Comorbid Psychiatric Disorders in Female Adolescents with First-Onset Anorexia Nervosa

Associations between parental rearing style and amygdala and hippocampal subfield abnormalities in drug-naive females with anorexia nervosa

BACKGROUND

Altered volumes in the hippocampus and amygdala have been linked to anorexia nervosa (AN). This study aimed to investigate amygdala and hippocampal subfields volume abnormalities in AN patients, and their associations with parental rearing practices and clinical psychological characteristics.

METHODS

This study included twenty-nine drug-naive females with AN from West China Hospital of Sichuan University, China, and fifty-nine age- and gender-matched healthy controls (HCs) recruited through advertisement. All participants underwent T1-weighted imaging. Amygdala and hippocampal subfields volume was calculated using FreeSurfer 7.0. The Core Self-Evaluation Scale (CSES) and Rosenberg Self-Esteem Scale (RSES) were used to assess the psychological characteristics of AN patients. The Egna Minnen av Barndoms Uppfostran (EMBU) was employed to evaluate parental rearing practices. Group differences in brain volumes were analyzed with covariates like age and total intracranial volume (TIV). Partial correlation analysis explored the correlations between brain region volumes and clinical psychological characteristics.

RESULTS

AN patients exhibited lower RSES and CSES scores, and more adverse parental rearing style than healthy norms. After adjusting for covariates, AN patients showed decreased gray matter volume (GMV) in the left medial (Me) and cortical (Co) nucleus, as well as in the right hippocampal-amygdala transition area (HATA). GMV in the left Me was correlated with years of education among HCs but not among AN patients. GMV in the right HATA was positively correlated with paternal penalty and severity, as well as maternal overinterference.

CONCLUSION

This study supports structure abnormalities in amygdala and hippocampus in AN patients and suggests that parental rearing practices may be associated with hippocampal abnormalities, potentially contributing to the pathophysiology of AN. Addressing appropriate parental rearing styles may offer a positive impact on AN.

Seeing oneself as an unattractive loser: Similar interpretation and memory biases in adolescents with anorexia nervosa and adolescents with depression or anxiety

OBJECTIVE

Anorexia nervosa (AN) is characterised by dysfunctional cognitive biases but these have rarely been investigated in adolescents with AN. The present study systematically assessed cognitive biases in adolescents with AN and addressed the questions of content-specificity (i.e., do biases occur only for eating disorder-related information?) and disorder-specificity (i.e., are biases unique to individuals with AN?).

METHODS

Cognitive biases on three information processing levels (attention, interpretation, memory) and for two types of information content (eating disorder-related, non-eating disorder-related) were assessed within a single experimental paradigm based on the Scrambled Sentences Task. 12-18-year-old adolescents with AN (n = 40) were compared to a healthy (HC; n = 40) and a clinical (girls with depression and/or anxiety disorders; CC; n = 34) control group.

RESULTS

Both clinical groups (AN and CC) showed pronounced negative interpretation and memory biases compared to the HC group, for both disorder-related and non-disorder-related information. Attention biases could not be analysed.

CONCLUSION

The results support the hypothesis that adolescents with AN show negative cognitive biases but these were not limited to disorder-related information. Adolescents with depression and/or anxiety disorders showed similar biases, suggesting them to be transdiagnostic phenomena. Important implications for cognitive-behavioural theories of AN, subsequent cognitive bias modification studies in AN, as well as clinical practice are discussed.

Adaptive and Maladaptive Exercise in Eating Disorders

While exercise is generally associated with positive health outcomes, in the context of eating disorders, exercise has high potential to become maladaptive. Maladaptive exercise is compelled or compulsive in nature for the purposes of weight and shape control or to obtain/avoid other eating disorder-relevant consequences. A transdiagnostic eating disorder feature with moderate-to-high prevalence across restrictive- and bulimic-spectrum eating disorders, maladaptive exercise is often associated with negative mental and physical health sequalae. Several proposed threat- and reward-related biobehavioral mechanisms may initiate or perpetuate maladaptive exercise. While exercise is generally contraindicated during periods of acute medical concern, adaptive forms of exercise are also present among those with eating disorders, and facilitation of adaptive exercise has potential to promote physical and mental health benefits during eating disorder recovery. Detailed assessment and targeted interventions are needed to address the clinical conundrum of how and when to integrate exercise into eating disorder treatment.

Age-varying associations between attempts to change weight and suicidal ideation among adolescents in the United States

PURPOSE

The goal of this study was to inform theory and suicide prevention efforts by examining how the link between attempts to change weight and suicidal ideation varies across adolescence, when it is strongest, and whether there are sex differences.

METHODS

Data were from 13,518 youth ages 14-18 years who participated in the 2019 Youth Risk Behavior Survey, a nationally representative study of U.S. high school students. Time-varying effect modeling was used to estimate associations between attempts to change weight and suicidal ideation as continuous functions of age and to test sex differences in these links.

RESULTS

The link between attempts to lose weight and suicidal ideation was positive and significant between ages 14.0-17.3 years, with the strongest association at age 15.0 (OR = 2.07). There were no sex differences in this age-varying association. The association between attempts to gain weight and suicidal ideation was positive and age-varying for girls, with the strongest association at age 17.2 years (OR = 2.79). This association was not significant for boys at any age.

CONCLUSIONS

Girls and boys who are trying to lose weight and girls who are trying to gain weight may be at elevated risk for suicidal ideation between ages 14 and 18 years. Findings illuminate patterns of association during adolescence and have implications for suicide prevention.

The Diagnosis and Treatment of Anorexia Nervosa in Childhood and Adolescence

BACKGROUND

Anorexia nervosa (AN) is a serious disease with a lifetime prevalence of up to 3.6% in women and 0.3% in men. Abnormally low weight and the associated starvation partly account for its somatic and mental manifestations.

METHODS

This review is based on publications retrieved by a selective search concerning AN in childhood and adolescence.

RESULTS

The peak age of onset of AN is 15.5 years. The frequency of inpatient treatment for AN rose by 40% during the COVID pandemic, indicating the importance of environmental factors; the heritability of AN is estimated at 0.5. The ICD-11 sets the threshold for AN-associated underweight at the fifth percentile for age of the body mass index, as long as the remaining diagnostic criteria are met. The main goal of the multiprofessional treatment of AN is the return to normal body weight, which is a central prerequisite for regaining somatic and mental health. The mean duration of AN is 3.4 years, and approximately twothirds of patients recover from the disease over the long term.

CONCLUSION

Marked weight loss in childhood and adolescence can trigger AN in the presence of a predisposition to this disease. Patients and their families should receive psychoeducation regarding the symptoms of starvation and their overlap with those of AN. Important objectives are to shorten the duration of the illness, minimize mortality and the risk of chronic illness, and to identify pharmacological approaches to treatment.

A new network analysis model in anorexia nervosa patients based on self-reported eating disorder symptoms, psychological distress, and cognitive flexibility

OBJECTIVES

Cognitive flexibility and psychological distress, such as depression and anxiety, have been implicated in the aetiology of Anorexia Nervosa (AN). Despite the known associations between eating disorder (ED) symptoms, depression, anxiety, and cognitive flexibility, the specific pathways that connect these constructs are unclear. We therefore used network analysis to examine the relationship between these symptoms in an AN sample.

METHODS

One hundred and ninety-three treatment-seeking individuals diagnosed with AN (95.6% female, M = 26.89 [SD = 9.45] years old) completed self-report measures assessing depression, anxiety, cognitive flexibility, and ED symptoms. To determine each symptom's influence in the network, we calculated the expected influence.

RESULTS

The two relationships with the greatest edges were those between (1) weight/shape concerns and eating/dietary restraint and (2) weight/shape concerns and psychological distress (a measure that combined depression and anxiety). Cognitive flexibility was not connected to weight/shape concerns but had negative partial associations with eating concerns/dietary restraint and psychological distress. There was also a slight, non-zero connection between eating concerns/dietary restraint and psychological distress.

CONCLUSIONS

The findings underscore the importance of weight/shape, eating/dietary concerns, and psychological distress in the AN network and suggest that addressing cognitive flexibility may be a useful target for eating concerns/dietary restraint and psychological distress. Future studies assessing the longitudinal course of psychopathology within the AN network structure may help in identifying whether specific symptoms function as risk factors or maintaining factors for this co-occurrence.

Risk Factors for Suicide Reattempt among Adolescents and Young Adults: The Role of Psychiatric Disorders

Suicidal behaviour among young people is a serious public health concern. Each suicide attempt is related to further suicide attempts and completed suicide. This study aims to explore risk factors associated with repeated suicide attempt among adolescents and young adults. The cohort included 510 patients aged 12-29 years residing in Piedmont Region in North-Western Italy, who had been admitted to hospital or emergency department with a diagnosis of suicide attempt between 2010 and 2020. Cox regression models were used to evaluate potential risk factors for repeated suicide attempt. During the 11-years follow-up, 20.6% of adolescents and young adults repeated suicide attempt, 24.8% of females and 12.3% of males. Nearly 90% of youth who attempted suicide had a diagnosis of psychiatric disorder. After adjustment, younger age of onset of suicidal behaviour, and diagnosis of schizophrenia, bipolar disorder, depressive disorder, anorexia nervosa and personality disorder were significantly associated with repeated suicide attempt. The early identification of patients at higher risk of repetition of suicidal behaviour is of crucial importance. Better understanding of risk factors and effective treatment of mental disorders could help suicide prevention to reduce the burden of the problem among young people. Special attention should be paid during the initial months following discharge from hospital or emergency department, when suicide reattempt risk is very high.

Non-suicidal self-injury among individuals with an eating disorder: A systematic review and prevalence meta-analysis

OBJECTIVE

This study aimed to quantify the prevalence of non-suicidal self-injury across eating disorders (EDs) and within diagnostic categories through systematic review and proportional, or so-called prevalence, meta-analysis.

METHOD

Included studies had to contain individuals with a verified diagnosis of an ED. The last literature search was conducted on September 11, 2023, for studies published on or before September 2023 without a restriction on earliest publication year. Results were synthesized and analyzed using the "metaprop" package in R and presented using forest plots. Bias was assessed by a Peters' regression test and funnel plot.

RESULTS

79 studies published between 1985 and 2023 were included encompassing 32,334 individuals with an ED. Importantly, 42 studies were not included in any other meta-analyses on self-injury in EDs to date. Overall prevalence of non-suicidal self-injury was 34.59% (95%CI = 30.49-38.81). Prevalence in anorexia nervosa restrictive type, binge/purge type, bulimia nervosa, binge eating disorder and other specified feeding/eating disorder were 23.19% (95%CI = 16.96-30.03%), 41.98% (95%CI = 32.35-51.91%), 36.97% (95%CI = 30.69-43.46%), 21.21% (95%CI = 14.93-28.12%) and 37.65% (95%CI = 28.59-47.09%), respectively. Prevalence estimations could not be estimated for other ED categories due to lack of a sufficient number of studies.

DISCUSSION

Non-suicidal self-injury is prevalent across both binge/purge and restrictive EDs. Considering the transdiagnostic nature of self-injurious behaviors in ED, the results highlight the importance of assessment and monitoring of self-injury in people with ED, irrespective of specific diagnoses. The method of determining self-injury varied across studies and may limit this study.

PUBLIC SIGNIFICANCE

This study highlights the prevalence of self-injury across eating disorders irrespective of diagnosis and within specific EDs. While diagnoses known to exhibit self-injurious behaviors (e.g., bulimia nervosa, anorexia nervosa binge/purge subtype) demonstrated the highest prevalence of self-injury, all diagnoses were found to have a prevalence greater than 20%. These findings suggest the importance of assessing and monitoring all individuals with an eating disorder for the presence of self-injury.

The role of mindfulness on the psychological aspects of anorexia nervosa

OBJECTIVE

Emotion regulation, perfectionism, and rumination are perpetuating factors in anorexia nervosa (AN). Mindfulness can be protective and therapeutic. We aimed to understand the relationship between these factors and mindfulness in AN.

METHODS

20 adolescent girls in the acute phase of the AN, 16 in remission, and 40 in the control group were evaluated.

RESULTS

Mindfulness was lowest in the acute AN group. The difference in the acute AN group regarding body dissatisfaction, emotion dysregulation, perfectionism, and mindfulness disappeared after controlling for the effects of depression and anxiety. The predictors of disordered eating in the entire study population were body dissatisfaction and depressive symptoms. Emotion regulation and perfectionism were the predictors of mindfulness in the acute AN group and the entire study population. When mindfulness decreased, concerns about body shape increased in both acute AN and remission groups, while dietary restriction and disordered eating behaviors increased only in the remission group.

DISCUSSION

Emotion regulation difficulties in acute AN could be related to depression and anxiety. Mindfulness interventions for emotion regulation could be used for depression during the acute phase while for perfectionism in remission. Early intervention for depression and body dissatisfaction seems protective, and mindfulness could be an appropriate intervention.

[Peculiarities of the dynamics of eating disorders in the structure of depressive states]

OBJECTIVE

To determine the main trajectories of the association between eating disorders (ED) and depressive symptoms and their impact on the quality of the prognosis of the disease as a whole.

MATERIAL AND METHODS

A total sample included 59 female patients, aged 15 to 25 years (average age 16.2+0.9), who were under outpatient and inpatient observation in the department for the study of endogenous mental disorders and affective states in the clinic at the Mental Health Research Center.

RESULTS

The authors identified variants of the main trajectories of the association between ED and depression, taking into account the role and place of ED and interdependence with depressive symptoms. The following variants have been established: with a stable (44.0%, n=26), labile type of dynamics (25.0%, n=19) and dynamics according to the type of selective dissociation (22.4%, n=14).

CONCLUSION

The study allows us to assume the development of fundamentally different trajectories of the conjugation of eating behavior and depression, showing prognostic capacity and different tropism for therapeutic interventions.

Family-based treatment takes longer for adolescents with mental health comorbidities: findings from a community mental health service

Children and adolescents diagnosed with an eating disorder often meet the diagnosis of another mental health disorder. In addition to eating disorders, individuals with comorbid disorders have higher suicide rates and more severe and chronic eating disorder symptoms. The present research aimed to investigate the influence of comorbid conditions on the treatment outcomes of children and adolescents that attended a public community mental health service. It was hypothesised that the patients with comorbidities would have a more extended treatment duration, slower rates of weight restoration, more hospital admissions for medical compromise, and poorer functioning than those without comorbidities. Data from 78 past patients at the Eating Disorder Program in Queensland, Australia, were analysed. Patients with comorbidities demonstrated similar recovery rates to those without comorbidities. However, those with comorbid conditions had longer episodes of treatment. The study's results support using Family Based Treatment for patients with and without comorbidities. The implications of the findings for public mental health services and directions for future research are discussed.

Differential alterations of amygdala nuclei volumes in acutely ill patients with anorexia nervosa and their associations with leptin levels

BACKGROUND

The amygdala is a subcortical limbic structure consisting of histologically and functionally distinct subregions. New automated structural magnetic resonance imaging (MRI) segmentation tools facilitate the in vivo study of individual amygdala nuclei in clinical populations such as patients with anorexia nervosa (AN) who show symptoms indicative of limbic dysregulation. This study is the first to investigate amygdala nuclei volumes in AN, their relationships with leptin, a key indicator of AN-related neuroendocrine alterations, and further clinical measures.

METHODS

T1-weighted MRI scans were subsegmented and multi-stage quality controlled using FreeSurfer. Left/right hemispheric amygdala nuclei volumes were cross-sectionally compared between females with AN (n = 168, 12-29 years) and age-matched healthy females (n = 168) applying general linear models. Associations with plasma leptin, body mass index (BMI), illness duration, and psychiatric symptoms were analyzed via robust linear regression.

RESULTS

Globally, most amygdala nuclei volumes in both hemispheres were reduced in AN v. healthy control participants. Importantly, four specific nuclei (accessory basal, cortical, medial nuclei, corticoamygdaloid transition in the rostral-medial amygdala) showed greater volumetric reduction even relative to reductions of whole amygdala and total subcortical gray matter volumes, whereas basal, lateral, and paralaminar nuclei were less reduced. All rostral-medially clustered nuclei were positively associated with leptin in AN independent of BMI. Amygdala nuclei volumes were not associated with illness duration or psychiatric symptom severity in AN.

CONCLUSIONS

In AN, amygdala nuclei are altered to different degrees. Severe volume loss in rostral-medially clustered nuclei, collectively involved in olfactory/food-related reward processing, may represent a structural correlate of AN-related symptoms. Hypoleptinemia might be linked to rostral-medial amygdala alterations.

Emotion Regulation Deficits in Adolescent Girls with Major Depression, Anorexia Nervosa and Comorbid Major Depression and Anorexia Nervosa

In adolescence, both major depression (MD) and anorexia nervosa (AN) are associated with deficits in emotion regulation (ER). However, studies have yet to compare ER profiles within the disorders and the effect of comorbid MD+AN is unclear. This study examined the habitual use of ER in 229 girls, aged 12-18 years, with MD (n = 84), AN (n = 37), comorbid MD+AN (n = 25), and healthy girls (n = 83). Girls with MD, AN and MD+AN reported more maladaptive and less adaptive ER strategies than healthy girls. MD and MD+AN groups showed more frequent use of maladaptive ER compared to only AN, with no differences between only MD and MD+AN. This suggests that MD+AN is not necessarily associated with higher ER deficits, rather, an additional diagnosis of MD exacerbates impairments in AN. Identifying specific ER profiles can provide important targets in prevention and treatment for AN, MD and AN+MD.

Latent anxiety and depression dimensions differ amongst patients with eating disorders: A Swedish nationwide investigation

OBJECTIVE

Anxiety and depression symptoms are common in individuals with eating disorders. To study these co-occurrences, we need high-quality self-report questionnaires. The 19-item self-rated Comprehensive Psychopathological Rating Scale for Affective Syndromes (CPRS-S-A) is not validated in patients with eating disorders. We tested its factor structure, invariance, and differences in its latent dimensions.

METHOD

Patients were registered by 45 treatment units in the Swedish nationwide Stepwise quality assurance database for specialised eating disorder care (n = 9509). Patients self-reported their anxiety and depression symptoms on the CPRS-S-A. Analyses included exploratory and confirmatory factor analyses (CFA) in split samples, and testing of invariance and differences in subscales across eating disorder types.

RESULTS

Results suggested a four-factor solution: Depression, Somatic and fear symptoms, Disinterest, and Worry. Multigroup CFA indicated an invariant factor structure. We detected the following differences: Patients with anorexia nervosa binge-eating/purging subtype scored the highest and patients with unspecified feeding and eating disorders the lowest on all subscales. Patients with anorexia nervosa or purging disorder show more somatic and fear symptoms than individuals with either bulimia nervosa or binge-eating disorder.

CONCLUSION

Our four-factor solution of the CPRS-S-A is suitable for patients with eating disorders and may help to identify differences in anxiety and depression dimensions amongst patients with eating disorders.

The Role of Leptin in Rodent and Human Sleep: A Transdiagnostic Approach with a Particular Focus on Anorexia Nervosa

This narrative review addressed to both clinicians and researchers aims to assess the role of hypoleptinemia in disordered sleep with a particular focus on patients with anorexia nervosa (AN). After introducing circadian rhythms and the regulation of circulating leptin, we summarize the literature on disordered sleep in patients with AN and in fasting subjects in general. We highlight novel single-case reports of substantially improved sleep within days after initiation of off-label metreleptin treatment. These beneficial effects are set in relationship to current knowledge of disordered sleep in animal models of an impaired leptin signaling. Specifically, both absolute and relative hypoleptinemia play a major role in animal models for insomnia, obstructive sleep apnea and obesity hypoventilation syndrome. We pinpoint future research required to complement our understanding of the role of leptin in sleep in patients with acute AN. Moreover, within the section clinical applications we speculate that human recombinant leptin may be useful for the treatment of treatment-resistant sleep-wake disorders, which are associated with (relative) hypoleptinemia. Overall, we stress the role of the hormone leptin in sleep.

Attention Biases for Eating Disorder-Related Stimuli Versus Social Stimuli in Adolescents with Anorexia Nervosa - An Eye-Tracking Study

Anorexia nervosa (AN) is characterized by attention biases for eating disorder-related information as well as altered attentional processing of social information. However, little is known about the interplay between the altered attentional processing of these two types of information. The present study investigates attention biases for eating disorder-related information (pictures of bodies) versus social information (pictures of faces), in adolescents with AN. Attention biases were assessed via eye-tracking during a passive-viewing task in which female bodies and faces were presented simultaneously and thus competed directly for attention. Female adolescents (13-18 years) with AN (n = 28) were compared to a clinical comparison group (adolescents with major depression; n = 20) and a comparison group of adolescents with no mental illness (n = 24). All groups looked longer at bodies than at faces, i.e., showed attention biases for bodies in maintenance of attention. These biases were more pronounced in adolescents with AN than in both comparison groups, particularly for underweight bodies, at the expense of looking less at social stimuli. The results indicate "dual" attention biases in adolescents with AN (i.e., towards bodies and away from emotional faces) which could have a twofold negative impact on eating disorder psychopathology: increased attention to eating disorder-related information might directly influence eating disorder symptoms while less attention to social information might have an indirect influence through the amplification of interpersonal difficulties.

Expressed emotion and treatment outcome in higher levels of care for eating disorders

OBJECTIVE

Expressed emotion (EE) among caregivers toward the affected offspring is a negative prognostic indicator for adolescent patients with eating disorders (EDs) in outpatient treatment. Less research has examined its impact on adolescents in higher levels of care (HLOC). The current study examined differences in caregiver EE according to the subtype of anorexia nervosa (AN) (restricting [AN-R] versus binge/purge [AN-BP]), and level of care (LOC). We also examined the main effects of baseline caregiver EE (emotional overinvolvement [EOI] or criticism), AN subtype, and their interaction on eating pathology and depression at discharge.

METHOD

Adolescent patients (N = 203) receiving treatment at HLOCs completed measures of ED pathology (Eating Disorder Examination-Questionnaire) and depression (Patient Health Questionnaire-9) at baseline and discharge, and one caregiver of each patient completed a measure of EE (Family Questionnaire) at baseline.

RESULTS

No differences in caregiver EE were found between patients with AN-R versus AN-BP, or relative to LOC. Caregiver EE did not predict outcome for ED symptoms or depression at discharge.

DISCUSSION

The impact of high caregiver EE may be less substantial at HLOCs than outpatient care given that caregivers are less involved in treatment at HLOCs. Future research is needed to determine if high caregiver EOI leads to poor treatment outcome for adolescents as it does for adults, or whether it is an appropriate expression of care for patients who are ill enough to require HLOC treatment.

PUBLIC SIGNIFICANCE STATEMENT

High caregiver EE was not found to predict treatment outcome for adolescents with eating disorders in higher levels of care (HLOCs), possibly due to the limited involvement of caregivers in HLOCs. However, patients step down to outpatient treatment, where high caregiver EE can have a significant negative impact on outcome. HLOCs should incorporate efforts to reduce high caregiver EE in anticipation of step-down to outpatient treatment.

General psychopathological symptoms in children, adolescents, and young adults with anorexia nervosa-a naturalistic study on follow-up and treatment

Recent research has assessed the role of general psychopathological symptoms in the natural history of mental health conditions, including anorexia nervosa (AN) in adults and obesity in children. Nevertheless, literature assessing general psychopathological symptoms in young patients with AN and their potential prognostic role in long-term outcomes is lacking. Observational, naturalistic study, involving young patients hospitalized for AN. General psychopathological symptoms were assessed by administering Symptom Check List-90-R (SCL-90-R) at admission (T0) and discharge (T1). AN-specific psychopathology was assessed with Eating Disorders Inventory-3 Eating Disorder Risk (EDRC) and Body Uneasiness Test Global Severity Index (BUT-GSI). Potential T0-T1 modifications of general psychopathological symptoms and their possible associations with baseline psychopathological, weight, and psychopharmacological variables were assessed with a generalized linear model (GLM), corrected for baseline SCL-90-R scores. Then, possible associations between T0 general psychopathological symptoms and the risk of re-hospitalization at 1 year were assessed with the Kaplan-Meier method and Cox regression. This study enrolled 133 patients (mean age 16.9 ± 2.9 years, F = 91.8%). A significant T0-T1 reduction (p < 0.001) in almost all the general psychopathological symptoms (except paranoia) emerged. The GLM revealed that higher EDI-3 EDRC scores were associated with higher T1 SCL-90-R scores in multiple domains. Cox regressions revealed a predictive role of SCL-90-R interpersonal sensitivity (B = 0.113, hazard ratio = 1.119, p = 0.023) on the risk of re-hospitalization at 1 year.  Conclusion: General psychopathological symptoms in young patients with AN may be influenced by hospital treatment interventions and have a potential prognostic role on post-discharge outcomes. Further longitudinal studies are required. What is Known: • General psychopathological symptoms represent a relevant feature that clinicians should consider in the diagnosis, treatment, and prognosis of multiple psychiatric conditions. Co-occurring psychiatric comorbidities, moreover, have been documented to impact individuals diagnosed with Anorexia Nervosa (AN) in the developmental age. Despite this evidence, the literature lacks studies assessing the occurrence and impact of general psychopathological symptoms in young patients with AN. What is New: • The clinical picture of children, adolescents, and young adults with AN mays be impacted by multiple general psychopathological symptoms, including Somatization, Obsession-compulsion, Interpersonal sensitivity, Depression, Anxiety, Hostility, Phobia, Paranoia, and Psychoticism, which may improve with a multidisciplinary hospital intervention. The occurrence of these symptoms, particularly "interpersonal sensitivity", may negatively impact the prognosis of the affected patients.

Eating disorders in sexual minority adolescents and young adults: examining clinical characteristics and psychiatric co-morbidities in an inpatient medical setting

BACKGROUND

Sexual minority adolescents and young adults are at higher risk of eating disorders compared to heterosexual peers. However, little is known about the clinical and psychiatric presentation of this population requiring inpatient medical stabilization. Given the increased risk for eating disorder behaviors in sexual minority individuals amidst increased rates of medical hospitalizations secondary to eating disorders, it is important to understand presenting characteristics of this population. The objectives of this study were to (1) describe the clinical characteristics of sexual minority adolescents and young adults with eating disorders admitted for medical instability and (2) compare psychiatric co-morbidities and suicidality of sexual minority adolescents and young adults to heterosexual peers.

METHODS

A retrospective chart review was conducted of 601 patients admitted to a large inpatient eating disorders medical stabilization unit between 2012 and 2020. Data collected included demographics, medical data including vital signs, and psychiatric characteristics. Chi square or t-tests were used to examine potential differences in clinical characteristics and psychiatric co-morbidities between groups. Modified Poisson regression was used to assess associations between sexual orientation and psychiatric co-morbidities.

RESULTS

Over one fifth (21.1%, n = 103) of our inpatient sample identified as a sexual minority individual. The average age of participants was 15.6 years (2.7). Sexual minority adolescents and young adults had higher percent median body mass index compared to heterosexual peers and yet equally severe vital sign instability on admission. Sexual minority adolescents and young adults were almost 1.5 times more likely to have a psychiatric comorbidity with higher rates of depression, anxiety, and post-traumatic stress disorder. Sexual minority adolescents and young adults were approximately two times more likely to have a history of self-injurious behaviors and/or suicidality.

CONCLUSIONS

Sexual minority adolescents and young adults with eating disorders have equally severe vital sign instability despite higher percent median body mass index on admission for medical stabilization. Sexual minority adolescents and young adults hospitalized for medical complications of eating disorders are far more likely to have an additional mental health disorder and a history of self-harm and/or suicidality, which may portend a less favorable long-term prognosis.

Predictors of caregiver burden before starting family-based treatment for adolescent anorexia nervosa and associations with weight gain during treatment

PURPOSE

Caregivers play a pivotal role in the success of family-based treatment (FBT) for anorexia nervosa (AN). Caregiver burden is frequently demonstrated in eating disorders (EDs) and may impact FBT outcomes. This study examined factors associated with caregiver burden before starting FBT and whether pre-treatment caregiver burden was associated with weight gain during FBT.

METHODS

Participants included 114 adolescents with AN or atypical AN (mean age = 15.6 years, SD = 1.4) and a primary caregiver (87.6% mothers) who received FBT in the United States. Before starting treatment, participants completed self-report measures of caregiver burden (via the Eating Disorder Symptom Impact Scale), caregiver anxiety, caregiver depression, and ED symptoms. Clinical characteristics and percentage of target goal weight (%TGW) at FBT session 1 and 3 and 6 months after starting treatment were obtained via retrospective chart review. Hierarchical regressions examined predictors of caregiver burden before FBT initiation. Associations between pre-treatment caregiver burden and %TGW gain at 3 and 6 months after starting FBT were assessed with hierarchical regressions.

RESULTS

Caregiver anxiety (p < 0.001), family history of EDs (p = 0.028), adolescent mental health treatment history (p = 0.024), and ED symptoms (p = 0.042) predicted caregiver burden before starting FBT. Pre-treatment caregiver burden was not associated with %TGW gain at 3 or 6 months. Males demonstrated less %TGW gain than females at 3 months (p = 0.010) and 6 months (p = 0.012).

CONCLUSION

Proactively evaluating caregiver burden before starting FBT is suggested. Providing recommendations and/or referrals for identified caregiver vulnerabilities could indirectly impact FBT progress. Males in FBT could require longer courses of treatment and extra vigilance to this demographic is suggested.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

The prevalence of orthorexia in exercising populations: a systematic review and meta-analysis

AIM

Orthorexia Nervosa (ON) describes a pathological obsession with proper and high-quality nutrition that is necessary to research further in order to elucidate its prevalence and correlates which may bear implications for prevention and treatment. The aim of this study was to review studies that report the prevalence of ON in people who exercise, calculate an overall prevalence through a random-effects meta-analysis approach and investigate the association of ON prevalence using a random-effects meta-regression. In addition, a sub-group-analysis based on ON-instruments and a sensitivity analysis excluding students samples, were conducted.

METHOD

Systematic searches were conducted in the following online databases: PubMed, Embase, Web of Science, PsychInfo, CINAHL, Google Scholar and OpenNet. The following search terms were used: Orthore* AND (prevalenc* OR incidenc* OR frequen* OR cut-off OR epidem*). A total of 613 unique hits were reviewed by two blinded authors, and 24 studies were coded and assessed for risk of bias (Holy et.al). The meta-regression included three independent variables (sex, type of sport, and sample size).

RESULTS

The overall prevalence of ON in the exercising population was 55.3% (95% CI 43.2-66.8). Cochran's Q was 11,436.38 (df = 23, p < 0.0000), and the I² was 98.4%, indicating high heterogeneity across studies. The sensitivity showed an overall prevalence of 51.3% (95% CI 51.3-70.0). There was a significant difference in prevalence estimates based on the instruments used (Q_bet = 33.6, df = 2, p < 0.01).

DISCUSSION

The overall prevalence of ON in exercising populations was very high. The between-study disparity was large and was partly explained by the ON-instrument administered. One fourth of the studies had a moderate risk of bias. The majority of the studies did not specify relevant demographic information about the sample, and information about the type of sport was frequently missing.

Individual differences in the positive outcome from adolescent ketamine treatment in a female mouse model of anorexia nervosa involve drebrin A at excitatory synapses of the medial prefrontal cortex

Anorexia nervosa (AN) is a mental illness with the highest rates of mortality and relapse, and no approved pharmacological treatment. Using an animal model of AN, called activity-based anorexia (ABA), we showed earlier that a single intraperitoneal injection of ketamine at a dose of 30 mg/kg (30mgKET), but not 3 mg/kg (3mgKET), has a long-lasting effect upon adolescent females of ameliorating anorexia-like symptoms through the following changes: enhanced food consumption and body weight; reduced running and anxiety-like behavior. However, there were also individual differences in the drug's efficacy. We hypothesized that individual differences in ketamine's ameliorative effects involve drebrin A, an F-actin-binding protein known to be required for the activity-dependent trafficking of NMDA receptors (NMDARs). We tested this hypothesis by electron microscopic quantifications of drebrin A immunoreactivity at excitatory synapses of pyramidal neurons (PN) and GABAergic interneurons (GABA-IN) in deep layer 1 of prefrontal cortex (PFC) of these mice. Results reveal that (1) the areal density of excitatory synapses on GABA-IN is greater for the 30mgKET group than the 3mgKET group; (2) the proportion of drebrin A+ excitatory synapses is greater for both PN and GABA-IN of 30mgKET than 3mgKET group. Correlation analyses with behavioral measurements revealed that (3) 30mgKET's protection is associated with reduced levels of drebrin A in the cytoplasm of GABA-IN and higher levels at extrasynaptic membranous sites of PN and GABA-IN; (5) altogether pointing to 30mgKET-induced homeostatic plasticity that engages drebrin A at excitatory synapses of both PN and GABA-IN.

Transgender and other gender diverse adolescents with eating disorders requiring medical stabilization

BACKGROUND

Despite the high prevalence of eating disorders in gender diverse adolescents, little is known about the characteristics of gender diverse youth with eating disorders who require inpatient medical stabilization. The primary objective of this study was to describe the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents hospitalized for eating disorders and compare these characteristics to cisgender peers hospitalized for eating disorders. The secondary objective was to evaluate percent median body mass index as one marker of malnutrition and treatment goal body mass index as a recovery metric between patients' birth-assigned sex and affirmed gender using standardized clinical growth charts.

METHODS

A retrospective chart review was conducted of 463 patients admitted to an inpatient eating disorders medical unit between 2012 and 2020. To compare medical, anthropometric, and psychiatric data between gender diverse and cisgender patients, chi-square/Fisher's exact and t-tests were used. Clinical growth charts matching the patients' birth-assigned sex and affirmed gender identity were used to assess percent of median body mass index and treatment goal body mass index.

RESULTS

Ten patients (2.2%) identified as gender diverse and were younger than cisgender patients [13.6 (1.5) years vs. 15.6 (2.7) years, p = 0.017]. Gender diverse patients were hospitalized with a higher percent median body mass index compared to cisgender peers [97.1% (14.8) vs. 87.9% (13.7), p = 0.037], yet demonstrated equally severe vital sign instability such as bradycardia [44 (8.8) beats per minute vs. 46 (10.6) beats per minute, p = 0.501], systolic hypotension [84 (7.1) mmHg vs. 84 (9.7) mmHg, p = 0.995], and diastolic hypotension [46 (5.8) mmHg vs. 45 (7.3) mmHg, p = 0.884]. Gender diverse patients had a higher prevalence of reported anxiety symptoms compared to cisgender patients (60% vs. 28%, p = 0.037).

CONCLUSIONS

Gender diverse patients demonstrated complications of malnutrition including vital sign instability despite presenting with a higher weight. This is consistent with a greater proportion of gender diverse patients diagnosed with atypical anorexia nervosa compared to cisgender peers. Additionally, psychiatric comorbidities were present among both groups, with a larger percentage of gender diverse patients endorsing anxiety compared to cisgender patients.

Suicidality in adolescents with onset of anorexia nervosa

OBJECTIVES

The mortality rate in patients with anorexia nervosa (AN) is 5 to 10 times higher than in general population and, suicide is one of the main causes of death. We evaluated the prevalence of suicidality (ideation, self-injurious behaviour, suicidal attempts) in 100 adolescents with onset of AN and we explored the correlation between suicidality, severity of AN symptoms and psychiatric comorbidity.

METHODS

We subdivided AN patients into restrictive (R-AN; n = 66) and restrictive atypical (A-AN; n = 34), according to the European Guidelines criteria. Assessment was performed using the eating disorder inventory 3rd version, the schedule for affective disorders and schizophrenia for school-age children-present and lifetime version interview, and the Columbia-suicide severity rating scale. Fisher's exact test and Mann-Whitney test (with correction for multiple testing) were used to compare the distribution of categorical and continuous variables between R-AN and A-AN patients, and between patients with vs. without suicidal behaviours.

RESULTS

Twenty-seven patients (27%) presented suicidality as clinical feature, expressed as at least one of the following: suicidal ideation (24%), self-cutting (19%), and suicidal attempt (6%). Patients with suicidality showed greater severity of psychiatric symptoms related to AN psychopathology and presented psychiatric comorbidity, especially depression, more often than patients who did not reported suicidality (70,4% vs 29,6%). No significant differences in terms of suicidal behaviours and AN-specific psychopathology were found between R-AN and A-AN.

CONCLUSIONS

Suicidality in adolescent patients with R-AN and A-AN seems to be related to ED symptoms. These data highlight the importance of screening for suicidality among adolescents at onset of AN, and confirms that A-AN should not be considered a milder disease.

LEVEL OF EVIDENCE

Level IV: Evidence obtained from multiple time series analysis such as case studies. (NB: Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

Family, friends, and feelings: the role of relationships to parents and peers and alexithymia in adolescents with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is associated with impairments in socio-emotional functioning, including difficulties in interpersonal relationships as well as alexithymia (difficulties identifying and describing one's emotions). Although the onset of the disorder is mostly in adolescence, a developmental period in which interpersonal relationships to parents as well as peers undergo major changes, only few studies have investigated the quality of interpersonal relationships in adolescent AN patients. Furthermore, the mechanisms linking poor relationship quality to eating disorder psychopathology are not yet clarified, albeit some research suggests that alexithymia might play a pivotal role. The aims of the present study were investigating the quality of interpersonal relationships to parents and peers in adolescents with AN compared to healthy adolescents as well as exploring the mediating role of alexithymia in the association between relationship quality and eating disorder symptoms.

METHODS

Self-report questionnaires were used to assess relationship quality (Inventory of Parent and Peer Attachment) and alexithymia (Toronto Alexithymia Scale) in 12-18 year old female adolescents with AN (n = 35) in comparison to healthy adolescents (n = 40).

RESULTS

Adolescents with AN reported lower relationship quality to both of their parents and to peers compared to healthy controls. Relationship quality scores were negatively correlated to alexithymia as well as eating disorder symptoms. Alexithymia fully meditated the association between eating disorder symptoms and relationship quality to parents and partially mediated the association between eating disorder symptoms and relationship quality to peers.

CONCLUSION

The results indicate difficulties in interpersonal relationships among adolescents with AN and emphasize the role of peer relationships for adolescents' eating disorder psychopathology. Alexithymia seems to play an important role in explaining the link between quality of relationships and eating disorder psychopathology. Results suggest that treatment should not only focus on family relationships but also address relationships to peers as well as adolescents' competence in identifying and dealing with their emotions.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Dynamic Structural Brain Changes in Anorexia Nervosa: A Replication Study, Mega-analysis, and Virtual Histology Approach

OBJECTIVE

Several, but not all, previous studies of brain structure in anorexia nervosa (AN) have reported reductions in gray matter volume and cortical thickness (CT) in acutely underweight patients, which seem to reverse upon weight gain. The biological mechanisms underlying these dynamic alterations remain unclear.

METHOD

In this structural magnetic resonance imaging study, we first replicated and extended previous results in (1) a larger independent sample of 75 acutely underweight adolescent and young adult female patients with AN (acAN; n = 54 rescanned longitudinally after partial weight restoration), 34 weight-recovered individuals with a history of AN (recAN), and 139 healthy controls (HC); and 2) a greater combined sample compiled of both our previous samples and the present replication sample (120 acAN [90 rescanned longitudinally], 68 recAN, and 207 HC). Next, we applied a "virtual histology" approach to the combined data, investigating relations between interregional profiles of differences in CT and profiles of cell-specific gene expression. Finally, we used the ENIGMA toolbox to relate aforementioned CT profiles to normative structural and functional connectomics.

RESULTS

We confirmed sizeable and widespread reductions of CT as well as volumes (and, to a lesser extent, surface area) in acAN and rapid increases related to partial weight restoration. No differences were detected between either short- or long-term weight-recovered patients and HC. The virtual histology analysis identified associations between gene expression profiles of S1 pyramidal cells and oligodendrocytes and brain regions with more marked differences in CT, whereas the remaining regions were those with a greater expression of genes specific to CA1 pyramidal, astrocytes, microglia, and ependymal cells. Furthermore, the most affected regions were also more functionally and structurally connected.

CONCLUSION

The overall data pattern deviates from findings in other psychiatric disorders. Both virtual histology and connectomics analyses indicated that brain regions most affected in AN are also the most energetically demanding.

A scoping review of non-specific predictors, moderators, and mediators of family-based treatment for adolescent anorexia and bulimia nervosa: a summary of the current research findings

PURPOSE

This scoping review presents an up-to-date synthesis of the current evidence base for non-specific predictors, moderators, and mediators of family-based treatment (FBT) for adolescent anorexia and bulimia nervosa.

METHODS

We identify ways in which end-of-treatment outcomes have been shown to differ based upon baseline clinical features and person-specific factors and explore psychological mechanisms that may explain differences in treatment response. We draw from this evidence base to outline recommendations for clinical practice, as well as directions for future clinical eating disorder research.

RESULTS

Noted findings from review include that early response in weight gain and parental criticism may be particularly influential in treatment for anorexia nervosa. Further, for adolescents with either anorexia or bulimia nervosa, eating-related obsessionality may be a key intervention target to improve outcomes.

CONCLUSION

In addition to highlighting a need for attention to specific patient- and caregiver-level factors that impact treatment response, recommendations for research and clinical practice include testing whether certain targeted treatments (e.g., exposure-based approaches) may be suitable within the context of FBT for eating disorders.

LEVEL OF EVIDENCE

Level I: Evidence obtained from: at least one properly designed randomized controlled trials; experimental studies.

Recognition and duration of illness in adolescent eating disorders: Parental perceptions of symptom onset

AIM

To understand the earliest parent reported signs suggesting their child may have an eating disorder (ED), and to quantify time from symptom onset to specialist assessment.

METHODS

This is a secondary analysis of data derived from parents of 78 young people presenting to a British community ED service who completed a questionnaire asking when they first noticed their child displaying (a) a change in eating pattern, (b) weight concerns, (c) shape concerns. Parents were also asked to describe the first thing they noticed in terms of possible ED symptoms.

RESULTS

Mean age was 14.9 (SD: 1.58), 94% were female with diagnoses of anorexia nervosa (n = 50), bulimia nervosa (n = 10) and atypical anorexia nervosa (n = 18). Weight and shape concerns were most often noticed over a year prior to assessment (mean 12.7 months [SD: 12.8] and 13.3 months [SD: 13.2], respectively), with eating pattern change observed a mean of 9.7 months (SD: 7.6) before referral to specialist care. Seven main themes were developed from parents' descriptions of their child's symptoms: (1) eating pattern change, (2) shape concern, (3) weight concern, (4) observed weight loss, (5) binge eating/compensatory behaviours, (6) other mental health concerns and (7) physical symptoms.

CONCLUSIONS

The most common parental concerns were eating pattern change, specifically their child becoming more rigid/rule-bound with regard to eating and dietary restraint. Such external changes are likely observed before physical changes such as weight loss, offering potential for early identification by parents, primary care and other professionals, with implications for improved prognosis.

The experience of healthcare professionals treating adolescents with eating disorders in psychiatric and pediatric inpatient units for adolescents: A qualitative study

OBJECTIVES

The recommended treatment for Eating Disorders (EDs) is multidisciplinary and multimodal. Nonetheless, the complex linkage of the different disciplines involved is not necessarily simple. We analyzed the experience of healthcare professionals faced with psychiatric and psychological symptoms in adolescents with EDs in two "multidisciplinary" inpatient units embedded predominantly in different paradigms - one pediatric and one psychiatric.

METHODS

Qualitative analysis of 20 healthcare staff members' interviews from different professional backgrounds working in inpatient units for EDs in Montreal (Canada) and Paris (France).

RESULTS

The "Complex patients" theme discusses the need for a global approach to the multiplicity of symptoms presented by these patients. "Management and its limits" describes the daily management of psychiatric symptoms in both units. "Psychiatry and Adolescent medicine: from opposition to collaboration" describes the different levels at which these disciplines work together and how this cooperation may be evolving.

CONCLUSIONS

The complex entanglement intrinsic in EDs of the patients' somatic, psychosocial, psychiatric, and adolescent problems requires collaboration between disciplines, but the modalities of this collaboration are multiple and evolve non-linearly in specialized treatment units. A multilevel approach must be offered, with the degree of collaboration (multidisciplinary, interdisciplinary and transdisciplinary) appropriate to the complexity of each adolescent's issues.

Eating disorder and social anxiety symptoms in Iranian preadolescents: a network analysis

PURPOSE

Network studies of eating disorder (ED) symptoms have identified central and bridge symptoms in Western samples, yet few network models of ED symptoms have been tested in non-Western samples, especially among preadolescents. The current study tested a network model of ED symptoms in Iranian preadolescents (ages 9 to 13), as well as a model of co-occurring social anxiety disorder (SAD) and ED symptoms.

METHOD

Preadolescent boys (n = 405) and girls (n = 325) completed the Children Eating Attitudes Test-20 and Social Anxiety Scale for Children. We estimated two network models (ED and ED/SAD networks) and identified central and bridge symptoms, as well as tested if these models differed by sex.

RESULTS

We found that discomfort eating sweets were the most central symptoms in ED networks. Concern over being judged was central in networks including both ED and SAD symptoms. Additionally, concern over being judged was the strongest bridge symptoms. Networks did not differ by sex.

CONCLUSION

Future research is needed to test if interventions focused on bridge symptoms (i.e., concern over being judged) as primary intervention points target comorbid ED-SAD pathology in preadolescents at risk for ED and SAD.

LEVEL OF EVIDENCE

Level III; Evidence obtained from well-designed observational study, including case-control design for relevant aspects of the study.

Secular trends in the incidence of eating disorders in China from 1990 to 2017: a joinpoint and age-period-cohort analysis

BACKGROUND

Eating disorders (ED) have increasingly become a global topic of concern for public health. A better understanding of ED incidence is a basic requirement for improving its management. However, the temporal trend of ED incidence in China is still unknown.

METHODS

The incidence rates of ED from 1990 to 2017 were collected from the Global Burden of Disease Study 2017 database according to the following: subtype, i.e. anorexia nervosa (AN) and bulimia nervosa (BN); sex; and age group. The average annual percent changes and relative risks were calculated using joinpoint regression and the age-period-cohort model, respectively.

RESULTS

From 1990 to 2017, age-standardized incidence rates of ED continued to increase in males and females, and this variation trend was observed in AN and BN. Joinpoint regression analysis showed that the incidence rates increased in all age groups. Adolescents had the highest risk of developing ED, followed by young adults. Age effects were the most influential risk factor for ED incidence. Period effects showed that the risk of developing ED continuously increased with increasing time periods in BN, but not in ED and AN. Concerning the cohort effects, people born after the 1990s presented a higher risk of ED, though they presented a lower risk of BN as compared to the whole cohort.

CONCLUSIONS

ED incidence rates continue to increase in China, particularly among adolescents and young adults. Further etiological studies are needed to explain these increases and to facilitate the early identification of high-risk individuals.

Eating disorder severity and psychological morbidity in adolescents with anorexia nervosa or atypical anorexia nervosa and premorbid overweight/obesity

PURPOSE

A significant proportion of adolescents with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) experience premorbid overweight/obesity, yet distinct characteristics among this subset of patients remain unclear. This study examined eating disorder (ED) symptom severity, psychological morbidity, and weight stigma in patients with premorbid overweight/obesity as compared to patients with premorbid normal weights.

METHODS

Participants included adolescents with AN or AAN (aged 12-18) who received multidisciplinary treatment at a pediatric medical center in the United States. ED symptoms, anxiety, and depression were compared among patients with premorbid overweight/obesity (n = 43) and premorbid normal weights (n = 63). Associations between weight stigma, ED severity, and psychological morbidity were also examined.

RESULTS

Patients with premorbid overweight/obesity reported greater ED severity (p = 0.04), anxiety (p < 0.003), depression (p = 0.02), and a higher frequency of weight-based teasing by peers (p = 0.003) and parent weight talk about their own weights (p < 0.001). Weight-based teasing was positively associated with ED symptoms, anxiety, and depression for all patients, regardless of premorbid weight status.

CONCLUSIONS

Adolescents with AN or AAN and a history of overweight/obesity may present with greater ED symptom severity and psychological morbidity than patients with normal weight histories. Distinct prevention and treatment interventions for adolescents with AN or AAN and premorbid overweight/obesity may be warranted.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Intact neural and behavioral correlates of emotion processing and regulation in weight-recovered anorexia nervosa: a combined fMRI and EMA study

Altered emotion processing and regulation mechanisms play a key role in eating disorders. We recently reported increased fMRI responses in brain regions involved in emotion processing (amygdala, dorsolateral prefrontal cortex) in acutely underweight anorexia nervosa (AN) patients while passively viewing negatively valenced images. We also showed that patients' ability to downregulate activity elicited by positively valenced pictures in a brain region involved in reward processing (ventral striatum) was predictive of worse outcomes (increased rumination and negative affect). The current study tries to answer the question of whether these alterations are only state effects associated with undernutrition or whether they constitute a trait characteristic of the disorder that persists after recovery. Forty-one individuals that were weight-recovered from AN (recAN) and 41 age-matched healthy controls (HC) completed an established emotion regulation paradigm using negatively and positively valenced visual stimuli. We assessed behavioral (arousal) and fMRI measures (activity in the amygdala, ventral striatum, and dorsolateral prefrontal cortex) during emotion processing and regulation. Additionally, measures of disorder-relevant rumination and affect were collected several times daily for 2 weeks after scanning via ecological momentary assessment. In contrast to our previous findings in acute AN patients, recAN showed no significant alterations either on a behavioral or neural level. Further, there were no associations between fMRI responses and post-scan momentary measures of rumination and affect. Together, these results suggest that neural responses to emotionally valenced stimuli as well as relationships with everyday rumination and affect likely reflect state-related alterations in AN that improve following successful weight-recovery.

Subjective Experience of Antidepressant Prescription Among Adolescents With Anorexia Nervosa

INTRODUCTION

Major depressive disorder is considered the most common comorbidity of anorexianervosa in adolescence. Some evidence argues against antidepressant use in this population. Moreover, the fear of being threatened with autonomy and of becoming dependent specific to this adolescent population and at the very core of the anorexic disease, make the proposal of such a treatment difficult to accept. This qualitative research aimed to explore the perspectives of view of adolescents with anorexia nervosa about antidepressants.

METHODS

We conducted interviews with adolescents suffering from anorexia nervosa who had been treated with an antidepressant agent during their inpatient or outpatient care at Cochin Hospital. Adolescents were chosen by convenience sampling. Both verbal and written questions were asked to elicit their lived experiences. Interpretative Phenomenological Analysis was used to examine the data.

RESULTS

Fifteen adolescents (13 girls and two boys) were interviewed. We have reached total data saturation. The analysis found two meta-themes, each with two separate themes. (I) Reactions to the proposal of antidepressant with (i) an opposition phase (about the existence of depressive symptoms and about negative preconceptions) and (ii) need to share with family and other teenagers. (II) Reactions to antidepressant use with (iii) ambivalence and an initial perception of coercion, and (iv) effects of antidepressants (psychological effects, effects on the body and on anorexia nervosa and effects perceived through the eyes of others).

DISCUSSION

Despite positive effects, ambivalence toward the treatment remained present throughout the interviews: these adolescents still worry greatly about loss of control and weight gain. Depression as comorbidity seems to be entangled in the denial of disease, cognitive distortion and acquired fearlessness specific to AN. Its existence in adolescence can uncover transgenerational issues, sometimes previously hidden. An orodispersible/drinkable form of antidepressants would facilitate adherence to treatment in this specific population. The intervention of a "patient-expert" could reduce adolescents' anxiety about loss of control. A latency period seems necessary to allow them to understand the prescription at their own level and in the complexity of their anorexic illness.

Autism and anorexia nervosa: Longitudinal prediction of eating disorder outcomes

BACKGROUND

Recently, elevated levels of autistic features and autism diagnoses have been reported among people with anorexia nervosa (AN). In clinical settings high levels of autistic features have been linked to more complex, highly comorbid illness presentation and poorer treatment outcome. This study aimed to examine whether autistic features predict AN symptom profile in long term.

METHODS

Altogether 118 women with lived experience of AN completed two autism assessments at time 1, the Autism Diagnostic Observation Schedule (ADOS) and the short version of the Autism Quotient (AQ10). Measures assessing AN symptom profile, including eating disorders symptoms, anxiety, depression, OCD symptoms, and Body Mass Index (BMI), were also recorded. The symptom profile measures were administered again 6 months and 2 years later. We conducted two analyses to examine the extent to which the ADOS and AQ10 scores predicted broad AN symptom profile at each three time points.

RESULTS

Overall, high levels of autistic features were consistently associated with worse psychological symptoms, but not BMI, across all time points. Both the analysis using baseline ADOS scores and self-reported AQ10 scores showed similar pattern.

CONCLUSION

The present findings consolidate previously reported associations between autistic features and worse psychological outcome among people with AN. The findings also suggest that self-report measures may be sufficient for assessing the impact of autistic features on illness outcome among people with AN. Importantly, the study highlights the need for development and further investigation of neurodiversity accommodations in the treatment of AN.

Brain Volume Loss, Astrocyte Reduction, and Inflammation in Anorexia Nervosa

Anorexia nervosa is the third most common chronic disease in adolescence and is characterized by low body weight, body image distortion, weight phobia, and severe somatic consequences. Among the latter, marked brain volume reduction has been linked to astrocyte cell count reduction of about 50% in gray and white matter, while neuronal and other glial cell counts remain normal. Exact underlying mechanisms remain elusive; however, first results point to important roles of the catabolic state and the very low gonadal steroid hormones in these patients. They also appear to involve inflammatory states of "hungry astrocytes" and interactions with the gut microbiota. Functional impairments could affect the role of astrocytes in supporting neurons metabolically, neurotransmitter reuptake, and synapse formation, among others. These could be implicated in reduced learning, mood alterations, and sleep disturbances often seen in patients with AN and help explain their rigidity and difficulties in relearning processes in psychotherapy during starvation.

The perception of food size and food shape in anorexia nervosa

Visual perception of food size and shape in anorexia nervosa (AN) is an understudied topic, notwithstanding its relevance in approaching food, key-element in weight restoration. In addition, it is unclear how visual perception in AN is related to the age and the duration of illness. Here, we compared patients with AN to healthy controls (HCs) on their spatial resolution, biases in perceived food size, and holistic processing of food shape. A total of 122 participants were enrolled: 48 adolescents (27 AN and 21 HCs) and 74 adults (33 AN and 41 HCs). Participants at two academic sites (Israel and Italy) completed measures of psychopathology and experiments measuring visual resolution (Just Noticeable Difference), biases in food-size perception (Points of Subjective Equality), and holistic processing of food shape (indicated by the height-width illusion). Adolescents and adults with AN differed in the duration of illness and body mass index but showed comparable eating psychopathology and body measures. Patients with AN showed preserved visual resolution but distorted perception of food size, perceiving food as bigger than non-food objects, in both age groups. Patients with AN, both adolescents and adults, also processed food stimuli in a more analytic fashion, and were immune to the height-width illusion. The preserved perception of non-food stimuli in AN coupled with biases in food-size perception and in analytic processing of food shape highlight patients' real-world difficulties in approaching food. Future treatments on AN may consider taking these differences into account.

The KOALA-study: study protocol for a comprehensive study of cognitive biases in adolescent anorexia nervosa patients compared to healthy and clinical controls

BACKGROUND

Anorexia nervosa (AN) is characterized by dysfunctional cognitions including cognitive biases at various levels of information processing. However, less is known about the specificity of these biases, i.e., if they occur for eating-disorder-related information alone or also for non-eating-disorder-related emotional information in AN patients (content-specificity) and if they are unique to individuals with AN or are also shown by individuals with other mental disorders (disorder-specificity).

METHODS

The present study systematically assesses cognitive biases in 12-18-year-old female adolescents with AN on three levels of information processing (attention, interpretation, and memory) and with regard to two types of information content (eating-disorder-related, i.e., stimuli related to body weight and shape, and non-eating-disorder-related). To address not only content- but also disorder-specificity, adolescents with AN will be compared not only to a healthy control group but also to a clinical control group (adolescents with major depression or particular anxiety disorders). Cognitive biases are assessed within a single experimental paradigm based on the Scrambled Sentences Task. During the task eye movements are recorded in order to assess attention biases while interpretation biases are derived from the behavioural outcome. An incidental free recall test afterwards assesses memory biases. We expect adolescents with AN to show more pronounced negative cognitive biases on all three levels of information processing and for both types of content compared to healthy adolescents. In addition, we expect the specificity of biases to translate into differential results for the two types of content: AN patients are expected to show stronger biases for disorder-related stimuli but similar or less pronounced biases for non-disorder-related stimuli compared to the clinical control group.

DISCUSSION

This is the first study to comprehensively assess cognitive biases in adolescents with AN. It will have essential implications not only for cognitive-behavioural models of AN but also for subsequent studies aiming to modify cognitive biases in this population, thereby addressing important maintaining factors already at an early stage of the disorder.

Psychosocial etiology of maladaptive exercise and its role in eating disorders: A systematic review

OBJECTIVE

Although maladaptive exercise (ME) is widely recognized as a clinical feature in transdiagnostic eating disorders, less is known about psychosocial factors that give rise to and perpetuate this behavior. This systematic review aimed to examine the empirical status of this association.

METHOD

We reviewed 46 full text articles examining longitudinal associations between psychosocial variables and ME.

RESULTS

Eighteen studies met full inclusion criteria. Based on our qualitative synthesis, evidence suggests reasonably consistent associations between early concern with weight and shape, and negative affect on later development of ME.

DISCUSSION

Inconsistent and insufficient assessment of ME across a majority of studies underscores caution in interpretation of results, but guides important discussion for future clinical and research efforts.

Vitamin D Level Trajectories of Adolescent Patients with Anorexia Nervosa at Inpatient Admission, during Treatment, and at One Year Follow Up: Association with Depressive Symptoms

(1) Background: Evidence has accumulated that patients with anorexia nervosa (AN) are at higher risk for vitamin D deficiency than healthy controls. In epidemiologic studies, low 25(OH) vitamin D (25(OH)D) levels were associated with depression. This study analyzed the relationship between 25(OH)D serum levels in adolescent patients and AN and depressive symptoms over the course of treatment. (2) Methods: 25(OH)D levels and depressive symptoms were analyzed in 93 adolescent (in-)patients with AN from the Anorexia Nervosa Day patient versus Inpatient (ANDI) multicenter trial at clinic admission, discharge, and 1 year follow up. Mixed regression models were used to analyze the relationship between 25(OH)D levels and depressive symptoms assessed by the Beck Depression Inventory (BDI-II). (3) Results: Although mean 25(OH)D levels constantly remained in recommended ranges (≥50 nmol/L) during AN treatment, levels decreased from (in)patient admission to 1 year follow up. Levels of 25(OH)D were neither cross-sectionally, prospectively, nor longitudinally associated with the BDI-II score. (4) Conclusions: This study did not confirm that 25(OH)D levels are associated with depressive symptoms in patients with AN. However, increasing risks of vitamin D deficiency over the course of AN treatment indicate that clinicians should monitor 25(OH)D levels.

Is the Severity of the Clinical Expression of Anorexia Nervosa Influenced by an Anxiety, Depressive, or Obsessive-Compulsive Comorbidity Over a Lifetime?

Purpose: The relationship between anxiety or depressive comorbidities, their chronology of onset, and the severity of anorexia nervosa (AN) is not well-studied. We hypothesize that the existence of a comorbidity, particularly before the onset of AN, is associated with greater severity of AN. Methods: One hundred seventy-seven subjects were assessed. The prevalence of major depressive disorder (MDD), obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), and social phobia (SP) as well as their chronology of onset were studied. The assessment criteria of AN severity were the overall clinical condition, body mass index (BMI) on admission, lowest BMI, intensity of the eating symptoms, age at the onset of AN, illness duration, number of hospitalizations, and quality of life. Results: Patients with AN had the greatest clinical severity when they had a comorbid disorder over their lifetime, such as MDD, GAD, or SP. These comorbidities along with OCD were associated with a higher level of eating symptoms and a more altered quality of life. A profile of maximum severity was associated with a higher prevalence of MDD and GAD. Concerning the chronology of onset, the age at the start of AN was later in cases of MDD or GAD prior to AN. Conclusion: There seems to be an association between severity of AN and both MDD and GAD. The chronology of onset of the comorbidity did not seem to be associated with the severity.

Restrictive eating disorders in children and adolescents: a comparison between clinical and psychopathological profiles

PURPOSE

DSM-5 describe three forms of restrictive and selective eating: Anorexia Nervosa-Restrictive (AN-R), Anorexia Nervosa-Atypical (AN-A), and Avoidant/Restrictive Food Intake Disorder (ARFID). While AN is widely studied, the psychopathological differences among these three diseases are not clear. The aim of this study was to (i) compare the clinical features of AN-R, AN-A, and ARFID, in a clinical sample recruited from a specialized EDs program within a tertiary care children's Hospital; (ii) identifying three specific symptom profiles, to better understand if restrictive ED share a common psychopathological basis.

METHODS

Data were collected retrospectively. Psychometric assessment included: the Children's Depression Inventory (CDI), the Multidimensional Anxiety Scale for Children (MASC), the Child Behavior Checklist (CBCL), and the Eating Disorder Inventory-3 (EDI-3).

RESULTS

A final sample of 346 children and adolescent patients were analyzed: AN-R was the most frequent subtype (55.8%), followed by ARFID (27.2%) and AN-A (17%). Patients with ARFID presented different features from AN-R and AN-A, characterized by lower weight and medical impairment, younger age at onset, and a frequent association with separation anxiety and ADHD symptoms. EDI-3 profiles showed specific different impairment for both AN groups compared to ARFID. However, no differences was detected for items: 'Interpersonal Insecurity', "Interoceptive Deficits", "Emotional Dysregulation", and "Maturity Fears".

CONCLUSIONS

Different ED profiles was found for the three groups, but they share the same general psychopathological vulnerability, which could be at the core of EDs in adolescence.

LEVEL OF EVIDENCE

III. Evidence obtained from case-control analytic studies.

Is set-shifting and central coherence in anorexia nervosa influenced by body mass index, anxiety or depression? A systematic review

BACKGROUND

Anorexia nervosa (AN) is a severe eating disorder, recognized by a relentless pursuit for thinness and extreme low body weight. The disorder is often accompanied by comorbid disorders such as anxiety and depression, and altered neuropsychological function in terms of poor set-shifting and reduced central coherence. The aim of this review was to evaluate whether neuropsychological impairments in AN are influenced by body mass index, anxiety or depression.

METHOD

A systematic review approach was used, following the PRISMA guidelines for systematic reviews. Literature was identified via searches in PubMed, PsychInfo and Embase database, by using the search words [anorexia nervosa] AND [central coherence], and [anorexia nervosa] AND [set-shifting]. Studies were included if they were written in English, peer-reviewed, included individuals with AN, included tests measuring set-shifting and/or central coherence, investigated associations between set-shifting/central coherence with anxiety and/or depression and/or BMI. Risk of bias was assessed by using a critical appraisal checklist from the Joanna Briggs Institute. Results were summarized in a narrative synthesis.

RESULTS

Although results are heterogeneous, the majority of studies report that neither body mass index (BMI), anxiety or depression is associated with altered central coherence and set-shifting in individuals with AN.

CONCLUSIONS

Findings indicate that BMI, depression and anxiety does not influence neuropsychological function in AN, suggesting that it could be a characteristic of the disorder. A complete understanding of predisposing, precipitating and maintaining factors in AN needs to be addressed in future research. This could contribute to the development of better and more targeted treatment strategies.

The effect of daily fast food consumption, family size, weight-caused stress, and sleep quality on eating disorder risk in teenagers

PURPOSE

Eating disorder (ED) is a common complication with disturbance of eating or eating-related behaviors that lead to physical and psychosocial disorders. The purpose of this study was to evaluate the association between eating disorders and daily fast food consumption, family size, weight-caused stress, and sleep quality in teenagers in Zanjan, Iran.

METHODS

Adolescent girl students aged 12-15 years (n = 370), selected in a cross-sectional study, completed the Eating Attitude Test-26 and Pittsburgh Sleep Quality Index questionnaires. The cluster random sampling method was used. Statistical analysis was performed using R software version 3.6.3. Logistic regression modeling was used for investigating the relationship between factors and odds of EDs. A p value of less than 0.05 was considered significant.

RESULTS

A significant relationship was found between family size (OR = 0.77, p = 0.049), fast food-daily consumption (OR = 5.42, p = 0.043), weight-caused stress (OR = 12.47, p < 0.001), and poor sleep quality (OR = 1.70, p = 0.024) and odds of eating disorder among teenage girls.

CONCLUSION

A significant positive association was found between a low number of family members, daily fast food consumption, stress status, poor sleep quality and odds of EDs. However more longitudinal studies are required to confirm the results.

Treatment of Eating Disorders in Adults Versus Adolescents: Similarities and Differences

FINDINGS

Although several individual psychotherapies for adults with eating disorders are empirically supported, with family-based treatment (FBT) being the leading recommended empiric treatment in adolescents, patients with eating disorders are still difficult to treat, and outcomes are often poor. In some countries, the clinical services for adolescents and adults are separate, and it is common for patients to receive treatments that differ in terms of both theory and content when they are switched from adolescent to adult services. Changes in the nature of treatment also often occur when patients move from less intensive types of care to more intensive treatment, and vice versa. These transitions may create a discontinuity in the care pathway and disorient patients and their significant others about the strategies and procedures used for addressing eating problems. However, the observation that younger and older patients essentially share the same eating-disorder psychopathology has led to evidence-based enhanced cognitive-behavioral therapy (CBT-E) being adapted for use in adolescents. Originally an evidence-based treatment for adults with eating disorders, CBT-E has yielded promising results in trials in cohorts of adolescent outpatients and inpatients, and is recommended as an alternative to FBT in adolescent patients.

IMPLICATIONS

With a unified treatment such as CBT-E, several issues that plague conventional eating-disorder services could be partially overcome, as patients can move seamlessly from adolescence to adulthood and through different levels of care, with no change in the nature of the treatment itself. Future randomized, controlled trials should compare FBT to CBT-E to better clarify the specific therapeutic needs of subgroups of adolescents and adult patients with eating disorders.

A comparison of eating disorder symptomatology, psychological distress and psychosocial function between early, typical and later onset anorexia nervosa

OBJECTIVE

Epidemiological studies suggest that the incidence of anorexia nervosa (AN) is increasing in younger populations, with some evidence that clinical differences occur according to age of onset (AOO), which may impact prognostic outcomes. The current study sought to compare eating disorder (ED) symptomatology, psychological distress and psychosocial function between early onset (EO), typical onset (TO) and later onset (LO) AN in a large sample of treatment-seeking patients with a diagnosis of AN.

METHODS

Participants included 249 individuals with a diagnosis of AN who were assessed at an outpatient ED service. The sample was divided into three groups based on AOO; those with an AOO ≤14 years (N = 58) were termed 'EO-AN', those with an AOO between 15 and 18 years (N = 113) were termed 'TO-AN' and those with an AOO of > 18 years (N = 78) were termed 'LO-AN'. Comparisons were made between AOO groups on assessments of ED symptomatology, psychological distress and psychosocial function.

RESULTS

EO-AN patients reported a significantly longer illness duration than both TO-AN and LO-AN groups. After controlling for effect of illness duration, the EO-AN group demonstrated significantly higher ED symptomatology and dysmorphic concern compared to the LO-AN group. The EO-AN group demonstrated significantly decreased cognitive flexibility compared to both the TO-AN and LO-AN groups.

DISCUSSION

These findings suggest that clinical differences do occur according to AOO in AN whereby EO-AN may represent a more severe form of illness that is not attributable to increased illness duration. Treatment strategies which specifically address patients with EO-AN may improve long term health outcomes and recovery.

Sounds unrealistic: an adolescent girl with anorexia nervosa consumes 19 L of fluid in a few hours: what happens to the physiology?

BACKGROUND

Adolescents with eating disorders (EDs) may present not only with abnormal eating behaviors but also with abnormal drinking behaviors varying widely. These behaviors include water loading to cheat on weight measurements, to feel full and suppress appetite and/or to induce vomiting; as well as restricting fluid intake in addition to food.

METHOD

We present a 16-year-old female adolescent with anorexia nervosa restrictive type and major depressive disorder who was hospitalized due to acute food refusal and developed generalized seizures due to dilutional hyponatremia in consequence of consuming excessive amount of water. Psychiatric diagnoses were made according to 'The Diagnostic and Statistical Manual of Mental Disorders' (5th ed.; DSM-5) criteria.

RESULTS

After starting nutritional rehabilitation with a low calorie meal plan to avoid refeeding syndrome, a weight gain of 2 kg was noted in the second day of hospitalization. At the bedside visit, she was observed in a disoriented manner and consecutively in seconds, lost consciousness with a generalized tonic-clonic seizure lasting 2 min. Her serum sodium level was measured as 116 mEq/L, which was normal at the time of admission. It was later learned that she secretly ingested 19 L of water in a short amount of time. She regained consciousness and no further seizures were observed after intravenous sodium deficit correction and fluid restriction therapy. Her serum sodium level was normalized (137 mEq/L) within 12 h.

CONCLUSION

A thorough clinical assessment of hydration and drinking behaviors as well as eating behaviors is essential for patients with EDs to avoid serious medical complications with high mortality and morbidity during follow-up. It is interesting that this amount of fluid consumption in such a short period of time did not present to the clinic with vomiting, gastric dilatation or bowel irrigation symptoms in a case with acute food refusal and restriction for a year, instead absorbed very quickly causing acute and severe symptomatic hyponatremia with generalized seizures.

Pharmacological treatment of acute-phase anorexia nervosa: Evidence from randomized controlled trials

BACKGROUND

Anorexia nervosa (AN) is the psychiatric disorder with the highest mortality rate, with a standard mortality ratio of 5.86. Despite the large use of psychotropic drugs in the clinical setting, Food and Drug Administration has not approved any psychoactive treatment for AN.

AIMS

The aim of this study was to perform an updated systematic review and meta-analysis of published randomized controlled trials (RCTs) investigating psychopharmacological treatment in acute-phase AN.

METHODS

The present paper follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. An extensive literature search was performed. All RCTs enrolling patients with acute-phase AN, comparing at least one psychotropic drug with another drug, placebo, treatment-as-usual or no treatment were included. The main outcome was the effect of psychoactive drugs on body mass index (BMI); data on psychopathological outcomes were also collected when available.

RESULTS

A total of 19 RCTs met all specified criteria. Of these, 11 were excluded from quantitative analyses. Of the eight studies included in the meta-analyses, five reported data on BMI, showing no significant difference between olanzapine and placebo for weight recovery. No significant result was found for AN psychopathology, depressive and anxious symptoms for any of the molecules studied.

CONCLUSIONS

RCTs published in this field display methodological biases, low sample sizes and short follow-up periods. Further research efforts are needed in this field as no evidence has been demonstrated for the use of any psychotropic drug in acute-phase AN neither for weight recovery, nor for comorbid psychiatric symptoms.