DSM-5 reduces the proportion of EDNOS cases: evidence from community samples

The optimal cut-off score of the Eating Attitude Test-26 for screening eating disorders in Japan

PURPOSE

The Eating Attitude Test-26 (EAT-26) is a screening tool for eating disorders (EDs) in clinical and non-clinical samples. The cut-off score was suggested to be varied according to target population. However, no studies have examined the appropriateness of the originally proposed score of 20 for screening DSM-5 eating disorders in Japan. This study aimed to identify an appropriate cut-off score to better differentiate clinical and non-clinical samples in Japan for EDs.

METHODS

The participants consisted of 54 patients with anorexia nervosa restricting type, 58 patients with anorexia nervosa binge-eating/purging type, 37 patients with bulimia nervosa diagnosed according to DSM-5 criteria, and 190 healthy controls (HCs). Welch's t test was used to assess differences in age, body mass index (BMI), and total EAT-26 scores between HCs and patients with EDs. Receiver operating characteristic (ROC) analysis was conducted to identify the optimal cut-off score.

RESULTS

The HCs had significantly higher BMI and lower total EAT-26 mean scores than patients with EDs. The area under the ROC curve was 0.925, indicating that EAT-26 had excellent performance in discriminating patients with EDs from HCs. An optimal cut-off score of 17 was identified, with sensitivity and specificity values of 0.866 and 0.868, respectively.

CONCLUSIONS

The result supports the suggestions that optimal cut-off score should be different according to target populations. The newly identified cut-off score of 17 would enable the identification of patients with EDs who have been previously classified as non-clinical samples in the EAT-26 test.

LEVEL OF EVIDENCE

III: evidence obtained from case-control analytic study.

An examination of adults with atypical anorexia nervosa at admission to treatment at higher levels of care: An attempt to increase diagnostic clarity

OBJECTIVE

Anorexia nervosa (AN) is a serious illness with a high mortality rate and multiple physiological complications. The vague definition of atypical AN allows for subjective interpretation. This retrospective study aimed to focus future research on the operational definition of atypical AN by examining four factors associated with atypical AN at admission to higher level of care treatment.

METHODS

Adults with atypical AN (n = 69) were examined within sample analyses among four groups: (1) >10% versus ≤10% weight loss; (2) weight loss within the previous 3 months versus >3 months; (3) engaging in purging behaviors versus absence of purging behaviors; and (4) endorsing versus not endorsing significant cognitive aspects of AN.

RESULTS

Patients with atypical AN endorsed elevated ED cognitions on the Eating Disorder Examination-Questionnaire and depressive symptoms; a lack of association was found between weight loss severity and weight loss time frame with depressive symptoms, eating concern, and restraint. Purging behavior was associated with a higher expected body weight percentage (%EBW) and dietary restraint, while greater AN cognitions were associated with a higher EBW and weight loss percentage. Few patients demonstrated bradycardia, hypophosphatemia, or amenorrhea.

DISCUSSION

This study demonstrated the severity of ED cognitions and depressive symptoms in this atypical AN sample and provided directions for future studies in the nosology of atypical AN. It may be important to distinguish between individuals with atypical AN who are purging and those who are not. Atypical AN was associated with a low frequency of physiological disturbances.

PUBLIC SIGNIFICANCE

This study provides further clarification regarding the operational definition of atypical AN; currently, a constellation of symptoms under Other Specified Feeding or Eating Disorders. This study was consistent with previous research in reporting severe eating disorder cognitions in adults with atypical AN, and noted the potential importance of distinguishing a purging distinction. A minority of patients in this study had physiological impairments.

Distribution and clinical comparison of restrictive feeding and eating disorders using ICD-10 and ICD-11 criteria

OBJECTIVE

Within the eleventh edition of the International Classification of Diseases (ICD-11), diagnostic criteria for feeding and eating disorders were revised and new diagnoses including avoidant/restrictive food intake disorder (ARFID) are classifiable; however, nothing is known about how these changes affect the prevalence of feeding and eating disorders. This study compared the distribution and clinical characteristics of restrictive feeding and eating disorders between ICD-10 and ICD-11.

METHOD

The Eating Disorder Examination (EDE), its child version, and the EDE ARFID module were administered to N = 82 patients (0-17 years) seeking treatment for restrictive feeding and eating disorders and their parents. Clinical characteristics were derived from medical records, questionnaires, and objective anthropometrics.

RESULTS

The number of residual restrictive eating disorders (rrED) significantly decreased from ICD-10 to ICD-11 due to a crossover to full-threshold disorders, especially anorexia nervosa (AN) or ARFID. Patients reclassified to ICD-11 ARFID were younger, had an earlier age of illness onset, more restrictive eating behaviors, and tended to have more somatic comorbidities compared to those reclassified to ICD-11 AN. Patients with rrED according to both ICD-10 and ICD-11 were younger, had an earlier age of illness onset, less shape concern, and more somatic comorbidities than patients who were reclassified from ICD-10 rrED to ICD-11 AN or ARFID.

DISCUSSION

This study highlights the inclusive approach of ICD-11 criteria, paving the way for more targeted treatment, and ARFID's high clinical relevance. Future studies considering nonrestrictive feeding and eating disorders across the life span may allow further analyses on diagnostic crossover.

PUBLIC SIGNIFICANCE

Changes in diagnostic criteria for restrictive eating disorders within the newly published ICD-11 led to an increase in full-threshold disorders, while the number of rrED was significantly lowered compared to ICD-10 criteria. The results thus highlight the diagnostic utility of ICD-11 criteria and may help providing adequate treatment to children and adolescents with rrED.

Mortality and care of eating disorders

INTRODUCTION

Eating disorders (EDs) are considered serious mental illnesses, with one of the highest lethality among psychiatric disorders, even though the issue of mortality due to these conditions is still controversial. The present study was aimed at comparing the mortality rate in a cohort of ED patients representative of the geographic area with that of the age and gender-matched general population of central Italy.

METHODS

Patients were enrolled between 1994 and 2018, among those attending the eating disorders treatment network of the Florence area (EDTN), which is a regional multidisciplinary treatment reference center for EDs covering the clinical population of the metropolitan Florence area (Italy). The life status of participants was determined through linkage with the Regional Mortality Registry.

RESULTS

A total of 1277 individuals with EDs were included, including 368 with Anorexia Nervosa (AN), 312 with Bulimia Nervosa (BN), and 597 individuals with Binge Eating Disorder (BED). Twenty-two patients (1.72%) died, during a median follow-up of 7.4 years. The mortality rates among ED patients did not significantly differ from that of the general population of the same age and sex with a Standardized Mortality Ratio (SMR) of 1.19, 95% CI 0.79-1.81. Only among BN patients, the mortality was significantly increased after 10 years from clinical evaluation (SMR 11.24, 95% CI 3.62-34.84).

CONCLUSION

The low mortality in EDs, compared to published studies, might be due to the EDTN treatment strategy, based on a large network which makes an integrated multidisciplinary team available for almost all the patients with EDs of the geographical area.

Eating Disorders in Children and Adolescent Males: A Peculiar Psychopathological Profile

(1) Background: Eating Disorders (EDs) are severe psychiatric disorders with high rates of mortality, multiple medical and psychiatric comorbidities associated, and often chronic illness. Historically, EDs are among the most gendered of psychiatric illnesses, and male presentations have been perceived as rare and unusual. This perception resulted in the systematic underrepresentation of males in research on Eds, and as consequence, in a scarcity of research investigating clinical and psychological features in this population. (2) Methods: The present study aims to evaluate clinical and psychopathological features in a sample of 287 children and adolescents, 27 males and 260 females with EDs, in order to identify similarities and differences. (3) Results: Males were younger than females, with similar medical and clinical conditions, but a different distribution of typology of EDs in middle childhood and middle adolescents. The Eating Disorders Inventory-3, TAS-20 for alexithymia and CDI for depressive symptoms' profiles are similar, while males showed higher scores at the global indexes of Symptom Checklist 90-Revised test in early adolescence. (4) Conclusions: Results suggest gender-specific similarities and differences in clinical and psychological features in children and adolescent males, which may require specific diagnosis and treatment.

Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa

PURPOSE OF REVIEW

To review the recent literature on the epidemiology of anorexia nervosa and bulimia nervosa in terms of incidence, prevalence and mortality.

RECENT FINDINGS

Although the overall incidence rate of anorexia nervosa is considerably stable over the past decades, the incidence among younger persons (aged <15 years) has increased. It is unclear whether this reflects earlier detection or earlier age of onset. Nevertheless, it has implications for future research into risk factors and for prevention programs. For bulimia nervosa, there has been a decline in overall incidence rate over time. The lifetime prevalence rates of anorexia nervosa might be up to 4% among females and 0.3% among males. Regarding bulimia nervosa, up to 3% of females and more than 1% of males suffer from this disorder during their lifetime. While epidemiological studies in the past mainly focused on young females from Western countries, anorexia nervosa and bulimia nervosa are reported worldwide among males and females from all ages. Both eating disorders may carry a five or more times increased mortality risk.

SUMMARY

Anorexia nervosa and bulimia nervosa occur worldwide among females and males of all age groups and are associated with an increased mortality risk.

Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature

OBJECTIVE

Currently, there is debate in the eating disorders field regarding how to define atypical anorexia (AAN), how prevalent it is in community and clinical settings, and how AAN rates compare with low-weight AN. This systematic review assesses AAN literature from 2007 to 2020, to investigate: (a) the demographic characteristics of AAN studies, (b) the prevalence of AAN compared with AN, (c) the range of operational definitions of AAN and the implications of these definitions, and (d) the proportion of patients with AAN and AN represented in consecutive admission and referral samples.

METHOD

PsychINFO, CINAHL, PubMed, Greylit.org, and ProQuest databases were searched according to methods for Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic reviews, yielding 3,184 potential articles. Seventy-five eligible studies were coded for sixty-one variables.

RESULTS

Clinical samples predominantly included younger, female, white samples with limited diversity. In epidemiological designs, AAN was typically as common or more common than AN, and AAN rates varied significantly based on the population studied and operational definitions. In consecutive clinical samples, AAN was frequently less represented.

DISCUSSION

Although AAN appears to occur more frequently than AN in communities, fewer patients with AAN are being referred and admitted to eating disorder specific care, particularly in the United States. Given the significant medical and psychosocial consequences of AAN, and the importance of early intervention, this represents a crucial treatment gap. Additionally, results suggest the need for fine-tuning diagnostic definitions, greater diversity in AAN studies, and increased screening and referral for this vulnerable population.

The Presentation of Eating Disorders in Saudi Arabia

Objective: There is lack of information on the presentation of eating disorders (EDs) in Saudi Arabia using gold standard clinical tools. The present study aimed to provide data on the presentation of EDs in Saudi Arabia using clinically validated measures.

Method: Hundred and thirty-three individuals (33 male) with a mean age of 22 years (2.63) completed three measures: the Eating Disorder Examination (EDE), a semi-structured interview, the Eating Disorder Examination Questionnaire (EDE-Q), a self-report measure, and the Depression Anxiety and Stress Scale (DASS-21) to measure comorbid symptoms.

Results: Individuals in Saudi Arabia reported higher levels of restraint, eating concern and shape concern and a higher global score, but lower levels of weight concern on the EDE-Q compared to the EDE. Female participants reported a higher global score, alongside significantly higher scores on the restraint, shape concern and weight concern subscales than males. The most common ED subtype was other specific feeding or ED. Compared with Western community samples, symptom severity in this purposive sample obtained from community settings was significantly higher in this sample.

Discussion: Individuals with eating, weight and shape concerns in Saudi Arabia may feel more comfortable expressing their symptoms on a self-report tool compared with a face to face interview. However, it is possible that a self-report measure may over-estimate the severity of symptoms. The data suggest that clinicians in Saudi Arabia should regularly screen for EDs in all genders. It is also important to note that ED symptoms are a cause for concern in young people in Saudi Arabia.

Psychometric proprieties of the Italian version of the questionnaire on eating and weight patterns (QEWP-5) and its accuracy in screening for binge-eating disorder in patients seeking treatment for obesity

PURPOSE

The aim of the current study was to assess the psychometric proprieties of the Italian version of the latest edition of the Questionnaire of Eating and Weight Patterns (QEWP-5), evaluating its accuracy in screening patients with binge-eating disorder (BED).

METHODS

The Italian translation of the tool was administered to 604 Italian-speaking adults seeking treatment for obesity. The clinical sample was given the Eating Disorder Examination interview to assess for BED. Participants also completed the Symptom Checklist 90, the Obesity-Related Well-Being and the Binge-Eating Scale.

RESULTS

The sensitivity of the QEWP-5 was 0.49, and its specificity 0.93. The positive and negative predictive values were 0.34 and 0.96, respectively. Agreement between QEWP-5 and EDE using Cohen's kappa was 0.35. Nevertheless, among patients with an EDE diagnosis of no BED, those 'QEWP-5-positive' for BED displayed higher eating-disorder and general psychopathology scores, poorer weight-related quality of life, and greater severity of binge-eating behaviours than those 'QEWP-5-negative' for BED.

CONCLUSION

Despite the low concordance with the EDE interview in terms of detecting the presence of BED, the QEWP-5 may be a useful initial screening tool for the clinical assessment of adults seeking treatment for obesity.

LEVEL OF EVIDENCE

Level V, Descriptive study.

Family-Based Treatment for Anorexia Nervosa Symptoms in High-Risk Youth: A Partially-Randomized Preference-Design Study

This pilot study adapted family-based treatment (FBT) for youth with potentially prodromal anorexia nervosa (AN). Fifty-nine youth with clinically significant AN symptom constellations, but who never met full Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) (DSM-IV) criteria for AN, were enrolled in a partially randomized preference design study. Participants were offered randomization to FBT or supportive psychotherapy (SPT); those who declined to be randomized because of a strong treatment preference were entered into a parallel, non-randomized self-selected intervention study. Without accessing outcome data, an observational analysis with three diagnostic subclasses was designed based on AN symptom severity profiles, combining randomized and non-randomized participants, such that participants receiving FBT and SPT within each subclass were similar on key baseline characteristics. Outcomes of this pilot study were explored by calculating effect sizes for end-of-treatment values within each subclass, and also with a longitudinal mixed effect model that accounted for subclass. Weight trajectory was measured by percent expected body weight. Psychological outcomes were fear of weight gain, feeling fat, importance of weight, and importance of shape. Results show that the pattern of symptom observations over time was dependent on subclass of SAN (least symptomatic, moderately symptomatic, or most symptomatic) and on the target outcome variable category (weight or psychological). Results from this study, which should be considered in the context of the small sample sizes overall and within groups, can generate hypotheses for future, larger research trials on early treatment strategies. Feasibility findings illustrate how the innovative partially randomized preference design has potential broader application for AN intervention research.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT00418977.

Screening four broad categories of eating disorders: suitability of a clinical algorithm adapted from the SCOFF questionnaire

BACKGROUND

We evaluated the performance of a clinical algorithm (Expali™), combining two or more positive answers to SCOFF questionnaire with Body Mass Index (BMI), to identify four Broad Categories of eating disorders (ED) derived from DSM-5.

METHODS

The clinical algorithm (Expali™) was developed from 104 combinations of BMI levels and answers to five SCOFF questions with at least two positive answers. Two senior ED physicians allocated each combination to one of the four Broad Categories of ED derived from DSM-5: restrictive disorder, bulimic disorder, hyperphagic disorder and other unspecified ED diagnosed by ED clinicians. The performance of Expali™ was evaluated on data from 206 patients with ED. Sensitivity, specificity values and Youden index were calculated for each category.

RESULTS

The 206 patients were diagnosed as follows: 31.5% restrictive disorder, 18.9% bulimic disorder, 40.8% hyperphagic disorder and 8.8% other ED. The sensitivity of Expali™ for restrictive, bulimic, hyperphagic and other unspecified ED were respectively: 76.9, 69.2, 79.7 and 16.7%. The Youden index was respectively 0.73, 0.57, 0.67 and 0.07.

CONCLUSIONS

In a SCOFF-positive ED population (at least two positive answers), the clinical algorithm Expali™ demonstrated good suitability by correctly classifying three of the four Broad Categories of eating disorders (restrictive, bulimic and hyperphagic disorder). It could be useful both to healthcare professionals and the general population to enable earlier detection and treatment of ED and to improve patient outcomes.

Eating Disorders: An Evolutionary Psychoneuroimmunological Approach

Eating disorders are evolutionarily novel conditions. They lead to some of the highest mortality rates of all psychiatric disorders. Several evolutionary hypotheses have been proposed for eating disorders, but only the intrasexual competition hypothesis is extensively supported by evidence. We present the mismatch hypothesis as a necessary extension to the current theoretical framework of eating disorders. This hypothesis explains the evolutionarily novel adaptive metaproblem that has arisen when mating motives conflict with the large-scale and easy availability of hyper-rewarding but obesogenic foods. This situation is exacerbated particularly in those contemporary environments that are characterized by sedentary lifestyles, ever-present junk foods, caloric surplus and the ubiquity of social comparisons that take place via social media. Our psychoneuroimmunological model connects ultimate-level causation with proximate mechanisms by showing how the adaptive metaproblem between mating motives and food rewards leads to chronic stress and, further, to disordered eating. Chronic stress causes neuroinflammation, which increases susceptibility to OCD-like behaviors that typically co-occur with eating disorders. Chronic stress upregulates the serotonergic system and causes dysphoric mood in anorexia nervosa patients. Dieting, however, reduces serotonin levels and dysphoric mood, leading to a vicious serotonergic-homeostatic stress/starvation cycle whereby cortisol and neuroinflammation increase through stringent dieting. Our psychoneuroimmunological model indicates that between-individual and within-individual variation in eating disorders partially arises from (co)variation in gut microbiota and stress responsivity, which influence neuroinflammation and the serotonergic system. We review the advances that have been made in recent years in understanding how to best treat eating disorders, outlining directions for future clinical research. Current evidence indicates that eating disorder treatments should aim to reduce the chronic stress, neuroinflammation, stress responsivity and gut dysbiosis that fuel the disorders. Connecting ultimate causes with proximate mechanisms and treating biopsychosocial causes rather than manifest symptoms is expected to bring more effective and sophisticated long-term interventions for the millions of people who suffer from eating disorders.

Gut-Brain Interactions: Implications for a Role of the Gut Microbiota in the Treatment and Prognosis of Anorexia Nervosa and Comparison to Type I Diabetes

Anorexia nervosa has poor prognosis and treatment outcomes and is influenced by genetic, metabolic, and psychological factors. Gut microbes interact with gut physiology to influence metabolism and neurobiology, although potential therapeutic benefits remain unknown. Type 1 diabetes is linked to anorexia nervosa through energy dysregulation, which in both disease states is related to the gut microbiota, disordered eating, and genetics.

Toward Quantifying the Psychopathology of Eating Disorders From the Autonomic Nervous System Perspective: A Methodological Approach

The phenomenology of Eating Disorders (ED) relates with altered functioning of the Autonomic Nervous System (ANS). The lack of agreement in what comes to the direction and significance of such alterations is possibly due to the variability in the ED spectrum. As the stress response system is an integral part of the ANS, we propose to investigate ANS tonic variations and phasic activations in response to stressors. We hypothesize that, while using stress as a test probe, characteristic ANS dysregulations in ED may be found when considering several physiological signals measured over time, and weighted by the individual psychological profiles. In this article we describe a novel methodological approach to investigate this hypothesis with the aim of providing further clarification on the ED spectrum conceptualization. The proposed methodology has been designed to be easily integrated in clinical practice and, eventually, in daily life. The population under observation includes both patients in treatment for ED, and matched controls. The study session has the duration of 1 day, including: (1) the administration of a stress task in a controlled environment and (2) naturalistic data collection. The stress task is designed to elicit both mentally and physically driven ANS activation. The naturalistic component intends to illustrate the psychophysiology in everyday life. We use wearable devices to continuously and non-invasively measure bio-signals related to ANS functioning. This information is complemented with psychometric information from validated stress and ED scales and ecological momentary assessments. The protocol has received ethical approval and has been implemented in practice, currently accounting for 37 patients (out of 120) and 16 controls (out of 60). Ongoing work focus on the definition and implementation of a data processing pipeline to quantitatively test our hypothesis, both standard statistical methods and more exploratory machine learning approaches will be considered.

Prevalence of eating disorders over the 2000-2018 period: a systematic literature review

BACKGROUND

Eating disorders (EDs) lead to multiple psychiatric and somatic complications and thus constitute a major public health concern.

OBJECTIVES

The aim of this study was to give an exhaustive view of the studies reporting the prevalence of the different EDs or total EDs and to study their evolution.

METHODS

A literature search following PRISMA Guidelines and limited to studies in English or French published between 2000 and 2018 was performed and relevant studies were included in this systematic review on the prevalence of EDs. The literature search revealed 94 studies with accurate ED diagnosis and 27 with broad ED diagnosis.

RESULTS

In 94 studies with accurate ED diagnosis, the weighted means (ranges) of lifetime ED were 8.4% (3.3-18.6%) for women and 2.2% (0.8-6.5%) for men. The weighted means (ranges) of 12-month ED prevalence were 2.2% (0.8-13.1%) for women and 0.7% (0.3-0.9%) for men. The weighted means (ranges) of point prevalence were 5.7% (0.9-13.5%) for women and 2.2% (0.2-7.3%) for men. According to continents, the weighted means (ranges) of point prevalence were 4.6% (2.0-13.5%) in America, 2.2% (0.2-13.1%) in Europe, and 3.5% (0.6-7.8%) in Asia.In addition to the former, 27 other studies reported the prevalence of EDs as broad categories resulting in weighted means (ranges) of total point prevalence of any EDs of 19.4% (6.5-36.0%) for women and 13.8% (3.6-27.1%) for men.

CONCLUSIONS

Despite the complexity of integrating all ED prevalence data, the most recent studies confirm that EDs are highly prevalent worldwide, especially in women. Moreover, the weighted means of point ED prevalence increased over the study period from 3.5% for the 2000-2006 period to 7.8% for the 2013-2018 period. This highlights a real challenge for public health and healthcare providers.

The Course of Eating Disorders Involving Bingeing and Purging Among Adolescent Girls: Prevalence, Stability, and Transitions

PURPOSE

To quantify eating disorder (ED) stability and diagnostic transition among a community-based sample of adolescents and young adult females in the United States.

METHODS

Using 11 prospective assessments from 9,031 U.S. females ages 9-15 years at baseline of the Growing Up Today Study, we classified cases of the following EDs involving bingeing and purging: bulimia nervosa (BN), binge ED, purging disorder (PD), and subthreshold variants defined by less frequent (monthly vs. weekly) bingeing and purging behaviors. We measured number of years symptomatic and probability of maintaining symptoms, crossing to another diagnosis, or resolving symptoms across consecutive surveys.

RESULTS

Study lifetime disorder prevalence was 2.1% for BN and roughly 6% each for binge ED and PD. Most cases reported symptoms during only one survey year. Twenty-six percent of cases crossed between diagnoses during follow-up. Among participants meeting full threshold diagnostic criteria, transition from BN was most prevalent, crossing most frequently from BN to PD (12.9% of BN cases). Within each disorder phenotype, 20%-40% of cases moved between subthreshold and full threshold criteria across consecutive surveys.

CONCLUSIONS

Diagnostic crossover is not rare among adolescent and young adult females with an ED. Transition patterns from BN to PD add support for considering these classifications in the same diagnostic category of disorders that involve purging. The prevalence of crossover between monthly and weekly symptom frequency suggests that a continuum or staging approach may increase utility of ED classification for prognostic and therapeutic intervention.

Enhanced cognitive behavioural therapy for patients with eating disorders: a systematic review

PURPOSE OF REVIEW

The aim of this study was to provide an update of the most recent (since January 2014) enhanced cognitive behavioural therapy (CBT-E) effectiveness studies (randomized controlled trials and open trials) on bulimia nervosa, binge eating disorder and transdiagnostic samples.

RECENT FINDINGS

Out of 451 screened studies, seven effectiveness studies (five randomized and two open trials) were included in this review: of these, three had a bulimia nervosa sample and four a transdiagnostic sample (all conducted in an outpatient setting). Substantial differences in posttreatment remission rates were found (range: 22.2-67.6%) due, in part, to differences in samples and operationalization of clinical significant change.

SUMMARY

There is robust evidence that CBT-E is an effective treatment for patients with an eating disorder. However, more studies on differential effects and working mechanisms are required to establish the specificity of CBT-E.

Other Specified Feeding or Eating Disorders (OSFED): Clinical heterogeneity and cognitive-behavioral therapy outcome

BACKGROUND

with the DSM-5 new eating disorders (EDs) diagnostic subtypes were identified within the Other Specified Feeding or Eating Disorders (OSFED) category, which have so far been under-researched. Objectives of this study were to examine differential features among OSFED subtypes, exploring short-term cognitive-behavioral therapy (CBT) response and identifying clinical predictors of therapy outcome.

METHODS

the sample included 176 female patients diagnosed with OSFED [82 atypical anorexia nervosa (atypical-AN), 57 purging disorder (PD), and 37 subthreshold bulimia nervosa (sub-BN)]. Assessment included eating-related, psychopathological and personality measures.

RESULTS

results showed similar clinical and personality profiles between the diagnostic subtypes, with hardly any differences, only observable in the core symptoms of each diagnosis. The sub-BN group was the one which showed more social impairment. Regarding treatment outcome, the three groups did not reveal significant differences in remission rates, therapeutic adherence or dropout rates, reaching rates of dropout from 36.8% to 50% (p = .391). However, different ED subtype predictors appear related with full remission or dropout risk, specifically personality traits.

CONCLUSIONS

our results suggest that OSFED patients may benefit similarly from the same CBT outpatient group approach. However, high dropout rates and low motivation seems to be an important limitation and challenge for future approaches.

Implications of DSM-5 for the diagnosis of pediatric eating disorders

OBJECTIVE

The aim of the study was to compare the DSM-IV, DSM-5, and ICD-10 eating disorders (ED) nomenclatures to assess their value in the classification of pediatric eating disorders. We investigated the prevalence of the disorders in accordance with each system's diagnostic criteria, diagnostic concordance between the systems, and interrater reliability.

METHOD

Participants were 1062 children and adolescents assessed at intake to a specialist Eating Disorders Program (91.6% female, mean age 14.5 years, SD = 1.75). Measures were collected from routine intake assessments.

RESULTS

DSM-5 categorization led to a lower prevalence of unspecified EDs when compared with DSM-IV. There was almost complete overlap for specified EDs. Kappa values indicated almost excellent agreement between the two coders on all three diagnostic systems, although there was higher interrater reliability for DSM-5 and ICD-10 when compared with DSM-IV.

DISCUSSION

DSM-5 nomenclature is useful in classifying eating disorders in pediatric clinical samples.

[Anorexia nervosa in males]

Anorexia nervosa in males Abstract. Anorexia nervosa (AN) is a rare disorder in boys and men with limited data and studies available. The recent update of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) will in all likelihood lead to an increase in the prevalence of AN in boys and men. This study aims to give an overview of the existing data in regards to gender differences in epidemiology, etiology, and symptoms of AN. We aim to highlight the differences in AN between the sexes, from a clinical point of view, and underline the need for further research on AN in boys.

A narrative review of binge eating disorder in adolescence: prevalence, impact, and psychological treatment strategies

Binge eating disorder (BED) represents one of the most problematic clinical conditions among youths. Research has shown that the developmental stage of adolescence is a critical stage for the onset of eating disorders (EDs), with a peak prevalence of BED at the age of 16–17 years. Several studies among adults with BED have underlined that it is associated with a broad spectrum of negative consequences, including higher concern about shape and weight, difficulties in social functioning, and emotional-behavioral problems. This review aimed to examine studies focused on the prevalence of BED in the adolescent population, its impact in terms of physical, social, and psychological outcomes, and possible strategies of psychological intervention. The review of international literature was made on paper material and electronic databases ProQuest, PsycArticles, and PsycInfo, and the Scopus index were used to verify the scientific relevance of the papers. Epidemiological research that examined the prevalence of BED in adolescent samples in accordance with Diagnostic and Statistical Manual of Mental Disorders, 4th Edition showed a prevalence ranging from 1% to 4%. More recently, only a few studies have investigated the prevalence of BED, in accordance with the Diagnostic and Statistical Manual of Disorders, Fifth Edition criteria, reporting a prevalence of ~1%–5%. Studies that focused on the possible impact that BED may have on physical, psychological, and social functioning showed that adolescents with BED have an increased risk of developing various adverse consequences, including obesity, social problems, substance use, suicidality, and other psychological difficulties, especially in the internalizing area. Despite the evidence, to date, reviews on possible and effective psychological treatment for BED among young population are rare and focused primarily on adolescent females.

Replication of a Modified Factor Structure for the Eating Disorder Examination-Questionnaire: Extension to Clinical Eating Disorder and Non-clinical Samples in Portugal

Psychometric investigations of the Eating Disorder Examination-Questionnaire (EDE-Q) have generally not supported the original scale structure. The present study tested an alternative brief factor structure in two large Portuguese samples: (1) a non-clinical sample of N = 4117 female students and (2) a treatment-seeking sample of N = 609 patients diagnosed with eating disorders. Confirmatory factor analysis revealed a poor fit for the original EDE-Q structure in both the non-clinical and the clinical samples but revealed a good fit for the alternative 7-item 3-factor structure (dietary restraint, shape/weight overvaluation and body dissatisfaction). Factor loadings were invariant across samples and across the different specific eating disorder diagnoses in the clinical sample. These confirmatory factor analysis findings, which replicate findings from studies with diverse predominately overweight/obese samples, supported a modified 7-item, 3-factor structure for the EDE-Q. The reliable findings across different non-clinical and clinical eating disorder groups provide confidence regarding the potential utility of this brief version. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Prevalence and severity of eating disorders: A comparison of DSM-IV and DSM-5 among German adolescents

OBJECTIVE

Changes in the DSM-5 eating disorders criteria sought to increase the clarity of the diagnostic categories and to decrease the preponderance of nonspecified eating disorders. The first objective of this study was to analyze how these revisions affect threshold and EDNOS/OSFED eating disorder diagnoses in terms of prevalence, sex ratios, and diagnostic distribution in a student sample. Second, we aimed to compare the impairment levels of participants with a threshold, an EDNOS/OSFED and no diagnosis using both DSM-IV and DSM-5.

METHOD

A sample of 1654 7th and 8th grade students completed self-report questionnaires to determine diagnoses and impairment levels in the context of an eating disorder prevention program in nine German secondary schools. Height and weight were measured.

RESULTS

The prevalence of threshold disorders increased from .48% (DSM-IV) to 1.15% (DSM-5). EDNOS disorders increased from 2.90 to 6.23% when using OSFED-categories. A higher proportion of girls was found throughout all the diagnostic categories, and the sex ratios remained stable. The effect sizes of DSM-5 group differences regarding impairment levels were equal to or larger than those of the DSM-IV comparisons, ranging from small to medium.

DISCUSSION

We provide an in-depth overview of changes resulting from the revisions of DSM eating disorder criteria in a German adolescent sample. Despite the overall increase in prevalence estimates, the results suggest that the DSM-5 criteria differentiate participants with threshold disorders and OSFED from those no diagnosis as well as or even more distinctly than the DSM-IV criteria.

Prevalence of eating disorders and picking/nibbling in elderly women

OBJECTIVE

The aim of this study was to examine the point prevalence of eating disorders and picking/nibbling in elderly women.

METHODS

This was a two-stage epidemiological study that assessed 342 women aged 65-94 years old. In Stage 1, the following screening measures were used to identify possible cases: the Mini-Mental State Examination, to screen and exclude patients with cognitive impairment; Weight Concerns Scale; SCOFF (Sick, Control, One, Fat, Food) Questionnaire; Eating Disorder Examination Questionnaire-dietary restraint subscale; and three questions to screen for picking/nibbling and night eating syndrome. Women selected for Stage 2 (n = 118) were interviewed using the diagnostic items of the Eating Disorder Examination.

RESULTS

According to the DSM-5, the prevalence of all eating disorders was 3.25% (1.83-5.7, 95% C.I.). Prevalence of binge-eating disorder was 1.68% (0.82-3.82, 95% C.I.), of other specified feeding or eating disorders was 1.48% (0.63-3.42, 95% C.I.), and of bulimia nervosa 0.3% (.05-1.7, 95% C.I.)]. Binge-eating episodes were reported by 5.62% of women. No cases of anorexia nervosa or night eating syndrome were identified. The prevalence of picking/nibbling was 18.9%. Picking/nibbling was associated with increased body mass index (t(322) = -3.28, p < .001) and binge-eating episodes (χ² (1) = 5.65, p < .017).

DISCUSSION

Prevalence rates of eating disorders on elderly Portuguese women were comparable to those found on young women. Our data support the literature that suggests that binge-eating disorder is particularly prevalent in older adults. Picking/nibbling was the most prevalent eating behavior and we provide further evidence for its association with weight and disordered eating.

The Impact of DSM-5 on Eating Disorder Diagnoses

OBJECTIVE

Eating disorder diagnostic criteria were revised from the fourth to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and -5, respectively). This study examines the impact of these revisions on rates of eating disorder diagnoses in treatment-seeking youth.

METHOD

Participants were 651 youth, ages 7-18 years, presenting to an outpatient eating disorders program who met criteria for a DSM-IV eating disorder diagnosis on intake. Patients completed well-validated semi-structured interviews to assess eating disorder psychopathology and psychiatric comorbidity.

RESULTS

Participants were predominantly female (n = 588; 90.3%) with an average age of 15.28 years (SD = 2.21), mean percent of median Body Mass Index (mBMI) of 101.91 (SD = 31.73), and average duration of illness of 16.74 months (SD = 17.63). Cases of DSM-IV Eating Disorder Not Otherwise Specified (EDNOS), now most consistent with DSM-5 Other Specified Feeding or Eating Disorder, decreased from 47.6% to 39.0%, Anorexia Nervosa increased from 29.6% to 33.5%, and Bulimia Nervosa increased from 22.7% to 24.7%.

DISCUSSION

Consistent with previous studies, and in keeping with the aims of the DSM-5 for eating disorders, the revised diagnostic criteria reduced cases of DSM-IV EDNOS and increased cases of specified eating disorders. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:578-581).

A Tale of Two Runners: A Case Report of Athletes' Experiences with Eating Disorders in College

Athletes are at higher risk than the general population for eating disorders, and risk is heightened for athletes in thin-build sports, including track. Collegiate athletes are particularly vulnerable to disordered eating when the transition from home to the college environment adds to the stress of performance pressures and the high demands of the sport environment. Male and female athletes who develop eating disorders share some common characteristics, yet their experiences can be quite different, in part as a consequence of their sex and how eating disorders develop, and are recognized, acknowledged, and treated, within the culture of sports. This case report describes the experiences of two track athletes, one male and one female, who were recruited to the same Division 1 collegiate track program. Both were elite athletes, freshmen in the same year, experiencing the same urban college environment, and experiencing an eating disorder characterized by restrictive eating, significant weight loss, injury, and compromised performance in sport. Both received treatment from a multidisciplinary team of professionals. Both athletes achieved weight restoration, recovery from the disorder, and success in their sport. In spite of the similarities, striking differences were apparent in clinical presentation, predisposing features, onset of symptoms, entry points to treatment, interventions received, and clinical courses through treatment that depict sex differences in how eating disorders present in athletes and are addressed in the sport environment. Findings endorse the need for research and inform prevention strategies, risk assessment, and intervention approaches for nutrition and sports medicine professionals and collegiate athletic departments.

Guided Self-help for Eating Disorders: A Systematic Review and Metaregression

BACKGROUND

Evidence-based self-help is a recommended first stage of treatment for mild-moderate eating disorders. The provision of guidance enhances outcome. The literature evaluating exclusively 'guided' self-help (GSH) has not been systematically reviewed.

METHODS

The aim was to establish the effectiveness of GSH for reducing global eating disorder psychopathology and abstinence from binge eating, compared with controls. Results were pooled using random effects meta-analysis and heterogeneity explored using metaregression.

RESULTS

Thirty randomised controlled trials met the inclusion criteria. Results showed an overall effect of GSH on global eating disorder psychopathology (-0.46) and binge abstinence (-0.20). There was strong evidence for an association between diagnosis of binge eating disorder and binge abstinence.

DISCUSSION

Current interventions need to be adapted to address features other than binge eating. Further research is required to help us understand the effectiveness of GSH in children and young people, invariably high dropout rates and how technology can enhance interventions. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Feeding and eating disorders in the DSM-5 era: a systematic review of prevalence rates in non-clinical male and female samples

OBJECTIVE

The objective of this study was to systematically review the literature on the prevalence of eating disorders (EDs) during the DSM-5 era, and to report rates of point- and lifetime prevalence.

METHOD

A PubMed search was conducted targeting articles on the epidemiology of EDs, in particular, reported rates of prevalence. The review was performed in accordance with PRISMA guidelines, and was limited to DSM-5 based eating disorder diagnoses published between 2012 and 2017.

RESULTS

A total of 19 studies fulfilled inclusion criteria and were included in the study.

DISCUSSION

Following the transition to DSM-5, it is evident that the prevalence of eating disorder not otherwise specified (EDNOS)/other specified feeding and eating disorders (OSFED) has decreased as intended, and there is preliminary evidence suggesting that rates of anorexia nervosa (AN) and bulimia nervosa (BN) and binge eating disorder (BED) have increased. Further, we observed higher rates of BED prevalence among females compared to males, with rates increasing with age. A limitation to the study was the search date, and that none of the included studies investigated the "new" DSM-5 feeding disorders avoidant restrictive food intake disorder (ARFID), pica or rumination disorder warranting attention in future studies investigating the epidemiology of feeding and eating disorders.

Reassessment of patients with Eating Disorders after moving from DSM-IV towards DSM-5: a retrospective study in a clinical sample

PURPOSE

To compare the relative prevalence of eating disorders moving from DSM-IV to DSM-5, and to reassess the overall medical impairment in the revised diagnostic classes.

METHODS

We applied DSM-5 to 206 patients (age 15-56 years) previously studied and classified according to DSM-IV. Medical impairment was classified as low, medium, or high, based on a cumulative score of clinical severity (SCS), computed as the sum of specific weights assigned to different pathological conditions and their ascertained prognostic impact.

RESULTS

Application of DSM-5 produced a decrease in Eating Disorders Not Otherwise Specified (EDNOS) by 17 %, an increase in anorexia (AN) by 14 % and bulimia (BN) by 2.4 %; 44.6 % of EDNOS migrated to AN, 8 % to BN, and 30.8 % was reclassified as Other Specified Feeding and Eating Disorders (OSFED). Mean SCS was higher in AN than in other diagnoses independent of classification. Differently from EDNOS, no high score was found in OSFED. BMI (OR 0.74, 95 % CI 0.56-0.98) and duration of amenorrhea >1 year (OR 6.63, 95 % CI 1.29-34.16) resulted significantly associated with the risk for medium-high SCS level in AN classified with DSM-5.

CONCLUSION

The results confirmed that DSM-5 reduces the number of EDNOS. DSM-5 seems to better represent the clinical picture in OSFED than in EDNOS. The clinical relevance of BMI and duration of amenorrhea should be considered even more now that they are no longer used as diagnostic hallmarks of AN.

Transitioning from DSM-IV to DSM-5: A systematic review of eating disorder prevalence assessment

OBJECTIVE

The objective of this study was to systematically review the literature on assessment of eating disorder prevalence during the DSM-IV era (1994-2015).

METHOD

A PubMed search was conducted targeting articles on prevalence, incidence and epidemiology of eating disorders. The review was performed in accordance with PRISMA guidelines, and was limited to DSM-IV based eating disorder diagnoses published between 1994 and 2015.

RESULTS

A total of 74 studies fulfilled inclusion criteria and were included in the study. Results yielded evidence of over 40 different assessment instruments used to assess eating disorder prevalence, with the EAT-40 being the most commonly used screening instrument, and the SCID being the most frequently used interview. The vast majority of studies employed two-stage designs, closely followed by clinical interviews. Observations of higher prevalence rates were found in studies employing self-reports compared to two-stage designs and interviews.

DISCUSSION

Eating disorder prevalence rates have varied significantly during the DSM-IV era, and are dependent on assessment methods used and samples investigated. Following the transition to the DSM-5, eating disorder prevalence will change, warranting novel approaches to assessment and treatment planning. © 2016 Wiley Periodicals, Inc.

Other specified and unspecified feeding or eating disorders among women in the community

OBJECTIVE

To examine the occurrence, course, and clinical picture of the DSM-5 residual categories 'Other Specified Feeding or Eating Disorder' (OSFED) and 'Unspecified Feeding or Eating Disorder' (UFED), to describe potential subtypes, and to evaluate whether the subdivision of the residual category appears meaningful.

METHOD

We screened women from the 1975-79 birth cohorts of Finnish twins (N = 2825) for lifetime eating disorders using questionnaires and the SCID interview. This analysis characterizes women who reported clinically significant eating disorder symptoms but did not fulfill diagnostic criteria for DSM-5 anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED).

RESULTS

Thirty-eight women (21% of those with an eating disorder) fell in the residual OSFED/UFED category. A third of them (N = 14) fulfilled OSFED criteria, whereas two thirds (N = 24) fell in the UFED category. The lifetime prevalence of OSFED/UFED was 1.5% (95% CI 1.1-2.0%), less than half of the prevalence of DSM-IV eating disorder not otherwise specified (EDNOS). The mean age of onset of OSFED/UFED was 18 years, median duration of symptoms was two years, and the 5-year probability of recovery was 60%. Over a third of women with OSFED/UFED suffered from comorbid psychiatric disorders. Both residual categories were clinically heterogeneous and included atypical forms of AN, BN, and BED.

CONCLUSIONS

Applying the DSM-5 criteria in a community sample of young women more than halved the occurrence of residual eating disorder diagnoses, but resulted in two instead of one clinically heterogeneous residual categories. Nevertheless, residual eating disorders were associated with considerable clinical severity. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1010-1017).

2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management

Eating disorders, such as anorexia nervosa and bulimia nervosa, can have devastating effects on both the health and performance of athletes. Compared to non-athletes, both female and male athletes are at higher risk of developing an eating disorder. This is especially true for athletes participating in sports where low body weight or leanness confers a competitive advantage. Screening for disordered eating behaviours, eating disorders and for related health consequences should be a standard component of preparticipation examinations, and team physicians should be knowledgeable of the updated diagnostic criteria for eating disorders in the Diagnostic and Statistical Manual-V. Athletes with eating disorders should undergo thorough evaluation and treatment by an experienced multidisciplinary team. Team physicians play a critical role in decision-making on clearance for participation and return to play. Using evidence-based guidelines for clearance and return to play encourages transparency and accountability between the sports medicine care team and the athlete. Efforts to prevent eating disorders should be aimed at athletes, coaches, parents and athletic administrators, and focused on expanding knowledge of healthy nutrition in support of sport performance and health.

Associations between Attention Deficit Hyperactivity Disorder and Eating Disorders by Gender: Results from the National Comorbidity Survey Replication

Few studies have assessed the association between attention-deficit hyperactivity disorder (ADHD) and eating disorders (ED) separately in men and women, especially in representative samples. Using data from the National Comorbidity Survey Replication, lifetime and past 12-month prevalence of Diagnostic and Statistical Manual of Mental Disorders IV, ADHD was compared in men and women with and without diagnoses of Diagnostic and Statistical Manual of Mental Disorders IV ED and any binge eating (BE) using logistic regression models adjusted for gender and age. In both sexes, those with lifetime and past 12-month BE and binge eating disorder had significantly higher prevalence of ADHD than those without BE and binge eating disorder, respectively. Women with lifetime and past 12-month bulimia nervosa and lifetime anorexia nervosa also had significantly higher prevalence of ADHD compared with women without these diagnoses. Given that ADHD invariably began earlier than the ED, ADHD may be an important risk factor for subsequent BE and related ED, and there may be opportunities for intervention among youth with ADHD. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

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.

The DSM-5 diagnostic criteria for anorexia nervosa may change its population prevalence and prognostic value

The definition of anorexia nervosa was revised for the Fifth Edition of the Diagnostic and Statistical Manual (DSM-5). We examined the impact of these changes on the prevalence and prognosis of anorexia nervosa. In a nationwide longitudinal study of Finnish twins born 1975-1979, the women (N = 2825) underwent a 2-stage screening for eating disorders at mean age 24. Fifty-five women fulfilled DSM-IV criteria for lifetime anorexia nervosa. When we recoded the interviews using DSM-5 criteria, we detected 37 new cases. We contrasted new DSM-5 vs. DSM-IV cases to assess their clinical characteristics and prognosis. We also estimated lifetime prevalences and incidences and tested the association of minimum BMI with prognosis. We observed a 60% increase in the lifetime prevalence of anorexia nervosa using the new diagnostic boundaries, from 2.2% to 3.6%. The new cases had a later age of onset (18.8 y vs. 16.5, p = 0.002), higher minimum BMI (16.9 vs. 15.5 kg/m(2), p = 0.0004), a shorter duration of illness (one year vs. three years, p = 0.002), and a higher 5-year probability or recovery (81% vs. 67%, p = 0.002). Minimum BMI was not associated with prognosis. It therefore appears that the substantial increase in prevalence of anorexia nervosa is offset by a more benign course of illness in new cases. Increased diagnostic heterogeneity underscores the need for reliable indicators of disease severity. Our findings indicate that BMI may not be an ideal severity marker, but should be complemented by prognostically informative criteria. Future studies should focus on identifying such factors in prospective settings.

Does specialization of treatment influence mortality in eating disorders?--A comparison of two retrospective cohorts

Eating disorders (EDs) are psychiatric disorders associated with high morbidity and mortality. It is well established that patients with anorexia nervosa (AN) have an increased risk of premature death, whereas mortality data are lacking for the other EDs. This study aimed to establish mortality rates in a sample of ED patients (n=998) with a mean follow-up of 12 years. This was compared to previous data from the same catchment area before a multidisciplinary centre was established. The standardized mortality ratio (SMR) was calculated. To compare the two cohorts, adjusted crude ratios were calculated with the confounding variables: body mass index (BMI), age at referral and diagnosis. In the latest cohort the SMR for AN was 2.89 vs 11.16 in the time before our specialization. SMR for bulimia nervosa (BN) and for eating disorder not otherwise specified (EDNOS) in the latest cohort were 2.37 and 1.14 respectively. When comparing two retrospective cohorts it is not possible to draw a definite conclusion, however the present study supports that integrating a somatic unit in a multidisciplinary centre may have a favourable influence on mortality in AN.

Testing the cognitive-behavioural maintenance models across DSM-5 bulimic-type eating disorder diagnostic groups: a multi-centre study

The original cognitive-behavioural (CB) model of bulimia nervosa, which provided the basis for the widely used CB therapy, proposed that specific dysfunctional cognitions and behaviours maintain the disorder. However, amongst treatment completers, only 40-50 % have a full and lasting response. The enhanced CB model (CB-E), upon which the enhanced version of the CB treatment was based, extended the original approach by including four additional maintenance factors. This study evaluated and compared both CB models in a large clinical treatment seeking sample (N = 679), applying both DSM-IV and DSM-5 criteria for bulimic-type eating disorders. Application of the DSM-5 criteria reduced the number of cases of DSM-IV bulimic-type eating disorders not otherwise specified to 29.6 %. Structural equation modelling analysis indicated that (a) although both models provided a good fit to the data, the CB-E model accounted for a greater proportion of variance in eating-disordered behaviours than the original one, (b) interpersonal problems, clinical perfectionism and low self-esteem were indirectly associated with dietary restraint through over-evaluation of shape and weight, (c) interpersonal problems and mood intolerance were directly linked to binge eating, whereas restraint only indirectly affected binge eating through mood intolerance, suggesting that factors other than restraint may play a more critical role in the maintenance of binge eating. In terms of strength of the associations, differences across DSM-5 bulimic-type eating disorder diagnostic groups were not observed. The results are discussed with reference to theory and research, including neurobiological findings and recent hypotheses.

The epidemiology and genetics of binge eating disorder (BED)

This narrative review provides an overview of the epidemiology of binge eating disorder (BED), highlighting the medical history of this disorder and its entry as an independent condition in the Feeding and Eating Disorders section of the recently published Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Estimates of prevalence are provided, as well as recognition that the female to male ratio is lower in BED than in other eating disorders. Evidence is also provided of the most common comorbidities of BED, including mood and anxiety disorders and a range of addiction disorders. In addition, discussion of the viewpoint that BED itself may be an addiction - at least in severe cases - is presented. Although the genetic study of BED is still in its infancy, current research is reviewed with a focus on certain neurotransmitter genes that regulate brain reward mechanisms. To date, a focal point of this research has been on the dopamine and the μ-opioid receptor genes. Preliminary evidence suggests that a predisposing risk factor for BED may be a heightened sensitivity to reward, which could manifest as a strong dopamine signal in the brain's striatal region. Caution is encouraged, however, in the interpretation of current findings, since samples are relatively small in much of the research. To date, no genome-wide association studies have focused exclusively on BED.

Deconstructing "Atypical" Eating Disorders: an Overview of Emerging Eating Disorder Phenotypes

Recent changes to the diagnostic framework of eating disorders (ED's) in DSM-5 were introduced to reduce the large preponderance of cases falling within the residual and undifferentiated category. However, current reports continue to illustrate overrepresentation of cases in this residual category, suggesting that clinical reality comprises more diverse ED psychopathology than is accounted for in the current diagnostic spectrum. However, with emerging evidence preliminarily delineating several additional distinct phenotypes, we aim to provide a narrative overview of emerging ED phenotypes which (i) are not currently located as a specific diagnostic category in diagnostic criteria for ED's, (ii) centrally feature ED psychopathology, and (iii) have emerging empirical evidence suggesting the distinct nature of the syndrome. A greater awareness of these emerging phenotypes will likely facilitate accurate diagnostic practice and may also serve to facilitate further empirical efforts.

ESCAP Expert Paper: New developments in the diagnosis and treatment of adolescent anorexia nervosa--a European perspective

Anorexia nervosa is a potentially life-threatening disorder with a typical onset in adolescence and high rates of medical complications and psychiatric comorbidity. This article summarizes issues relating to classification in DSM-5 and presents a narrative review of key evidence-based medical and behavioral interventions for adolescent AN and subthreshold restricting eating disorders, mainly, but not exclusively published between 2012 and 2014. In addition, it systematically compares the clinical guidelines of four European countries (Germany, Spain, The Netherlands, and United Kingdom) and outlines common clinical practice, in relation to treatment settings, nutritional rehabilitation, family-oriented and individual psychotherapy, and psychopharmacological treatment. With the exception of family-based treatment, which is mainly evaluated and practiced in Anglo-American countries, the evidence base is weak, especially for medical interventions such as refeeding and pharmacological intervention. There is a need for common European research efforts, to improve the available evidence base and resulting clinical guidance.

Overlap in Eating Disorders and Obesity in Adolescence

While eating disorders and obesity have traditionally been conceptualized as separate conditions, recent research suggests important overlap in several areas including etiology, comorbidity, risk factors, and prevention approaches. Examining the commonality among these conditions is particularly important as adolescents who present with both eating disorder symptomology and obesity demonstrate poorer outcomes within weight control treatments and are at greater risk for future development of full threshold eating disorders and additional weight gain. The purpose of this paper is to review the research examining the overlap in prevalence rates for eating disorders and obesity in adolescents, as well as shared etiology, risk factors, and psychiatric and medical comorbidities. Current preventive and treatment approaches also will be discussed, while highlighting the need for more integrated assessment, prevention, and treatment efforts that focus on maladaptive eating and activity patterns shared by both eating disorders and obesity.

The impact of revised DSM-5 criteria on the relative distribution and inter-rater reliability of eating disorder diagnoses in a residential treatment setting

This study evaluated the relative distribution and inter-rater reliability of revised DSM-5 criteria for eating disorders in a residential treatment program. Consecutive adolescent and young adult females (N=150) admitted to a residential eating disorder treatment facility were assigned both DSM-IV and DSM-5 diagnoses by a clinician (n=14) via routine clinical interview and a research assessor (n=4) via structured interview. We compared the frequency of diagnostic assignments under each taxonomy and by type of assessor. We evaluated concordance between clinician and researcher assignment through inter-rater reliability kappa and percent agreement. Significantly fewer patients received either clinician or researcher diagnoses of a residual eating disorder under DSM-5 (clinician-12.0%; researcher-31.3%) versus DSM-IV (clinician-28.7%; researcher-59.3%), with the majority of reassigned DSM-IV residual cases reclassified as DSM-5 anorexia nervosa. Researcher and clinician diagnoses showed moderate inter-rater reliability under DSM-IV (κ=.48) and DSM-5 (κ=.57), though agreement for specific DSM-5 other specified feeding or eating disorder (OSFED) presentations was poor (κ=.05). DSM-5 revisions were associated with significantly less frequent residual eating disorder diagnoses, but not with reduced inter-rater reliability. Findings support specific dimensions of clinical utility for revised DSM-5 criteria for eating disorders.

Classification of eating disorders: comparison of relative prevalence rates using DSM-IV and DSM-5 criteria

DSM-5 contains substantial changes to eating disorder diagnoses. We examined relative prevalence rates of DSM-IV and DSM-5 eating disorder diagnoses using Eating Disorder Examination-Questionnaire diagnostic algorithms in 117 community out-patients. DSM-5 criteria produced a reduction in combined 'other specified feeding or eating disorder' and 'unspecified feeding or eating disorder' from 46% to 29%, an increase in anorexia nervosa diagnoses from 35% to 47%, the same number of bulimia nervosa diagnoses and a 5% rate of binge eating disorder diagnoses.

Mechanisms of influence of body checking on binge eating

Despite the theorized role of body checking behaviours in the maintenance process of binge eating, the mechanisms by which they may impact binge eating remain unclear. Using objectification model of eating pathology as a theoretical framework, the authors examined the potential intervening roles of body shame, appearance anxiety, and dietary restraint in the pathway between body checking and binge eating. Data collected from a large sample of treatment-seeking people with Bulimic-type Eating Disorders (N = 801) were analysed trough structural equation modelling. Results showed that, regardless of specific DSM-5 diagnostic categories, body checking behaviours were indirectly associated with binge eating and dietary restraint through body shame and appearance anxiety, whereas dietary restraint was directly linked to binge eating. The findings have clinical utility as they contribute to gaining insight into how critical scrutiny of one's body may act in several indirect ways to affect binge eating. We discuss practical implications of the findings.

Update on the medical management of eating disorders in adolescents

The medical practitioner has an important role to play in the management of adolescents with eating disorders, usually as part of a multidisciplinary team. This article reviews the role of the medical practitioner in the diagnosis and treatment of eating disorders, updating the reader on the changing epidemiology of eating disorders, revised diagnostic criteria, newer methods of assessing degree of malnutrition, more aggressive approaches to refeeding, and current approaches to managing low bone mass.

Epidemiology, health-related quality of life and economic burden of binge eating disorder: a systematic literature review

PURPOSE

To perform a systematic review on the epidemiology, the health-related quality of life (HRQoL) and economic burden of binge eating disorder (BED).

METHODS

A systematic literature search of English-language articles was conducted using Medline, Embase, PsycINFO, PsycARTICLES, Academic Search Complete, CINAHL Plus, Business Source Premier and Cochrane Library. Literature search on epidemiology was limited to studies published between 2009 and 2013. Cost data were inflated and converted to 2012 US$ purchasing power parities. All of the included studies were assessed for quality.

RESULTS

Forty-nine articles were included. Data on epidemiology were reported in 31, HRQoL burden in 16, and economic burden in 7 studies. Diagnosis of BED was made using 4th Edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria in 46 studies. Lifetime prevalence of BED was 1.1-1.9% in the general population (DSM-IV). BED was associated with significant impairment in aspects of HRQoL relating to both physical and mental health; the Short Form 36 Physical and Mental Component Summary mean scores varied between 31.1 to 47.3 and 32.0 to 49.8, respectively. Compared to individuals without eating disorder, BED was related to increased healthcare utilization and costs. Annual direct healthcare costs per BED patient ranged between $2,372 and $3,731.

CONCLUSIONS

BED is a serious eating disorder that impairs HRQoL and is related to increased healthcare utilization and healthcare costs. The limited literature warrants further research, especially to better understand the long-term HRQoL and economic burden of BED.

A retrospective study of the impact of DSM-5 on the diagnosis of eating disorders in Victoria, Australia

BACKGROUND

This study compares the DSM-IV and DSM-5 diagnostic criteria for eating disorders. DSM-IV resulted in a large number of patients being diagnosed with Eating Disorder Not Otherwise Specified (EDNOS). In DSM-5 the residual category is renamed Other Specified Feeding and Eating Disorders (OSFED) and Unspecified Eating Disorders (UFED) however the diagnostic criteria for the residual category in each of the diagnostic systems remains the same. This study aims to evaluate the changes in percentages of patients in a residual DSM-IV category compared to a residual DSM-5 category by retrospectively applying DSM-5 criteria to the clinical records of a patient population in a clinical setting. It also aims to compare the psychopathology between the EDNOS and OSFED/UFED groups.

METHODS

285 participants were recruited from a specialised eating disorder clinic in Australia over a 5-year period from 2009 until 2014. The clinical records of patients with diagnoses of anorexia nervosa (AN), bulimia nervosa (BN) and EDNOS were retrospectively assessed using the DSM-5 criteria. All patients who had attended the clinic and received an eating disorder diagnosis during this period were included in the study. No patients were diagnosed with binge eating disorder during the study period. This is surprising given the prevalence of binge eating disorder in the community. It is possible that individuals with binge eating disorder were not referred to the clinic following the initial referral and assessment due to the lack of binge eating specific interventions available. The referral process may also have been skewed towards AN, BN and EDNOS due to a perception by referring parties that binge eating disorder was a 'milder' condition that did not require specialist intervention. Information in the clinical records included structured clinical interviews, and self-rating scales of eating disorder and other psychiatric symptoms and a longitudinal narrative of patient performance and attitude during observed meals.

RESULTS

We observed a 23.5% reduction in the diagnosis of OSFED/UFED with the implementation of DSM-5 compared to EDNOS with DSM-IV. The removal of Criterion D, amenorrhoea, was the leading cause for transition from EDNOS to AN.

CONCLUSIONS

DSM-5 has reduced the reliance on EDNOS. However this study was unable to examine the reliability of the new diagnostic criteria or the impact of DSM-5 on binge eating disorder.

Adolescent eating disorders: update on definitions, symptomatology, epidemiology, and comorbidity

The prevalence of eating disorders among adolescents continues to increase. The starvation process itself is often associated with severe alterations of central and peripheral metabolism, affecting overall health during this vulnerable period. This article aims to convey basic knowledge on these frequent and disabling disorders, and to review new developments in classification issues resulting from the transition to DSM-5. A detailed description is given of the symptomatology of each eating disorder that typically manifests during adolescence. New data on epidemiology, and expanding knowledge on associated medical and psychiatric comorbidities and their often long-lasting sequelae in later life, are provided.