Should non-fat-phobic anorexia nervosa be included in DSM-V?

Exploring latent profiles of disordered eating using an indicator of dietary restriction in an undergraduate sample of men and women

OBJECTIVE

Latent class or latent profile analysis (LPA) studies in patients with eating disorders consistently identify a low-weight, restrictive eating subgroup that does not endorse weight/shape concerns. To date, similar studies in samples unselected for disordered eating symptoms have not identified a high restriction-low weight/shape concerns group, which may be due to a lack of inclusion of measures of dietary restriction.

METHOD

We conducted an LPA using data from 1623 college students (54% female) recruited across three different studies. The Eating Pathology Symptoms Inventory Body Dissatisfaction, Cognitive Restraint, Restricting, and Binge Eating subscales were used as indicators, and body mass index, gender, and dataset were covaried. Purging, excessive exercise, emotion dysregulation, and harmful alcohol use were compared across resulting clusters.

RESULTS

Fit indices supported a 10-class solution, including five disordered eating groups (largest to smallest): "Elevated General Disordered Eating", "Body Dissatisfied Binge Eating," "Most Severe General Disordered Eating," "Non-Body Dissatisfied Binge Eating," and "Non-Body Dissatisfied Restriction." The "Non-Body Dissatisfied Restriction" group scored as low on other measures of traditional eating pathology and harmful alcohol use as non-disordered eating groups but scored as high on a measure of emotion dysregulation as other disordered eating groups.

DISCUSSION

This study is the first to identify a latent restrictive eating group that does not endorse traditional disordered eating cognitions in an unselected sample of undergraduate students. Results underscore the importance of using measures of disordered eating behaviors without implied motivation to capture overlooked problematic eating patterns in the population that are distinct from our "traditional" understanding of disordered eating.

PUBLIC SIGNIFICANCE

We identified a group of individuals with high levels of restrictive eating but low body dissatisfaction and intent to diet in an unselected adult sample of men and women. Results underscore the need to investigate restrictive eating outside of the traditional lens of body shape concerns. Findings also suggest that individuals with nontraditional eating difficulties may struggle with emotion dysregulation, putting them at risk of poor psychological and relational outcomes.

Learned industriousness as a translational mechanism in anorexia nervosa

It remains unexplained why some behaviours persist despite being non-hedonic and ostensibly aversive. This phenomenon is especially baffling when such behaviours are taken to excess in the form of psychopathology. Anorexia nervosa is one psychiatric disorder in which effortful behaviours that most people find unpleasant (suchas restrictive eating) are persistently performed. We propose thatthe social psychology theory of learned industriousness providesa novel mechanistic account for such phenomena. This theoryposits that high-effort behaviour can be conditioned to acquire secondary reinforcing properties through repeated pairing with reward. Accordingly, effort sensations become less aversive andmore appetitive, increasing willingness to engage in effortful behaviour. In this Perspective, we review pre-clinical behaviouraland biological data that support learned industriousness, contrast learned industriousness with other models of non-hedonic persistence (such as habit learning), highlight evidence that supports learned industriousness in individuals with anorexia nervosa and consider implications of the model, including translation to other psychiatric presentations.

Visualizing Emotional Arousal within the Context of Body Size Evaluation: A Pilot Study of Steady-State Visual Evoked Potentials in Women with Anorexia Nervosa and Healthy Controls

Maladaptive body size evaluation processes and body dissatisfaction are known as central risk factors for the development and maintenance of anorexia nervosa (AN). This study aimed to experimentally test potential key facets, such as (psycho)physiological, cognitive-verbal and behavioral mechanisms, within the context of these evaluation processes. Twenty-two females with AN (AN-G) and 22 healthy controls (HC-G) looked at pictures of their body gradually increasing in weight using a morphing technique. Implicit emotional arousal was assessed using steady-state visual evoked potentials (SSVEP) in electroencephalography. Additionally, in a forced-choice body size evaluation task, participants were asked to classify pictures of their own body as not big or big while reaction times were captured. A significantly earlier increase in SSVEPs emerged in AN-G compared to HC-G (p <.05), with AN-G evaluating their bodies in the morphing process as big at a significantly thinner body size (p <.05). The AN-G showed faster reaction times in the categorical evaluation of body stimuli (p <.05). Findings from this multimodal paradigm underline the importance of body size evaluation mechanisms and underlying emotional arousal for AN. A differentiated understanding of these processes is essential, since the effectiveness of therapeutic interventions for AN is limited and relapses are frequent.

Beyond Description and Deficits: How Computational Psychiatry Can Enhance an Understanding of Decision-Making in Anorexia Nervosa

PURPOSE OF REVIEW

Despite decades of research, knowledge of the mechanisms maintaining anorexia nervosa (AN) remains incomplete and clearly effective treatments elusive. Novel theoretical frameworks are needed to advance mechanistic and treatment research for this disorder. Here, we argue the utility of engaging a novel lens that differs from existing perspectives in psychiatry. Specifically, we argue the necessity of expanding beyond two historically common perspectives: (1) the descriptive perspective: the tendency to define mechanisms on the basis of surface characteristics and (2) the deficit perspective: the tendency to search for mechanisms associated with under-functioning of decision-making abilities and related circuity, rather than problems of over-functioning, in psychiatric disorders.

RECENT FINDINGS

Computational psychiatry can provide a novel framework for understanding AN because this approach emphasizes the role of computational misalignments (rather than absolute deficits or excesses) between decision-making strategies and environmental demands as the key factors promoting psychiatric illnesses. Informed by this approach, we argue that AN can be understood as a disorder of excess goal pursuit, maintained by over-engagement, rather than disengagement, of executive functioning strategies and circuits. Emerging evidence suggests that this same computational imbalance may constitute an under-investigated phenotype presenting transdiagnostically across psychiatric disorders. A variety of computational models can be used to further elucidate excess goal pursuit in AN. Most traditional psychiatric treatments do not target excess goal pursuit or associated neurocognitive mechanisms. Thus, targeting at the level of computational dysfunction may provide a new avenue for enhancing treatment for AN and related disorders.

Cultural shifts in the symptoms of Anorexia Nervosa: The case of Orthorexia Nervosa

Orthorexia Nervosa (ON) is a term describing a fixation on food purity, involving ritualized eating patterns and a rigid avoidance of "unhealthy foods." Those self-identified as having ON tend to focus on food composition and feel immense guilt after eating food deemed "unhealthy." Although not formally recognized as a psychiatric disorder by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ON has received increasing attention since its identification in 1997. There is ongoing work to establish diagnostic and empirical tools for measuring ON; embedded in this is the question as to whether or not ON is a new eating disorder. In this paper, we argue ON is not a new psychiatric disorder but rather a new cultural manifestation of anorexia nervosa (AN). We begin by providing an overview of historical representations and classification of eating disorders, with a specific focus on AN. This is followed by discussion of the rise in diet culture and healthism since the 19th century. We conclude by examining the diagnostic validity and utility of ON through a discussion of empirical evidence. Classifying ON under the diagnostic umbrella of AN may improve our understanding of factors underlying restrictive eating behaviors.

Eating disorders are associated with adverse obstetric and perinatal outcomes: a systematic review

Objective:

To systematically review the literature focusing on obstetric and perinatal outcomes in women with previous or current eating disorders (EDs) and on the consequences of maternal EDs for the offspring.

Methods:

The study was performed following the systematic review and meta-analysis (PRISMA) statement. PubMed, SciELO, and Cochrane databases were searched for non-interventional studies published in English or Portuguese from January 1980 to December 2020. Risk of bias was assessed using the Methods guide for effectiveness and comparative effectiveness reviews (American Agency for Healthcare Research and Quality).

Results:

The search yielded 441 records, and 30 articles were included. The psychiatric outcome associated with EDs in women was mainly perinatal depression. The most prevalent obstetric outcomes observed in women with EDs were vomiting, hyperemesis, bleeding, and anemia. Most studies found maternal anorexia nervosa and bulimia nervosa to be associated with low birth weight and slow fetal growth. Women with binge EDs delivered children with increased birth weight. Of the 30 studies included, methodological quality was good in seven, fair in eight, and poor in 15 studies.

Conclusion:

A considerable body of evidence was reviewed to assess obstetric and perinatal outcomes in EDs. Acute and lifetime EDs, especially if severe, correlated with poor perinatal, obstetric, and neonatal outcomes. Obstetricians and general practitioners should be vigilant and screen for EDs during pregnancy.

Overcoming limitations of self-report: an assessment of fear of weight gain in anorexia nervosa and healthy controls using implicit association tests

BACKGROUND

Fear of weight gain is a characteristic feature of anorexia nervosa (AN), and reducing this fear is often a main target of treatment. However, research shows that 20% of individuals with AN do not report fear of weight gain. Studies are needed that evaluate the centrality of fear of weight gain for AN with a method less susceptible to deception than self-report.

METHODS

We approximated implicit fear of weight gain by measuring implicit drive for thinness using implicit association tests (IATs). We asked 64 participants (35 AN, 29 healthy controls [HCs]) to categorize statements as pro-dieting vs. non-dieting and true vs. false in a questionnaire-based IAT, and pictures of underweight vs. normal-weight models and positive vs. negative words in a picture-based IAT using two response keys. We tested for associations between implicit drive for thinness and explicitly reported psychopathology within AN as well as group differences between AN and HC groups.

RESULTS

Correlation analyses within the AN group showed that higher implicit drive for thinness was associated with more pronounced eating disorder-specific psychopathology. Furthermore, the AN group showed a stronger implicit drive for thinness than HCs in both IATs.

CONCLUSION

The results highlight the relevance of considering fear of weight gain as a continuous construct. Our implicit assessment captures various degrees of fear of weight gain in AN, which might allow for more individually tailored interventions in the future.

Severe and Enduring Anorexia Nervosa: Enduring Wrong Assumptions?

To the extent that severe and lasting anorexia nervosa (SE-AN) is defined in terms of refractoriness to the best treatments available, it is mandatory to scrutinize the proven effectiveness of the treatments offered to patients. The array of so-called current evidence-based treatments for anorexia nervosa (AN) encompasses the entire spectrum of treatments ranging from specialized brand-type treatments to new treatments adapted to the specific characteristics of people suffering from AN. However, after several randomized control trials, parity in efficacy is the characteristic among these treatments. To further complicate the landscape of effective treatments, this "tie score" extends to the treatment originally conceived as control conditions, or treatment as usual conditions. In retrospection, one can understand that treatments considered to be the best treatments available in the past were unaware of their possible iatrogenic effects. Obviously, the same can be said of the theoretical assumptions underpinning such treatments. In either case, if the definition of chronicity mentioned above is applied, it is clear that the responsibility for the chronicity of the disorder says more about the flagrant inefficacy of the treatments and the defective assumptions underpinning them, than the nature of the disorder itself. A historical analysis traces the emergence of the current concept of "typical" AN and Hilde Bruch's contribution to it. It is concluded that today's diagnostic criteria resulting from a long process of acculturation distort rather than capture the essence of the disorder, as well as marginalizing and invalidating patients' perspectives.

The moderating effects of self and other mentalizing on the relationship between distress and disordered eating: A cross-cultural examination

OBJECTIVE

Cross-cultural comparisons that focus on underlying psychological mechanisms in disordered eating (DE) are lacking. With the aim of addressing this gap, we investigated the interplay between mentalizing, distress, and DE in two cultural groups: the ultra-Orthodox and secular Jewish societies in Israel.

METHOD

A combination of performance-based and self-report measures of two mentalizing-related constructs (emotional awareness and alexithymia), along with self-report measures of distress, DE, and values preferences, were employed in a community sample (N = 300) of ultra-Orthodox and secular Jewish women.

RESULTS

Distress predicted DE in both cultural groups, yet there were cultural differences in the moderating role of mentalizing. Both mentalizing measures moderated the distress-DE link in the secular group, but not in the ultra-Orthodox group. Furthermore, there were cultural differences in the moderating effects of self versus other mentalizing.

CONCLUSIONS

The results suggest cultural differences in the underlying psychological mechanism of DE.

The changing profile of eating disorders and related sociocultural factors in Japan between 1700 and 2020: A systematic scoping review

OBJECTIVE

The purpose of this study was to investigate the changing profile of the phenotypic expression of eating disorders (EDs) and related sociocultural factors in Japan between 1700 and 2020.

METHOD

The authors conducted a systematic scoping review in accordance with the PRISMA statement guidelines for scoping reviews.

RESULTS

Findings indicate that Kampo doctors reported more than 50 patients with restrictive EDs in the 1700s, when Japan adopted a national isolation policy. On the other hand, only a few reports of EDs were found between 1868 and 1944, when rapid Westernization occurred. After World War II, providers began diagnosing patients with anorexia nervosa (AN) around 1960. Patients reported experiencing fat phobia, but did not engage in restriction for achieving slimness. However, after the 1970s, Japan experienced a rise in patients with AN who engaged in restriction to achieve thinness. Cases of patients who engaged in binge/purge symptomatology increased after the 1980s, followed by a steady increase in total ED cases after the 1990s. At various time points, providers attributed family conflicts, internalization of a thin ideal of beauty, changing food environments, and pressures associated with traditional gender roles to the onset and maintenance of EDs in Japan.

DISCUSSION

Findings reveal that restrictive EDs were present as early as the 18th century; Japanese patients may present with both "typical" and "atypical" forms of AN; ED symptoms can persist in the absence of Western influence; and sociocultural factors, such as gender-specific stressors and family dynamics, may contribute to EDs for Japanese populations.

Eating disorder symptomatology, clinical impairment, and comorbid psychopathology in racially and ethnically diverse college women with eating disorders

OBJECTIVE

To examine eating disorder (ED) symptomatology, related clinical impairment, and comorbid psychopathology in college women with EDs across five racial and two ethnic groups.

METHOD

Participants were 690 women from 28 US universities who screened positive for an ED. Thirteen variables assessing ED symptoms, related clinical impairment, and comorbid psychopathology were compared across racial and ethnic groups using analyses of variance (ANOVAs) and independent samples t-tests.

RESULTS

Across racial groups, significant differences emerged in binge eating and laxative use. Asian women reported significantly more binge eating than White women (p < .01). Individuals self-identified as the "Other" racial group reported greater laxative use than Asian and White women (ps ≤ .01). No other significant differences emerged across all other variables (ps ≥ .13). Across ethnic groups, Hispanic women reported significantly more laxative use (p < .01), and more comorbid insomnia symptoms (p = .03) than non-Hispanic women. No other significant differences were observed (ps ≥ .24).

DISCUSSION

Findings suggest that binge eating, laxative use, and insomnia symptoms differ across racial and ethnic groups in US college women who screened positive for EDs. Findings can inform tailoring of ED screening to reduce current disparities in these underrepresented populations.

Muscle dysmorphia: A systematic and meta-analytic review of the literature to assess diagnostic validity

OBJECTIVE

Although muscle dysmorphia (MD) is a new addition to DSM-5 as a specifier of body dysmorphic disorder (BDD), previous studies have treated MD as a stand-alone diagnosis. We aimed to assess the validity of MD as a stand-alone diagnosis via systematic and meta-analytic review of MD literature using both Robins and Guze criteria and additional criteria from Kendler.

METHOD

We performed a systematic search of ProQuest, PsycInfo, and PubMed databases for the period of January 1993 to October 2019 resulting in 40 papers to examine Robins and Guze's criteria (clinical picture) as well as those added by Kendler (antecedent validators; concurrent validators; predictive validators).

RESULTS

We identified two distinct symptomatic presentations of MD using cluster analysis, a behavioral type and cognitive/behavioral type. For examining the concurrent validators, quantitative meta-analyses differentiated MD populations from controls; however, results were inconclusive in delineating MD from existing disorders. For assessing antecedent and predictive validators, the symptomatic profiles, treatment response, and familial links for MD were similar to those for BDD and for eating disorders.

DISCUSSION

We found preliminary support for MD as a clinically valid presentation, but insufficient evidence to determine whether it is best categorized as a specifier of BDD or unique psychiatric condition.

Disgust and fear: common emotions between eating and phobic disorders

Eating disorders (ED) are prevalent mental illnesses composed mainly of anorexia nervosa, bulimia nervosa and binge eating disorders. Anxiety disorders are another set of mental illnesses, with phobic disorder (PD) being the most prevalent disorder. ED and PD are highly comorbid. The aim of this study is to assess, in 131 individuals attending an outpatient clinic for different health issues, the level of fear related to situations generating avoidance such as in social anxiety and specific phobias according to the fear questionnaire (FQ), the level of disgust according to the disgust scale (DS-R) and the vulnerability towards ED according to the SCOFF scale to demonstrate that high levels of both fear and disgust increase the vulnerability towards ED. The study demonstrated that the level of disgust increased when fear increases (r = 0.377, p < 0.001 for the first part of the FQ; r = 0.225, p = 0.01 for the second part of the FQ). Moreover, individuals with vulnerability towards having an ED presented a higher level of disgust than individuals without this vulnerability (p = 0.009). Furthermore, individuals with vulnerability towards ED have a higher level of anxiety related to PD subtypes (p = 0.008 for agoraphobia; p = 0.001 for injection/blood phobia) as well as to social anxiety (p = 0.01), independently from having a depressive or another anxiety disorder. In the multivariate analysis, a history of psychiatric consultation has been the only significantly different parameter between individuals with or without vulnerability towards ED (p = 0.0439). Accordingly, fear and disgust are negative emotions that seem to be clinically associated which better explains the comorbidity of ED with PD. LEVEL OF EVIDENCE: Level III. Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

Fat-Phobic and Non-Fat-Phobic Anorexia Nervosa: A Conjoint Analysis on the Importance of Shape and Weight

With the introduction of new diagnostic criteria in DSM-5, fear of weight gain no longer represents a sine qua non-criterion for the diagnosis of anorexia nervosa (AN). This is of relevance as a subgroup of individuals with AN denies fear of weight gain as the reason for restrictive eating but still remain at a very low weight. As self-reports are susceptible to bias, other methods are needed to confirm the existence of the subtype in order to provide adapted treatment. Therefore, we aimed to measure fear of weight gain using a novel method in clinical psychology, the conjoint analysis (CA). Relative importance and preference scores for various life aspects, including appearance/shape and weight were assessed in women with fat-phobic AN (FP-AN, n = 30), NFP-AN (n = 7), and healthy controls (n = 29). Individuals with FP-AN showed a significant lower preference for weight gain versus weight maintenance than HC (p = 0.011, ηp2 = 0.107). Correlation between explicitly assessed drive for thinness and CA score was low. As expected, in FP-AN the explicitly endorsed fear of weight gain was confirmed by the marked preference for weight maintenance compared to HC, while for NFP-AN explicit and implicit measures diverged, indicating that against their self-report they may experience at least some fear of weight gain. The utility of CA as a tool to measure fear of weight gain — and potentially other psychopathological constructs —requires further confirmation.

Characteristics and clinical trajectories of patients meeting criteria for avoidant/restrictive food intake disorder that are subsequently reclassified as anorexia nervosa

OBJECTIVE

To examine the initial assessment profiles and early treatment trajectories of youth meeting the criteria for avoidant/restrictive food intake disorder (ARFID) that were subsequently reclassified as anorexia nervosa (AN).

METHOD

A retrospective cohort study of patients assessed and treated in a tertiary care eating disorders (ED) program was completed.

RESULTS

Of the 77 included patients initially meeting criteria for ARFID, six were reclassified as having AN (7.8%) at a median rate of 71 days after the first assessment. Patients in this cohort presented at very low % treatment goal weight (median 71.6%), self-reported abbreviated length of illness (median 6 months), and exhibited low resting heart rates (median 46 beats per minute). Nutrition and feeding focused worries related more to general health as opposed to specific weight and shape concerns or fears at assessment in half of those reclassified with AN. Treatment at the 6-month mark varied among patients, but comprised family and individual therapy, as well as prescription of psychotropic medication.

CONCLUSION

Prospective longitudinal research that utilizes ARFID-specific as well as traditional eating disorder diagnostic measures is required to better understand how patients with restrictive eating disorders that deny fear of weight gain can be differentiated and best treated.

Adult avoidant/restrictive food intake disorder: a case report

ABSTRACT The aim this report is to present an adult case of avoidant/restrictive food intake disorder (ARFID) in a patient with atypical development. To emphasize the diagnostic and behavioral characteristics of this new nosological category included in the Feeding and Eating Disorders (FED) section of DSM-5. A woman with Down Syndrome in early adulthood who developed restriction and avoidance symptoms of food until the total eating refusal with weight loss, malnutrition and dependence exclusively on enteral feeding by gastrostomy tube. This case exemplified how ARFID may remain a hidden diagnosis and even be misdiagnosed as other eating disorders, such as anorexia nervosa. The increase in diagnostic suspicion for this nosological entity with neurobiological/behavioral mechanisms involved in its clinical presentations in mind, might increase knowledge about this serious eating disorder, aiming the development of evidence-based interventions.

The classification of eating disorders in China: A categorical model or a dimensional model

OBJECTIVE

According to the ICD-10 and DSM-5, eating disorders (EDs) are classified using a categorical model that assumes the subtypes are qualitatively different from one another. However, it is still intensely debated that a dimensional model is more suitable. The aim of this study is to examine whether EDs have a categorical or dimensional latent structure using a sample of Chinese ED patients.

METHOD

The sample included 322 patients, diagnosed with an ED from 2010 to 2017 in the Shanghai Mental Health Center, and comparison participants (N = 850), recruited from undergraduate students in one university in Shanghai. Participants were evaluated with the Eating Disorder Inventory-2 (EDI-2) questionnaire and another questionnaire developed by the researchers. Three taxometric procedures (MAXimum EIGenvalue [MAXEIG], latent-mode factor analysis [L-Mode], and Mean Above Minus Below A Cut [MAMBAC]) were applied, respectively, to analyze the patients' clinical symptoms data.

RESULTS

Patients were divided into three groups according to their clinical diagnosis. The plots of the three taxometric analysis procedures supported the categorical construct in anorexia nervosa, binge-eating/purging group, and bulimia nervosa group. The Comparison Curve Fit Indices of the MAXEIG, L-Mode, and MAMBAC procedures were 0.694, 0.709, 0.704 in the AN-BP group and 0.727, 0.67, 0.62 in the BN group, respectively, which also support the categorical construct.

DISCUSSION

The results support two distinct classes of ED subtypes among Chinese sample. Further work on applying hybrid model in analysis has been discussed.

A systematic scoping review of diagnostic validity in avoidant/restrictive food intake disorder

OBJECTIVE

Avoidant/restrictive food intake disorder (ARFID) was introduced as a new diagnosis in the DSM-5. This systematic scoping review explores how ARFID as a diagnostic entity is conceptualized in the research literature and evaluates the diagnostic validity according to the Feighner criteria.

METHOD

A systematic scoping review of papers on ARFID in PubMed/MEDLINE and Web of Science was undertaken, following PRISMA and Joanna Briggs Institute guidelines.

RESULTS

Fifty-one original research publications, 23 reviews and commentaries, and 20 case reports were identified. The use of ARFID as a conceptual category varies significantly within this literature. At this time, the ARFID diagnosis does not fulfil the Feighner criteria for evaluating the validity of diagnostic constructs, the most urgent problem being the demarcation toward other disorders. A three-dimensional model-lack of interest in food, selectivity based on sensory sensitivity, and fear of aversive consequences-is gaining support in the research literature.

DISCUSSION

The introduction of the ARFID diagnosis has undoubtedly increased the recognition of a previously largely neglected group of patients. However, this article points to an inability of the current DSM-5 diagnostic criteria to ensure optimal diagnostic validity, which risks making them less useful in clinical practice and in epidemiological research. To increase the conceptual validity of the ARFID construct, several possible alterations to the current diagnostic criteria are suggested, including a stronger emphasis of the three identified subdomains and further clarifying the boundaries of ARFID.

Implicit attitudes toward dieting and thinness distinguish fat-phobic and non-fat-phobic anorexia nervosa from avoidant/restrictive food intake disorder in adolescents

OBJECTIVE

The majority of individuals with anorexia nervosa (AN) have a fat-phobic (FP-AN) presentation in which they explicitly endorse fear of weight gain, but a minority present as non-fat-phobic (NFP-AN). Diagnostic criteria for avoidant/restrictive food intake disorder (ARFID) specifically exclude fear of weight gain. Differential diagnosis between NFP-AN and ARFID can be challenging and explicit endorsements do not necessarily match internal beliefs.

METHOD

Ninety-four adolescent females (39 FP-AN, 13 NFP-AN, 10 low-weight ARFID, 32 healthy controls [HC]) completed implicit association tests (IATs) categorizing statements as pro-dieting or non-dieting and true or false (questionnaire-based IAT), and images of female models as underweight or normal-weight and words as positive or negative (picture-based IAT). We used the Eating Disorder Examination to categorize FP- versus NFP-AN presentations.

RESULTS

Individuals with FP-AN and NFP-AN demonstrated a stronger association between pro-dieting and true statements, whereas those with ARFID and HCs demonstrated a stronger association between pro-dieting and false statements. Furthermore, while all groups demonstrated a negative implicit association with underweight models, HC participants had a significantly stronger negative association than individuals with FP-AN and NFP-AN.

DISCUSSION

Individuals with NFP-AN exhibited a mixed pattern in which some of their implicit associations were consistent with their explicit endorsements, whereas others were not, possibly reflecting a minimizing response style on explicit measures. In contrast, individuals with ARFID demonstrated implicit associations consistent with explicit endorsements. Replication studies are needed to confirm whether the questionnaire-based IAT is a promising method of differentiating between restrictive eating disorders that share similar clinical characteristics.

What keeps Maya from eating? A case study of disordered eating from North India

Anthropologists have paid much attention to food and eating practices in India, but surprisingly few scholars in any discipline have examined eating disorders. This article presents an ethnographic case study of disordered eating, based on a story of a young female pharmacist from one of the Northern Indian states. Advocating ethnography as an essential method to uncovering the multiple facets of "not eating," I first show how this phenomenon may reflect resistance to Brahmanical patriarchy, especially the institution of arranged marriage. Secondly, I illustrate how "not eating" may be an embodied expression of distress, in this case related to the inability to fulfil filial obligations of reciprocity. Finally, I argue that "not eating" in India may be associated with the ways in which personhood, as locally understood, is influenced by regional socioeconomic development. Thus, while young, unmarried, and highly educated women have increasingly better opportunities for formal employment, they may find themselves at the crossroads of conflicting social expectations, and "not eating" may arise as an after-effect. While making large-scale generalizations of these findings across India would be inappropriate, this case study sheds light on the complexity of disordered eating in this country and calls for further ethnographic studies, sensitive to local meanings of (not) eating.

Beyond the clinic? Eluding a medical diagnosis of anorexia through narrative

The persistence and recurrence of anorexia nervosa poses a clinical challenge, and provides support for critiques of oppressive and injurious facets of society inscribed on women's bodies. This essay illustrates how a phenomenological, linguistic anthropological approach fruitfully traverses clinical and cultural perspectives by directing attention beyond the embodied experience of patients diagnosed with anorexia nervosa to those who are not clinically diagnosed. Extending a model of illness and recovery as entailing sufferers' emplotting of past, present, and imagined future selves, I argue that women's accounts of their experiences do not simply reflect lived reality, but actually propel health-relevant states of being by enlivening and creating these realities in the process of their telling. In indexical interaction with public and clinical discourses, narratives' grammar, lexicon, and plot structures modify subjects' experiences and interpretations of the events and feelings recounted. This article builds on the insight that linear narratives of "full recovery" that adopt a clinical and feminist voice can help tellers stay recovered, whereas for those "struggling to recover," a genre of contingent, uncertain, sideshadowing narratives alternatively renders recovery an elusive and ambivalently desired object. This essay then identifies a third narrative genre, eluding a diagnosis, which combines elements of the first two genres to paradoxically keep its teller simultaneously sheltered from, and invisible to the well-meaning clutches of medical care, leaving her suffering, yet free, to starve. This focus on narrative genres illustrates the utility of linguistic analyses for discerning and interpreting distress in subclinical populations.

Prevalence and characteristics of orthorexia nervosa in a sample of university students in Italy

AIMS

Orthorexia nervosa (ON) has been recently defined as a pathological approach to feeding related to healthiness concerns and purity of food and/or feeding habits. This condition recently showed an increasing prevalence particularly among young adults. In order to investigate the prevalence of ON and its relationship with gender and nutritional style among young adults, we explored a sample of students from the University of Pisa, Italy.

METHODS

Assessments included the ORTO-15 questionnaire and a socio-demographic and eating habits form. Subjects were dichotomized for eating habits (i.e. standard vs vegetarian/vegan diet), gender, parents' educational level, type of high school attended, BMI (low vs high vs normal BMI). Chi square tests were performed to compare rates of subjects with overthreshold ORTO-15 scores, and Student's unpaired t test to compare mean scores between groups. Two Classification tree analyses with CHAID growing method were employed to identify the variables best predicting ON and ORTO-15 total score.

RESULTS

more than one-third of the sample showed ON symptoms (ORTO-15 ≥ 35), with higher rates among females. Tree analyses showed diet type to predict ON and ORTO-15 total score more than gender.

CONCLUSIONS

Our results seem to corroborate recent data highlighting similarities between ON and anorexia nervosa (AN). We propose an interpretation of ON as a phenotype of AN in the broader context of Feeding and eating disorders (FEDs) spectrum.

Eating disorders in children: is avoidant-restrictive food intake disorder a feeding disorder or an eating disorder and what are the implications for treatment?

Avoidant-restrictive food intake disorder (ARFID) is a current diagnosis in the "Feeding and Eating Disorders" section of the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) and captures a heterogeneous presentation of eating disturbances. In recent years, ARFID has been studied primarily within the context of eating disorders despite having historical roots as a feeding disorder. The following review examines ARFID's similarities with and differences from feeding disorders and eating disorders, focusing on research published within the last three years. Implications of this differentiation for treatment are discussed.

Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC)

The diagnosis of mental disorder initially appears relatively straightforward: Patients present with symptoms or visible signs of illness; health professionals make diagnoses based primarily on these symptoms and signs; and they prescribe medication, psychotherapy, or both, accordingly. However, despite a dramatic expansion of knowledge about mental disorders during the past half century, understanding of their components and processes remains rudimentary. We provide histories and descriptions of three systems with different purposes relevant to understanding and classifying mental disorder. Two major diagnostic manuals—the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders—provide classification systems relevant to public health, clinical diagnosis, service provision, and specific research applications, the former internationally and the latter primarily for the United States. In contrast, the National Institute of Mental Health’s Research Domain Criteria provides a framework that emphasizes integration of basic behavioral and neuroscience research to deepen the understanding of mental disorder. We identify four key issues that present challenges to understanding and classifying mental disorder: etiology, including the multiple causality of mental disorder; whether the relevant phenomena are discrete categories or dimensions; thresholds, which set the boundaries between disorder and nondisorder; and comorbidity, the fact that individuals with mental illness often meet diagnostic requirements for multiple conditions. We discuss how the three systems’ approaches to these key issues correspond or diverge as a result of their different histories, purposes, and constituencies. Although the systems have varying degrees of overlap and distinguishing features, they share the goal of reducing the burden of suffering due to mental disorder.

Are eating disorders "all about control?" The elusive psychopathology of nonfat phobic presentations

OBJECTIVE

There are a subset of individuals with eating disorders (EDs) who do not overevaluate body shape/weight (i.e., nonfat phobic ED; NFP-ED). According to the transdiagnostic cognitive-behavioral conceptualization of EDs, a need for control, in general, is hypothesized as the core psychopathology of NFP-EDs, with shape- and weight-related motivations for ED behavior merely superimposed in FP-ED presentations. This study tested the need for control as motivation for restriction in NFP-ED, using items aimed at assessing control from the Eating Disorder Examination (EDE) Restraint scale.

METHOD

Females ages 13-27 years consecutively admitted to residential treatment completed the EDE, Eating Disorder Inventory-3 Drive for Thinness subscale (EDI-DFT), and other self-report measures of psychopathology. We included patients with DSM-5 EDs, but excluded patients with avoidant/restrictive food intake disorder. Twenty participants had NFP-ED (≤14 on EDI-DFT) and 124 had fatphobic ED (FP-ED; >14 on EDI-DFT).

RESULTS

NFP-ED scored significantly lower than FP-ED on EDE Restraint scale shape/weight [χ² (1) = 10.73-35.62, p's < .01] and on control items [χ² (1) = 10.72-20.62, p's < .01], in addition to scoring lower on measures of general psychopathology and impairment.

DISCUSSION

Findings suggest those with NFP-ED report lower psychopathology overall and the new EDE Restraint scale control items do not capture additional motivation for restriction beyond that captured in the original Restraint scale shape/weight items. Future research should examine whether this latter finding is due to a minimizing response style in NFP-ED, an incomplete capture of desire for control by the EDE assessment method, or indeed reflects that need for control does not motivate restriction in NFP-EDs.

Differentiating constitutional thinness from anorexia nervosa in DSM 5 era

INTRODUCTION

Constitutional thinness (CT) is an underweight state characterized by normal menstruations and no change in feeding behaviour. Thinness is the only resemblance between Anorexia Nervosa (AN) and CT. Removal of amenorrhea from the new DSM 5 definition of AN might result in misdiagnosis between these two populations. The objective of this study was to compare CT, AN and Control subjects in terms of biological, anthropometric, and psychological markers in order to better distinguish AN from CT subjects.

MATERIALS AND METHODS

Body composition, nutritional markers, pituitary hormones, bone markers and psychological scores were evaluated in three groups of young women: fifty-six CT, forty restrictive-type AN and fifty-four Control subjects. For every marker, a receiver Operator Characteristics (ROC) curve was calculated to evaluate the accuracy of differentiation between AN and CT groups.

RESULTS

For most studied parameters, CT subjects were similar to Controls but dramatically different from AN subjects. DEBQ Restrained Eating subscale score was identified by ROC data analysis as the only psychological parameter tested to successfully differentiate AN from CT. Free-T3 and Leptin were shown to be powerful markers to differentiate AN and CT populations as they were highly specific and sensitive ones.

CONCLUSION

The exclusive use of psychological testing criteria is not always sufficient to differentiate AN and CT patients. Minimally, additional testing of Free T3 levels, which is cheap and widely accessible for general practitioners, should be completed to avoid misdiagnosis which could result in the implementation of ineffective treatment plans and social stigmatization for CT women.

Will I get fat? 22-year weight trajectories of individuals with eating disorders

OBJECTIVE

For some, fat phobia or fear of uncontrollable weight gain is diagnostic of eating disorders, often inhibiting treatment engagement and predicting symptom relapse. Prior research has reported weight changes at infrequent or long intervals, but rate, shape, and magnitude of long-term changes remain unknown. Our study examined 22-year longitudinal trajectories of body mass index (BMI) in women with anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

Participants were followed over 10 years (N = 225) and at 22-year follow-up (N = 175). Using latent growth curves, we examined: (1) shape and rate of intra-individual BMI change over 10 years; (2) predictors of BMI change over 10 years, (3) 22-year BMI outcomes; and (4) BMI changes over 10 years as predictors of 22-year BMI.

RESULTS

The best-fitting model captured overall intra-individual rates of BMI change in three intervals, showing moderate rate of BMI increase from intake to year 2, modest increase from year 2 to 5, and plateau from year 5 to 10. At 22 years, 14% were underweight, 69% were normal weight, and only 17% were overweight or obese. Greater increases from intake to year 2 predicted higher BMI at 22 years (β = 0.43, p < 0.01) and were predicted by intake diagnosis of AN-restricting (β = 0.31, p < 0.01) or AN-binge eating/purging (β = 0.29, p < 0.01).

DISCUSSION

BMI increased most rapidly during earlier years of the study for those with lower weight at study intake (i. e., AN) and plateaued over time, settling in the normal range for most. Psychoeducation about expected BMI trajectory may challenge patients' long-term fat phobic predictions.

Characterizing severe and enduring anorexia nervosa: An empirical approach

Targeted approaches for the treatment of severe and enduring anorexia nervosa (SE-AN) have been recommended, but there is no consensus definition of SE-AN to inform research and clinical practice. This study aimed to take initial steps toward developing an empirically based definition of SE-AN by characterizing associations among putative indicators of severity and chronicity in eating disorders. Patients with AN (N = 355) completed interviews and questionnaires at treatment admission and discharge; height and weight were assessed to calculate body mass index (BMI). Structural equation mixture modeling was used to test whether associations among potential indicators of SE-AN (illness duration, treatment history, BMI, binge eating, purging, quality-of-life) formed distinct subgroups, a single group with one or more dimensions, or a combination of subgroups and dimensions. A three-factor (dimensional), two-profile (categorical) mixture model provided the best fit to the data. Factor 1 included eating disorder behaviors; Factor 2 comprised quality-of-life domains; Factor 3 was characterized by illness duration, number of hospitalizations, and admission BMI. Profiles differed on eating disorder behaviors and quality-of-life, but not on indicators of chronicity or BMI. Factor scores, but not profile membership, predicted outcome at discharge from treatment. Data suggest that patients with AN can be classified on the basis of eating disorder behaviors and quality-of-life, but there was no evidence for a chronic subgroup of AN. Rather, indices of chronicity varied dimensionally within each class. Given that current definitions of SE-AN rely on illness duration, these findings have implications for research and clinical practice.

Psychometric properties and validation of the Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4) with a sample of Japanese adolescent girls

The Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4) is a 22-item five-factor measure that assesses thin- and muscular-ideal internalization as well as appearance-related pressures from peers, family, and media. The scale has been validated in Western cultures, but has not yet been examined in Eastern samples. Two studies were conducted to examine the psychometric properties of the SATAQ-4 among 946 Japanese adolescent girls. In Study 1, exploratory factor analysis of the SATAQ-4 indicated that the five-factor structure was largely replicated with the exception of two cross-loading items. In Study 2, confirmatory factor analysis indicated good fit for the full 22-item and reduced 20-item versions of the measure. SATAQ-4 subscales exhibited good internal consistency and were correlated in the expected direction with experiences of appearance teasing, strategies to lose and/or gain weight, and drive for muscularity. Overall, results support the reliability and validity of the SATAQ-4 among Japanese adolescent girls.

Eating disorders

Twenty years have passed from the International Classification of Diseases, Tenth Revision (ICD-10) to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and, in the meanwhile, a lot of research data about eating disorders has been published. This article reviews the main modifications to the classification of eating disorders reported in the "Feeding and Eating Disorders" chapter of the DSM-5, and compares them with the ICD-10 diagnostic guidelines. Particularly, we will show that DSM-5 criteria widened the diagnoses of anorexia and bulimia nervosa to less severe forms (so decreasing the frequency of Eating Disorders, Not Otherwise Specified (EDNOS) diagnoses), introduced the new category of Binge Eating Disorder, and incorporated several feeding disorders that were first diagnosed in infancy, childhood, or adolescence. On the whole, the DSM-5 revision should allow the clinician to make more reliable and timely diagnoses for eating disorders.

Examining weight suppression as a predictor of eating disorder symptom trajectories in anorexia nervosa

OBJECTIVE

Research in individuals with bulimia nervosa has highlighted the clinical significance of weight suppression (WS), defined as the difference between one's highest and current weight. More recently, studies have suggested that WS also may play a role in symptom maintenance and weight gain during treatment in anorexia nervosa (AN) and that the influence of WS on AN outcomes may depend on an individual's body mass index (BMI). However, no study has investigated whether WS or the interaction between WS and BMI is associated with the longer-term course of eating pathology following treatment discharge in patients with AN.

METHOD

The current study examined a sample of females with AN (N = 180) who completed interviews and self-report questionnaires at discharge from intensive treatment and at 3, 6, and 12-months after discharge. Latent growth curve models tested whether WS, BMI, or the WS by BMI interaction significantly predicted the trajectory of eating disorder symptoms (i.e., Eating Disorder Examination global score, BMI, frequency of loss of control eating, frequency of purging) over the year following discharge.

RESULTS

WS at discharge predicted change in BMI, and the interaction between WS and BMI predicted growth in eating disorder severity and purging frequency over time. Neither WS nor its interaction with BMI predicted growth in loss of control eating frequency.

DISCUSSION

Results provide further support for the clinical significance of WS in AN symptom maintenance, but suggest that the influence of WS likely depends on an individual's BMI as well as the outcome being measured. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:753-763).

Risk for self-reported anorexia or bulimia nervosa based on drive for thinness and negative affect clusters/dimensions during adolescence: A three-year prospective study of the TChAD cohort

OBJECTIVE

This study explored the cross-sectional and predictive effect of drive for thinness and/or negative affect scores on the development of self-reported anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

K-means were used to cluster the Eating Disorder Inventory-Drive for Thinness (DT) and Child Behavior Checklist Anxious/Depressed (A/D) scores from 615 unrelated female twins at age 16-17. Logistic regressions were used to assess the effect of these clusters on self-reported eating disorder diagnosis at ages 16-17 (n = 565) and 19-20 (n = 451).

RESULTS

DT and A/D scores were grouped into four clusters: Mild (scores lower than 90th percentile on both scales), DT (higher scores only on DT), A/D (higher scores only on A/D), and DT-A/D (higher scores on both the DT and A/D scales). DT and DT-A/D clusters at age 16-17 were associated cross-sectionally with AN and both cross-sectionally and longitudinally with BN. The DT-A/D cluster had the highest prevalence of AN at follow-up compared with all other clusters. Similarly, an interaction was observed between DT and A/D that predicted risk for AN.

DISCUSSION

Having elevated DT and A/D scores may increase risk for eating disorder symptomatology above and beyond a high score on either alone. Findings suggest that cluster modeling based on DT and A/D may be useful to inform novel and useful intervention strategies for AN and BN in adolescents.

[Pathological fear of weight gain is a necessary criterion of anorexia nervosa]

OBJECTIVE

To analyze the diagnostic value of fear of weight gain (obesity) criterion in anorexia nervosa (AN).

MATERIAL AND METHODS

Authors examined 30 patients with significant weight loss due to self-restriction of food intake. The patients were stratified into the group (n = 15) that met ICD-10 criteria of AN (restrictive variant) and the group with somatoform dysfunction of the autonomic nervous system of the gastrointestinal tract. Authors compared these groups and presented a description of two cases.

RESULTS

The patients of the second group met 3 of 4 AN criteria and would be formally diagnosed with atypical AN but they had not the fear of weight gain. Moreover, the patients of this group significantly differed by several clinical parameters and responses to treatment. In diagnostic view, the most important is the presence of the dysmorphophobia/dysmorphomania syndrome in patients with AN and hypochondriac syndrome in the patients with somatoform dysfunction.

CONCLUSION

The diagnostic criteria of eating disorders should be revised. However, "fear of weight gain", to our opinion, should be considered as a necessary criterion of AN.

Dynamic longitudinal relations between emotion regulation difficulties and anorexia nervosa symptoms over the year following intensive treatment

OBJECTIVE

Emotion regulation difficulties have been implicated in theoretical models of anorexia nervosa (AN) development/maintenance, and several treatments for AN have been designed to target emotion dysregulation. However, no research has used longitudinal methodology to examine whether emotion regulation difficulties predict the maintenance of AN symptoms, or vice versa. The current study evaluated dynamic longitudinal relations between emotion dysregulation and AN symptom severity over the year following discharge from intensive treatment in order to enhance theoretical models and treatments for AN.

METHOD

Participants were 191 patients with AN recruited during intensive treatment. Assessments including the Eating Disorders Examination and the Difficulties in Emotion Regulation Scale were completed at discharge from treatment and at 3-, 6-, and 12-month follow-ups. Bivariate latent change score models were used to examine the direction of associations between emotion dysregulation and AN symptom severity across time.

RESULTS

Emotion dysregulation predicted change in AN symptom severity, but the reverse relationship did not occur. Individuals with high levels of emotion dysregulation experienced an increase and subsequent maintenance of AN psychopathology, whereas low emotion dysregulation predicted a decreasing AN symptom trajectory. Importantly, these dynamic temporal relationships could not be accounted for by body mass index or depressive symptoms and were present for patients with the restricting and binge-eating/purging subtypes of AN.

CONCLUSIONS

Emotion regulation difficulties appear to be involved in the maintenance of AN symptom severity over time. Findings provide support for an increasing emphasis on emotion regulation in the development of novel treatments for AN.

Eating disorders in women

Eating disorders, especially anorexia nervosa and bulimia nervosa have been classically described in young females in Western population. Recent research shows that they are also seen in developing countries including India. The classification of eating disorders has been expanded to include recently described conditions like binge eating disorder. Eating disorders have a multifactorial etiology. Genetic factor appear to play a major role. Recent advances in neurobiology have improved our understanding of these conditions and may possibly help us develop more effective treatments in future. Premorbid personality appears to play an important role, with differential predisposition for individual disorders. The role of cultural factors in the etiology of these conditions is debated. Culture may have a pathoplastic effect leading to non-conforming presentations like the non fat-phobic form of anorexia nervosa, which are commonly reported in developing countries. With rapid cultural transformation, the classical forms of these conditions are being described throughout the world. Diagnostic criteria have been modified to accommodate for these myriad presentations. Treatment of eating disorders can be quite challenging, given the dearth of established treatments and poor motivation/insight in these conditions. Nutritional rehabilitation and psychotherapy remains the mainstay of treatment, while pharmacotherapy may be helpful in specific situations.

Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network

OBJECTIVE

Few published studies have evaluated the clinical utility of new diagnostic criteria for avoidant/restrictive food intake disorder (ARFID), a DSM-5 reformulation of feeding and eating disorder of infancy or early childhood. We examined the prevalence of ARFID and inter-rater reliability of its diagnostic criteria in a pediatric gastrointestinal sample.

METHOD

We conducted a retrospective chart review of 2,231 consecutive new referrals (ages 8-18 years) to 19 Boston-area pediatric gastroenterology clinics for evidence of DSM-5 ARFID.

RESULTS

We identified 33 (1.5%) ARFID cases; 22 of whom (67%) were male. Most were characterized by insufficient intake/little interest in feeding (n = 19) or limited diet due to sensory features of the food (n = 7). An additional 54 cases (2.4%) met one or more ARFID criteria but there was insufficient information in the medical record to confer or exclude the diagnosis. Diagnostic agreement between coders was adequate (κ = 0.72). Common challenges were (i) distinguishing between diagnoses of ARFID and anorexia nervosa or anxiety disorders; (ii) determination of whether the severity of the eating/feeding disturbance was sufficient to warrant diagnosis in the presence of another medical or psychiatric disorder; and (iii) assessment of psychosocial impairment related to eating/feeding problems.

DISCUSSION

In a pediatric treatment-seeking sample where ARFID features were common, cases meeting full criteria were rare, suggesting that the diagnosis is not over-inclusive even in a population where eating/feeding difficulties are expected.

Anorexia nervosa in a girl of Chinese origin: psychological, somatic and transcultural factors

The increased prevalence of anorexia nervosa reported in non-Western societies inevitably raises the issue of the influence of cultural factors in the genesis and the patterns of this disorder. Anorexia nervosa is not a straightforward Western culture-bound syndrome, although an influence of Western ideals of thinness does exist. The illness seems more related to rapid cultural shifts, either societal or individual, such as those occurring in the migratory process. Migrants and their children have to face the acculturation process and may experience a culture-clash. The pathology can also fulfil a positive acculturative function. This is a case study concerning a second-generation Chinese girl born in France presenting with anorexia nervosa. This case leads us to raise the issue of the choice of diagnostic criteria in relation to cultural background. We will also discuss the impact of the family's migratory history on the construction of identity in adolescence. Finally we will explore the specific features of care provision for anorexia nervosa in a transcultural setting.

Do recognizable lifetime eating disorder phenotypes naturally occur in a culturally asian population? A combined latent profile and taxometric approach

BACKGROUND

We examined whether empirically derived eating disorder (ED) categories in Hong Kong Chinese patients (N = 454) would be consistent with recognizable lifetime ED phenotypes derived from latent structure models of European and American samples.

METHOD

We performed latent profile analysis (LPA) using indicator variables from data collected during routine assessment, and then applied taxometric analysis to determine whether latent classes were qualitatively versus quantitatively distinct.

RESULTS

Latent profile analysis identified four classes: (i) binge/purge (47%); (ii) non-fat-phobic low-weight (34%); (iii) fat-phobic low-weight (12%); and (iv) overweight disordered eating (6%). Taxometric analysis identified qualitative (categorical) distinctions between the binge/purge and non-fat-phobic low-weight classes, and also between the fat-phobic and non-fat-phobic low-weight classes. Distinctions between the fat-phobic low-weight and binge/purge classes were indeterminate.

CONCLUSION

Empirically derived categories in Hong Kong showed recognizable correspondence with recognizable lifetime ED phenotypes. Although taxometric findings support two distinct classes of low weight EDs, LPA findings also support heterogeneity among non-fat-phobic individuals.

Bidirectional associations between binge eating and restriction in anorexia nervosa. An ecological momentary assessment study

This study examined the association between restrictive eating behaviors and binge eating in anorexia nervosa (AN) using data collected in the natural environment. Women (N = 118) with DSM-IV full or subthreshold AN reported eating disorder behaviors, including binge eating episodes, going ≥ 8 waking hours without eating, and skipping meals, during 2 weeks of ecological momentary assessment (EMA). Time-lagged generalized estimating equations tested the following hypotheses: 1) dietary restriction would predict binge eating while controlling for binge eating the previous day; 2) binge eating would predict restriction the subsequent day while controlling for restriction the previous day. After controlling for relevant covariates, the hypotheses were not supported; however, there appeared to be a cumulative effect of repeatedly going 8 consecutive hours without eating (i.e. fasting) on the risk of binge eating among individuals who recently engaged in binge eating. In addition, skipping meals was associated with a lower risk of same day binge eating. The relationship between binge eating and dietary restriction appears to be complex and may vary by type of restrictive eating behavior. Future research should aim to further clarify the nature of the interaction of binge eating and restrictive eating among individuals with AN in order to effectively eliminate these behaviors in treatment.

Characteristics and stability of empirically derived anorexia nervosa subtypes: towards the identification of homogeneous low-weight eating disorder phenotypes

Anorexia nervosa (AN) is characterized by within-group heterogeneity in symptom presentation, which poses problems for research on etiology and treatment. This study sought to identify homogeneous subtypes of AN, and examine their short-term stability, using empirical methods. A treatment-seeking sample with AN (n = 194) was assessed at baseline and 6- and 12-month follow-ups. Latent class analysis was used to identify homogeneous AN subgroups, and latent transition analysis was used to examine the stability of latent classes. Three low-weight eating disorder classes were identified: 1) fat-phobic restricting (AN-R-FP); 2) fat-phobic binge-eating/purging (AN-BP-FP); and 3) non-fat-phobic restricting (AN-R-NFP). Subtype membership was stable over follow-up, with .68 to .88 probabilities of remaining in the same class from baseline to 6 months, and .87 to 1.00 from 6 months to 12 months. The most common transition pattern was between AN-R-FP and AN-R-NFP (56.8% of transitions); the majority of these participants transitioned from AN-R-FP to AN-R-NFP (n = 20/21). Predictors of latent class membership included lifetime mood and substance use disorder comorbidities, negative temperament, illness duration, and body mass index at treatment presentation. Disinhibition (vs. constraint), history of overweight or obesity, and illness duration decreased the probability of latent transition. Findings support the presence of 3 low-weight eating disorder phenotypes that are highly stable over short-term follow-up. Identification of a stable non-fat-phobic AN phenotype is intriguing and highlights the importance of studying mechanisms that differentiate fat-phobic and non-fat-phobic eating disorders.

Social insecurity in relation to orbitofrontal activity in patients with eating disorders: a near-infrared spectroscopy study

BACKGROUND

Functional neuroimaging techniques are widely used to elucidate changes in brain activity, and various questionnaires are used to investigate psychopathological features in patients with eating disorders (ED). It is well known that social skills and interpersonal difficulties are strongly associated with the psychopathology of patients with ED. However, few studies have examined the association between brain activity and social relationships in patients with ED, particularly in patients with extremely low body weight.

METHODS

In this study, 22-channel near-infrared spectroscopy was used to quantify regional hemodynamic changes during a letter fluency task (LFT) in 20 female patients with ED with a mean body mass index of 14.0 kg/m(2) and 31 female controls (CTLs). Symptoms were assessed using the Eating Disorder Inventory-2 and Beck Depression Inventory. We hypothesized that frontal activity in patients with ED would be lower than in CTLs and would show different correlations with psychopathological features compared with CTLs.

RESULTS

The LFT performance and score on the social insecurity subscale of the Eating Disorder Inventory-2 were significantly higher in the ED group than in the CTL group. The mean change in oxygenated hemoglobin (oxy-Hb) in bilateral frontal regions during the LFT was significantly smaller in the ED group than in the CTL group. Social insecurity score was positively correlated with the concentration of oxy-Hb in the bilateral orbitofrontal cortex in the ED group but not in the CTL group.

CONCLUSIONS

These results suggest that activity of the orbitofrontal cortex is associated with social insecurity and disturbed in patients with ED. Therefore, disturbed orbitofrontal cortex activity may underlie the lack of insight and social isolation that is characteristic of patients with ED.

Typical and atypical anorexia nervosa in a Japanese sample

OBJECTIVE

We examined the existence of nonfat-phobic anorexia nervosa (NFP-AN) and fat-phobic AN, with no evidence of distortions related to body shape and weight (AN-NED), in a Japanese sample and studied eating disorder pathology and psychopathology in NFP-AN and AN-NED.

METHOD

The study participants were 200 (52.2%) women with typical AN, 86 (22.5%) women with NFP-AN, and 97 (25.3%) women with AN-NED. Diagnosis of the three types of AN was made by structured clinical interviews. The Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI) were administered to all the participants.

RESULTS

There were significant differences among the three groups in terms of duration of illness, maximum and minimum BMIs and AN subtypes. There was no transition from the NFP-AN and AN-NED groups to the typical AN group during the 2- to 7-year follow-up period. There were significant differences among the three groups in scores of the EAT, the EDI total, and all the subscales of the EDI.

DISCUSSION

Besides typical AN, there were two types of atypical AN in terms of fat phobia and body image disturbance in this Japanese sample. The findings of the current study suggest that there may be significant differences among the three groups in terms of eating disorder pathology and psychopathology.

The diagnostic classification of eating disorders: current situation, possible alternatives and future perspectives

The current nosography of eating disorders (ED) has various limitations in terms of validity and accuracy. The changes adopted in the DSM-5 limit some of the current problems, such as excessive prevalence of ED not otherwise specified (EDNOS) and the lack of longitudinal stability, but are unlikely to adequately capture the clinical complexity of ED. Many authors suggest the need for a thorough review of the current nosography to support evidence-based classification. In this paper, we discuss the validity of the current diagnostic categories and their possible reorganization. Furthermore, we review the main empirical models of classification and the diagnostic approach from a personality perspective, with particular attention to research and to the prognostic and therapeutic implications.

Comparing operational definitions of DSM-5 anorexia nervosa for research contexts

OBJECTIVE

DSM-5 anorexia nervosa (AN) criteria include several changes that increase reliance on clinical judgment. However, research contexts require operational definitions that can be applied reliably and that demonstrate validity. The present study evaluated different operational definitions for DSM-5 AN.

METHOD

DSM-5 AN criteria were applied to diagnostic interview data from 364 women varying two features: threshold for determining low weight for Criterion A (body mass index [BMI] <17.0 kg/m(2) vs. <18.5 kg/m(2)) and explicit endorsement of weight phobia (Criterion B explicit vs. inferred). Resulting groups of individuals with DSM-5 AN were compared on estimated frequency. In addition, AN groups were compared to non-eating disorder controls and individuals with an other specified feeding or eating disorder (OSFED) on external validators.

RESULTS

All operational DSM-5 definitions produced higher lifetime frequency estimates than reported for DSM-IV AN, with a particularly large increase associated with the broadest definition. All definitions produced significant differences in comparison to controls on external validators that were associated with medium to large effect sizes. Only definitions that required a lower weight threshold or explicit endorsement of weight phobia demonstrated significant differences compared to OSFED on external validators, and these were of small effect size. The specific combination of BMI <18.5 kg/m(2) with inferred weight phobia exhibited few meaningful distinctions from the OSFED group.

DISCUSSION

To balance inclusivity, syndromal reliability, and validity, an operational definition for DSM-5 AN in research contexts should define low weight as BMI <18.5 kg/m(2) and require measurable rather than inferred weight phobia.

Insight impairment in body image disorders: delusionality and overvalued ideas in anorexia nervosa versus body dysmorphic disorder

The two body image disorders anorexia nervosa (AN) and body dysmorphic disorder (BDD) share many similarities. Delusionality in BDD has recently gained increased attention, as the new DSM-5 criteria for BDD include an insight specifier. However, delusionalilty in AN has rarely been examined. We evaluated the delusionality of appearance-related beliefs in AN (n=19) vs. BDD (n=22) via structured interview. Participants also completed measures of disorder-specific psychopathology and body image. Compared to those with AN, individuals with BDD exhibited significantly greater delusionality on a dimensional scale (p=0.0014, d=1.07), and were more likely to meet dichotomous criteria for delusional beliefs (p=0.021, V=0.36). In AN, delusionality was associated specifically with shape concerns and drive for thinness; in BDD, delusionality was related to the severity of BDD symptoms (all p<0.05). Delusionality of appearance beliefs is present in individuals with AN, but is less pronounced than in BDD. Nevertheless, as high delusionality might predict poor treatment outcome in AN, treatment strategies that were originally developed to address delusionality in BDD might be modified for AN.