DSM-5 eating disorders and other specified eating and feeding disorders: is there a meaningful differentiation?

Let's get aligned! Developing a core outcome set for clinical trials in eating disorders

OBJECTIVE

Our study aimed to review the outcome measures/assessment instruments used and to assess their heterogeneity/homogeneity in eating disorders (EDs) randomised controlled trials.

METHODS

APA PsycInfo, PubMed, and Embase were searched in December 2022 to identify studies published between and inclusive of January 2012 and December 2022. Inclusion/exclusion criteria were: (1) complete articles published in peer-reviewed scientific journals, which were: (2) randomised trials, (3) in a clinical setting (4) with human subjects, (5) with an ICD or DSM diagnosis of Anorexia Nervosa, Binge Eating Disorder, or Bulimia Nervosa. The selected papers also: (6) used one or more standardised instruments designed to measure one or more psychometric characteristics associated with ED as a primary or secondary outcome, as judged by the authors of this systematic review, and (7) were published in English or Danish.

RESULTS

Ninety one articles were included, and a total of 196 outcome measures were collected.

DISCUSSION

The diversity of outcome measures in ED trials hampers result comparability and data integration. We suggest creating a core outcome measure set using the Delphi method, including clinician and patient-reported ED assessments, along with relevant comorbidity scales.

Is there a basis for a weight cut-off point? A large-scale investigation of atypical anorexia and anorexia nervosa subtypes among patients at a residential treatment centre

OBJECTIVE

There is debate surrounding how to differentiate between anorexia nervosa (AN) and atypical AN (atypAN) as diagnostic entities, and whether a distinction based on BMI is warranted. Better understanding eating disorder (ED) and emotional symptoms across atypAN and AN subtypes [AN-restricting (AN-R), AN-binge/purge (AN-BP)], with and without controlling for BMI, can elucidate how atypAN differs from AN subtypes and whether there is a basis for a BMI cut-off.

METHODS

1810 female patients at an ED treatment centre completed intake surveys. ANCOVAs assessed differences across AN-R (n = 853), AN-BP (n = 726), and atypAN (n = 231) groups on ED, depressive, and anxiety symptoms, anxiety sensitivity, experiential avoidance, and mindfulness, with and without controlling for BMI.

RESULTS

Relative to AN-R, atypAN and AN-BP groups endorsed significantly higher ED and depressive symptoms, anxiety sensitivity, experiential avoidance, and significantly lower mindfulness (all p < 0.001), but atypAN and AN-BP groups did not differ from one another. When controlling for BMI, all previously significant differences between atypAN and AN-R did not remain significant.

CONCLUSION

Individuals with atypAN who have a higher BMI experience more pronounced ED and emotional symptoms, suggesting that relying solely on BMI as a marker of illness severity may be problematic.

Sociodemographic correlates of parent and youth-reported eating disorder symptoms in the Adolescent Brain Cognitive Development Study

Purpose

Eating Disorders (EDs) often start in adolescence, though ED-related concerns in diverse youth samples remain understudied. We leveraged data from the Adolescent Brain Cognitive Development (ABCD) Study to identify the prevalence of parent- and youth-reported ED symptoms and their sociodemographic characteristics.

Methods

Data were drawn from baseline (ages 9-11 years, n=11,868) and 2-year follow-up (ages 11-14 years; n=10,908) from the ABCD Study. A tetrachoric factor analysis summarized clusters of ED symptoms, which were compared between parent and youth reports and across sociodemographic variables.

Results

Three factors emerged reflecting "weight distress", "weight control", and "binge eating" (prevalence range: 1.5-7.3%). Symptoms loaded onto similar factors between reporters. Rates of symptom endorsement were similar between sexes, with disproportionately higher endorsement rates for youth who self-identified as sexual minority, Hispanic, Black, or Mixed race participants, and those from a disadvantaged socioeconomic background, compared to the reference ABCD sample. Youth and parent reports at 2-year showed ~12% overlap.

Conclusions

ED-related concerns among historically understudied racial and sexual minority groups call for greater attention to the detection and treatment of these symptoms in these groups. Applying a transdiagnostic approach to ED symptoms can inform effective detection and intervention efforts.

Some hope for a dimensional assessment? A critical review of psychometric validated (semi-)structured interview to assess eating disorders

OBJECTIVE

Given that eating disorders (EDs) are considered one of the deadliest mental illnesses, the development of appropriate assessment instruments is a necessity. Despite the extensive literature on assessing EDs, there has been a lack of focus on semi-structured interviews. The purpose of this article is to provide a comprehensive review of psychometrically validated semi-structured interviews for EDs.

METHODS

Included studies (N = 24) were required to present a semi-structured interview for EDs that has been validated through a psychometric process. The APA PsycNet, MEDLINE, APA Psycinfo, Pubmed, and Health & Psychosocial Instruments databases were searched. The literature search included publications through May 2024, with no earliest year restriction.

RESULTS

A total of six instruments were identified and reviewed in terms of conceptual design, purpose and content, psychometric characteristics, and strengths and limitations. Three main findings were highlighted: (a) only half of the instruments are up to date; (b) the instruments are based on either a categorical or a mixed categorical-dimensional approach; and (c) the predominance of the categorical approach.

CONCLUSIONS

The results are discussed regarding the conceptual approaches of the instrument to provide clinical and research implications. Despite the many strengths of the instrument, additional psychometric research is needed.

The role of self-reliance and denial in the help-seeking process for eating disorders among university students

OBJECTIVE

This study investigated how self-reliance and denial influence the relationship between help-seeking attitudes and behaviour.

METHOD

Australian university students (N = 406) completed an online survey and females with elevated eating disorder (ED) concerns and high impairment were included in the study (N = 137). Participants completed measures of help-seeking attitudes, perceived barriers, and actual help-seeking behaviour. Via moderated logistic regression, we examined self-reliance and denial as perceived barriers to help-seeking.

RESULTS

Of the total sample, over 33.7% of university students reported substantial ED concerns and impairment of whom 65.0% believed they needed help. While a majority reported that help-seeking would be useful (85.4%), only a minority of participants had sought professional help for their concerns (38.7%). Self-reliance and denial were frequently endorsed barriers and moderated the relationship between help-seeking attitudes and behaviours.

CONCLUSION

ED concerns are common among university students and perceived barriers play a moderating role between attitudes and help-seeking. Future prevention and early intervention programs should address students' denial, while the importance of reaching out for professional help (rather than relying on themselves) could be highlighted with peer support.

The role of readiness and confidence to change in the treatment of atypical anorexia nervosa and bulimia nervosa

OBJECTIVE

Atypical anorexia nervosa (AN) is a serious eating disorder that is more common in the population than AN. Despite this, people with atypical AN are less likely to be referred or admitted for eating disorder treatment and there is evidence that they are less likely to complete or benefit from existing interventions. This study examined whether baseline readiness and/or confidence moderated outcomes from 10-session cognitive behavioral therapy among people with atypical AN and bulimia nervosa (BN), and whether the impact of these variables differed between diagnoses.

METHODS

Participants (n = 67; 33 with atypical AN) were a subset from an outpatient treatment study. Linear mixed model analyses were conducted to examine whether baseline readiness and/or confidence moderated outcomes.

RESULTS

People with BN who had higher levels of readiness or confidence at baseline had steeper decreases in eating disorder psychopathology over time. There was no evidence that readiness or confidence moderated outcomes for people with atypical AN.

DISCUSSION

This study suggests that the moderators that have been identified for other eating disorders may not apply for people with atypical AN and highlights a need for future work to routinely investigate whether theoretically or empirically driven variables moderate outcomes in this little-understood population.

PUBLIC SIGNIFICANCE STATEMENT

People with bulimia nervosa with higher readiness and confidence experienced greater decreases in eating disorder symptoms than people with lower readiness and confidence when treated with cognitive behavioral therapy. These findings did not apply to people with atypical anorexia nervosa. Results demonstrate that future work is urgently required to identify helpful treatments for people with atypical anorexia nervosa as well as the variables that have a positive impact on outcomes in treatment for these individuals.

Eating disorder-related functional impairment predicts greater depressive symptoms across one semester of college

Eating disorder (ED) behaviors and depression are associated with numerous negative outcomes, including lower quality of life and functional impairment. College women are at elevated risk for both. Prior research indicates ED behaviors, including binge eating, self-induced vomiting, and fasting, predict increases in future depressive symptoms. However, symptom heterogeneity in EDs is common, and all disordered eating, or its associated distress, cannot be captured by the endorsement of behaviors. Impairment that results from ED behaviors may be a comparable, or stronger, predictor of depressive symptoms. We sought to characterize the longitudinal relationship between ED-related functional impairment, ED behaviors, and depressive symptoms. College-aged women [N = 304; 72 % white, mean (SD) age = 18.45 (0.88)] completed an online survey in August (baseline), and then three months later in November (follow-up). Baseline ED-related functional impairment, but not baseline ED behaviors, significantly predicted depressive symptoms at follow-up, controlling for baseline depressive symptoms, negative affect, and body mass index. Findings indicate ED-related functional impairment is a risk factor for increases in depressive symptoms across one semester of college, irrespective of ED behavior engagement, weight status, and dispositional negative affect. Intervening upon ED-related functional impairment may reduce or prevent future depressive symptoms among college-aged women.

When Eating Intuitively Is Not Always a Positive Response: Using Machine Learning to Better Unravel Eaters Profiles

BACKGROUND

The aim of the present study was to identify eaters profiles using the latest advantages of Machine Learning approach to cluster analysis.

METHODS

A total of 317 participants completed an online-based survey including self-reported measures of body image dissatisfaction, bulimia, restraint, and intuitive eating. Analyses were conducted in two steps: (a) identifying an optimal number of clusters, and (b) validating the clustering model of eaters profile using a procedure inspired by the Causal Reasoning approach.

RESULTS

This study reveals a 7-cluster model of eaters profiles. The characteristics, needs, and strengths of each eater profile are discussed along with the presentation of a continuum of eaters profiles.

CONCLUSIONS

This conceptualization of eaters profiles could guide the direction of health education and treatment interventions targeting perceptual and eating dimensions.

Proposal for increasing diagnostic clarity in research and clinical practice by renaming and reframing atypical anorexia nervosa as "Restrictive Eating Disorder" (RED)

Atypical anorexia nervosa (AAN) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), is characterized by meeting all criteria for anorexia nervosa (AN) except for weight being within or above the "normal" range despite significant weight loss. The current definition is plagued by several problems, resulting in widely heterogeneous operationalizations in research and clinical practice. As such, the poorly defined diagnosis of AAN negatively impacts affected individuals and frustrates research attempts to better understand the syndrome. We consider conceptual flaws in the AAN description and contend that the undefined weight range and nature of weight loss renders these two factors functionally inapplicable in research and practice. They also represent a departure from the originally intended use of the AAN category, i.e., arresting a negative weight trajectory likely to result in AN, making the target population, and the application of the label, unclear. We propose revised criteria and a new name, restrictive eating disorder (RED), intended to reduce stigma and encompass a wide but better-defined range of presentations. The RED criteria focus on clinically significant restrictive behavior that disrupts normal living (i.e., impairment), and cognitive symptoms of overevaluation, disturbed experience, and lack of recognition of illness seriousness. We believe that RED may enable more appropriate clinical application, but also inspire coordinated research toward a more valid psychiatric nosology in the eating disorders field.

From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders

PURPOSE

Atheoretical and descriptive conceptualizations of eating disorders (EDs) have faced substantial criticism due to their limited ability to assess patients' subjective characteristics and experiences, as needed to determine the most appropriate treatment options. The present article provides an overview of the clinical and empirical literature supporting the potential contribution of the Psychodynamic Diagnostic Manual (PDM-2) to both diagnostic assessment and treatment monitoring.

METHODS

Following a discussion of the most relevant shortcomings of current diagnostic models of EDs and a description of the rationale and structure of the PDM-2, evidence supporting the core PDM-2 dimensions of ED patients' subjective experiences (i.e., affective states, cognitive processes, relational patterns, somatic/bodily experiences and states) are examined, alongside their relevance to ED diagnosis and treatment.

RESULTS

Overall, the reviewed studies support the diagnostic importance of these patterns of subjective experiences in EDs, highlighting their potential role as either predisposing or maintaining factors to target in psychotherapy. A growing body of multidisciplinary evidence also shows that bodily and somatic experiences are central to the diagnosis and clinical management of ED patients. Moreover, there is evidence that a PDM-based assessment may enable closer monitoring of patient progress during treatment, with regard to both subjective experiences and symptom patterns.

CONCLUSIONS

The study suggests that current diagnostic frameworks for EDs would benefit from the addition of a person-centered perspective that considers not only symptoms, but also patients' full range of functioning-including their deep and surface-level emotional, cognitive, interpersonal, and social patterns-to improve patient-tailored interventions.

LEVEL OF EVIDENCE

Level V, narrative review.

Epidemiology of eating disorders: population, prevalence, disease burden and quality of life informing public policy in Australia-a rapid review

BACKGROUND

Understanding of the epidemiology and health burden of eating disorders has progressed significantly in the last 2 decades. It was considered one of seven key areas to inform the Australian Government commissioned National Eating Disorder Research and Translation Strategy 2021-2031, as emerging research had highlighted a rise in eating disorder prevalence and worsening burden-of-illness. The aim of this review was to better understand the global epidemiology and impact of eating disorders to inform policy decision-making.

METHODS

Using a systematic Rapid Review methodology, ScienceDirect, PubMed and Medline (Ovid) were searched for peer-reviewed studies published between 2009 and 2021. Clear inclusion criteria were developed in consultation with experts in the field. Purposive sampling of literature was conducted, which predominately focused on higher-level evidence (meta-analyses, systematic reviews, and large epidemiological studies), synthesised, and narratively analysed.

RESULTS

135 studies were deemed eligible for inclusion in this review (N = 1324). Prevalence estimates varied. Global Lifetime prevalence of any eating disorder ranged from 0.74 to 2.2% in males, and 2.58-8.4% in females. Australian 3-month point-prevalence of broadly defined disorders was around 16% in females. Eating disorders appeared more prevalent in young people and adolescents, particularly females (in Australia: eating disorders ~ 22.2%; disordered eating ~ 25.7%). Limited evidence was found on sex, sexuality and gender diverse (LGBTQI +) individuals, particularly males, who had a six-fold increase in prevalence compared to the general male population, with increased illness impact. Similarly, limited evidence on First Australian's (Aboriginal and Torres Strait Islander) suggests prevalence rates similar to non-Indigenous Australians. No prevalence studies were identified specifically assessing culturally and linguistically diverse populations. Global disease burden of any eating disorder was 43.4 age-standardised disability-adjusted-life-years per 100,000; increasing by 9.4% between 2007 and 2017. Australian's total economic cost was estimated at $84 billion from years-of-life lost due to disability and death, and annual lost earnings ~ $1.646 billion."

CONCLUSIONS

There is no doubt that eating disorder prevalence and impact are on the rise, particularly in at-risk and understudied populations. Much of the evidence came from female-only samples, and Western, high-income countries which more readily have access to specialised services. Future research should examine more representative samples. There is an urgent need for more refined epidemiological methods to better understand these complex illnesses over time, to guide health policy and development-of-care.

Paediatric eating disorders: Exploring virtual family therapy during a global pandemic

AIM

Explore treatment response and effectiveness of virtual treatment for a paediatric eating disorder sample.

METHODS

Twenty patients and their families who received either virtual or in-person family therapy were included in the study. Family therapy was informed by family-based treatment (FBT) principles. Patients' weight restoration at 1, 3, and 6 months after starting treatment was examined. Independent sample t tests assessed group differences and a Fisher exact test was used to evaluate the association between treatment group and weight restoration.

RESULTS

Weight restoration did not significantly differ between treatment groups (virtual vs. in-person) at any time point and there was no association between group and remission weight at 6 months.

CONCLUSIONS

Study results are considered exploratory. Future research addressing study limitations is needed. Results suggest that paediatric eating disorder patients may benefit from family therapy delivered via a virtual platform.

"How Do I Exist in This Body…That's Outside of the Norm?" Trans and Nonbinary Experiences of Conformity, Coping, and Connection in Atypical Anorexia

Addressing eating disorders (EDs) within trans and nonbinary (TNB) populations is a growing concern, as TNB individuals are two to four times more likely to experience EDs than cisgender women. This study explored the lived experiences of TNB people with atypical anorexia by examining how gender identity impacted experiences of ED illness and (potential) recovery. Nine TNB adults with atypical anorexia were followed for one year and completed semi-structured, in-depth, longitudinal qualitative interviews at baseline, 6 months, and 12 months. Interviews were coded using Braun and Clark's thematic analysis procedures. Four themes, along with subthemes, emerged regarding the intersection of gender identity and ED experiences: (1) Conforming, (2) Coping, (3) Connecting, and (4) Critiquing. In Conforming, participants highlighted how societal pressures around gender contributed to ED vulnerability. In Coping, participants explained that their EDs represented attempts to cope with the overlapping influences of body dissatisfaction, gender dysphoria, and body disconnection. In Connecting, participants described ED recovery as a process of connecting to self, others, and communities that welcomed and affirmed their diverse identities. In Critiquing, participants described how current ED treatment settings were often unwelcoming of or unprepared for non-cisgender patients. Overall, participants viewed their EDs as intricately linked to their gender identity and experiences of social pressure and discrimination. This study suggests the need for targeted ED prevention and intervention efforts within TNB communities, and the ethical imperative to meaningfully address the needs of TNB patients in ED treatment settings.

The structure of eating disorder and somatic symptoms

Individuals with eating disorders (EDs) often present with somatic concerns in treatment, such as bloating, fullness, and feeling tight clothes on skin. However, most research generally focuses on general interoception (e.g., heartbeat) rather than sensations relevant to EDs (e.g., sensations related to the gastrointestinal system or body movement). In the current study (N = 181), we used network analysis to model the structure of ED symptoms and somatic concerns among individuals with anorexia nervosa, bulimia nervosa, and other specified feeding and eating disorder. Results showed that heightened sensitivity to somatic concerns had the highest strength centrality within a symptom network comprising ED and somatic symptoms. Exploratory graph analysis identified four symptom dimensions: cognitive-affective ED symptoms, behavioral ED symptoms, general interoception, and ED-specific proprioception. Findings suggest that heightened sensitivity to somatic concerns may maintain ED symptoms and mutually reinforce other somatic concerns. Implications concerning assessment and treatment of EDs are discussed.

Non-verbal social communication in individuals with eating disorders: an ethological analysis in experimental setting

PURPOSE

Evidence that social difficulties promote the development and the maintenance of eating disorders (EDs) derive from self-reported data and only partially from experimental tasks. This study objectively assessed non-verbal behaviors of individuals with EDs in a psycho-social stress scenario.

METHODS

Thirty-one women suffering from EDs (13 with anorexia nervosa and 18 with bulimia nervosa) and 15 healthy women underwent the Trier Social Stress Test (TSST), the paradigm of psycho-social stress, and were videotaped. Throughout the procedure, anxiety feelings were measured by the State-Trait Anxiety Inventory state subscale and saliva samples were collected to evaluate cortisol levels. Non-verbal behaviors were analyzed through the Ethological Coding System for Interviews and were compared between study samples through multivariate analysis of variance. Multivariate regression analyses were performed to assess the association between anxiety, cortisol and behavioral responses to TSST.

RESULTS

Women with EDs showed reduced submissiveness, flight (cutoff from social stimuli) and gesture compared to healthy peers during TSST. Submissiveness and flight behaviors were negatively associated with stress-induced anxiety, while TSST-induced anxiety and cortisol increases were positively associated with looking at the other's face behavior in participants with EDs. In this population, cortisol reactivity was also positively associated with submissiveness and negatively with gesture.

CONCLUSION

Women with EDs showed a hostile and freezing response to acute psycho-social stress: reduced submissiveness and flight may represent strategies to manage social anxiety. These findings confirm that the non-verbal behavior assessment provides complementary information to those derived from traditional measurements and suggests research and clinical implications.

LEVEL OF EVIDENCE I

Evidence obtained from experimental study.

Worldwide prevalence of DSM-5 eating disorders among young people

PURPOSE OF REVIEW

Eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder, and other eating disorders) affect young people worldwide. This narrative review summarizes key studies conducted on the prevalence of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) eating disorders among young people in 2013-22.

RECENT FINDINGS

In Western settings, a substantial proportion of young people have reported an eating disorder. Overall, 5.5--17.9% of young women and 0.6-2.4% of young men have experienced a DSM-5 eating disorder by early adulthood. Lifetime DSM-5 anorexia nervosa was reported by 0.8-6.3% of women and 0.1-0.3% of men, bulimia nervosa by 0.8-2.6% of women and 0.1-0.2% of men, binge eating disorder by 0.6-6.1% of women and 0.3-0.7% of men, other specified feeding or eating disorders by 0.6-11.5% of women and 0.2-0.3% of men, and unspecified feeding or eating disorders 0.2-4.7% of women and 0-1.6% of men. Gender and sexual minorities were at particularly high risk. Emerging studies from Eastern Europe, Asia, and Latin America show similar high prevalences. During the COVID-19 pandemic, the incidence of eating disorders has still increased.

SUMMARY

Eating disorders are a global health concern among young people. Improved detection, management, and prevention methods are urgently needed.

Understanding the Effects of Disordered Eating on Fertility and Fertility Outcomes

Disordered eating and subthreshold eating disorders can affect fertility. A negative cumulative energy balance that occurs through inadequate nutrition and excessive exercise is often found in individuals engaging in disordered eating behaviors; these disruptions can affect the normal functioning of the hypothalamic-pituitary-gonadal axis and, thus, fertility. Appropriate screening; assessment; and medical, nutritional, and psychosocial interventions are needed to successfully treat these individuals. Educating nurses about the impact of disordered eating on fertility status will enable those who work with clients of reproductive age to better recognize signs and symptoms of disordered eating and to ultimately provide better care. This article addresses how to appropriately recognize and treat individuals presenting with infertility and disordered eating symptomatology.

Examining the prevalence of disordered eating in a cohort of young Australians presenting for mental health care at a headspace centre: results from a cross-sectional clinical survey study

OBJECTIVES

The aim of this study was to determine the prevalence of disordered eating in young people attending a headspace centre, an enhanced primary care centre providing early intervention services for mental health disorders for young people aged 12-25 years, in metropolitan Sydney.

DESIGN

Cross-sectional assessment of disordered eating symptoms and behaviours.

SETTING

An enhanced primary care youth mental health service in inner urban Sydney, Australia.

PARTICIPANTS

A sequential cohort of 530 young people aged 14-26 years presenting to headspace Camperdown for support with mental health concerns.

OUTCOME MEASURES

Participants completed a series of questionnaires online which included items assessing the presence of eating disorder symptoms and behaviours.

RESULTS

Over one-third of young people aged 14-26 years presenting to headspace Camperdown in a 22-month period reported symptoms of disordered eating. Of these, 32% endorsed overeating behaviours, 25% endorsed dietary restriction and 8% reported purging behaviours. In total, 44% reported engaging in one of more of these behaviours on a regular basis. Almost half reported experiencing significant shape and weight concerns. Eating disorder behaviours were particularly prevalent among female and gender-diverse participants (48% of females and 46% of gender-diverse participants compared with 35% of males) and overall scores across all of the eating disorder and body image items assessed were significantly higher for female participants compared with males.

CONCLUSIONS

Disordered eating behaviours and symptoms are common among those presenting to youth mental health primary care services. Proactive screening for these behaviours presents opportunities for early detection and specific interventions.

TRIAL REGISTRATION NUMBER

ACTRN12618001676202; Results.

A network approach can improve eating disorder conceptualization and treatment

Eating disorders are severe mental illnesses with the second highest mortality rate of all psychiatric illnesses. Eating disorders are exceedingly deadly because of their complexity. Specifically, eating disorders are highly comorbid with other psychiatric illnesses (up to 95% of individuals with an eating disorder have at least one additional psychiatric illness), have extremely heterogeneous presentations, and individuals often migrate from one specific eating disorder diagnosis to another. In this Perspective, we propose that understanding eating disorder comorbidity and heterogeneity via a network theory approach offers substantial benefits for both conceptualization and treatment. Such a conceptualization, strongly based on theory, can identify specific pathways that maintain psychiatric comorbidity, how diagnoses vary across individuals, and how specific symptoms and comorbidities maintain illness for one individual, thereby paving the way for personalized treatment.

Hyper-palatable food consumption during binge-eating episodes: A comparison of intake during binge eating and restricting

OBJECTIVE

The study aim was to elucidate the degree to which hyper-palatable foods (HPF) are consumed during binge episodes compared to restricting episodes, and to test the association between HPF intake during each episode and respective episode frequency.

METHOD

This study was a secondary analysis of data from a larger study on eating disorders. The present sample included adults (N = 147, 83% women) diagnosed with sub-threshold (41%) or full-threshold (59%) bulimia nervosa (BN). Foods consumed during binge and restricting episodes were assessed using the Eating Pathology Symptoms Inventory-Clinician Rated Version. A standardized definition of HPF developed previously was applied to foods consumed during binge and restricting episodes. A Wilcoxon matched-pairs signed-rank test was used to test the difference between total caloric intake from HPF (KcalHPF) and percentage of caloric intake from HPF (PercHPF) during binge episodes relative to restricting episodes. Four linear regression models tested HPF intake (KcalHPF and PercHPF) during both episode types (binge and restricting) as predictors of respective episode frequency.

RESULTS

There was a significant difference between median KcalHPF (1846.6 vs. 279.6; Z = -13.38, p < .001) and PercHPF during binge compared to restricting episodes (95% vs. 61%; Z = -7.35, p < .001). Regression analyses demonstrated that KcalHPF during binge episodes was significantly associated with binge episode frequency (B = 0.002; p < .001), but not PercHPF (p = .287).

DISCUSSION

Results suggest that HPF may be primarily consumed during binge episodes among individuals with BN, and may be associated with greater binge-eating frequency.

PUBLIC SIGNIFICANCE

Findings from the current study support an underlying assumption of theoretical models of binge eating, suggesting that highly rewarding, hyper-palatable foods (HPF), may constitute the vast majority of energy intake during binge-eating episodes. Additionally, a substantial amount of energy intake from HPF may occur during restricting episodes among people with bulimia nervosa. Greater HPF intake during binge eating may also be associated with binge-eating severity.

How Different Are Threshold and Other Specified Feeding and Eating Disorders? Comparing Severity and Treatment Outcome

Background

Other Specified Feeding and Eating Disorders (OSFED) are characterized by less frequent symptoms or symptoms that do not meet full criteria for another eating disorder. Despite its high prevalence, limited research has examined differences in severity and treatment outcome among patients with OSFED compared to threshold EDs [Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED)]. The purpose of the current study was to examine differences in clinical presentation and treatment outcome between a heterogenous group of patients with OSFED or threshold EDs.

Method

Patients with threshold EDs (AN = 42, BN = 50, BED = 14) or OSFED (n = 66) presenting for eating disorder treatment completed self-report questionnaires at intake and discharge to assess eating disorder symptoms, depression symptoms, impairment, and self-esteem.

Results

At intake, OSFED patients showed lower eating concerns compared to patients with BN, but similar levels compared to AN and BED. The OSFED group showed higher restraint symptoms compared to BED, and similar restraint to AN and BN. Global symptoms as well as shape and weight concerns were similar between OSFED and threshold ED groups. There were no differences between diagnostic groups in self-esteem, depression scores, or symptom change from intake to discharge.

Discussion

Our findings suggest that individuals with OSFED showed largely similar ED psychopathology and similar decreases in symptoms across treatment as individuals diagnosed with threshold EDs. Taken together, findings challenge the idea that OSFED is less severe and more resistant to treatment than threshold EDs.

Using shape and weight overvaluation to empirically differentiate severity of other specified feeding or eating disorder

BACKGROUND

Although no severity specifiers are noted in the Diagnostic and Statistical Manual of Mental Disorders - 5 for other specified feeding or eating disorder (OSFED), shape/weight overvaluation is a proposed eating disorder (ED) severity specifier. We used structural equation modeling (SEM) Trees to empirically determine values of shape/weight overvaluation that differentiate OSFED severity. We additionally tested whether the SEM Tree-defined thresholds or a clinical cutoff for shape/weight overvaluation differentiated severity more meaningfully.

METHODS

Participants were 690 females with OSFED presenting to residential ED treatment. SEM Tree analyses specified an outcome model of OSFED severity and then recursively partitioning the outcome model into severity groups. The SEM Tree-defined and clinical cutoff severity groups were compared on clinical characteristics.

RESULTS

SEM Trees identified one split that occurred at value 5.12 on our shape/weight overvaluation items from the Eating Disorder Examination Questionnaire. The subgroup with higher overvaluation had significantly greater intensity of ED and depressive symptoms and longer lengths of stay. The subgroups created from the shape/weight overvaluation clinical-cut off value of 4 differed on the same clinical characteristics as the SEM Tree-derived groups, with the exception of laxative use frequency. Effect sizes were larger for the clinical cutoff as compared to the SEM Tree severity specification scheme.

LIMITATIONS

These cross-sectional data were used from a predominately white and female residential treatment sample; this likely skewed the subgroups and may limit generalizability.

CONCLUSIONS

Shape/weight overvaluation can meaningfully differentiate OSFED severity. The clinical cutoff slightly outperformed the empirically determined thresholds for shape/weight overvaluation.

Subcortical brain volume and cortical thickness in adolescent girls and women with binge eating

OBJECTIVE

Alterations in brain structure have been implicated in the onset and acute phases of several forms of psychopathology. However, there is a dearth of research investigating brain structure in persons with binge eating, contributing to poor understanding of mechanisms associated with binge eating.

METHOD

Adolescent girls and women (aged 14-35 years) with binge eating (n = 56) and group age-matched girls and women without binge eating (n = 26) completed structural magnetic resonance imaging (MRI) scans and interview-based and self-report assessments of eating disorder and general psychopathology. MRI data were processed using FreeSurfer. Analysis of covariance tested mean differences in subcortical volume and cortical thickness of a priori selected regions of interest between binge-eating and non-binge-eating groups, controlling for age, body mass index, purging frequency, depression, and medication use. Exploratory partial correlations tested associations between brain structure and eating disorder symptoms within participants with binge eating.

RESULTS

We did not observe differences in regional subcortical volume and cortical thickness between girls and women with and without binge eating. Within participants with binge eating, severity of attitudinal eating disorder symptoms was inversely associated with caudal middle frontal gyrus, right precentral gyrus, right postcentral gyrus, superior parietal, left inferior parietal thickness, and left accumbens volume; however, these associations would not survive multiple-comparison corrections.

DISCUSSION

Correlations between attitudinal eating disorder symptoms and frontoparietal thinning may represent a state marker of binge eating. Future research could investigate whether frontoparietal thinning worsens with illness duration or persists beyond binge eating cessation.

An empirical evaluation of the diagnostic threshold between full-threshold and sub-threshold bulimia nervosa

Previous research has failed to find differences in eating disorder and general psychopathology and impairment between people with sub- and full-threshold bulimia nervosa (BN). The purpose of the current study was to test the validity of the distinction between sub- and full-threshold BN and to determine the frequency of objective binge episodes and inappropriate compensatory behaviors that would best distinguish between sub- and full-BN. Community-recruited adults (83.5% female) with current sub-threshold (n = 105) or full-threshold BN (n = 99) completed assessments of eating-disorder psychopathology, clinical impairment, internalizing problems, and drug and alcohol misuse. Receiver operating characteristic curve analysis was used to evaluate whether eating-disorder psychopathology, clinical impairment, internalizing problems, and drug and alcohol misuse could empirically discriminate between sub- and full-threshold BN. The frequency of binge episodes and inappropriate compensatory behaviors (AUC = 0.94) was "highly accurate" in discriminating between sub- and full-threshold BN; however, only objective binge episodes was a significant predictor of BN status. Internalizing symptoms (AUC = 0.71) were "moderately accurate" at distinguishing between sub- and full-BN. Neither clinical impairment (AUC = 0.60) nor drug (AUC = 0.56) or alcohol misuse (AUC = 0.52) discriminated between groups. Results suggested that 11 episodes of binge eating and 17 episodes of inappropriate compensatory behaviors optimally distinguished between sub- and full-BN. Overall, results provided mixed support for the distinction between sub- and full-threshold BN. Future research to clarify the most meaningful way to discriminate between sub- and full-threshold is warranted to improve the criterion-related validity of the diagnostic system.

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.

An empirical taxonomy of reward response patterns in a transdiagnostic eating disorder sample

Reward response patterns may contribute to risk and maintenance of eating disorders (EDs), and there may be clinically meaningful heterogeneity in behavioral responses to different actual and anticipated rewards across ED diagnoses. We used an empirical approach to classify individuals with EDs based on self-reported tendencies for responding to reward-related stimuli. Latent profile analysis was conducted in a transdiagnostic ED sample (N = 104) using Temperament and Character Inventory (Cloninger et al., 1993) subscales to categorize participants on reward responses of behavioral activation towards immediate, hedonic rewards (Novelty Seeking subscale), persistence towards long-term rewards (Persistence subscale), and maintenance by social rewards (Reward Dependence subscale) rewards. Two profiles were identified: (1) Behavioral Activation group (elevated Novelty Seeking; n = 62); and (b) Behavioral Persistence group (elevated Persistence; n = 42). Generalized linear models comparing profiles showed that frequency of these reward response profiles did not differ in probable AN, BN, or OSFED groups; however, individuals with probable BED more often demonstrated the Behavioral Activation profile (p = .041). These profiles exhibited comparable ED severity, but different presentations. Across probable ED diagnoses, the Behavioral Activation group reported greater binge eating (p = .006, d = 0.32) and had higher BMIs (p = .001, d = 0.57); the Behavioral Persistence group endorsed greater driven exercise (p = .042, d = 0.33). Categorization by activation to novel, immediate rewards versus persistence towards long-term rewards was associated with different symptoms across diagnoses, potentially supporting the role of specific reward response profiles in ED phenomenology.

Prevalence of binge-eating disorder among children and adolescents: a systematic review and meta-analysis

The objective is to estimate the prevalence of binge-eating disorder (BED) and subclinical BED in children and adolescents. Relevant articles were searched in the databases of PubMED and PsycINFO. Articles were included if they measured BED, subclinical BED, binge eating and/or loss of control (LOC) eating in samples of up to 20 years of age or with a mean age below 20 years. Subclinical BED covers participants with < 4 OBEs but ≥ 1 OBE pr. month and studies measuring subclinical DSM-IV/DSM-5 BED, but where all criteria were not met. All study types and measuring methods were accepted, but studies were excluded if they did not assess and exclude cases of recurrent compensatory behaviors. Meta-analyses were used to obtain an overall estimate of the prevalence of BED and subclinical BED, while stratified meta-analyses were used to assess sources of heterogeneity. 39 studies measuring BED, subclinical BED and/or a low frequency of binge eating were included. Two meta-analyses resulted in an overall estimated prevalence of 1.32% BED and 3.0% subclinical BED in children and adolescents. The results were influenced by high heterogeneity. Potential sources to heterogeneity in the BED result were weight of participants and sample types as well as level of risk of bias in the included studies. BED seems to be as frequent in children and adolescents as anorexia nervosa and bulimia nervosa. Hence, treatment of BED and BED symptoms in younger populations should be prioritized on the same terms as anorexia and bulimia nervosa.

The Mediator Effect of Personality on the Relationship Between Symptomatic Impairment and Treatment Outcome in Eating Disorders

Features of personality disorders (PDs) have been found to explain meaningful variance in the onset, maintenance, and symptomatic presentation of eating disorders (EDs), and a co-occurent personality pathology is commonly associated with poorer response to ED treatment. The "pathoplasty model" of the relationship between personality and EDs implies that, once both conditions are established, they are likely to interact in ways that modify therapy outcome; however, to date, no studies have explored overall personality functioning, and especially PD clusters, as a mediator of treatment outcome. The present study aimed at conjointly exploring the associations between personality functioning and PDs, respectively, with pre-treatment ED symptomatic impairment and therapy outcome; and the mediating role of personality variables. At treatment onset, a sample of 107 women with ED problems were evaluated using both the Structured Clinical Interview for DSM-5 (SCID-5-CV) and the Shedler-Westen Assessment Procedure-200 (SWAP-200)-a clinician-rated procedure to dimensionally assess personality. Participants were also asked to complete self-report questionnaires on overall ED symptomatology, symptoms of binge eating and purging behaviors, and therapy outcome. The findings showed that, over and above the categorical ED diagnosis, the SWAP-200 healthy personality functioning score mediated the relationship between baseline ED symptom severity and therapy outcome, as well as the association between baseline bulimic symptoms and treatment outcome; furthermore, SWAP-200 Cluster B PD scores mediated the link between baseline binge eating and purging symptoms and therapy outcome, whereas scores in Clusters A and C showed no significant effects. The findings suggest that personality-based outcome research may improve treatment effectiveness in this difficult-to-treat population.

Detection, treatment, and course of eating disorders in Finland: A population-based study of adolescent and young adult females and males

Objective:

We assessed the detection, treatment and outcomes of DSM-5 eating disorders in a nationwide community setting.

Method:

The FinnTwin12 cohort comprises twins born in 1983–1987 in Finland (n = 5,600), with follow-up starting at age 12. We outline treatment and outcomes of the 127 females and 15 males diagnosed with a lifetime DSM-5 eating disorder in interviews conducted for a subsample (n = 1,347) in their early 20s.

Results:

Only 45 (32%) of those diagnosed with eating disorder in the interviews had their condition detected in healthcare, and even fewer received treatment (30% of females, 13% of males). Anorexia nervosa (AN), bulimia nervosa, and atypical AN were detected and treated more often than other eating disorders. Five years after disease onset, 41% of those diagnosed had recovered. There were no statistically significant differences in the course of different eating disorders (log-rank p = 0.66) but the outcome was more favourable among males (log-rank p = 0.008). The likelihood of 5-year recovery did not differ between those who had and who had not received treatment (41.1% vs. 40.5%, log-rank p = 0.66).

Conclusion:

Although eating disorders are common and symptoms are persistent for many, they remain under-diagnosed and under-treated. In real-world settings, effectiveness of provided treatments may be limited.

Negative urgency combined with negative emotionality is linked to eating disorder psychopathology in community women with and without binge eating

OBJECTIVE

Previous research has shown that negative emotionality (NE) and negative urgency (NU) are each risk factors for disordered eating behaviors among undergraduates and treatment-seekers. However, the interaction of these traits in community-based adults with clinical levels of binge eating is unknown and has implications for risk and maintenance models of disordered eating.

METHOD

We examined a moderated-mediation model of cross-sectional associations among levels of NE (independent variable), NU (mediator), and eating disorder psychopathology (i.e., eating, shape, and weight concerns, and restraint; dependent variable) in 68 community-recruited women with current regular binge eating and 75 control women with no eating disorder history (group = moderator). Participants completed semi-structured diagnostic interviews and self-report questionnaires measuring NE, NU, eating disorder psychopathology, and anxiety and depression symptoms.

RESULTS

After adjusting for anxiety and depression symptoms and body mass index, women with binge eating experienced greater NU and eating disorder psychopathology than control women with no eating disorder history. Despite similar levels of NE across groups, both groups exhibited an indirect effect of NE on eating disorder psychopathology via NU.

DISCUSSION

Our findings suggest that greater NE, coupled with a propensity to engage in rash action when experiencing negative emotions, are associated with eating disorder psychopathology in women with and without eating disorders characterized by binge eating. These findings may help explain why some individuals engage in disordered eating behaviors when experiencing negative affect.

Reward learning in unmedicated women with bulimia nervosa: A pilot investigation

Bulimia nervosa (BN) is characterized by recurrent engagement in eating disorder behaviors despite negative consequences, potentially reflecting aberrant stimulus-response or reward-learning processes. Indeed, frontostriatal circuitry involved in reward learning is altered in persons with BN and preliminary research suggests reward learning is impaired in persons with BN. Additional research on reward learning in BN and its association with eating disorder symptom expression is warranted to further the field's understanding of potential pathophysiological mechanisms of BN. To this end, the probabilistic reward learning task (PRLT) was administered to unmedicated women with BN (n = 15) and demographically matched psychiatrically healthy women (n = 18). Contrary to our hypotheses, results demonstrated that women with BN showed greater reward learning during the PRLT relative to healthy comparison women when covarying for symptoms of depression, social anxiety, and mania. Exploratory analyses showed that binge-eating frequency was inversely associated with reward learning in women with BN; however, results should be interpreted with caution due to the small sample size. Together, results suggest that women with BN do not have deficits in implicit reward learning. Given the preliminary nature of this investigation, larger-scale studies are needed to further examine reward learning in current BN and could compare reward learning using general (e.g., monetary) and disorder-specific (e.g., food) reinforcers. Further work is needed to confirm the inverse association between reward learning and binge eating.

Reconsidering delay discounting in bulimia nervosa

Delay discounting measures one's preference for smaller-sooner versus larger-later reward and is a facet of impulsivity. Studying delay discounting in bulimia nervosa (BN) may enhance clinical understanding of BN, as BN is characterized by engagement in behaviors that provide immediate reward (i.e., binge eating, purging) at the expense of future well-being. Prior research suggests that individuals with BN prefer smaller amounts of money available sooner compared to psychiatrically healthy (HC) persons. Here, we aimed to replicate and extend previous work by studying delay discounting of both monetary and food reward in women with BN relative to HC women. We also compared delay discounting of monetary and food reward, and examined associations among delay discounting, trait impulsivity, and eating disorder symptom expression in women with BN. Participants were 20 women with sub- or full-threshold DSM-5 BN and 20 HC women who completed a diagnostic interview, paper-and-pencil measures of delay discounting of monetary and food commodities, and a measure of trait impulsivity. Contrary to previous work, we found that women with BN showed decreased delay discounting of monetary and food reward relative to HC women. Within-group analyses demonstrated that women with BN showed elevated delay discounting of food reward relative to monetary reward. Within women with BN, elevated delay discounting of food, but not money, was associated with elevated negative and positive urgency, two facets of trait impulsivity that relate to acting rashly when experiencing strong emotion. Results suggest that delay discounting may be more variable in BN than previously assumed.

Electroencephalographic (EEG) alterations in young women with high subclinical eating pathology levels: a quantitative EEG study

PURPOSE

To explore electroencephalographic (EEG) alterations in young women with different eating disorder (ED) psychopathology levels.

METHODS

Thirty-seven young women completed general and ED psychopathology (i.e., the ED Examination Questionnaire; EDE-Q) measures. EEG power spectra data were investigated in two conditions: (a) 5 min of resting state (RS) and (b) 5 min of RS after a single taste of a milkshake (ML-RS). EEG analyses were performed using exact Low-Resolution Electromagnetic Tomography software (eLORETA).

RESULTS

Cluster analysis performed on the EDE-Q responses revealed a group of 17 women with high levels of ED pathology falling into the subclinical (i.e., sub-threshold) EDs category and a group of 20 women with low levels of ED pathology (controls). In the RS conditions, no significant modifications were observed between groups. Compared to controls, women with subclinical EDs showed an increase in theta activity in the parieto-occipital areas in the ML-RS condition. After controlling for body mass index and general psychopathology, theta activity in these brain structures was positively associated with EDE-Q global and subscale (restraint, shape and weight concern) scores.

CONCLUSIONS

Our results may reflect the neurophysiological substrate of ED psychopathology core features like shape/weight concerns. Previous brain imaging and qEEG studies with full-syndrome ED patients also underscored the involvement of parieto-occipital areas in ED pathophysiology. These studies also found brain alterations in the RS condition, not observed here. This is notable given that full-syndrome and subclinical EDs are considered as different manifestations of the same disease along a severity spectrum.

LEVEL OF EVIDENCE

Level V, cross-sectional, electroencephalographic, descriptive study.

The relationship between perfectionism and eating-related symptoms in adolescents: A systematic review

The clinical significance of two major aspects of perfectionism, perfectionistic strivings (PS) and perfectionistic concerns (PC), in eating disorders (EDs) symptoms was well-established among adults. However, no systematic review has assessed evidence examining associations between both unidimensional and multidimensional perfectionism and EDs in early and middle adolescence. For this aim, three online databases (PsycINFO, Medline and PsycArticle) were searched for articles published until January 2019, and observational studies were considered. Study quality was systematically appraised, and results were summarized using a narrative synthesis approach. Fifty-one cross-sectional and 28 longitudinal studies were included. Most studies supported the relationship between perfectionism and EDs, with the majority adopting a unidimensional approach for assessing perfectionism. Among studies that employed multidimensional measures of perfectionism, the majority (n = 11) of evidence supported the relationship between eating symptoms and PC, while fewer (n = 5) studies provided significant unique associations with PS. These findings are consistent with the body of research suggesting the strength of the relationship between PC and EDs was greater than between PS and EDs. It was recommended that preventive interventions should be primarily focused on reducing self-critical perfectionism, since it resulted to be the most relevant perfectionistic dimension in the development of eating symptoms in adolescents.

DSM-5 eating disorders among adolescents and young adults in Finland: A public health concern

OBJECTIVE

We aimed to assess the lifetime prevalence, 10-year incidence, and peak periods of onset for eating disorders as defined by the Fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) among adolescents and young adults born in the 1980s in Finland.

METHOD

Virtually all Finnish twins born in 1983-1987 (n = 5,600) were followed prospectively from the age of 12 years. A subsample of participants (n = 1,347) was interviewed using a semi-structured diagnostic interview in their early twenties.

RESULTS

The prevalence of lifetime DSM-5 eating disorders was 17.9% for females and 2.4% for males (pooled across genders, 10.5%). The estimated lifetime prevalences for females and males, respectively, were 6.2 and 0.3% for anorexia nervosa (AN), 2.4 and 0.16% for bulimia nervosa (BN), 0.6 and 0.3% for binge-eating disorder (BED), 4.5 and 0.16% for other specified feeding or eating disorder (OSFED), and 4.5 and 1.6% for unspecified feeding or eating disorder (UFED). Among females, the prevalence of OSFED subcategories was as follows: atypical AN 2.1%, purging disorder 1.3%, BED of low frequency/limited duration 0.7%, and BN of low frequency/limited duration 0.4%. The 10-year incidence rate of eating disorders was 1,700 per 100,000 person-years among females (peak age of onset 16-19 years) and 220 per 100,000 person-years among males.

DISCUSSION

Eating disorders are a common public health concern among youth and young adults, affecting one in six females and one in 40 males. Adequate screening efforts, prevention, and interventions are urgently needed.

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.

Tackling mixed messages: Practitioner reflections on working with adolescents with atypical anorexia and their families

The treatment of atypical anorexia nervosa (AN) poses new research and practice challenges for the field of eating disorders. The objective of this study was to describe frontline practitioners' perceptions of differences between adolescents living with atypical versus typical AN, as well as the intervention challenges they experience when working with these adolescents and their families. We followed the principles of fundamental qualitative description and recruited a purposeful sample of practitioners treating adolescent eating disorders to complete a one-on-one semi-structured interview. Conventional content analysis and the constant comparison technique were used for data analysis. A total of 23 practitioners from four countries participated in this study. Practitioners described that adolescents with atypical AN present with higher pre-morbid weights and rates of weight-based teasing compared to their AN peers. Clinical challenges perceived by practitioners to be specific to working with adolescents with atypical AN included: addressing conflicting messages about eating disorders and weight loss, empathizing with a justified fear of weight gain, and increased risk for parental and therapist collusion with the eating disorder. Findings have implications for delivering interventions to adolescents seeking care for atypical AN.

Obsessions are strongly related to eating disorder symptoms in anorexia nervosa and atypical anorexia nervosa

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are highly comorbid. However, little research has examined which specific cognitive-behavioral aspects (e.g., checking, obsessing) of OCD are most relevant in those with AN. Furthermore, there is no research examining aspects of OCD in Atypical AN. The current two studies (N = 139 and N = 115 individuals diagnosed with AN/Atypical AN) examined a) which aspects of OCD were most related to AN symptomatology and b) if there were differences in OCD between individuals diagnosed with AN vs Atypical AN. We found that obsessing was most related to AN symptoms. We also found that there were no substantial significant differences between AN and Atypical AN. These findings add to the literature suggesting minimal differences between AN and Atypical AN, specifically regarding OCD symptomatology. These findings clarify that obsessions (rather than compulsions) may be the specific aspect of OCD most warranting treatment intervention in AN and Atypical AN.

Preserved white matter microstructure in adolescent patients with atypical anorexia nervosa

OBJECTIVE

Patients with atypical anorexia nervosa (AN) are often in the normal-weight range at presentation; however, signs of starvation and medical instability are not rare. White matter (WM) microstructural correlates of atypical AN have not yet been investigated, leaving an important gap in our knowledge regarding the neural pathogenesis of this disorder.

METHOD

We investigated WM microstructural integrity in 25 drug-naïve adolescent patients with atypical AN and 25 healthy controls, using diffusion tensor imaging (DTI) with a tract-based spatial statistics (TBSS) approach. Psychological variables related to the eating disorder and depressive symptoms were also evaluated by administering the eating disorder examination questionnaire (EDE-Q) and the Montgomery-Åsberg depression rating scale (MADRS-S) respectively, to all participants.

RESULTS

Patients and controls were in the normal-weight range and did not differ from the body mass index standard deviations for their age. No between groups difference in WM microstructure could be detected.

DISCUSSION

Our findings support the hypothesis that brain structural alterations may not be associated to early-stage atypical AN. These findings also suggest that previous observations of alterations in WM microstructure in full syndrome AN may constitute state-related consequences of severe weight loss. Whether the preservation of WM structure is a pathogenetically discriminant feature of atypical AN or only an effect of a less severe nutritional disturbance, will have to be verified by future studies on larger samples, possibly directly comparing AN and atypical AN.

Stay the course: practitioner reflections on implementing family-based treatment with adolescents with atypical anorexia

BACKGROUND

Atypical anorexia nervosa (AN) has received minimal empirical attention regarding effective diagnosis and treatment. Family-based treatment (FBT) might be a promising treatment for atypical AN, yet it is unclear as to what adaptations are needed to the current manualized FBT for AN model. The objective of the current study was to identify how FBT practitioners applied FBT for atypical AN for adolescents in their clinical practice, and if there were any implementation challenges and adaptations to the model for this population.

METHODS

The current study employed fundamental qualitative description, with the aim of capturing practitioners' reflections on working with adolescents with atypical AN in clinical practice. A purposeful sample of practitioners with training in FBT were recruited and each participant completed an individual, semi-structured interview. Data was analyzed using conventional content analysis.

RESULTS

A total of 23 practitioners participated in this study. The results indicate that practitioners maintained some fidelity to manualized FBT in treating atypical AN, but they differed in their discussions around target weights, what constitutes weight restoration, and the dosage for FBT phases. Salient practice challenges included operationalizing the Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-5) definition of atypical AN, identifying a 'goal weight' for adolescents and activating parents to take charge of the re-nourishment process.

CONCLUSIONS

The results of this qualitative study demonstrate practitioner reflections on the delivery and adaptations of FBT for adolescents with atypical AN. These reflections highlight the need to establish the delivery of coherent and consistent treatment and messaging with patients and families. Further, practitioners' reflections highlight common strategies to increase the sense of urgency in parents to support their child with atypical AN.

Typical-Atypical Interactions: One Patient's Experience of Weight Bias in an Inpatient Eating Disorder Treatment Setting

This article examines one patient's experiences with weight bias in an inpatient eating disorder treatment setting with a focus on interactions between the patient and her primary therapist. These therapeutic interactions had multiple unintended consequences, including bolstering feelings of denial, modeling of disordered behaviors, and disrupting the therapeutic alliance. Additional instances of weight bias with other treatment professionals, including an inpatient nutritionist and psychiatrist, are briefly discussed. The article ends with several brief recommendations for how clinicians can more skillfully approach issues of weight and size in the therapeutic alliance in order to resist size-related oppressions rather than reinforce them.

Reduced resting-state connectivity in areas involved in processing of face-related social cues in female adolescents with atypical anorexia nervosa

Atypical anorexia nervosa (AN) has a high incidence in adolescents and can result in significant morbidity and mortality. Neuroimaging could improve our knowledge regarding the pathogenesis of eating disorders (EDs), however research on adolescents with EDs is limited. To date no neuroimaging studies have been conducted to investigate brain functional connectivity in atypical AN. We investigated resting-state functional connectivity using 3 T MRI in 22 drug-naïve adolescent patients with atypical AN, and 24 healthy controls. Psychological traits related to the ED and depressive symptoms have been assessed using the Eating Disorders Examination Questionnaire (EDE-Q) and the Montgomery-Åsberg Depression Rating Scale self-reported (MADRS-S) respectively. Reduced connectivity was found in patients in brain areas involved in face-processing and social cognition, such as the left putamen, the left occipital fusiform gyrus, and specific cerebellar lobules. The connectivity was, on the other hand, increased in patients compared with controls from the right inferior temporal gyrus to the superior parietal lobule and superior lateral occipital cortex. These areas are involved in multimodal stimuli integration, social rejection and anxiety. Patients scored higher on the EDE-Q and MADRS-S questionnaires, and the MADRS-S correlated with connectivity from the right inferior temporal gyrus to the superior parietal lobule in patients. Our findings point toward a role for an altered development of socio-emotional skills in the pathogenesis of atypical AN. Nonetheless, longitudinal studies will be needed to assess whether these connectivity alterations might be a neural marker of the pathology.

[Genetics factors in pathogenesis and clinical genetics of binge eating disorder]

Genetic studies have shown that binge eating disorder (ВЕD) aggregates in families, heritability was estimated as about 60% and additive genetic influences on BED up to 50%. Using a genetic approach has proved useful for verifying the diagnostic categories of BED using DSM-IV criteria and supporting the validity of considering this pathology as a separate nosological category. The results confirmed the genetic and pathogenic originality of BED as a separate psychopathological phenomenon, but not a subtype of obesity. It seems fruitful to considerate BED as a disease with hereditary predisposition with significant genetic influence and a complex psychopathological syndrome, including not only eating disorders, but also depressive and addictive component. A possible mechanism of pathogenesis of BED may be the interaction of the neuroendocrine and neurotransmitters systems including the active involvement of the reward system in response to a variety of chronic stress influences with the important modulatory role of specific personality traits. The high level of genetic influence on the certain clinical manifestations of BED confirms the ability to identify the subphenotypes of BED on genetic basis involving clinical criteria. It can not only contribute to further genetic studies, taking into account more homogeneous samples, but also help in finding differentiated therapeutic approaches.

Longitudinal and personalized networks of eating disorder cognitions and behaviors: Targets for precision intervention a proof of concept study

INTRODUCTION

Despite the high mortality and significant societal and personal costs associated with eating disorders (EDs) there are few evidence-based treatments. Part of the difficulty developing and implementing evidence-based treatments in EDs is due to the extremely high heterogeneity (e.g., variability in treatment outcome, symptom presentation etc) present.

METHODS

To begin to identify specific symptom heterogeneity within persons, the current study used novel within and between group and intra-individual network analyses to create longitudinal and within-person networks of ED cognitions and behaviors (N = 66 individuals diagnosed with an ED). This article provides a proof of concept study for how to use between and within-person network analyses both for the EDs and other forms of psychopathology.

RESULTS

We found that cognitions focused on desiring thinness played a likely maintaining role in ED pathology, across network type and across time. Furthermore, we showed that three individuals with the same diagnosis (anorexia nervosa) differed in which symptoms maintained the disorder. We use these participants to exemplify how to use intra-individual network analysis to personalize treatment focused on the primary maintaining symptoms. Finally, we found that amount of time (e.g., 4 hr vs. simultaneously) impacts how symptoms maintain each other.

CONCLUSIONS

These findings have implications for the development of novel personalized evidence-based treatments for EDs, as well as implications for how the field understands how psychopathology maintains itself. These data represent a first-step towards using intra-individual network analyses in the ED field, as well as for hypotheses generation in future research.

Social anxiety in the eating disorders: a systematic review and meta-analysis

Social anxiety disorder is one of the most common comorbid conditions in eating disorders (EDs). The aim of the current review and meta-analysis is to provide a qualitative summary of what is known about social anxiety (SA) in EDs, as well as to compare levels of SA in those with EDs and healthy controls. Electronic databases were systematically searched for studies using self-report measures of SA in ED populations. In total, 38 studies were identified, 12 of which were included in the meta-analyses. For both anorexia nervosa (AN) and bulimia nervosa, there were significant differences between ED groups and HCs, with medium to large effect sizes. Findings from the qualitative review indicate that levels of SA are similar across the ED diagnoses, and SA improves with treatment in AN. In addition, high levels of SA are associated with more severe ED psychopathology, but not body mass index. These findings add to the wider literature on socio-emotional functioning in EDs, and may have implications for treatment strategies.

Online prevention of disordered eating in at-risk young-adult women: a two-country pragmatic randomized controlled trial

BACKGROUND

Disordered eating (DE) is a widespread, serious problem. Efficacious prevention programs that can be delivered at-scale are needed.

METHODS

A pragmatic randomized controlled trial of two online programs was conducted. Participants were young-adult women from Australia and New Zealand seeking to improve their body image. Media Smart-Targeted (MS-T) and Student Bodies (SB) were both 9-module interventions released weekly, whilst control participants received positive body image information. Primary [Eating Disorder Examination-Questionnaire (EDE-Q) Global], secondary (DE risk factors) and tertiary (DE) outcome measures were completed at baseline, post-program, 6- and 12-month follow-up.

RESULTS

Baseline was completed by 608 women (M age = 20.71 years); 33 were excluded leaving 575 randomized to: MS-T (N = 191); SB (N = 190) or control (N = 194). Only 66% of those randomized to MS-T or SB accessed the intervention and were included in analyses with controls; 78% of this sample completed measures subsequent to baseline. Primary intent-to-treat (ITT) analyses revealed no differences between groups, while measure completer analyses found MS-T had significantly lower EDE-Q Global than controls at 12-month follow-up. Secondary ITT analyses found MS-T participants reported significantly higher quality of life-mental relative to both SB and controls (6-month follow-up), while MS-T and controls had lower clinical impairment relative to SB (post-program). Amongst measure completers, MS-T scored significantly lower than controls and SB on 5 variables. Of those with baseline DE, MS-T participants were significantly less likely than controls to have DE at 12-month follow-up.

CONCLUSIONS

Given both programs were not therapist-moderated, MS-T has potential to achieve reductions in DE risk at low implementation costs.

A new approach to eating-disorder classification: Using empirical methods to delineate diagnostic dimensions and inform care

OBJECTIVE

Despite changes to the diagnostic criteria for eating disorders (EDs) in the DSM-5, the current diagnostic system for EDs has limited ability to inform treatment planning and predict outcomes. Our objective was to test the clinical utility of a novel dimensional approach to understanding the structure of ED psychopathology.

METHOD

Participants (N = 243; 82.2% women) were community-recruited adults with a DSM-5 ED assessed at baseline, 6-month, and 1-year follow-up. Hierarchical factor analysis was used to identify a joint hierarchical-dimensional structure of eating, mood, and anxiety symptoms. Exploratory structural equation modeling was used to test the ability of the dimensional model to predict outcomes.

RESULTS

At the top of the hierarchy, we identified a broad Internalizing factor that reflected diffuse symptoms of eating, mood, and anxiety disorders. Internalizing branched into three subfactors: distress, fear-avoidance (fears of certain stimuli and behaviors to neutralize fears, including ED behaviors designed to reduce fear of weight gain), and body dissatisfaction, which was nested within distress. The lowest level of the hierarchy was characterized by 15 factors. The hierarchical model predicted 60.1% of the variance in outcomes at 6-month follow-up, whereas all DSM eating, mood, and anxiety disorders combined predicted 35.8% of the variance in outcomes.

DISCUSSION

A dimensional approach to understanding and diagnosing EDs improved the ability to prospectively predict clinical course above-and-beyond the traditional categorical (DSM-based) approach. Our findings have implications for endeavors to improve the prediction of ED prognosis and course, and to develop more effective trans-diagnostic treatments.

Atypical anorexia nervosa is not related to brain structural changes in newly diagnosed adolescent patients

OBJECTIVE

Patients with atypical anorexia nervosa (AN) have many features overlapping with AN in terms of genetic risk, age of onset, psychopathology and prognosis of outcome, although the weight loss may not be a core factor. While brain structural alterations have been reported in AN, there are currently no data regarding atypical AN patients.

METHOD

We investigated brain structure through a voxel-based morphometry analysis in 22 adolescent females newly-diagnosed with atypical AN, and 38 age- and sex-matched healthy controls (HC). ED-related psychopathology, impulsiveness and obsessive-compulsive traits were assessed with the Eating Disorder Examination Questionnaire (EDE-Q), Barratt Impulsiveness Scale (BIS-11) and Obsessive-compulsive Inventory Revised (OCI-R), respectively. Body mass index (BMI) was also calculated.

RESULTS

Patients and HC differed significantly on BMI (p < .002), EDE-Q total score (p < .000) and OCI-R total score (p < .000). No differences could be detected in grey matter (GM) regional volume between groups.

DISCUSSION

The ED-related cognitions in atypical AN patients would suggest that atypical AN and AN could be part of the same spectrum of restrictive-ED. However, contrary to previous reports in AN, our atypical AN patients did not show any GM volume reduction. The different degree of weight loss might play a role in determining such discrepancy. Alternatively, the preservation of GM volume might indeed differentiate atypical AN from AN.