Temperament-based treatment for anorexia nervosa

Temperament impact on eating disorder symptoms and habit formation: a novel model to inform treatment

BACKGROUND

Temperament has long been described as the biological dimension of personality. Due to advancing brain-imaging technology, our understanding of temperament has deepened and transformed over the last 25 years. Temperament combines genetic, neurobiological and trait research. Temperament has been included peripherally in some eating disorder (ED) treatment approaches but has been ignored by most. Temperament fills a fundamental treatment gap by clarifying who is more vulnerable to develop ED and why some individuals are susceptible to specific ED symptoms while others are not. In addition, temperament targets possible treatment solutions.

MAIN TEXT

There is a need for a novel model that incorporates and explores the role of temperament in ED treatment intervention. This paper is a metaphoric temperament model to inform treatment intervention. It describes how temperament traits influences new decisions which impact new behavioural responses. In turn, it neurobiologically tracks how and why the brain efficiently transforms new decisions into new habits. This model integrates both temperament and habit research to explore (a) what temperament is; (b) how new decisions develop into habits neurobiologically; (c) that the brain wires destructive symptoms into habits in the same way that it wires healthy/productive behaviours into habits; (d) traits that trigger ED symptoms are the same traits that influence productive behaviours; and in regard to treatment implications (e) when treatment structure and intervention target client temperaments, the potential for new healthy "trait-syntonic" habits could develop.

CONCLUSIONS

This paper introduces a metaphoric model that synthesizes and integrates temperament neurobiological and trait findings with ED symptoms, habits, and client trait-based solutions. The model synthesizes and integrates different research domains to establish a brain-based foundation to inform treatment intervention. The model targets clients' temperament traits as central collections of innate self-expressions that could be utilized as tools to redirect client trait-syntonic ED responses into trait-syntonic productive outcomes. The brain bases of temperament and habit formation serve as a biological foundation for ED treatment intervention.

Examining anxious temperament in anorexia nervosa: Behavioural inhibition and intolerance of uncertainty and their contribution to trait anxiety in adolescents with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a serious and complex psychiatric disorder yet treatment results are suboptimal. Insight into the etiology of this illness is much needed. Research highlights the implication of anxiety-related traits in the development and maintenance of AN. This study investigates firstly, behavioural inhibition and intolerance for uncertainty (IU) in adolescents with and without AN, and secondly relations between these traits.

METHODS

In a cross-sectional study, 165 adolescent girls (AN = 94, HC = 71) completed questionnaires measuring behavioural inhibition, IU and trait anxiety. ANOVAs tested differences between AN and HC groups, and mediation models with IU as a mediator between behavioural inhibition and trait anxiety were run.

RESULTS

AN adolescents reported significantly higher levels of behavioural inhibition, IU and trait anxiety compared to their peers. In both AN and HC, a direct and a total effect of behavioural inhibition on trait anxiety was found. However, only in the AN group IU partially mediated the relation between behavioural inhibition and trait anxiety.

LIMITATIONS

Data is cross-sectional and longitudinal studies are required. A mean illness duration of nearly 2 years may mean early effects of malnourishment and habituation and future studies should include patients with shorter illness duration.

CONCLUSIONS

Results highlight that behavioural inhibition and IU may contribute to anxiety in AN whilst their peers may have developed better executive and social-emotional skills to manage uncertainty. Adolescents with AN may benefit from interventions targeting behavioural inhibition and IU.

Machine learning models for diagnosis and risk prediction in eating disorders, depression, and alcohol use disorder

This study uses machine learning models to uncover diagnostic and risk prediction markers for eating disorders (EDs), major depressive disorder (MDD), and alcohol use disorder (AUD). Utilizing case-control samples (ages 18-25 years) and a longitudinal population-based sample (n=1,851), the models, incorporating diverse data domains, achieved high accuracy in classifying EDs, MDD, and AUD from healthy controls. The area under the receiver operating characteristic curves (AUC-ROC [95% CI]) reached 0.92 [0.86-0.97] for AN and 0.91 [0.85-0.96] for BN, without relying on body mass index as a predictor. The classification accuracies for MDD (0.91 [0.88-0.94]) and AUD (0.80 [0.74-0.85]) were also high. Each data domain emerged as accurate classifiers individually, with personality distinguishing AN, BN, and their controls with AUC-ROCs ranging from 0.77 to 0.89. The models demonstrated high transdiagnostic potential, as those trained for EDs were also accurate in classifying AUD and MDD from healthy controls, and vice versa (AUC-ROCs, 0.75-0.93). Shared predictors, such as neuroticism, hopelessness, and symptoms of attention-deficit/hyperactivity disorder, were identified as reliable classifiers. For risk prediction in the longitudinal population sample, the models exhibited moderate performance (AUC-ROCs, 0.64-0.71), highlighting the potential of combining multi-domain data for precise diagnostic and risk prediction applications in psychiatry.

Perfectionism in anorexia nervosa: Associations with clinical picture and personality traits

Although many researchers addressed the topics, no consistent data are currently available regarding the relationship between perfectionism and personality traits in anorexia nervosa (AN). The present study aimed to assess differences between high- and low-perfectionism groups of patients with AN and to identify which variables show the strongest association with perfectionism. A group of inpatients with AN (n = 193) was recruited and completed a battery of self-report questionnaires regarding eating-related and general psychopathology, perfectionism, and personality. On the basis of perfectionism scores, patients were divided into high- and low-perfectionism groups. High-perfectionist patients displayed higher eating-related and general psychopathology; higher depressive, cyclothymic, irritable and anxious temperament, and lower self-directedness, cooperativeness and self-esteem. Perfectionism was associated with the drive for thinness, cooperativeness, self-esteem and anxious temperament. On the basis of the two personality traits most strongly correlated with perfectionism (i.e., cooperativeness and anxious temperament), patients could be correctly assigned to the high- or low-perfectionism group by an algorithm. The study suggests that perfectionism in AN is related to eating psychopathology, especially of restrictive type, and personality features such as cooperativeness and anxious temperament. These findings confirm the important role of perfectionism in AN, not only concerning eating behaviour but personality as well.

Acceptability, feasibility and short-term outcomes of temperament based therapy with support (TBT-S): a novel 5-day treatment for eating disorders

BACKGROUND

Temperament Based Therapy with Support (TBT-S) aims to target the mechanisms underlying the aetiology and maintenance of eating disorders, and was developed as an adjunct to treatment as usual. There is limited research investigating acceptability, feasibility and possible benefits of TBT-S. Therefore, the primary aim of the current study was to assess treatment feasibility and acceptability at a tertiary specialized eating disorders service in Norway, with a secondary aim to explore possible benefits in clinical outcome.

METHODS

Forty-one patients (mean age 25.3, range 18-43) and 58 supports were assessed pre- and post TBT-S. The majority of the patients were diagnosed with either anorexia nervosa or atypical anorexia nervosa. Participants completed an 18-item Patient and Support Satisfaction Questionnaire, in addition to a questionnaire assessing the usefulness of the different intervention components and strategies utilised in TBT-S, as well as a 4-item treatment satisfaction questionnaire. Measures of treatment efficacy were completed at both time-points, whereas treatment acceptability was only assessed post-treatment.

RESULTS

Findings reveal that TBT-S is a feasible treatment with high client satisfaction. Preliminary outcome data were also encouraging, and in line with previous studies. There were no voluntary drop-outs. All participants, both patients and supports, reported that TBT-S helped them deal more effectively with their challenges. After completing treatment, there was a significant decrease in patients' self-reported eating disorder psychopathology, psychosocial impairment and state anxiety, while trait anxiety remained unchanged. Patients also reported significantly improved social relationships, whereas supports reported a significant increase in (own) psychological health. There were no differences in family functioning.

CONCLUSIONS

TBT-S is a promising new treatment for eating disorders with high acceptability scores and low treatment attrition. Future studies should aim to explore methods which can most appropriately measure the effect of TBT-S and the usefulness of the different components of this treatment. Randomised controlled trials are needed to assess treatment efficacy of TBT-S.

Central Autonomic Network Alterations in Anorexia Nervosa Following Peripheral Adrenergic Stimulation

BACKGROUND

Anorexia nervosa (AN) is characterized by low body weight, disturbed eating, body image disturbance, anxiety, and interoceptive dysfunction. However, the neural processes underlying these dysfunctions in AN are unclear. This investigation combined an interoceptive pharmacological probe, the peripheral β-adrenergic agonist isoproterenol, with resting-state functional magnetic resonance imaging to examine whether individuals with AN relative to healthy comparison participants show dysregulated neural coupling in central autonomic network brain regions.

METHODS

Resting-state functional magnetic resonance imaging was performed in 23 weight-restored female participants with AN and 23 age- and body mass index-matched healthy comparison participants before and after receiving isoproterenol infusions. Whole-brain functional connectivity (FC) changes were examined using central autonomic network seeds in the amygdala, anterior insular cortex, posterior cingulate cortex, and ventromedial prefrontal cortex after performing physiological noise correction procedures.

RESULTS

Relative to healthy comparison participants, adrenergic stimulation caused widespread FC reductions in the AN group between central autonomic network regions and motor, premotor, frontal, parietal, and visual brain regions. Across both groups, these FC changes were inversely associated with trait anxiety (State-Trait Anxiety Inventory-Trait), trait depression (9-item Patient Health Questionnaire), and negative body image perception (Body Shape Questionnaire) measures, but not with changes in resting heart rate. These results were not accounted for by baseline group FC differences.

CONCLUSIONS

Weight-restored females with AN show a widespread state-dependent disruption of signaling between central autonomic, frontoparietal, and sensorimotor brain networks that facilitate interoceptive representation and visceromotor regulation. Additionally, trait associations between central autonomic network regions and these other brain networks suggest that dysfunctional processing of interoceptive signaling may contribute to affective and body image disturbance in AN.

Altered Reinforcement Learning from Reward and Punishment in Anorexia Nervosa: Evidence from Computational Modeling

OBJECTIVES

Anorexia nervosa (AN) is associated with altered sensitivity to reward and punishment. Few studies have investigated whether this results in aberrant learning. The ability to learn from rewarding and aversive experiences is essential for flexibly adapting to changing environments, yet individuals with AN tend to demonstrate cognitive inflexibility, difficulty set-shifting and altered decision-making. Deficient reinforcement learning may contribute to repeated engagement in maladaptive behavior.

METHODS

This study investigated learning in AN using a probabilistic associative learning task that separated learning of stimuli via reward from learning via punishment. Forty-two individuals with Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 restricting-type AN were compared to 38 healthy controls (HCs). We applied computational models of reinforcement learning to assess group differences in learning, thought to be driven by violations in expectations, or prediction errors (PEs). Linear regression analyses examined whether learning parameters predicted BMI at discharge.

RESULTS

AN had lower learning rates than HC following both positive and negative PE (p < .02), and were less likely to exploit what they had learned. Negative PE on punishment trials predicted lower discharge BMI (p < .001), suggesting individuals with more negative expectancies about avoiding punishment had the poorest outcome.

CONCLUSIONS

This is the first study to show lower rates of learning in AN following both positive and negative outcomes, with worse punishment learning predicting less weight gain. An inability to modify expectations about avoiding punishment might explain persistence of restricted eating despite negative consequences, and suggests that treatments that modify negative expectancy might be effective in reducing food avoidance in AN.

Multi-family therapy for eating disorders across the lifespan: A systematic review and meta-analysis

Eating disorders (EDs) have an estimated prevalence rate of 1%-5% across Europe. Effective adjunct interventions are needed to support the 20%-40% of families whose recovery requires additional support to first line approaches. This systematic review and meta-analysis aimed to establish whether multi-family therapy (MFT) improves the physical and psychological health of patients and family members. Searches were conducted in PsycINFO, MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Library in March 2021. 15 studies (850 patients) met the inclusion criteria. Meta-analysis demonstrated MFT resulted in significant benefits in weight gain, ED symptoms, patients' and parents' depression symptoms, and parents' negative experiences of caregiving. However, significant improvements were only evident when comparisons were drawn before and after the intervention; these dissipated when MFT was compared to another intervention. There was no evidence MFT improves family functioning, positive aspects of caregiving, nor patient and parental anxiety. Intervention completion rates ranged from 86% to 100% indicating a high level of acceptability. Studies varied with regard to intervention length and structure, follow-up period, and outcome measures utilised; most were rated as moderate or weak in methodological quality. More rigorous and large scale randomised controlled trials are needed to fully assess the effectiveness of MFT.

Mediation models of anxiety and depression between temperament and drive for thinness and body dissatisfaction in anorexia nervosa

PURPOSE

Anorexia nervosa (AN) is a life-threatening condition in which temperament, anxiety, depression, and core AN body-related psychopathology (drive for thinness, DT, and body dissatisfaction, BD) are intertwined. This relationship has not been to date disentangled; therefore, we performed a multiple mediation analysis aiming to quantify the effect of each component.

METHODS

An innovative multiple mediation statistical method has been applied to data from 184 inpatients with AN completing: Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire, Eating Disorders Inventory-2, State-Trait Anxiety Inventory, and Beck Depression Inventory.

RESULTS

All affective temperaments but the hyperthymic one were involved in the relationship with DT and BD. Only the anxious temperament had a significant unmediated direct effect on DT after the strictest correction for multiple comparisons, while the depressive temperament had a significant direct effect on DT at a less strict significance level. State anxiety was the strongest mediator of the link between affective temperament and core AN body-related psychopathology. Depression showed intermediate results while trait anxiety was not a significant mediator at all.

CONCLUSION

Affective temperaments had a relevant impact on body-related core components of AN; however, a clear direct effect could be identified only for the anxious and depressive temperaments. Also, state anxiety was the strongest mediator thus entailing interesting implications in clinical practice.

LEVEL OF EVIDENCE

V, cross-sectional study.

Understanding relations between intolerance of uncertainty and body checking and body avoiding in anorexia nervosa

BACKGROUND

A key feature of anorexia nervosa is body image disturbances and is often expressed by dysfunctional body-related behaviours such as body checking and body avoiding. These behaviours are thought to contribute to both the maintenance and relapse of AN, yet empirical evidence is scarce. One variable that may contribute to the need for engaging in these behaviours is intolerance of uncertainty. This study aims to investigate body checking and body avoiding and its relations with intolerance of uncertainty in women with anorexia nervosa (AN-ill; 70), women recovered from AN (AN-rec; 85) and control group (127).

METHODS

Three questionnaires were completed, measuring eating pathology, intolerance of uncertainty and body checking and body avoiding. One-way ANOVAS were used to test group differences. Moderation analyses were used to investigate associations between variables.

RESULTS

Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill followed by AN-rec and, lastly, the control group, confirming group differences. Intolerance of uncertainty was associated with body checking in the AN-rec group and the control group but not in the AN-ill group. The association between intolerance of uncertainty and body avoiding was reported in the AN-rec group and only marginally in the control group.

CONCLUSION

Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill, however still elevated in AN-rec, confirming the presence of body image disturbances, even after recovery. The unique associations between intolerance of uncertainty and body checking and body avoiding within the studied groups may represent different stages of the illness. In the AN-rec group, the relation between intolerance of uncertainty, body checking and body avoiding may be driven by trait anxiety. For AN-ill group, body checking and body avoiding may eventually have grown into habitual patterns, rather than a strategy to ameliorate anxiety and uncertainty. Women with anorexia nervosa often experience disturbances in their body image and are expressed in body-related behaviours such as body checking and body avoiding. These behaviours are thought to contribute to both the maintenance and relapse of anorexia nervosa. Intolerance of uncertainty is defined as the incapacity to tolerate uncertainty and may contribute to the need for engaging in these behaviours. This study aims to investigate body checking and body avoiding and its relations with intolerance of uncertainty in women with anorexia nervosa (AN-ill; 70), women recovered from AN (AN-rec; 85) and control group (127). Three questionnaires were completed, measuring eating pathology, intolerance of uncertainty and body checking and body avoiding. Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill and still elevated in AN-rec, even after recovery. The associations between intolerance of uncertainty and body checking and body avoiding within the studied groups may represent different stages of the illness. In the AN-rec group, the relation between intolerance of uncertainty, body checking and body avoiding may be driven by trait anxiety. For AN-ill group, body checking and body avoiding may have grown into habitual patterns, rather than a strategy to ameliorate anxiety and uncertainty.

Working with families of adults affected by eating disorders: uptake, key themes, and participant experiences of family involvement in outpatient treatment-as-usual

BACKGROUND

Eating disorders are associated with significant personal and family costs. Clinical guidelines recommend family members be involved and supported during care, but little has been reported regarding the preferences of adults around carer involvement in treatment. The necessary intensity of family work with adults is also unknown. A trial of a standardised brief family involvement method was conducted in an adult eating disorder service offering treatment-as-usual. Uptake and feasibility of implementing the approach as part of standard outpatient care and the preliminary impact on issues identified by adult patients and carers were evaluated.

METHODS

Eligible referrals at an adult eating disorders outpatient clinic were offered as needed family consultation to address presenting interpersonal problems identified by patients and their family members, and outcomes were evaluated 4 weeks later. Pre and post intervention surveys identified participant self-reported change in (i) problem frequency, (ii) distress and disruption caused, and (iii) confidence regarding presenting problems. Open text responses provided an overview of patient and carer goals for family involvement and revealed how the novel method impacted these areas as well as overall experience of, and feedback regarding, the brief family intervention.

RESULTS

Twenty-four female participants aged 18-53, and 22 carers participated in 31 consultations. Common concerns raised were eating disorder related interpersonal and communication issues. The focused sessions, offered on a one-at-a-time basis, showed preliminary effectiveness for reducing both patients and carer concerns. For example, adult patients reported that life interference from interpersonal problems was lower and confidence to deal with them was higher following family consultation. Carers also reported that frequency, level of worry, and life interference around presenting problems were lower after the structured family intervention.

CONCLUSIONS

Brief family consultation, with a single focus on issues identified by family members and adult patients, was a safe and feasible procedure with adults affected by eating disorders. Effective at meeting the needs of participants, the framework investigated in the current study may also be a useful direction for adult services to consider when looking to support families and meet recommendations for their routine involvement in the outpatient care.

TRIAL REGISTRATION

Australian Clinical Trials Register number: ACTRN12621000047897 (www.anzctr.org.au).

Neurosurgery and neuromodulation for anorexia nervosa in the 21st century: a systematic review of treatment outcomes

As current psychosocial and pharmacological interventions show limited efficacy in the treatment of anorexia nervosa (AN), interest in the potential value of neurosurgical intervention and neuromodulation in managing severe and enduring illness has grown. We conducted a systematic review of 20 trials of neurosurgical and neuromodulatory treatments for AN, including neurosurgical ablation, deep brain stimulation (DBS), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS). Overall, there is evidence to support the role of stereotactic ablation and DBS in the treatment of AN. In contrast, results for rTMS and tDCS have been modest and generally more mixed. Neurosurgical treatment may offer important new avenues for the treatment of AN. Additional randomized clinical trials with comparable patient populations will be needed, in which change in affective, cognitive, and perceptual symptom phenomena, and interrogation of targeted circuits, pre- and post-intervention, are carefully documented.

Gastrointestinal Interoception in Eating Disorders: Charting a New Path

PURPOSE OF REVIEW

Abnormal interoception has been consistently observed across eating disorders despite limited inclusion in diagnostic conceptualization. Using the alimentary tract as well as recent developments in interoceptive neuroscience and predictive processing as a guide, the current review summarizes evidence of gastrointestinal interoceptive dysfunction in eating disorders.

RECENT FINDINGS

Eating is a complex process that begins well before and ends well after food consumption. Abnormal prediction and prediction-error signals may occur at any stage, resulting in aberrant gastrointestinal interoception and dysregulated gut sensations in eating disorders. Several interoceptive technologies have recently become available that can be paired with computational modeling and clinical interventions to yield new insights into eating disorder pathophysiology. Illuminating the neurobiology of gastrointestinal interoception in eating disorders requires a new generation of studies combining experimental probes of gut physiology with computational modeling. The application of such techniques within clinical trials frameworks may yield new tools and treatments with transdiagnostic relevance.

The peril and promise of sensitivity in eating disorders

Differential susceptibility, a reconceptualization of the diathesis-stress model of psychopathology, describes gene-environment interactions that reflect individual differences in responsiveness to environmental influences, both detrimental and beneficial. This model has been described metaphorically by the classification of orchids, which thrive under optimal care but wither under adverse conditions, and dandelions, which weather broad environmental circumstances but are less responsive to careful cultivation. Etiological research in the field of eating disorders has largely focused on the identification of specific behavioral phenotypes, temperamental traits, genotypes and neurobiological processes that confer risk. In this article, we propose that these putative vulnerability factors represent phenotypes and endophenotypes of a genetic predisposition towards environmental sensitivity. We assert that this sensitivity not only transmits eating disorder risk but also confers resilience, depending on the circumstances. In particular, we propose that differential susceptibility can be used as a framework to organize disparate temperamental and neurobiological findings and their complex interplay with various developmental, environmental and sociocultural influences to increase eating disorder risk and treatment responsiveness. Finally, we assert that viewed through the lens of differential susceptibility, sensitivity can be leveraged to refine our interventions and develop novel treatment and prevention strategies to support favorable outcomes for individuals with eating disorders.

Are Sensitivity to Punishment, Sensitivity to Reward and Effortful Control Transdiagnostic Mechanisms Underlying the Eating Disorder/Obesity Spectrum?

Although it has been postulated that eating disorders (EDs) and obesity form part of a broad spectrum of eating- and weight-related disorders, this has not yet been tested empirically. In the present study, we investigated interindividual differences in sensitivity to punishment, sensitivity to reward, and effortful control along the ED/obesity spectrum in women. We used data on 286 patients with eating disorders (44.6% AN-R, 24.12% AN-BP, and 31.82% BN), 126 healthy controls, and 640 Class II/III obese bariatric patients (32.81% Class II and 67.19% Class III) with and without binge eating. Participants completed the behavioral inhibition and behavioral activation scales, as well as the effortful control scale, to assess sensitivity to punishment and reward and effortful control. Results showed that patients with EDs scored significantly higher on punishment sensitivity (anxiety) compared to healthy controls and Class II/III obese patients; the different groups did not differ significantly on reward sensitivity. Patients with binge eating or compensatory behaviors scored significantly lower on effortful control than patients without binge eating. Differences in temperamental profiles along the ED/obesity spectrum appear continuous and gradual rather than categorical. This implies that it may be meaningful to include emotion regulation and impulse regulation training in the treatment of both EDs and obesity.

Temperament-based treatment for young adults with eating disorders: acceptability and initial efficacy of an intensive, multi-family, parent-involved treatment

BACKGROUND

Adult eating disorder treatments are hampered by lack of access and limited efficacy. This open-trial study evaluated the acceptability and preliminary efficacy of a novel intervention for adults with eating disorders delivered to young adults and parent-supports in an intensive, multi-family format (Young Adult Temperament-Based Treatment with Supports; YA-TBT-S).

METHODS

38 YA-TBT-S participants (m age = 19.58; SD 2.13) with anorexia nervosa (AN)-spectrum disorders, bulimia nervosa (BN)-spectrum disorders, and avoidant/restrictive food intake disorder (ARFID) completed self-report assessments at admission, discharge, and 12-month follow-up. Assessments measured program satisfaction, eating disorder psychopathology and impairment, body mass index (BMI), and trait anxiety. Outcomes were analyzed using linear mixed effects models to examine changes in outcome variables over time.

RESULTS

Treatment was rated as highly satisfactory. 53.33% were in partial or full remission at 12-month follow-up. 56% of participants received other treatment within the 12-month follow-up period, suggesting that YA-TBT-S may be an adjunctive treatment. Participants reported reductions in ED symptomatology (AN and BN), increases in BMI (AN and ARFID), and reductions in clinical impairment (AN and ARFID) at 12-month follow-up.

CONCLUSIONS

YA-TBT-S is a feasible and acceptable adjunctive treatment for young adults with a broad range of ED diagnoses and may be a method for involving parents in ED treatment in ways that are acceptable to both parents and YA. Further evaluation of efficacy is needed in larger samples, and to compare YA-TBT-S to other ED treatment approaches. Plain English summary Eating disorders are costly and dangerous psychiatric disorders that affect millions of individuals each year. Despite their risks and societal costs, currently available treatments are limited. This study examined the acceptability and efficacy of Young Adult, Temperament-Based Treatment with Supports (YA-TBT-S), a new treatment program for adults with eating disorders. YA-TBT-S was rated highly, and a significant portion of participants improved based on ratings collected 12 months after program participation. Those with anorexia nervosa (AN) and bulimia nervosa (BN) showed significant reductions in eating disorder pathology, and those with AN and avoidant/restrictive food intake disorder (ARFID) showed increases in BMI over time.

Challenging rigidity in Anorexia (treatment, training and supervision): questioning manual adherence in the face of complexity

BACKGROUND

Anorexia Nervosa is a debilitating illness. While there have been many advancements to treatment protocols and outcomes for people with eating disorders, the field acknowledges there remains considerable room for improvement. This timely Special Edition of the Journal of Eating Disorders has invited those of us in the field to consider a range of topics in aid of this task, including potential modifications and implementation of evidence-based practice, specific and common psychotherapy factors, treatment manuals, adherence and individualising treatment approaches for individuals and families. BODY: In this paper, we briefly outline the key manualised treatments currently available to treat children, adolescents and adults with Anorexia Nervosa, considering the benefits, potential reasons for adaptations and limitations. We then review the current evidence for training strict adherence to treatment manuals which is often a key focus in training and supervision, questioning the association of increased treatment adherence with improved therapeutic outcome. We then summarise some key evidence behind other therapeutic factors which have been demonstrated to affect outcome regardless of which manual is implemented, such as readiness to change and therapeutic alliance.

CONCLUSION

The paper concludes with implications and considerations for future research, clinical guidelines, training and supervision, highlighting the need to consider the therapeutic relationship and processes alongside manual content to conduct best evidence-informed practice.

Predictors of Stepping Up to Higher Level of Care Among Eating Disorder Patients in a Partial Hospitalization Program

Partial hospitalization programming (PHP) is a treatment option available for individuals with eating disorders (ED) who have made insufficient progress in outpatient settings or are behaviorally or medically unstable. Research demonstrates that this level of care yields efficacy for the majority of patients. However, not all patients achieve recovery in PHP and later admit to a higher level of care (HLOC) including residential treatment or inpatient hospitalization. Although PHP is an increasingly common treatment choice for ED, research concerning outcome predictors in outpatient, stepped levels of care remains limited. Thus, the current study sought to identify the predictors of patients first admitted to PHP that later enter residential or inpatient treatment. Participants were 788 patients (after exclusions) enrolled in adolescent or adult partial hospitalization programs in a specialized ED clinic. When compared to patients who maintained treatment in PHP, a significantly greater proportion of patients who discharged to a HLOC had previously received ED residential treatment. Moreover, patients who discharged to a HLOC were diagnosed with a comorbid anxiety disorder and reported greater anxious and depressive symptomatology. A logistic regression model predicting discharge from PHP to a HLOC was significant, and lower body mass index (BMI) was a significant predictor of necessitating a HLOC. Supplemental programming in partial hospitalization settings might benefit individuals with previous ED residential treatment experience, higher levels of anxiety and depression, and lower BMIs. Specialized intervention for these cases is both practically and economically advantageous, as it might reduce the risk of rehospitalization and at-risk patients needing to step up to a HLOC.

Last word: a call to view temperamental traits as dual vulnerabilities and strengths in anorexia nervosa

Research suggests that individuals with anorexia nervosa (AN) have certain temperamental traits (e.g. perfectionism, anxiety, harm avoidance), which often onset prior to the eating disorder (ED), and may persist following recovery. Although these traits are often represented as vulnerabilities to developing an ED, there is reason to believe that within certain contexts, these traits may serve as assets. We propose that traits can be harnessed within or outside of treatment to promote long-term success, and possibly relate to recovery. To do so, the current paper will: (1) outline literature on traits viewed as strengths; (2) review precedents for strengths-based interventions drawing from other areas of research; (3) propose a framework for future research to assess these strengths in AN; and (4) discuss the implications of the proposed research for the destigmatization of EDs. This last word calls for a shift to a dual consideration of traits as vulnerabilities and strengths.

How are families included in the treatment of adults affected by eating disorders? A scoping review

OBJECTIVE

The involvement of families in the treatment of adults with eating disorders is recommended as a core component of comprehensive care, yet little is known about the optimal way to implement or routinely facilitate this. This article evaluates the recent evidence on the inclusion of families in treatment programs for adults with eating disorders.

METHOD

A systematic literature search was conducted to identify evidence of family inclusive treatment approaches for adults with eating disorders. A scoping review framework was applied to assess and synthesize findings.

RESULTS

Sixty-eight studies were identified. Substantial conceptual research contributing to the theoretical basis of current practice with families of adults with eating disorders and clinical applications in current use were identified. Most research used uncontrolled studies with few experimental designs, reflecting the standing of the extant literature. Common elements of existing approaches have been distinguished and shared core components of interventions identified.

DISCUSSION

Results confirmed that family members of adults were willing to be involved with eating disorder treatment services and appeared to respond to interventions of varying intensity and duration. The impact on individual patients, and effect on treatment outcomes, are yet to be established. The localized settings of existing studies, the homogenous nature of interventions used, and the limited diversity in research subjects, make it difficult to generalize from the results to the wide range of adult eating disorder presentations seen in practice. Suggestions for future research and further clinical developments are discussed.

Personality correlates of eating pathology severity and subtypes in The National Comorbidity Survey Adolescent Supplement

OBJECTIVE

We examined how personality traits are associated with eating pathology (EP) across a range of severities and symptom subtypes.

METHOD

The National Comorbidity Survey Adolescent Supplement (N = 10,148) was used to compare personality across severities (i.e., clinical Eating Disorders [EDs], subclinical disordered eating, preclinical weight concerns, or no weight/EP [no W/EP]), subclinical subtypes (i.e., Binge Eating Only, Binge-Purge, Binge-Restrict, Restrict-Purge, or no W/EP), and clinical subtypes (i.e., Anorexia Nervosa [AN]), Bulimia Nervosa [BN], Binge Eating Disorder [BED], internalizing disorders, or no ED or internalizing disorder) of EP.

RESULTS

More severe EP was associated with more extreme personality trait endorsements. Impulsivity-related traits did not consistently distinguish binge eating/purging from restricting subtypes, although behavioral disinhibition differentiated adolescents with BN or BED from AN.

CONCLUSION

Personality traits related to affectivity and impulsivity were more consistently associated with severity rather than subtype of EP.

The open versus blind weight conundrum: A multisite randomized controlled trial across multiple levels of patient care for anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a disorder characterized by a profound fear of weight gain, resulting in significant weight loss, as well as behavioral symptoms that interfere with weight normalization. In concert, weight gain remains a proximal goal of treatment, and patient weighing is a critical component of treatment. However, divergent approaches exist in how patient weighing is undertaken in clinical practice. The aim of this study is to investigate the impact of a brief course of open weighing (sharing weight data with patients) versus blind weighing (not sharing weight data with patients) on distress around being weighed and AN symptom severity.

METHOD

216 patients with AN and atypical AN will be randomized to receive 4 weeks of open or blind weighing practices across residential, intensive outpatient, and outpatient treatment settings, within the context of manualized empirically supported treatment. Following 4 weeks of open or blind weighing, all patients will be enrolled into open weighing practices. Primary outcomes of interest will be patient-reported distress around being weighed at week 5 and eating disorder symptom severity at week 5. Secondary outcomes will assess weight prediction error, intolerance of uncertainty, and the fear of food.

DISCUSSION

No best practice guidelines exist in determining optimal practices around weighing patients with AN. This multisite randomized controlled trial will provide the first known data on the impact of open versus blind weighing practices upon weight-related distress and AN symptom severity.

Emotional instability as a trait risk factor for eating disorder behaviors in adolescents: Sex differences in a large-scale prospective study

BACKGROUND

Temperament and personality traits, including negative emotionality/neuroticism, may represent risk factors for eating disorders. Further, risk factors may differ by sex. We examined longitudinal temperament/personality pathways of risk for purging and binge eating in youth stratified by sex using data from a large-scale prospective study.

METHODS

Temperament, borderline personality features, sensation seeking, 'big five' personality factors, and depressive symptoms were measured at five time points from early childhood to adolescence in 5812 adolescents (3215 females; 2597 males) in the Avon Longitudinal Study of Parents and Children. We conducted univariate analyses with these predictors of binge eating and purging at 14 and 16 years for total and sex-stratified samples. We used structural equation modeling (SEM) to fit data to a path analysis model of hypothesized associations.

RESULTS

Of the total sample, 12.54% engaged in binge eating and 7.05% in purging by 16 years. Prevalence was much greater and increased dramatically for females from 14 years (7.50% binge eating; 2.40% purging) to 16 years (15.80% binge eating; 9.50% purging). For both sexes, borderline personality, depressive symptoms and lower emotional stability predicted eating disorder behaviors; sensation seeking and conscientiousness were also significant predictors for females. SEM identified an 'emotional instability' pathway for females from early childhood into adolescence (RMSEA = 0.025, TLI = 0.937 and CFI = 0.970).

CONCLUSIONS

Binge eating and purging are common in female and male adolescents. Early temperament/personality factors related to difficulty regulating emotions were predictive of later adolescent eating disorder behaviors. Results have important clinical implications for eating disorder prevention and intervention.

Neural Insensitivity to the Effects of Hunger in Women Remitted From Anorexia Nervosa

OBJECTIVE

Anorexia nervosa has the highest mortality rate of any psychiatric condition, yet the pathophysiology of this disorder and its primary symptom, extreme dietary restriction, remains poorly understood. In states of hunger relative to satiety, the rewarding value of food stimuli normally increases to promote eating, yet individuals with anorexia nervosa avoid food despite emaciation. This study's aim was to examine potential neural insensitivity to these effects of hunger in anorexia nervosa.

METHODS

At two scanning sessions scheduled 24 hours apart, one after a 16-hour fast and one after a standardized meal, 26 women who were in remission from anorexia nervosa (to avoid the confounding effects of malnutrition) and 22 matched control women received tastes of sucrose solution or ionic water while functional MRI data were acquired. Within a network of interest responsible for food valuation and transforming taste signals into motivation to eat, the authors compared groups across conditions on blood-oxygen-level-dependent (BOLD) signal and task-based functional connectivity.

RESULTS

Participants in the two groups had similar BOLD responses to sucrose and water tastants. A group-by-condition interaction in the ventral caudal putamen indicated that hunger had opposite effects on tastant response in the control group and the remitted anorexia nervosa group, with an increase and a decrease, respectively, in BOLD response when hungry. Hunger had a similar opposite effect on insula-to-ventral caudal putamen functional connectivity in the remitted anorexia nervosa group compared with the control group. Exploratory analyses indicated that lower caudate response to tastants when hungry was associated with higher scores on harm avoidance among participants in the remitted anorexia nervosa group.

CONCLUSIONS

Reduced recruitment of neural circuitry that translates taste stimulation to motivated eating behavior when hungry may facilitate food avoidance and prolonged periods of extremely restricted food intake in anorexia nervosa.

The predictive value of the early maladaptive schemas in social situations in anorexia nervosa

BACKGROUND

Patients with anorexia nervosa (AN) show an impairment in the recognition and expression of emotions, as well as an increased sensitivity to being socially excluded, and rigid maladaptive schemas. The Cyberball paradigm is a virtual ball-toss game that can simulate social exclusion and inclusion. Our aim is to evaluate how cognitive schemas can influence the perception and the evaluation of the experiences of social inclusion/exclusion.

METHODS

Thirty-two AN patients and 34 healthy controls completed a psychological evaluation and were randomly assigned to exclusion or overinclusion paradigm of the Cyberball task.

RESULTS

Patients with AN showed a significantly higher level of maladaptive schemas as well as higher sensitivity to being ostracized by peers in comparison with healthy controls. Regression analyses identified specific significant relation between being ostracized and dependence/incompetence, negativity/pessimism, and self-sacrifice.

DISCUSSION

Our findings provide evidence that patients with AN may be ineffective in expressing their mood in exclusive and overinclusive social situations. Specific cognitive/temperamental schemas might play a role in the way people communicate their feelings, and they could be considered targets for psychotherapy interventions to improve social interpretation and emotional recognition/communication.

Temperament in Adults Who Stutter and Its Association With Stuttering Frequency and Quality-of-Life Impacts

Purpose The study aim was to determine whether self-reported temperament traits differentiate adults who stutter (AWS) from adults who do not stutter (AWNS). Additionally, associations between temperament and stuttering frequency, and between temperament and quality of life impacts of stuttering, were investigated in AWS. Method Self-reported temperament traits were documented for 33 AWS and 43 AWNS using the Adult Temperament Questionnaire (ATQ; Evans & Rothbart, 2007). Quality-of-life impacts of stuttering were assessed using the Overall Assessment of the Speaker's Experience with Stuttering (Yaruss & Quesal, 2010). Stuttering frequency was calculated from 100-word monologue and reading samples. Results A between-groups difference in scores on the ATQ Positive Affect subscale was nominally significant (i.e., before correcting for multiple tests) and also approached statistical significance after Bonferroni correction. Positive Affect scores were lower for AWS, and the size of this trending effect was moderate. Within AWS, a statistically significant positive correlation was found between impact scores on the General Information section of the Overall Assessment of the Speaker's Experience with Stuttering and ATQ Frustration subscale scores after Bonferroni correction. No associations were detected between temperament traits and stuttering frequency. Conclusions Results reveal a nontrivial tendency for AWS to experience decreased positive affect compared to AWNS. In addition, increased frustration was found to be associated with reduced general knowledge about stuttering in AWS. Neither effect has been previously reported for adults or children who stutter. Finally, self-reported temperament traits were not found to vary with stuttering frequency in adults, consistent with previous results for AWS.

Motivation to eat and not to eat - The psycho-biological conflict in anorexia nervosa

Anorexia nervosa is a severe psychiatric illness with high mortality. Brain imaging research has indicated altered reward circuits in the disorder. Here we propose a disease model for anorexia nervosa, supported by recent studies, that integrates psychological and biological factors. In that model, we propose that there is a conflict between the conscious motivation to restrict food, and a body-homeostasis driven motivation to approach food in response to weight loss. These opposing motivations trigger anxiety, which maintains the vicious cycle of ongoing energy restriction and weight loss.

Affect, reward, and punishment in anorexia nervosa: a narrative overview

INTRODUCTION

Anorexia nervosa (AN) is a serious psychiatric disorder that is difficult to treat and often follows a protracted course. A number of theoretical models have been proposed for the etiology and maintenance of AN. Two domains that have received substantial attention in the literature on AN are affect and reward/punishment processes. However, despite an overlap in the nature and implications of these processes, studies of AN addressing these constructs have typically investigated them independently.

PURPOSE

The purpose of this narrative review is to integrate the literature on the role of affect, reward, and punishment in AN.

METHOD

We provide a focused narrative overview of the literature relating to the affect, reward, and punishment in AN via a synthesis of recent reviews and meta-analyses.

RESULTS

We first describe several prominent affect and reward/punishment-based conceptualizations of AN, followed by a brief overview of the existing empirical literature in these domains.

CONCLUSION

We provide a critical discussion of the disparate nature of these literatures in AN, including associated limitations. We then conclude with an extensive discussion of directions for future research that integrate the study of affect and reward/punishment processes in AN.

LEVEL OF EVIDENCE

Level V, narrative review.

Interoceptive Anxiety and Body Representation in Anorexia Nervosa

Individuals with anorexia nervosa (AN) typically display anxious traits prior to the onset of food avoidance and weight loss that characterize the disorder. Meal associated anxiety is an especially common clinical feature in these patients, and heightened sensitivity to sympathetically mediated interoceptive sensations has also been observed. However, it remains unclear how heightened interoceptive sensitivity relates to experiences of anxiety before and after meals. To investigate this relationship, we experimentally induced anxiety and panic symptoms with isoproterenol, a peripheral sympathetic agonist similar to adrenaline, across several different conditions: during panic provocation, during anticipation of a 1,000 Calorie meal, and after meal consumption. Fifteen AN and 15 age- and sex-matched healthy comparisons received bolus infusions of isoproterenol and saline in a double-blinded, randomized design. Participants rated anxiety symptoms after each infusion, completed panic rating scales, and traced the location of perceived palpitations on a manikin to index interoceptive "body map" representation. The AN group reported significantly elevated anxiety relative to healthy comparisons during infusions before and after the meal, but surprisingly, not during panic provocation. These symptoms were accompanied by geographical differences in patterns of perceived heartbeat sensations across each condition. In particular, the AN group localized heartbeat sensations disproportionately to the chest during meal related saline infusions, when no cardiorespiratory modulation actually occurred. The AN group also showed a trend toward higher panic attack rates during the meal anticipation period. Correcting for anxiety levels reported during saline infusions abolished group differences in anxiety change across all conditions, suggesting a significant contribution of anxious traits in AN. The observation of meal related "visceral illusions" provides further evidence that AN is associated with abnormal interoceptive representation of the heartbeat and suggests that meal consumption, particularly when anticipated, preferentially alters the processing of interoception related signals in AN.

The acceptability, feasibility, and possible benefits of a neurobiologically-informed 5-day multifamily treatment for adults with anorexia nervosa

OBJECTIVE

Novel treatments for adults with anorexia nervosa (AN) are lacking. Recent scientific advances have identified neurobiologically-driven temperament contributors to AN symptoms that may guide development of more effective treatments. This preliminary study evaluates the acceptability, feasibility and possible benefits of a multicenter open trial of an intensive 5-day neurobiologically-informed multifamily treatment for adults with AN and their supports (SU). The temperament-focused treatment combines psychoeducation of AN neurobiology and SU involvement to develop skills to manage traits contributing to disease chronicity.

METHOD

Fifty-four adults with AN and at least one SU (n = 73) received the 5-day treatment. Acceptability, feasibility, and attrition were measured post-treatment. Clinical outcome (BMI, eating disorder psychopathology, family function) was assessed post-treatment and at >3-month follow-up.

RESULTS

The treatment had low attrition, with only one drop-out. Patients and SU rated the intervention as highly acceptable, and clinicians reported good feasibility. At post-treatment, patients demonstrated significantly increased BMI, reduced eating disorder psychopathology, and improved family function. Benefits were maintained in the 39 patients who completed follow-up assessment, with 62% reporting full or partial remission.

DISCUSSION

Preliminary results are promising and suggest this novel treatment is feasible and acceptable. To establish treatment efficacy, fully-powered randomized controlled trials are necessary.

Repetitive Transcranial Magnetic Stimulation (rTMS) Treatment of Depression and Anxiety in a Patient with Anorexia Nervosa

Anorexia nervosa (AN) is characterized by restricted eating, emaciation, and distorted body image and tends to be a chronic and deadly disorder with a high risk of developing a relapsing course described as a severe and enduring anorexia. This case study reports a patient with AN with comorbid depression and anxiety who was treated by repetitive transcranial magnetic stimulation (rTMS).

Our patient’s first hospitalization in our ED clinic was at the age of 25 in 2012. Her anorexia symptoms have been developing over 1.5 years. The body mass index (BMI) at admission was 12.21 kg/m².

She was stimulated by use of a MAGSTIM Super Rapid 2 device, every Monday through Friday (5 days a week) with the frequency 10 Hz, 15 trains/day, 100 pulses/train, intertrain interval 107 s for 10 days. The specific spot of stimulation was over the left DLPFC. The therapy was evaluated, both by the team and by the patient, as ineffective. Shortly after the therapy was finished, the patient was discharged with final weight of 46 kg and BMI 13.15 kg/m².

We showed, that despite our positive clinical experiences with rTMS therapy in depression and anxiety, the treatment of AN and comorbid depressive disorder with anxious distress, our patient’s anorexic, anxious, and depressive symptoms remained unaffected. In this case, only invasive medical intervention helped the patient to reach normal weight, but without any significant changes in her psychology.

This case study shows the need for further investigation of the influence that body weight might have and whether the number of sessions has an effect on rTMS efficacy.

The Role of Working Memory for Cognitive Control in Anorexia Nervosa versus Substance Use Disorder

Prefrontal cortex executive functions, such as working memory (WM) interact with limbic processes to foster impulse control. Such an interaction is referred to in a growing body of publications by terms such as cognitive control, cognitive inhibition, affect regulation, self-regulation, top-down control, and cognitive–emotion interaction. The rising trend of research into cognitive control of impulsivity, using various related terms reflects the importance of research into impulse control, as failure to employ cognitions optimally may eventually result in mental disorder. Against this background, we take a novel approach using an impulse control spectrum model – where anorexia nervosa (AN) and substance use disorder (SUD) are at opposite extremes – to examine the role of WM for cognitive control. With this aim, we first summarize WM processes in the healthy brain in order to frame a systematic review of the neuropsychological, neural and genetic findings of AN and SUD. In our systematic review of WM/cognitive control, we found n = 15 studies of AN with a total of n = 582 AN and n = 365 HC participants; and n = 93 studies of SUD with n = 9106 SUD and n = 3028 HC participants. In particular, we consider how WM load/capacity may support the neural process of excessive epistemic foraging (cognitive sampling of the environment to test predictions about the world) in AN that reduces distraction from salient stimuli. We also consider the link between WM and cognitive control in people with SUD who are prone to ‘jumping to conclusions’ and reduced epistemic foraging. Finally, in light of our review, we consider WM training as a novel research tool and an adjunct to enhance treatment that improves cognitive control of impulsivity.

Affective temperaments in anorexia nervosa: The relevance of depressive and anxious traits

BACKGROUND

Affective temperaments have been so far understudied in anorexia nervosa (AN) despite the relevance of personality and both affective and anxious comorbidity with regard to vulnerability, course, and outcome of this deadly disorder.

METHODS

Ninety-eight female inpatients diagnosed with AN and 131 healthy controls (HCs) were enrolled in this study and completed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) in addition to assessments of eating psychopathology, depression, and anxiety.

RESULTS

AN patients and HCs differed in all affective temperaments. The diagnostic subtypes of AN differed as well with binge-purging individuals being more cyclothymic and anxious than those with restricting-type AN. TEMPS-A scores correlated with body mass index and eating psychopathology but not with duration of illness. Concerning comorbidity, grater scores on the depressive and lower scores on the hyperthymic temperaments were found in depressed patients. Those who had either an anxious or irritable temperament were significantly more diagnosed with an anxious disorder than those who did not show this temperament. When logistic regression was performed, high depressive/low hyperthymic and high irritable/anxious traits resulted to be associated with depressive and anxious comorbidity, respectively, independently of confounding factors.

LIMITATIONS

Cross-sectional design, some patients on medications, few baseline clinical differences between diagnostic subtypes, no other personality assessments.

CONCLUSIONS

An affective continuum strongly associated with mood and anxious comorbidity emerged in AN. Such an evaluation could have several research and clinical implications given the need of improving treatment individualization and early interventions for such a complex disorder.

Treating Eating Disorders at Higher Levels of Care: Overview and Challenges

Higher levels of care (HLC)-including inpatient hospitalization, residential treatment, partial hospitalization, and intensive outpatient treatment-are frequently utilized within routine care for eating disorders. Despite widespread use, there is limited research evaluating the efficacy of HLC, as well as clinical issues related to care in these settings. This review describes the different levels of care for eating disorders and briefly reviews the most up-to-date guidelines and research regarding how to choose a level of care. In addition, as HLC approaches for ED continue to be developed and refined, pragmatic and conceptual challenges have emerged that provide barriers to clinical efficacy and the execution of high-quality treatment research. This review includes a discussion of various issues specific to HLC, as well as a summary of recent literature addressing them.

Interoception and Autonomic Correlates during Social Interactions. Implications for Anorexia

The aim of this study is to investigate the bodily-self in Restrictive Anorexia, focusing on two basic aspects related to the bodily self: autonomic strategies in social behavior, in which others' social desirability features, and social cues (e.g., gaze) are modulated, and interoception (i.e., the sensitivity to stimuli originating inside the body). Furthermore, since previous studies carried out on healthy individuals found that interoception seems to contribute to the autonomic regulation of social behavior, as measured by Respiratory Sinus Arrhythmia (RSA), we aimed to explore this link in anorexia patients, whose ability to perceive their bodily signal seems to be impaired. To this purpose, we compared a group of anorexia patients (ANg; restrictive type) with a group of Healthy Controls (HCg) for RSA responses during both a resting state and a social proxemics task, for their explicit judgments of comfort in social distances during a behavioral proxemics task, and for their Interoceptive Accuracy (IA). The results showed that ANg displayed significantly lower social disposition and a flattened autonomic reactivity during the proxemics task, irrespective of the presence of others' socially desirable features or social cues. Moreover, unlike HCg, the autonomic arousal of ANg did not guide behavioral judgments of social distances. Finally, IA was strictly related to social disposition in both groups, but with opposite trends in ANg. We conclude that autonomic imbalance and its altered relationship with interoception might have a crucial role in anorexia disturbances.

Applying neurobiology to the treatment of adults with anorexia nervosa

BACKGROUND

Anorexia nervosa is a severe, biologically based brain disorder with significant medical complications. It is critical that new, effective treatments are developed to interrupt the persistent course of the illness due to the medical and psychological sequelae. Several psychosocial, behavioral and pharmacologic interventions have been investigated in adult anorexia nervosa; however, evidence shows that their impact is weak and treatment effects are generally small.

METHOD

This paper describes a new neurobiological anorexia nervosa model that shifts focus from solely external influences, such as social and family, to include internal influences that integrate genetic and neurobiological contributions, across the age span. The model serves as a theoretical structure for a new, five-day treatment, outlined in this paper, targeting anorexia nervosa temperament, which integrates neurobiological dimensions into evidence-based treatment interventions. The treatment is in two phases. Phase I is a five day, 40 hour treatment for anorexia nervosa adults. Phase II is the follow-up and is currently being developed.

RESULTS

Preliminary qualitative acceptability data on 37 adults with anorexia nervosa and 60 supports (e.g., spouses, parents, aunts, friends, partners, children of anorexia nervosa adults) are promising from Phase I. Clients with anorexia nervosa and their supports report that learning neurobiological facts improved their understanding of the illness and helped equip them with better tools to manage anorexia nervosa traits and symptoms. In addition, nutritional knowledge changed significantly.

CONCLUSIONS

This is the first neurobiologically based, five-day treatment for adults with anorexia nervosa and their supports. It is a new model that outlines underlying genetic and neurobiological contributions to anorexia nervosa that serves as a foundation to treat both traits and symptoms. Preliminary qualitative findings are promising, with both clients and supports reporting that the neurobiological treatment approach helped them better understand the illness, while better conceptualizing how to respond to their traits and manage their symptoms. Data in Phase I shows promise as a neurobiologically based intervention for anorexia nervosa, and it serves as a foundation for the development of Phase II. Evidence of ongoing program efficacy will be described as data are reported on Phase II.

TRIAL REGISTRATION

NCT NCT02852538 Registered 1 August 2016.

Impulsivity-related traits distinguish women with co-occurring bulimia nervosa in a psychiatric sample

OBJECTIVE

This study investigated impulsivity-related personality traits using the Revised NEO Personality Inventory (NEO PI-R) in women diagnosed with co-occurring bulmia nervosa and borderline personality disorder (BN-BPD), borderline personality disorder (BPD no-BN), or major depressive disorder (MDD-only).

METHOD

The sample included 672 adult female admissions to a psychiatric day hospital treatment program. The NEO PI-R facets of impulsiveness (N5), excitement-seeking (E5), self-discipline (C5), and deliberation (C6) provided a proxy assessment of impulsivity-related traits tapping negative urgency, sensation-seeking, lack of perseverance, and lack of premeditation/planning.

RESULTS

After adjusting for age, BN-BPD displayed significantly higher levels of negative urgency and lack of premeditation than BPD without co-occurring BN. Women with BN-BPD also had significantly higher levels of impulsivity traits than MDD across domains, except for lack of perseverance.

DISCUSSION

Impulsivity-related traits of negative urgency and lack of premeditation significantly differentiated women with versus without co-occurring BN among women with borderline personality disorder. Lower levels of impulsivity-related traits in women with MDD indicated that effects were not simply attributable to any form of psychopathology. Of the impulsivity traits, negative urgency demonstrated the strongest effect, providing further evidence of the important relationship between negative urgency and the expression of bulimic symptomology. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1093-1096).

A comprehensive review of psychodynamic treatments for eating disorders

PURPOSE

To comprehensively review the existing literature on the effectiveness of psychodynamic psychotherapies in eating disorders (EDs) and to stimulate both debate and research on this topic.

METHODS

Online and hand searches were conducted to identify papers published between 1980 and 2015 on psychodynamic treatments delivered to adults with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).

RESULTS

A total of 47 studies were finally included in this review. Fifteen studies were available for AN, 9 for BN, 12 for BED, and 11 for samples with mixed diagnoses. Several methodological flaws emerged, but overall psychodynamic interventions showed promising results at the end of treatment and follow-up, when available.

CONCLUSIONS

The body of literature on psychodynamic treatments is sparse and sometimes methodologically questionable; nevertheless, current data provide support to the effectiveness of these interventions, particularly for AN. However, both a defined approach (focus, themes, and techniques) and randomized controlled trials (RCTs) are warranted to clarify the effectiveness of psychodynamic psychotherapies.

Extinction theory & anorexia nervosa: Deepening therapeutic mechanisms

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

Is Anorexia Nervosa a Disorder of the Self? A Psychological Approach

The debate concerning the pathogenesis and the maintaining factors of eating disorders, anorexia nervosa in particular, is ongoing especially since therapeutic interventions do not result in satisfactory and enduring rates of remission. This paper presents a model for the pathogenesis of eating disorders, based on the hypothesis of a deficiency in the development of the self. We present the theory in light of new evidence concerning the role of attachment insecurity in the development and maintenance of eating disorders. In particular, we define the self in eating disorders in a comprehensive way by taking into account recent evidence from experimental psychology and neurobiology. The paper considers the development of the self in terms of its synchronic (i.e., experienced in the moment) and diachronic (i.e., experienced as continuous over time) aspects. Both synchronic and diachronic aspects of the self are relevant to the expression of eating disorder symptoms. Further, the maturation of the self is interwoven with the development of attachment functioning from infancy to adolescence. This interplay between these developmental processes of the self and of attachment could be crucial in understanding the pathogenesis of eating disorders. The final part of the paper suggests a neurobiological link between the theory of the self in the eating disorders and the spatiotemporal functioning of the brain. Disturbances in spatiotemporal functioning may represent the neurobiological pathway by which deficiencies in the self is related to attachment functions in individuals with eating disorders.

Neurobiologically informed treatment for adults with anorexia nervosa: a novel approach to a chronic disorder

Anorexia nervosa (AN) is a severe and debilitating disorder with significant medical and psychological sequelae. To date, there are no effective treatments for adults, resulting in high rates of chronicity, morbidity, and mortality. Recent advances in brain imaging research have led to an improved understanding of etiology and specific neurobiological mechanisms underlying symptoms. Despite this, there are no treatments focused on targeting symptoms using this empirically supported mechanistic understanding of the illness. Updated treatment approaches focused on targeting neurobiological mechanisms underlying core AN symptomatology are necessary to improve treatment out-comes for this population. Neurobiologically Enhanced With Family Eating Disorder Trait Response Treatment (NEW FED TR) is a neurobiologically informed treatment targeting key temperament constructs associated with the illness through the delivery of psychoeducation and skills training to patients and nominated carers.

Cardiac changes in anorexia nervosa

Introduction Anorexia nervosa is an eating disorder, which is associated with many different medical complications as a result of the weight loss and malnutrition that characterise this illness. It has the highest mortality rate of any psychiatric disorder. A large portion of deaths are attributable to the cardiac abnormalities that ensue as a result of the malnutrition associated with anorexia nervosa. In this review, the cardiac complications of anorexia nervosa will be discussed.

METHODS

A comprehensive literature review on cardiac changes in anorexia nervosa was carried out.

RESULTS

There are structural, functional, and rhythm-type changes that occur in patients with anorexia nervosa. These become progressively significant as ongoing weight loss occurs.

CONCLUSION

Cardiac changes are inherent to anorexia nervosa and they become more life-threatening and serious as the anorexia nervosa becomes increasingly severe. Weight restoration and attention to these cardiac changes are crucial for a successful treatment outcome.

Temperament and personality in eating disorders

PURPOSE OF REVIEW

In the last decades, three main different personality domains have been investigated in the field of eating disorders: personality traits, temperament, and personality disorders. The use of a wide range of instruments and the presence of many different approaches in the definition of personality dimensions make it difficult to summarize the emerging results from different studies. The aim of this narrative review is to critically highlight and discuss all interesting developments in this field, as reflected in the recent literature.

RECENT FINDINGS

The study of personality and temperament in eating disorders seems to be in line with the recently suggested dimensional approach, which highlights the importance of symptoms aggregation, rather than the categorical diagnoses. Recent literature seems to confirm that specific personality and temperamental profiles can be drawn for patients with eating disorders, which can discriminate different eating disorders' diagnoses/symptoms.

SUMMARY

These observations have relevant clinical implications as treatment of eating disorders is largely based on psychotherapeutic interventions. However, large longitudinal studies are needed to better clarify the suggested relationships and to identify more defined therapeutic strategies.