to the project implicit mental health website ( https://implicit.harvard.edu/ ) self-reported their ED status (current ED: n = 374, past ED: n = 436; no ED: n = 2,970), their current depression/anxiety status, and their ED symptoms (using the Eating Attitudes Test). ANOVAs with post hoc comparisons were used to examine relationships between ED symptoms and comorbid depression/anxiety status among currently ill, recovered, and never ill individuals.

RESULTS

Participants without comorbidities had the least and participants with both comorbidities had the most severe ED symptoms (p = .021). Participants with anxiety alone had more severe ED symptoms relative to those with depression alone across groups (current ED: p = .024; past ED: p = .019; no EDs: p = .021).

DISCUSSION

These findings demonstrate, in contrast with an earlier study among youth with EDs (Hughes et al., 2013), that comorbid anxiety may be linked with more severe ED symptoms relative to comorbid depression. It is possible that anxiety serves as a maintaining factor for ED symptoms such that dieting and other ED-related behaviors may function to modulate symptoms of anxiety.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Vegetarianism and veganism compared with mental health and cognitive outcomes: a systematic review and meta-analysis

CONTEXT

Vegetarian and vegan diets are increasing in popularity. Although they provide beneficial health effects, they may also lead to nutritional deficiencies. Cognitive impairment and mental health disorders have a high economic burden.

OBJECTIVE

A meta-analysis was conducted to examine the relationship between vegan or vegetarian diets and cognitive and mental health.

DATA SOURCES

PubMed, Scopus, ScienceDirect, and Proquest databases were examined from inception to July 2018.

STUDY SELECTION

Original observational or interventional human studies of vegan/vegetarian diets were selected independently by 2 authors.

DATA EXTRACTION

Raw means and standard deviations were used as continuous outcomes, while numbers of events were used as categorical outcomes.

RESULTS

Of 1249 publications identified, 13 were included, with 17 809 individuals in total. No significant association was found between diet and the continuous depression score, stress, well-being, or cognitive impairment. Vegans/vegetarians were at increased risk for depression (odds ratio = 2.142; 95%CI, 1.105-4.148) and had lower anxiety scores (mean difference = -0.847; 95%CI, -1.677 to -0.018). Heterogeneity was large, and thus subgroup analyses showed numerous differences.

CONCLUSIONS

Vegan or vegetarian diets were related to a higher risk of depression and lower anxiety scores, but no differences for other outcomes were found. Subgroup analyses of anxiety showed a higher risk of anxiety, mainly in participants under 26 years of age and in studies with a higher quality. More studies with better overall quality are needed to make clear positive or negative associations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42018097204.

Post-hospitalization Daycare Treatment for Adolescents With Eating Disorders

Background: There are several possible facilities for the treatment of eating disorders (EDs). Specifically, there is the issue of the use of specialized daycare and ambulatory services over inpatient settings and the place of daycare programs following inpatient treatment. Aim: We sought to examine the contribution of post-hospitalization daycare program to the treatment of adolescents hospitalized with an ED. Methods: We assessed 61 female adolescents hospitalized with an ED. All but three were diagnosed with clinical or subthreshold anorexia nervosa (AN). Three were diagnosed with bulimia nervosa. Thirty-seven patients continued with a post-hospitalization daycare program for at least 5 months, whereas 24 did not enter or were enrolled in the program for <5 months. Patients completed on admission to, and discharge from, inpatient treatment self-rating questionnaires assessing ED-related symptoms, body-related attitudes and behaviors, and depression and anxiety. Social functioning was assessed 1 year from discharge using open-ended questions. One-year ED outcome was evaluated according to the patients' body mass index (BMI) and according to composite remission criteria, assessed with a standardized semistructured interview. To be remitted from an ED, patients were required to maintain a stable weight, to have regular menstrual cycles, and not to engage in binging, purging, and restricting behaviors for at least eight consecutive weeks before their assessment. Results: BMI was within normal range at follow-up, whether completing or not completing daycare treatment, and around 75% of the patients had menstrual cycles. By contrast, when using comprehensive composite remission criteria, less than a quarter of former inpatients not entering/not completing daycare program achieved remission vs. almost a half of the completers. In addition, a greater percentage of completers continued with psychotherapy following discharge. Fifty percent of both groups showed good post-discharge social functioning. No between-group differences were found in the BMI and the scores of the self-rating questionnaires at admission to, and discharge from, inpatient treatment. Conclusion: Adolescent females with EDs can maintain a normal-range BMI from discharge to 1-year follow-up, even if not completing daycare treatment. By contrast, completion of a post-hospitalization daycare program may improve the 1-year follow-up ED-related outcome of former ED inpatients.

Vegetarian Diets and Eating Disorders in Adolescents and Young Adults: A Systematic Review

BACKGROUND

Eating disorders are more common among adolescents and young adults. An increase in the rates of these disorders has been reported during the last years. Meanwhile, vegetarianism is becoming more popular in these age groups. The purpose of the present paper is to evaluate the association between eating disorders and vegetarian diets in adolescents and young adults.

METHODS

Systematic review of related articles published in PubMed, PsycInfo and Google Scholar up to 30 May 2019.

RESULTS

A total of 20 studies (14,391 subjects) were deemed eligible for this systematic review. The majority of the studies reported significant correlations between vegetarianism and eating disorders. However, due to the cross-sectional design, a causal link between eating disorders and vegetarian status cannot be established.

CONCLUSIONS

Vegetarianism seems to be associated with eating disorders. Longitudinal studies are needed to establish temporal patterns between vegetarianism and the emergence of disordered eating.

Childhood maltreatment in patients with binge eating disorder with and without night eating syndrome vs. control

This study compared women with binge eating disorders or bulimia nervosa with and without night eating syndrome regarding childhood maltreatment and psychopathology relative to healthy controls. The 426 participants (aged 18-60) were divided into two groups: eating disorders (n = 158) and healthy controls (n = 268). Eating disorders was divided into bulimia nervosa, binge eating disorder, and night eating syndrome with binge eating. Participants completed questionnaires: childhood trauma, eating disorders, self-esteem, and psychopathology. No significant differences were found for most variables in the eating disorders subgroups except physical neglect, which was more prevalent in night eating syndrome with binge eating. All variables differed significantly between eating disorders and healthy controls. Significant correlations emerged between childhood maltreatment, psychopathology, emotional abuse, and self-esteem in eating disorders. Regression showed that emotional abuse significantly predicted self-esteem in eating disorders, and group significantly moderated the effect of emotional abuse on psychopathology. Results emphasize that in this specific sample and variables, night eating syndrome with binge eating may be a variant of binge eating disorder or bulimia nervosa and not a separate diagnostic entity. The results highlight the importance of early assessment of childhood maltreatment, particularly emotional abuse, in patients with night eating syndrome.

Comorbid depression as a negative predictor of weight gain during treatment of anorexia nervosa: A systematic scoping review

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness with high rates of relapse and mortality. Psychiatric comorbidities are common but their impact on the prognosis is largely unknown.

OBJECTIVE

The aim was to investigate the influence of psychiatric comorbidity on weight gain during treatment of AN.

METHODS

A systematic search was performed in PubMed/MEDLINE, EMBASE and PsycINFO. Studies evaluating psychiatric comorbidity as a predictor for treatment outcome (weight gain) were included, however, comorbid alcohol/drug addiction was excluded from this review.

RESULTS

Four thousand five hundred and twenty six publications were identified from which 15 were included. The majority of the included studies had a prospective open naturalistic study design, a short-term follow-up period, and were based on small populations of primarily adolescent and adult women. Four studies indicate depression, and two obsessiveness as negative prognostic factors, whilst one study indicated moderate depression and yet another, neuroticism, as positive predictors for weight gain.

DISCUSSION

The systematic scoping review found a large number of publications whereof only a few directly described the influence of psychiatric comorbidity on weight gain in AN. Overall, studies were heterogeneous in design, purpose and outcome making comparisons difficult. Findings were divergent but depression had a negative influence on weight gain in four studies.

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

RATIONALE

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Implicit Association of High-Fat Food and Shame Among Women Recovered From Eating Disorders

BACKGROUND

Despite the growing literature about recovery from eating disorders (EDs), it is still unknown if women who report being recovered from EDs present with differing implicit attitudes about high-fat (vs. low-fat) food relative to women who report having a current ED and women who report never having had an ED.

METHODS

Female volunteers (N = 2,785) to the Project Implicit Mental Health (PIMH) website (https://implicit.harvard.edu/) were divided into three ED groups: current ED (n = 335), prior ED (n = 393), and healthy controls (n = 1,843). Participants completed, between 2016 and 2017, a background questionnaire, together with the Implicit Association Test (IAT), measuring implicit associations between high-fat (vs. low-fat) food and shame (vs. acceptableness). Linear regression models were conducted to examine cross-sectional differences between groups.

RESULTS

Women with prior EDs had stronger implicit associations relative to healthy controls (p = 0.041) and similar implicit associations relative to women with current EDs (p = 0.424).

DISCUSSION

The implicit association between high-fat food and shame may not diminish over time among women with EDs. Future longitudinal studies are warranted to clarify whether an experience of EDs may leave a "scar," manifested in specific implicit associations, that may potentially lead to recurrence after remission.

Selflessness as a predictor of remission from an eating disorder: 1-4 year outcomes from an adolescent day-care unit

OBJECTIVE

To assess the potential role of selflessness in predicting remission from an eating disorder (ED) following discharge from an adolescent day-care unit.

METHOD

Participants were 95 female patients (aged 13-19 years) with an ED diagnosis across the spectrum admitted to an adolescent day-care unit for EDs between 2008 and 2012. Forty-one of these participants completed the follow-up assessment, between 12 and 46 months following discharge. No significant differences were found in Time 1 variables between patients who participated in Time 2 and those who did not. At both time points, ED and psychiatric comorbidity diagnoses were made using standard structured interviews. Patients were also administered the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), The Eating Attitude Test (EAT-26), The Eating Disorder Inventory (EDI-2) and the Selflessness Scale (SS)*.

RESULTS

Only baseline Selflessness Scale was significant in predicting the continuous variable of ED symptomatology level in follow-up. When dividing EDI total score into its subscales at baseline, one of those, maturity fears, was found, together with the SS, significant in the prediction. In predicting remission (this time as a dichotomized variable) in follow-up, only the SS, maturity fears, EDI total, and EAT-26, at baseline, predicted remission at follow-up, but the strength of selflessness was the greatest.

CONCLUSIONS

Psychological features are not the main target of the important search for predictors of remission from ED. The findings of the present study add the psychological feature of selflessness to this search. Psychotherapy can be enriched by identifying psychological features such as selflessness as one of its foci. The present findings might also renew interest in maturity fears as an additional focus in psychotherapy.

LEVEL OF EVIDENCE

Level III, cohort study.

Residual eating disorder symptoms and clinical features in remitted and recovered eating disorder patients: A systematic review with meta-analysis

OBJECTIVE

In psychiatry, the presence of residual symptoms after treatment is linked to the definitions of remission and recovery. To identify the presence of residual eating disorder (ED) symptoms and associated non-ED clinical features in remitted and recovered EDs, the current systematic review with meta-analysis was performed.

METHOD

A systematic review was conducted on residual ED symptoms and non-ED clinical features including comorbid psychopathology, neurophysiological functioning, cognitive functioning, and quality of life in ED patients considered remitted or recovered. To examine residual ED symptoms, meta-analyses were performed while considering age, study quality, remission, and recovery criteria strictness as moderators. Sensitivity, publication bias, and heterogeneity analyses were also conducted.

RESULTS

The 64 studies selected for the systematic review underscored the presence of residual ED symptoms in anorexia nervosa (AN) and bulimia nervosa (BN), and impairments and deficits in the additional features examined. From the 64 studies, 31 were selected regarding residual ED symptoms in AN for meta-analysis. Large effect sizes indicated that remitted/recovered AN patients reported significantly lower body mass index (Hedges' g = -0.62[-0.77, -0.46]) and significantly greater symptomatology in terms of ED examination-questionnaire (Hedges'g = 0.86 [0.48,1.23]) and ED inventory (Hedges' g = 0.94[0.64,1.24]) than healthy controls, independently of remission and recovery criteria strictness, age, and study quality.

DISCUSSION

The presence of residual ED symptoms in AN is quantitatively supported, whereas the presence of residual ED symptoms in BN should be further investigated. Data on binge-eating disorder are missing. Future research should use consistent, multicomponent, and standardized comparable indicators of recovery.

A systematic review of studies probing longitudinal associations between anxiety and anorexia nervosa

The current study aimed to establish whether anxiety predicts subsequent anorexia nervosa onset and maintenance. A systematic review of longitudinal studies assessing the association between stable anxiety exposures (e.g. trait anxiety/anxiety disorder pathology) and anorexia nervosa development or maintenance was undertaken. Eight studies met inclusion criteria. Seven probed the association between anxiety and anorexia nervosa onset, and one assessed the association between anxiety and anorexia nervosa maintenance. Individuals with anorexia nervosa were more likely to report childhood anxiety compared to healthy individuals, but whether childhood anxiety explains unique variance in anorexia nervosa development is unclear. Current evidence does not support longitudinal associations between specific anxiety disorders (independently of other anxiety disorders) and subsequent anorexia nervosa onset, however anxiety disorder diagnosis in general may predict increased anorexia nervosa risk. The single study probing the association between anxiety and anorexia nervosa maintenance did not find evidence supporting a relationship. The quality of individual studies was fair to high, however the body of evidence was of low quality. Further research that minimises bias, allowing for strong conclusions concerning longitudinal associations between anxiety and subsequent anorexia nervosa outcomes, is required to inform anorexia nervosa aetiology. This in turn may promote improved prevention and treatment.

Beyond the Activity-Based Anorexia Model: Reinforcing Values of Exercise and Feeding Examined in Stressed Adolescent Male and Female Mice

Anorexia nervosa (AN), mostly observed in female adolescents, is the most fatal mental illness. Its core is a motivational imbalance between exercise and feeding in favor of the former. The most privileged animal model of AN is the "activity-based anorexia" (ABA) model wherein partly starved rodents housed with running wheels exercise at the expense of feeding. However, the ABA model bears face and construct validity limits, including its inability to specifically assess running motivation and feeding motivation. As infant/adolescent trauma is a precipitating factor in AN, this study first analyzed post-weaning isolation rearing (PWIR) impacts on body weights and wheel-running performances in female mice exposed to an ABA protocol. Next, we studied through operant conditioning protocols i) whether food restriction affects in a sex-dependent manner running motivation before ii) investigating how PWIR and sex affect running and feeding drives under ad libitum fed conditions and food restriction. Besides amplifying ABA-elicited body weight reductions, PWIR stimulated wheel-running activities in anticipation of feeding in female mice, suggesting increased running motivation. To confirm this hypothesis, we used a cued-reward motivated instrumental task wherein wheel-running was conditioned by prior nose poke responses. It was first observed that food restriction increased running motivation in male, but not female, mice. When fed grouped and PWIR mice were tested for their running and palatable feeding drives, all mice, excepted PWIR males, displayed increased nose poke responses for running over feeding. This was true when rewards were proposed alone or within a concurrent test. The increased preference for running over feeding in fed females did not extend to running performances (time, distance) during each rewarded sequence, confirming that motivation for, and performance during, running are independent entities. With food restriction, mice displayed a sex-independent increase in their preference for feeding over running in both group-housed and PWIR conditions. This study shows that the ABA model does not specifically capture running and feeding drives, i.e. components known to be affected in AN.

The complexity of the interaction between binge-eating and attention

OBJECTIVE

To investigate whether binge-eating in patients with eating disorders (EDs) is associated with attentional deficits.

METHODS

We studied ED patients with binge-eating (n = 51), no binge-eating (n = 59) and controls (n = 58). ED patients were assessed following the stabilization of weight and ED pathology. Attention assessment included evaluation of attention deficit hyperactivity disorder (ADHD) diagnosis, the Adult ADHD Self-Report (ASRS) and ADHD Rating Scale-IV-Home Version (ADHD-RS) questionnaires, and attention functioning assessed with neuropsychological tools. The severity of eating-related pathology, depression, anxiety and obsessionality was also monitored.

RESULTS

Patients with binge-eating showed more ADHD symptomatology on the ADHD-RS compared with non-binge-eating patients. No differences were found between binge-eating and non-binge-eating patients in ADHD diagnosis and neuropsychological functioning. Among the specific ED subtypes, patients with anorexia nervosa binge/purge type (AN-B/P) showed the highest rates of ADHD symptomatology on the ADHD-RS, and were characterized with sustained attention deficits.

CONCLUSION

Binge-eating is not associated with attention deficits as measured by objective neuropsychological tools. Nonetheless, it is associated with attentional difficulties as measured with the self-reported ADHD-RS. AN-B/P patients are the only ED category showing objective sustained attention deficits.

Depressive Symptoms and Vegetarian Diets: Results from the Constances Cohort

The association between depressive symptoms and vegetarian diets is controversial. This study examines the cross-sectional association between depressive symptoms and vegetarian diets while controlling for potential confounders. Among 90,380 subjects from the population-based Constances cohort, depressive symptoms were defined by a score ≥19 on the Centre of Epidemiologic Studies-Depression (CES-D) scale and diet types (omnivorous, pesco-vegetarian, lacto-ovo-vegetarian and vegan) were determined with a food frequency questionnaire. Associations between depressive symptoms and diet were estimated through logistic regressions adjusting for socio-demographics, other foods, alcohol and tobacco consumption, physical activity and health-related concerns; specificity analyses considered the exclusion of any other food group. Depressive symptoms were associated with pesco-vegetarian and lacto-ovo-vegetarian diets in multivariable analyses (Odds-Ratio [95% confidence interval]: 1.43 [1.19–1.72] and 1.36 [1.09–1.70], respectively), especially in case of low legumes intake (p for interaction < 0.0001), as well as with the exclusion of any food group (e.g., 1.37 [1.24–1.52], 1.40 [1.31–1.50], 1.71 [1.49–1.97] for meat, fish and vegetables exclusion, respectively). Regardless of food type, the Odds-Ratio of depressive symptoms gradually increased with the number of excluded food groups (p for trend < 0.0001). Depressive symptoms are associated with the exclusion of any food group from the diet, including but not restricted to animal products.

Examining a momentary mediation model of appearance-related stress, anxiety, and eating disorder behaviors in adult anorexia nervosa

PURPOSE

Appearance-related stress may result from appearance-focused events such as seeing one's reflection, seeing media images, and shopping for clothes. The purpose of this study was to examine the prospective association between momentary appearance-related stress and eating disorder (ED) behaviors (i.e., binge eating and vomiting) among women with anorexia nervosa (AN) using ecological momentary assessment (EMA). We hypothesized that appearance-related stress at Time 1 would predict binge eating and vomiting at Time 2, and that this prospective association would be mediated by momentary anxiety at Time 2 (controlling for anxiety at Time 1).

METHODS

Women with AN completed a 2-week EMA protocol involving repeated daily assessments of experiences and behaviors.

RESULTS

Momentary appearance-related stress preceded binge eating and vomiting, and momentary anxiety mediated the prospective association between appearance-related stress and ED behaviors.

CONCLUSIONS

Targeted momentary interventions delivered in the natural environment that address appearance-related stress may have utility in the treatment of ED behaviors.

Two sides of the same coin? A new instrument to assess body checking and avoidance behaviors in eating disorders

Body checking (BC) and avoidance behaviors (BA) are the dominant behavioral features of body image disturbances (BID) that characterize most individuals with eating disorders (EDs). Whereas BC can be reliably assessed, a valid assessment tool for BA is lacking, preventing an adequate assessment of BID differences across different EDs (anorexia nervosa, AN; bulimia nervosa, BN; binge eating disorder, BED). A total of 310 women with EDs and 112 nonclinical controls completed measures of BC-, BA- and ED-related symptoms. BA did not differentiate between EDs, whereas BC did: it was highest in AN and BN, and lowest in BED. Multivariate analyses also discriminated AN from BN based on BC. Given that results are of preliminary nature, evidence is promising that EDs can be discriminated from healthy controls and that differential BID profiles for the behavioral component among ED subgroups exist. However, replication of the factor structure remains open within ED subsamples.

The effects of intranasal oxytocin on smoothie intake, cortisol and attentional bias in anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by severe malnutrition as well as intense fear and anxiety around food and eating with associated anomalies in information processing. Previous studies have found that the neuropeptide, oxytocin, can influence eating behaviour, lower the neurobiological stress response and anxiety among clinical populations, and alter attentional processing of food and eating related images in AN.

METHODOLOGY

Thirty adult women with AN and twenty-nine healthy comparison (HC) women took part in the current study. The study used double blind, placebo controlled, crossover design to investigate the effects of a single dose of intranasal oxytocin (40 IU) on a standard laboratory smoothie challenge, and on salivary cortisol, anxiety, and attentional bias towards food images before and after the smoothie challenge in AN and HC participants. Attentional bias was assessed using a visual probe task.

RESULTS

Relative to placebo intranasal oxytocin reduced salivary cortisol and altered anomalies in attentional bias towards food images in the AN group only. The oxytocin-induced reduction in attentional avoidance of food images correlated with oxytocin induced reduction in salivary cortisol in the AN group before the smoothie challenge. Intranasal oxytocin did not significantly alter subjective feelings of anxiety or intake during the smoothie challenge in the AN or HC groups.

CONCLUSIONS

Intranasal oxytocin may moderate the automated information processing biases in AN and reduce neurobiological stress. Further investigation of the effects of repeated administration of oxytocin on these processes as well as on eating behaviour and subjective anxiety would be of interest.

Predictors of short-term outcome variables in hospitalised female adolescents with eating disorders

OBJECTIVE

Research in eating disorders (EDs) suggests that outcome variables other than that of the ED per se, such as the presence of comorbid disorders and overall functioning at follow-up, may influence the ED condition at that time. We sought to assess the factors potentially predicting these different outcome variables.

METHODS

Eighty-eight female adolescent in-patients with an ED were assessed on admission, discharge, and around one-year post-discharge using clinical interviews and self-rating questionnaires assessing ED and other relevant symptoms.

RESULTS

The mean body mass index (BMI) of patients with anorexia nervosa increased from admission to discharge and was maintained at follow-up. Twenty-eight patients were remitted at follow-up, whereas 48 and 12 patients had intermediate and poor ED-related outcome, respectively. Follow-up BMI was correlated with baseline BMI. Good ED-related outcome at follow-up according to accepted criteria was associated with more lifetime suicide attempts and more severe baseline ED symptomatology. Elevated psychiatric comorbidity at follow-up was associated with elevated baseline anxiety and with re-hospitalisation during the post-discharge follow-up period. Better academic/occupational functioning and social functioning at follow-up were associated with less lifetime suicide attempts, less re-hospitalisation and lower baseline anxiety.

CONCLUSIONS

In EDs, diverse factors may predict different outcome variables.

Computerized assessment of body image in anorexia nervosa and bulimia nervosa: comparison with standardized body image assessment tool

Body image disturbances are a prominent feature of eating disorders (EDs). Our aim was to test and evaluate a computerized assessment of body image (CABI), to compare the body image disturbances in different ED types, and to assess the factors affecting body image. The body image of 22 individuals undergoing inpatient treatment with restricting anorexia nervosa (AN-R), 22 with binge/purge AN (AN-B/P), 20 with bulimia nervosa (BN), and 41 healthy controls was assessed using the Contour Drawing Rating Scale (CDRS), the CABI, which simulated the participants' self-image in different levels of weight changes, and the Eating Disorder Inventory-2-Body Dissatisfaction (EDI-2-BD) scale. Severity of depression and anxiety was also assessed. Significant differences were found among the three scales assessing body image, although most of their dimensions differentiated between patients with EDs and controls. Our findings support the use of the CABI in the comparison of body image disturbances in patients with EDs vs.

CONTROLS

Moreover, the use of different assessment tools allows for a better understanding of the differences in body image disturbances in different ED types.

Behavioral and psychological aspects of exercise across stages of eating disorder recovery

This study examined the relationship between behavioral and psychological aspects of exercise and eating disorder recovery. Participants were categorized as having an eating disorder (n = 53), partially recovered (n = 15), fully recovered (n = 20), or non-eating disorder controls (n = 67). Groups did not differ significantly in time spent exercising, but did differ in exercise intensity, guilt-related exercise, obsessive exercise cognitions, and appearance/weight management and stress/mood management motivations for exercise. Results support the importance of measuring psychological aspects of exercise in particular across the course of an eating disorder.

Extinction theory & anorexia nervosa: Deepening therapeutic mechanisms

By virtue of adopting the core symptomatic fear (i.e., a fear of weight gain) as a primary treatment target, the treatment of AN centrally involves exposure-driven processes. However, exposure trials targeting the fear of weight gain in AN have been sparse, yielding mixed results to date. In translating extinction theory to the treatment of AN, it is likely that the absence of a clear distinction between what constitutes the core feared cue and the core feared outcome has stymied the application of exposure treatments in AN. This review considers several configurations of the core fear association in AN, noting distinct therapeutic strategies which may allow for more precise efforts in violating fear-based expectancies. Specific guidance is offered in the clinical decision making process as to which strategies might best promote inhibitory learning, and a clinical case is discussed, in which treatment was adjusted to specifically violate the core underlying fear association.

Sensory modulation disorder symptoms in anorexia nervosa and bulimia nervosa: A pilot study

OBJECTIVE

Individuals with anorexia nervosa (AN) and bulimia nervosa (BN) may exhibit reduced ability to modulate sensory, physiological, and affective responses. The aim of the present study is to assess sensory modulation disorder (SMD) symptoms in patients with AN and BN.

METHOD

We assessed female adolescent and young adult inpatients with restrictive type anorexia nervosa (AN-R; n = 20) and BN (n = 20) evaluated in the acute stage of their illness, and 27 female controls. Another group of 20 inpatients with AN-R was assessed on admission and discharge, upon achieving their required weight. Participants completed standardized questionnaires assessing the severity of their eating disorder (ED) and the sensory responsiveness questionnaire (SRQ).

RESULTS

Inpatients with AN-R demonstrated elevated overall sensory over-responsiveness as well as elevated scores on the taste/gustatory, vestibular/kinesthetic and somatosensory/tactile SRQ modalities compared with patients with BN and controls. Significant correlations between the severity of sensory over-responsiveness and ED-related symptomatology were found in acutely-ill patients with AN-R and to a lesser extent, following weight restoration. Elevated sensory over-responsiveness was retained in weight-restored inpatients with AN-R. Inpatients with BN demonstrated greater sensory under-responsiveness in the intensity subscale of the SRQ, but not in the frequency and combined SRQ dimensions.

DISCUSSION

Female inpatients with AN-R exhibited sensory over-responsiveness both in the acute stage of their illness and following weight restoration, suggesting that sensory over-responsiveness may represent a trait related to the illness itself above and beyond the influence of malnutrition. The finding for sensory under-responsiveness in BN is less consistent.

Alteration in serum klotho levels in anorexia nervosa patients

BACKGROUND & AIMS

Klotho is a trans-membrane protein which can be shed to act as a hormone; its blood levels may be regulated by the GH/IGF-1 axis. Klotho deficient mice exhibit short lifespan and characteristics of aging and malnutrition, including decreased fat and muscle mass, osteopenia, and impaired fertility. As anorexia nervosa (AN) is characterized by malnutrition and GH resistance, we hypothesized klotho levels would be altered in AN, and aimed to assess klotho levels in undernourished AN patients and changes in klotho following weight rehabilitation.

PARTICIPANTS AND METHODS

19 adolescent female AN inpatients (aged 16.1 ± 1.8 years) admitted to an inpatient service for eating disorders in a tertiary center were recruited. Blood samples were obtained on admission and after weight restoration (interval 4.0 ± 2.3 months) and analyzed for klotho, IGF-1, calcium, phosphorus, and alkaline phosphatase.

RESULTS

Klotho levels on admission were lower than expected for age, and correlated with lumbar spine BMD Z-score (r = -0.81, p < 0.001) and alkaline phosphatase levels (r = 0.66, p = 0.003) but not with age, height-SDS, weight-SDS, BMI-SDS, or serum calcium, phosphorus and IGF-1 levels. Both IGF-1 and klotho levels increased significantly during hospitalization (IGF-1: 44 ± 17 nmol/l to 53 ± 11 nmol/l, p = 0.008; klotho: 1061 ± 421 pg/ml to 1519 ± 781 pg/ml, p = 0.008).

CONCLUSIONS

Klotho levels are low in the acute stage of AN and increase with nutritional rehabilitation. Low klotho on admission may be secondary to low IGF-1 levels and may contribute to the clinical manifestations of AN. The role of klotho in the pathophysiology of AN and as a novel marker of disease severity should be further explored.

Has the time come for a staging model to map the course of eating disorders from high risk to severe enduring illness? An examination of the evidence

AIM

To examine the evidence to support using a staging heuristic for eating disorders, suggesting that the diagnosis of an eating disorder follows a trajectory across the life course. Specifically, to examine whether high-risk markers and prodromal features presenting in childhood and adolescence can later transition to the full manifestation of the illness in early adulthood, and whether over time, the illness can be described as becoming severe and enduring, often resistant to treatment.

METHODS

We conducted a comprehensive literature search on the MEDLINE, PubMed, PsycINFO, EMBASE and Cochrane databases from using the following terms: staging, duration of illness, early intervention, developmental epidemiology, neurobiological marker, phenotype, partial syndrome, severe enduring, chronic, prospective, longitudinal, cohort, epidemiology, adolescent, adult with anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder. The evidence was organized according to the staging heuristic defined by McGorry.

RESULTS

Evidence from epidemiological studies, neuropsychological findings, treatment responsivity and prognosis, support a specific staging trajectory for anorexia nervosa in that there is a longitudinal trajectory with evidence of neurobiological progression and evidence that interventions matched to stage of illness may optimize the benefit. There is less data at the moment to support such a model for bulimia nervosa and binge eating disorder.

CONCLUSION

The staging heuristic is a useful model for anorexia nervosa in terms of providing prognostic information and stage matched interventions. Although the evidence is encouraging, further research is needed before a similar model could be applied for bulimia nervosa and binge eating disorder.

Severe growing-up phobia, a condition explained in a 14-year-old boy

We present the clinical case of a 14-year-old boy with gerascophobia or an excessive fear of aging, who felt his body development as a threat, to the point where he took extreme measures to stop or otherwise hide growth. He had a history of separation anxiety, sexual abuse, and suffering bullying. He presented with anxious and depressive symptoms and food restriction, criticized his body image, had negative feelings towards the maturation process, suffered at the thought of being rejected, and was preoccupied with certain physical characteristics. We conducted an analysis of biological, psychological, and environmental factors and their possible interactions and established treatment with psychotherapy and fluoxetine. Because of the favorable results, this approach could be considered a good option in such cases.

Integrated circuits and molecular components for stress and feeding: implications for eating disorders

Eating disorders are complex brain disorders that afflict millions of individuals worldwide. The etiology of these diseases is not fully understood, but a growing body of literature suggests that stress and anxiety may play a critical role in their development. As our understanding of the genetic and environmental factors that contribute to disease in clinical populations like anorexia nervosa, bulimia nervosa and binge eating disorder continue to grow, neuroscientists are using animal models to understand the neurobiology of stress and feeding. We hypothesize that eating disorder clinical phenotypes may result from stress-induced maladaptive alterations in neural circuits that regulate feeding, and that these circuits can be neurochemically isolated using animal model of eating disorders.

Negative affective experiences in relation to stages of eating disorder recovery

The purpose of this study was to examine a collection of negative affect symptoms in relation to stages of eating disorder recovery. Depressive symptoms, anxiety symptoms, loneliness, and perceived stress are known to be present in individuals with eating disorders; however, less is known about the presence of such constructs throughout the recovery process. Does this negative affect fog continue to linger in individuals who have recovered from an eating disorder? Female participants seen at some point for an eating disorder at a primary care clinic were categorized into one of three groups using a stringent definition of eating disorder recovery based on physical, behavioral, and psychological criteria: active eating disorder (n=53), partially recovered (n=15; psychological criteria not met), and fully recovered (n=20; all recovery criteria met). Additionally, data were obtained from 67 female controls who had no history of an eating disorder. Self-report data indicated that controls and women fully recovered from an eating disorder scored significantly lower than partially recovered and active eating disorder groups in perceived stress, depression, and anxiety. Controls and the fully recovered group were statistically indistinguishable from each other in these domains, as were the partially recovered and active eating disorder groups, suggesting an interesting divide depending on whether psychological criteria (e.g., normative levels of weight/shape concern) were met. In contrast, controls and fully recovered and partially recovered groups all reported feeling significantly less lonely relative to those with an active eating disorder suggesting that improved perceptions of interpersonal functioning and social support may act as a stepping stone toward more comprehensive eating disorder recovery. Future research may want to longitudinally determine if an increase in actual or perceived social support facilitates the movement toward full recovery and whether this, in turn, has salutatory effects on depression, anxiety, and perceived stress.

Attitudes toward life and death and suicidality among inpatient female adolescents with eating disorders

This study investigated whether attitudes about life and death are associated with suicidal behavior in eating disorders (EDs). We examined 43 nonsuicidal inpatients with EDs, 32 inpatients with EDs who attempted suicide, and 21 control participants with scales assessing attitudes to life and death, body-related attitudes, core ED symptoms, depression, and anxiety. Both ED groups showed less attraction to life and more repulsion from life than did the control participants. The suicide attempters showed greater attraction to death, less repulsion from death, and more negative attitudes toward their body than did the nonsuicidal ED and control participants. Fear of life was associated with elevated depression, body-related problems, and childhood sexual abuse. Pathological attitudes toward death were associated with greater depression and body-related problems. Suicide attempts were found in the inpatients with EDs showing binge/purge ED pathology and maladaptive attitudes toward death. This study suggests that whereas fear of life is a core feature of an ED, maladaptive attitudes toward death appear only in ED patients who have attempted suicide.

Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment

Restoration of weight and nutritional status are key elements in the treatment of anorexia nervosa (AN). This review aims to describe issues related to the caloric requirements needed to gain and maintain weight for short and long-term recovery for AN inpatients and outpatients.We reviewed the literature in PubMed pertaining to nutritional restoration in AN between 1960-2012. Based on this search, several themes emerged: 1. AN eating behavior; 2. Weight restoration in AN; 3. Role of exercise and metabolism in resistance to weight gain; 3. Medical consequences of weight restoration; 4. Rate of weight gain; 5. Weight maintenance; and 6. Nutrient intake.A fair amount is known about overall caloric requirements for weight restoration and maintenance for AN. For example, starting at 30-40 kilocalories per kilogram per day (kcal/kg/day) with increases up to 70-100 kcal/kg/day can achieve a weight gain of 1-1.5 kg/week for inpatients. However, little is known about the effects of nutritional deficits on weight gain, or how to meet nutrient requirements for restoration of nutritional status.This review seeks to draw attention to the need for the development of a foundation of basic nutritional knowledge about AN so that future treatment can be evidenced-based.

Associations between retrospective versus ecological momentary assessment measures of emotion and eating disorder symptoms in anorexia nervosa

This study examined the unique associations between eating disorder symptoms and two emotion-related constructs (affective lability and anxiousness) assessed via distinct methodologies in anorexia nervosa (AN). Women (N = 116) with full or subthreshold AN completed baseline emotion and eating disorder assessments, followed by two weeks of ecological momentary assessment (EMA). Hierarchical regressions were used to examine unique contributions of baseline and EMA measures of affective lability and anxiousness in accounting for variance in baseline eating disorder symptoms and EMA dietary restriction, controlling for age, body mass index, depression, and AN diagnostic subtype. Only EMA affective lability was uniquely associated with baseline eating disorder symptoms and EMA dietary restriction. Anxiousness was uniquely associated with baseline eating disorder symptoms regardless of assessment method; neither of the anxiousness measures was uniquely associated with EMA dietary restriction. Affective lability and anxiousness account for variance in global eating disorder symptomatology; AN treatments targeting these emotion-related constructs may prove useful.

Assessment of anorexia nervosa: an overview of universal issues and contextual challenges

AIM

Anorexia Nervosa (AN) is a complex and clinically challenging syndrome. Intended for specialist audiences, this narrative review aims to summarise the available literature related to assessment in the adult patient context, synthesising both research evidence and clinical consensus guidelines.

METHOD

We provide a review of the available literature on specialist assessment of AN focusing on common trajectories into assessment, obstacles accessing assessment, common presenting issues and barriers to the assessment process, the necessary scope of assessment, and tools and techniques. It describes the further step of synthesising assessment information in ways that can inform resultant care plans.

RESULTS

In addition to assessment of core behaviours and diagnostic skills, considerations for the expert assessor include the functions of primary care, systemic and personal barriers, knowledge of current assessment tools and research pertaining to comorbid pathology in AN, assessing severity of illness, role of family at assessment, as well as medical, nutritional and compulsory elements of assessment.

CONCLUSION

Comprehensive assessment of AN in the current healthcare context still remains largely the remit of the specialist ED clinician. Assessment should remain an on-going process, paying particular attention to available empirical evidence, thereby reducing the gap between research and practice.

Factors associated with recovery from anorexia nervosa

Previous studies of prognostic factors of anorexia nervosa (AN) course and recovery have followed clinical populations after treatment discharge. This retrospective study examined the association between prognostic factors--eating disorder features, personality traits, and psychiatric comorbidity--and likelihood of recovery in a large sample of women with AN participating in a multi-site genetic study. The study included 680 women with AN. Recovery was defined as the offset of AN symptoms if the participant experienced at least one year without any eating disorder symptoms of low weight, dieting, binge eating, and inappropriate compensatory behaviors. Participants completed a structured interview about eating disorders features, psychiatric comorbidity, and self-report measures of personality. Survival analysis was applied to model time to recovery from AN. Cox regression models were used to fit associations between predictors and the probability of recovery. In the final model, likelihood of recovery was significantly predicted by the following prognostic factors: vomiting, impulsivity, and trait anxiety. Self-induced vomiting and greater trait anxiety were negative prognostic factors and predicted lower likelihood of recovery. Greater impulsivity was a positive prognostic factor and predicted greater likelihood of recovery. There was a significant interaction between impulsivity and time; the association between impulsivity and likelihood of recovery decreased as duration of AN increased. The anxiolytic function of some AN behaviors may impede recovery for individuals with greater trait anxiety.

Daily patterns of anxiety in anorexia nervosa: associations with eating disorder behaviors in the natural environment

The role of anxiety has been emphasized in etiological/maintenance models of anorexia nervosa. This study identified daily patterns of anxiety in anorexia nervosa and examined the likelihood of the occurrence of eating disorder behaviors in each trajectory, the daily temporal distribution of eating disorder behaviors in each trajectory, and the extent to which the tendency to exhibit particular anxiety trajectories was associated with baseline diagnostic and trait-level personality variables. Women with full or subthreshold anorexia nervosa (N = 118) completed a 2-week ecological momentary assessment (EMA) protocol during which they reported on a variety of behavioral and affective variables, including anxiety and eating disorder behaviors. Using latent growth mixture modeling to classify EMA days (N = 1,526) based on anxiety ratings, we identified 7 distinct daily anxiety trajectories. Overall differences between trajectories were found for rates of binge eating, self-induced vomiting, body checking, skipping meals, and dietary restriction. Furthermore, distinct daily temporal distributions of eating disorder behaviors were found across the trajectories, with peaks in the probability of behaviors frequently coinciding with high levels of anxiety. Finally, traits of personality pathology (affective lability, self-harm, social avoidance, and oppositionality) and the presence of a co-occurring mood disorder were found to be associated with the tendency to experience particular daily anxiety trajectories (e.g., stable high anxiety). Findings support the presence of within-person variability in daily anxiety patterns in anorexia nervosa and also provide evidence for an association between these anxiety patterns and eating disorder behaviors.

Purging disorder: a comparison to established eating disorders with purging behaviour

This study is part of the larger Christina Barz Study, and it compared consecutively admitted patients with purging disorder (PurD; N = 225) with consecutively admitted patients with anorexia nervosa binge eating/purging subtype (AN-bp; N = 503) and bulimia nervosa purging subtype (BN-p; N = 756). Participants answered self-rating questionnaires on admission, at the end of inpatient treatment, and in a 5-year follow-up. Patients with PurD reported lower severity of general psychopathology than patients with AN-bp and lower severity of eating disorder symptoms than patients with AN-bp and BN-p on admission. Eating disorder symptoms of patients with PurD improved less during the course than of the comparison groups. Diagnostic perseverance was stronger in the PurD group than for patients with AN-bp; mortality was higher than for patients with BN-p. Predictors for better outcome differed for the groups. Our results provide new data about the long-term course of patients with PurD and indicate clinical relevance of the disorder.

Vegan lifestyle behaviors: an exploration of congruence with health-related beliefs and assessed health indices

This study aimed to investigate health belief as a major motive for diet and lifestyle behaviors of 100 vegans in the United States; and to determine congruence with selected health and nutrition outcomes. Response data from an administered questionnaire was analyzed. Statistical analyses determined the most common factors influencing diet choice; the number of vegans practicing particular lifestyle behaviors; body mass index; and prevalence of self-reported chronic disease diagnoses. Nutrient intakes were analyzed and assessed against Dietary Reference Intakes. Health was the most reported reason for diet choice (47%). In the health belief, animal welfare, and religious/other motive categories, low percentages of chronic disease diagnoses were reported: 27%, 11%, and 15%, respectively. There were no significant differences in health behaviors and indices among vegan motive categories, except for product fat content choices. Within the entire study population, health-related vegan motive coincided with regular exercise; 71% normal BMI (mean=22.6); minimal alcohol and smoking practices; frequently consumed vegetables, nuts, and grains; healthy choices in meal types, cooking methods, and low-fat product consumption; and adequate intakes for most protective nutrients when compared to reference values. But incongruence was found with 0% intake adequacy for vitamin D; and observation of excessive sodium use.