Outcome of eating disorders

A Systematic Review to Explore a Neuropsychological Profile that Predates Anorexia Nervosa

OBJECTIVE

Research demonstrates reduced cognitive flexibility and weak central coherence during acute illness and following recovery from anorexia nervosa (AN). This systematic review investigated if these impairments are present in first-degree relatives of individuals with AN, representing a possible neuropsychological risk profile.

METHODS

A systematic review of electronic databases was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search ended on July 14, 2023. Established search terms and inclusion criteria identified relevant research. Risk of bias was assessed using the Critical Appraisal Skills Program. The review was registered with Prospero international prospective register of systematic reviews (No. CRD42023401268). Study selection, descriptive data, critical appraisal, and risk of bias are presented in tables and figures.

RESULTS

The search yielded 10 studies. The included studies conducted neuropsychological assessments of discordant AN relatives and lifetime longitudinal study participants. Most studies found cognitive flexibility and central coherence to be significantly reduced in participants with AN and their relatives compared with controls. One study found decision making to be significantly impaired in AN participants and relatives. Effect sizes were moderate to large.

DISCUSSION

Reduced cognitive flexibility and weak central coherence appear to be endophenotypes of AN. Further research is required with relatives concordant for AN to establish whether these biomarkers co-segregate with AN within families. These findings suggest a possibility of developing screeners to identify individuals at risk of AN allowing for early intervention.

Towards collaborative care for severe and enduring Anorexia Nervosa - a mixed-method approach

BACKGROUND

Severe and Enduring Eating Disorders (SEED), in particular SEED-Anorexia Nervosa (SE-AN), may represent the most difficult disorder to treat in psychiatry. Furthermore, the lack of empirical research in this patient group, and, consequently the lack of guidelines, call for an urgent increase in research and discussion within this field. Meanwhile experts concur that effective care should be structured in a collaborative manner.

OBJECTIVE

To identify the challenges in providing care to patients with SE-AN in the Dutch healthcare context, and propose a collaborative care treatment model to address these issues.

METHODS

A pragmatic mixed-method approach was used, structured as follows: (1) Identifying perceived barriers and treatment needs from the viewpoint of both patients and eating disorder healthcare professionals through an evaluation questionnaire; (2) Investigating current treatment practices for SEED/SE-AN via benchmarking; (3) Gaining insight into the optimal structure and content of care by interviewing network partners and experts-by-experience. Based on these findings, and drawing from literature on severe and enduring disorders, a treatment model for SE-AN was proposed and implemented.

RESULTS

The key challenges identified included a lack of knowledge about eating disorders among network partners, treatment ambivalence among patients and poor collaboration between professionals. The proposed model enhances self-management and collaborative relationships with healthcare providers, offers user-friendly and practical guidance, and aims at stabilization, reducing relapses, deterioration, and readmissions, thereby being cost-effective. Importantly, the model operates across levels of care (primary, secondary, tertiary).

CONCLUSION

This study, describing a collaborative care program for SE-AN, developed and implemented in a highly specialized treatment center for eating disorders, sets the stage for further explanatory/efficacy research to build on the findings in this study, with the following aims: addressing the critical gap in care for SEED/SE-AN, improving better healthcare organization, reducing relapse rates, and lowering costs for this often overlooked patient group.

Partnerships with primary care providers: Opportunities to prevent eating disorders and mitigate their progression in young people

Epidemiologic research has identified numerous interpersonal and individual risk factors for and warning signs of emerging eating disorders in adolescents. These findings have informed public health prevention and treatment strategies, including translation of findings to clinical recommendations for primary care providers (PCPs). A next step in this translational work could include a comprehensive approach where PCPs are seen as partners in efforts to improve population health outcomes. PCPs have great potential to implement high-yield interventions that prevent or attenuate the course of adolescent eating disorders. To illustrate this potential, we present a case that highlights missed opportunities for a PCP to prevent, detect, and intervene during a patient's developing eating disorder. We then relate the case to two emerging research programs that utilize PCP partnerships: one trains PCPs in Strengths-Based Adolescent Healthcare to improve eating disorder prevention; the other adapts Family-Based Treatment for primary care to improve early access to evidence-based treatment. In addition to these promising areas of research, efforts are needed to widen requirements for eating disorder curricula in medical training programs and to address weight stigma in primary care. Together these efforts will help PCPs become effective partners in the prevention and treatment of eating disorders.

Sex Differences in Mental Health Symptoms in Elite Athletes: A Systematic Review and Meta-analysis

CONTEXT

Mental health is a growing area of concern for elite athletes.

OBJECTIVE

To determine the sex differences in mental health symptoms in elite athletes.

DATA SOURCES

PubMed, EMBASE, and Cochrane Library databases were used.

STUDY SELECTION

Included studies included comparisons of mental health symptoms of athletes by sex.

STUDY DESIGN

Systematic review and meta-analysis were conducted following the PRISMA guidelines.

LEVEL OF EVIDENCE

Level 2a.

DATA EXTRACTION

The rate ratio (RR) was calculated as the rates in female and male athletes. Data were pooled using a random-effects model.

RESULTS

Of 1945 articles identified, 60 articles were included. Male athletes reported higher alcohol misuse (RR, 0.74; CI, 0.68-0.80), illicit drug abuse (RR, 0.82; CI, 0.75-0.89), and gambling problems (RR, 0.14; CI, 0.08-0.25). Female athletes reported higher overall anxiety (RR, 1.17; CI, 1.08-1.27), depression (RR, 1.42; CI, 1.31-1.54), distress (RR, 1.98; CI, 1.40-2.81), and disordered eating (RR, 2.19; CI, 1.58-3.02). Sleep disturbances were reported at similar rates in male and female athletes (RR, 1.13; CI, 0.98-1.30).

CONCLUSION

Female and male athletes have significant differences in reported mental health symptoms. Female athletes are more likely to report anxiety, depression, distress, and disordered eating, while male athletes report more alcohol misuse, illicit drug abuse, and gambling. Monitoring and evaluation of mental health is a necessary part of any sport, including access to resources. Longitudinal studies following athletes over time to determine the development and causation for mental health symptoms should be included in future research directions.

The Role of Central and Peripheral Brain-Derived Neurotrophic Factor (BDNF) as a Biomarker of Anorexia Nervosa Reconceptualized as a Metabo-Psychiatric Disorder

Neurotrophic factors play pivotal roles in shaping brain development and function, with brain-derived neurotrophic factor (BDNF) emerging as a key regulator in various physiological processes. This review explores the intricate relationship between BDNF and anorexia nervosa (AN), a complex psychiatric disorder characterized by disordered eating behaviors and severe medical consequences. Beginning with an overview of BDNF's fundamental functions in neurodevelopment and synaptic plasticity, the review delves into recent clinical and preclinical evidence implicating BDNF in the pathophysiology of AN. Specifically, it examines the impact of BDNF polymorphisms, such as the Val66Met variant, on AN susceptibility, prognosis, and treatment response. Furthermore, the review discusses the interplay between BDNF and stress-related mood disorders, shedding light on the mechanisms underlying AN vulnerability to stress events. Additionally, it explores the involvement of BDNF in metabolic regulation, highlighting its potential implications for understanding the metabolic disturbances observed in AN. Through a comprehensive analysis of clinical data and animal studies, the review elucidates the nuanced role of BDNF in AN etiology and prognosis, emphasizing its potential as a diagnostic and prognostic biomarker. Finally, the review discusses limitations and future directions in BDNF research, underscoring the need for further investigations to elucidate the complex interplay between BDNF signaling and AN pathology.

A case report about anorexia nervosa and ischemic stroke: what can we learn?

INTRODUCTION

Anorexia Nervosa (AN) is a complex psychiatric illness, characterized by a high risk of developing cardiovascular complications. Given the high risk of vascular diseases in patients with AN, we can assume that patients with severe AN have a high risk of developing ischemic stroke. However, to the best of our knowledge, no reports of patients with AN presenting with ischemic stroke have been published, other than a report of the development of IS during refeeding therapy in patients with severe AN.

CASE PRESENTATION

The present case report is aimed at describing the characteristics of an ischemic stroke occurring in a 19-year-old university student who had a 6-month history of AN. She was a non-smoker, had no relevant medical history and no family history of stroke. Upon hospital admission due to symptoms of stroke (aphasia and facial droop), she exhibited severe malnutrition with a BMI of 12.8 kg/m2. Computerized tomography imaging revealed occlusion of the left M2 branch and a congruous extensive area of hypoperfusion. Further investigations ruled out all common causes of stroke: she had no vascular stenosis, no heart diseases or arrhythmias, and no shunts, and gave negative results in autoimmune, toxicological and thrombophilia screenings.

CONCLUSION

Clinicians should suspect development of severe complications, including ischemic stroke, in patients with severe AN. Further extensive group studies or group-based studies are needed to elucidate the etiology of ischemic stroke in patients with severe AN. This will enable us to develop more precise and effective interventions.

Behavior Change Techniques Within Digital Interventions for the Treatment of Eating Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Previous systematic reviews of digital eating disorder interventions have demonstrated effectiveness at improving symptoms of eating disorders; however, our understanding of how these interventions work and what contributes to their effectiveness is limited. Understanding the behavior change techniques (BCTs) that are most commonly included within effective interventions may provide valuable information for researchers and developers. Establishing whether these techniques have been informed by theory will identify whether they target those mechanisms of action that have been identified as core to changing eating disorder behaviors. It will also evaluate the importance of a theoretical approach to digital intervention design.

OBJECTIVE

This study aims to define the BCTs within digital self-management interventions or minimally guided self-help interventions for adults with eating disorders that have been evaluated within randomized controlled trials. It also assessed which of the digital interventions were grounded in theory and the range of modes of delivery included.

METHODS

A literature search identified randomized controlled trials of digital intervention for the treatment of adults with eating disorders with minimal therapist support. Each digital intervention was coded for BCTs using the established BCT Taxonomy v1; for the application of theory using an adapted version of the theory coding scheme (TCS); and for modes of delivery using the Mode of Delivery Ontology. A meta-analysis evaluated the evidence that any individual BCT moderated effect size or that other potential factors such as the application of theory or number of modes of delivery had an effect on eating disorder outcomes.

RESULTS

Digital interventions included an average of 14 (SD 2.6; range 9-18) BCTs. Self-monitoring of behavior was included in all effective interventions, with Problem-solving, Information about antecedents, Feedback on behavior, Self-monitoring of outcomes of behavior, and Action planning identified in >75% (13/17) of effective interventions. Social support and Information about health consequences were more evident in effective interventions at follow-up compared with postintervention measurement. The mean number of modes of delivery was 4 (SD 1.6; range 2-7) out of 12 possible modes, with most interventions (15/17, 88%) being web based. Digital interventions that had a higher score on the TCS had a greater effect size than those with a lower TCS score (subgroup differences: χ21=9.7; P=.002; I²=89.7%) within the meta-analysis. No other subgroup analyses had statistically significant results.

CONCLUSIONS

There was a high level of consistency in terms of the most common BCTs within effective interventions; however, there was no evidence that any specific BCT contributed to intervention efficacy. The interventions that were more strongly informed by theory demonstrated greater improvements in eating disorder outcomes compared to waitlist or treatment-as-usual controls. These results can be used to inform the development of future digital eating disorder interventions.

TRIAL REGISTRATION

PROSPERO CRD42023410060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=410060.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Interplay of polygenic liability with birth-related, somatic, and psychosocial factors in anorexia nervosa risk: a nationwide study

BACKGROUND

Although several types of risk factors for anorexia nervosa (AN) have been identified, including birth-related factors, somatic, and psychosocial risk factors, their interplay with genetic susceptibility remains unclear. Genetic and epidemiological interplay in AN risk were examined using data from Danish nationwide registers. AN polygenic risk score (PRS) and risk factor associations, confounding from AN PRS and/or parental psychiatric history on the association between the risk factors and AN risk, and interactions between AN PRS and each level of target risk factor on AN risk were estimated.

METHODS

Participants were individuals born in Denmark between 1981 and 2008 including nationwide-representative data from the iPSYCH2015, and Danish AN cases from the Anorexia Nervosa Genetics Initiative and Eating Disorder Genetics Initiative cohorts. A total of 7003 individuals with AN and 45 229 individuals without a registered AN diagnosis were included. We included 22 AN risk factors from Danish registers.

RESULTS

Risk factors showing association with PRS for AN included urbanicity, parental ages, genitourinary tract infection, and parental socioeconomic factors. Risk factors showed the expected association to AN risk, and this association was only slightly attenuated when adjusted for parental history of psychiatric disorders or/and for the AN PRS. The interaction analyses revealed a differential effect of AN PRS according to the level of the following risk factors: sex, maternal age, genitourinary tract infection, C-section, parental socioeconomic factors and psychiatric history.

CONCLUSIONS

Our findings provide evidence for interactions between AN PRS and certain risk-factors, illustrating potential diverse risk pathways to AN diagnosis.

Clinical Experiences Using Cognitive-Behavioral Therapy for Eating Disorders

Data suggests that despite the availability of evidence-based psychological treatments for eating disorders (EDs), techniques from these therapies may be less frequently used within real-life clinical practice. The aim of this study was to provide the opportunity for clinicians to give feedback on their experiences treating EDs using cognitive-behavioral therapy (CBT) through reporting on use of CBT techniques and barriers to treatment implementation in naturalistic settings. Clinicians (N = 126) who self-identified as using CBT for EDs reported demographic information, frequency/usefulness of empirically supported treatment techniques, problems/limitations of CBT, and barriers faced while implementing CBT. The most frequently used technique reported by clinicians was psychoeducation, and the least frequently used technique was use of surveys to address mind reading. Patients' unwillingness to follow a meal plan/nutritional guide was rated as the most impactful barrier, alongside ED severity. Of the problems/limitations of CBT, too little guidance on treating co-occurring symptoms was rated as the most impactful. This study provided a mechanism for clinicians to share their experiences using CBT for EDs in real-world settings. Overall, results regarding frequency of use and usefulness of techniques indicate a high level of endorsement. Moreover, the most frequently endorsed barriers to/limitations of CBT related to lack of guidance on treating complex ED presentations. Future research should explore ways to treat cases that go beyond the prototypical ED case and explore ways to adapt CBT to meet the needs of naturalistic treatment settings.

No Evidence for Cross-Sectional or Longitudinal Associations between Cognitive Flexibility Performances and Nutritional Status in a Cohort of Inpatients with Anorexia Nervosa

BACKGROUND

According to the Cognitive-Interpersonal model of anorexia nervosa (AN), the combined influence of cognitive and socio-emotional difficulties would constitute vulnerability and maintaining factors. Poor cognitive flexibility is one of the endophenotypic candidates (i.e., a trait marker) of the disorder, but few studies have examined its association with illness symptom variations, notably weight status. The study aimed to evaluate the relationships between cognitive flexibility performances and nutritional status indices (BMI; body composition) at different times of the disorder.

METHODS

Cross-sectional and longitudinal associations between cognitive flexibility (TAP 2.1) and nutritional status indices, along with anxious and depressive (HAD) and eating disorder (EDE-Q) symptomatology were investigated using univariate and multivariate analyses in a cohort of AN inpatients evaluated at hospital admission (N = 167) and discharge (N = 94).

RESULTS

We found no or negligible associations between nutritional status and HAD or EDE-Q scores or cognitive flexibility performances, either cross-sectionally or longitudinally. Cognitive performances did not significantly differ between the AN subtypes.

CONCLUSIONS

In agreement with the Cognitive-Interpersonal model of AN, cognitive flexibility is independent of nutritional status, as well as the AN subtype. It is also independent of the levels of anxious, depressive, or ED symptomatology. A new therapeutic approach targeting cognitive flexibility and intolerance to change could benefit severely emaciated people with AN, regardless of disease subtype and level of dysphoria.

Epigenetic alterations in patients with anorexia nervosa-a systematic review

Anorexia nervosa (AN) is a complex metabolic and psychological disorder that is influenced by both heritable genetic components and environmental factors. Exposure to various environmental influences can lead to epigenetically induced changes in gene expression. Epigenetic research in AN is still in its infancy, and studies to date are limited in determining clear, valid links to disease onset and progression are limited. Therefore, the aim of this systematic review was to compile and critically evaluate the available results of epigenetic studies specifically in AN and to provide recommendations for future studies. In accordance with the PRISMA guidelines, a systematic literature search was performed in three different databases (PubMed, Embase, and Web of Science) through May 2023. Twenty-three original papers or conference abstracts on epigenetic studies in AN were collected. Epigenome-wide association studies (EWASs), which analyze DNA methylation across the genome in patients with AN and identify potential disease-relevant changes in promoter/regulatory regions of genes, are the most promising for future research. To date, five EWASs on AN have been published, suggesting a potential reversibility of malnutrition-induced epigenetic changes once patients recover. Hence, determining differential DNA methylation levels could serve as a biomarker for disease status or early diagnosis and might be involved in disease progression or chronification. For future research, EWASs with a larger sample size, longitudinal study design and uniform methods should be performed to contribute to the understanding of the pathophysiology of AN, the development of individual interventions and a better prognosis for affected patients.

Pragmatic clinical trials to advance research in children and adolescents with eating disorders

OBJECTIVE

To discuss the utility of pragmatic clinical trials (PCTs) to help advance research in eating disorders (EDs).

METHODS

We describe challenges associated with traditional explanatory research trials and examine PCTs as an alternative, including a review of the PRECIS-2 tool.

RESULTS

There are many challenges associated with the design and completion of traditional RCTs within the field of EDs. Pragmatic clinical trials are studies that closely align with conditions available in everyday practice and focus on outcomes that are relevant to patients and clinicians. Results of PCTS maximize applicability and generalizability to clinical settings.

DISCUSSION

Available therapies established for the treatment of EDs provide remission rates that rarely exceed 50%, implying a need for additional research on new or adjunctive treatments. In addition to a general overview of PCTs, we draw upon published literature and our own experiences involving adjunctive olanzapine for the treatment of children and youth with anorexia nervosa to help highlight challenges associated with randomized controlled trial (RCT) design and implementation, and offer pragmatic suggestions that would allow patients greater choice in treatment trials, while at the same time capturing outcomes that are most likely to advance treatment efforts.

CONCLUSIONS

Pragmatic clinical trials provide alternatives to RCT design that can help bolster research in EDs that aims to explore real-world effects of interventions.

PUBLIC SIGNIFICANCE

Available therapies established for the treatment of eating disorders (EDs) in children and adolescents provide remission rates that rarely exceed 50%, implying a need for additional research on new or adjunctive treatments. In this article, we discuss the utility of pragmatic trials to help promote research that can help advance knowledge that is relevant to clinical care settings.

Severe enduring anorexia nervosa (SE-AN) treatment options and their effectiveness: a review of literature

INTRODUCTION

 For nearly 20% of patients diagnosed with Anorexia Nervosa (AN), the eating disorder (ED) is prolonged and becomes long-lasting. It has been reported that patients diagnosed with Severe Enduring Anorexia Nervosa (SE-AN) have worse ED symptoms, higher rates of lifetime hospitalization, and lower psychosocial well-being compared to patients with shorter disease duration.

OBJECTIVES

 This review aims to describe the treatments proposed to date and their effectiveness on SE-AN-related outcomes.

METHODS

 We conducted a PubMed search for studies addressing the issue of treatment approach to SE-AN adults, that were published between 2003 and 2023, peer-reviewed, written in the English language, and available in full-text. Next, we inductively created relevant macro-themes by synthesizing the data from the included articles.

RESULTS

 Of 251 PubMed studies, 25 articles were considered for data extraction, all published between 2003 and 2022. We identified three macro-themes. The first macro-theme, "Psychotherapy", mostly takes into consideration treatment effectiveness of cognitive behavioral therapy (CBT). Various reports determined its greater effectiveness compared to Specialist Supportive Clinical Management (SSCM), and one study proved that outpatient CBT is a valid alternative to hospitalization. The second one involves "Pharmacological Treatments". Research on dronabinol, a synthetic orexigenic cannabinoid, antipsychotics (in particular, olanzapine and haloperidol), and ketamine showed some mixed results regarding the often-complementary areas of weight gain and improvement in ED-related symptoms. Regarding the third macro-theme, "Brain Stimulation Therapies," such as Repetitive Transcranial Magnetic Stimulation (rTMS) and Deep Brain Stimulation (DBS), we found promising results in improving ED-related psychological traits (such as mood and anxiety), affective regulation, and quality of life. However, we have observed divergent results regarding outcome measures such as BMI and weight gain.

CONCLUSIONS

 SE-AN patients are predicted to encounter both medical complications and psychological distress of increasing severity that will inevitably affect their quality of life; to our knowledge, research evidence on treatment options for SE-AN remains limited, and the methodological quality of studies is generally low. These findings denote the need to focus future research efforts on effective treatment strategies specific to long-lasting EDs.

Using machine learning with passive wearable sensors to pilot the detection of eating disorder behaviors in everyday life

BACKGROUND

Eating disorders (ED) are serious psychiatric disorders, taking a life every 52 minutes, with high relapse. There are currently no support or effective intervention therapeutics for individuals with an ED in their everyday life. The aim of this study is to build idiographic machine learning (ML) models to evaluate the performance of physiological recordings to detect individual ED behaviors in naturalistic settings.

METHODS

From an ongoing study (Final N = 120), we piloted the ability for ML to detect an individual's ED behavioral episodes (e.g. purging) from physiological data in six individuals diagnosed with an ED, all of whom endorsed purging. Participants wore an ambulatory monitor for 30 days and tapped a button to denote ED behavioral episodes. We built idiographic (N = 1) logistic regression classifiers (LRC) ML trained models to identify onset of episodes (~600 windows) v. baseline (~571 windows) physiology (Heart Rate, Electrodermal Activity, and Temperature).

RESULTS

Using physiological data, ML LRC accurately classified on average 91% of cases, with 92% specificity and 90% sensitivity.

CONCLUSIONS

This evidence suggests the ability to build idiographic ML models that detect ED behaviors from physiological indices within everyday life with a high level of accuracy. The novel use of ML with wearable sensors to detect physiological patterns of ED behavior pre-onset can lead to just-in-time clinical interventions to disrupt problematic behaviors and promote ED recovery.

Comprehensive elucidation of resting-state functional connectivity in anorexia nervosa by a multicenter cross-sectional study

BACKGROUND

Previous research on the changes in resting-state functional connectivity (rsFC) in anorexia nervosa (AN) has been limited by an insufficient sample size, which reduced the reliability of the results and made it difficult to set the whole brain as regions of interest (ROIs).

METHODS

We analyzed functional magnetic resonance imaging data from 114 female AN patients and 135 healthy controls (HC) and obtained self-reported psychological scales, including eating disorder examination questionnaire 6.0. One hundred sixty-four cortical, subcortical, cerebellar, and network parcellation regions were considered as ROIs. We calculated the ROI-to-ROI rsFCs and performed group comparisons.

RESULTS

Compared to HC, AN patients showed 12 stronger rsFCs mainly in regions containing dorsolateral prefrontal cortex (DLPFC), and 33 weaker rsFCs primarily in regions containing cerebellum, within temporal lobe, between posterior fusiform cortex and lateral part of visual network, and between anterior cingulate cortex (ACC) and thalamus (p < 0.01, false discovery rate [FDR] correction). Comparisons between AN subtypes showed that there were stronger rsFCs between right lingual gyrus and right supracalcarine cortex and between left temporal occipital fusiform cortex and medial part of visual network in the restricting type compared to the binge/purging type (p < 0.01, FDR correction).

CONCLUSION

Stronger rsFCs in regions containing mainly DLPFC, and weaker rsFCs in regions containing primarily cerebellum, within temporal lobe, between posterior fusiform cortex and lateral part of visual network, and between ACC and thalamus, may represent categorical diagnostic markers discriminating AN patients from HC.

Efficacy of a therapist-guided smartphone-based intervention to support recovery from bulimia nervosa: Study protocol of a randomized controlled multi-centre trial

OBJECTIVE

Although inpatient treatment is highly effective for patients with bulimia nervosa (BN), some patients show a resurgence of symptoms and relapse after discharge. Therefore, the aim of this study is to evaluate the efficacy of a guided smartphone-based aftercare intervention following inpatient treatment to support recovery.

METHOD

172 female patients with BN (DSM-5: 307.51) will be randomized to receive a 16-week smartphone-based aftercare intervention (German version of 'Recovery Record') with therapist feedback as an add-on element to treatment as usual (TAU) or TAU alone. Assessments will take place at baseline (discharge, T0), during the intervention (after 4 weeks, T1), post-intervention (after 16 weeks, T2) and at 6-month follow-up (T3). Primary outcome will be remission at T2. Moderator and mediator analyses will investigate for whom the aftercare intervention suits best and how it works.

CONCLUSIONS

This is the first randomized controlled trial to examine a guided smartphone-based aftercare intervention following inpatient treatment of patients with BN. We expect that this innovative aftercare intervention is highly accepted by the patients and that it has the potential to support recovery after inpatient treatment and thereby could contribute to improving aftercare for patients with BN.

Eye movement desensitisation and reprocessing as add-on treatment to enhanced cognitive behaviour therapy for patients with anorexia nervosa reporting childhood maltreatment: A quasi-experimental multicenter study

OBJECTIVE

This quasi-experimental study aimed to compare the outcome of patients with Anorexia Nervosa (AN) reporting moderate/severe childhood maltreatment (CM) treated exclusively with Enhanced Cognitive Behaviour Therapy (CBT-E) or with CBT-E plus Eye Movement Desensitisation and Reprocessing (EMDR).

METHOD

A total of 75 patients with AN reporting moderate/severe CM were initially assessed regarding body mass index (BMI), general and eating disorder (ED)-specific psychopathology, and dissociative symptoms, and re-evaluated after 40 CBT-E sessions (T1). Then, 18 patients received EMDR, whereas the others were placed on a waiting list and continued CBT-E. T2 assessment was performed after 20-25 sessions of EMDR or CBT-E. A control group of 67 patients without CM was also enroled and treated with CBT-E.

RESULTS

Contrary to patients without CM, neither of the traumatised groups improved in BMI, general and ED psychopathology, or dissociation at T1. However, at T2, both traumatised groups improved in BMI and ED-specific psychopathology, with the CBT + EMDR group demonstrating greater improvements. Moreover, only the CBT + EMDR group improved in general psychopathology and dissociative symptoms. The reduction of ED symptoms in traumatised patients was mediated by the amelioration of dissociation.

DISCUSSION

The addition of EMDR to CBT-E may benefit patients with AN reporting moderate/severe CM.

Outcomes in people with eating disorders: a transdiagnostic and disorder-specific systematic review, meta-analysis and multivariable meta-regression analysis

Eating disorders (EDs) are known to be associated with high mortality and often chronic and severe course, but a recent comprehensive systematic review of their outcomes is currently missing. In the present systematic review and meta-analysis, we examined cohort studies and clinical trials published between 1980 and 2021 that reported, for DSM/ICD-defined EDs, overall ED outcomes (i.e., recovery, improvement and relapse, all-cause and ED-related hospitalization, and chronicity); the same outcomes related to purging, binge eating and body weight status; as well as mortality. We included 415 studies (N=88,372, mean age: 25.7±6.9 years, females: 72.4%, mean follow-up: 38.3±76.5 months), conducted in persons with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding and eating disorders (OSFED), and/or mixed EDs, from all continents except Africa. In all EDs pooled together, overall recovery occurred in 46% of patients (95% CI: 44-49, n=283, mean follow-up: 44.9±62.8 months, no significant ED-group difference). The recovery rate was 42% at <2 years, 43% at 2 to <4 years, 54% at 4 to <6 years, 59% at 6 to <8 years, 64% at 8 to <10 years, and 67% at ≥10 years. Overall chronicity occurred in 25% of patients (95% CI: 23-29, n=170, mean follow-up: 59.3±71.2 months, no significant ED-group difference). The chronicity rate was 33% at <2 years, 40% at 2 to <4 years, 23% at 4 to <6 years, 25% at 6 to <8 years, 12% at 8 to <10 years, and 18% at ≥10 years. Mortality occurred in 0.4% of patients (95% CI: 0.2-0.7, n=214, mean follow-up: 72.2±117.7 months, no significant ED-group difference). Considering observational studies, the mortality rate was 5.2 deaths/1,000 person-years (95% CI: 4.4-6.1, n=167, mean follow-up: 88.7±120.5 months; significant difference among EDs: p<0.01, range: from 8.2 for mixed ED to 3.4 for BN). Hospitalization occurred in 26% of patients (95% CI: 18-36, n=18, mean follow-up: 43.2±41.6 months; significant difference among EDs: p<0.001, range: from 32% for AN to 4% for BN). Regarding diagnostic migration, 8% of patients with AN migrated to BN and 16% to OSFED; 2% of patients with BN migrated to AN, 5% to BED, and 19% to OSFED; 9% of patients with BED migrated to BN and 19% to OSFED; 7% of patients with OSFED migrated to AN and 10% to BN. Children/adolescents had more favorable outcomes across and within EDs than adults. Self-injurious behaviors were associated with lower recovery rates in pooled EDs. A higher socio-demographic index moderated lower recovery and higher chronicity in AN across countries. Specific treatments associated with higher recovery rates were family-based therapy, cognitive-behavioral therapy (CBT), psychodynamic therapy, and nutritional interventions for AN; self-help, CBT, dialectical behavioral therapy (DBT), psychodynamic therapy, nutritional and pharmacological treatments for BN; CBT, nutritional and pharmacological interventions, and DBT for BED; and CBT and psychodynamic therapy for OSFED. In AN, pharmacological treatment was associated with lower recovery, and waiting list with higher mortality. These results should inform future research, clinical practice and health service organization for persons with EDs.

Recovery Trajectories in Adolescent Girls with Anorexia Nervosa

Background: This study aimed to document recovery trajectories among adolescents with anorexia nervosa (AN) based on three markers of remission, namely changes in body weight, food restriction, and excessive exercise, and to identify predictors of these trajectories. Methods: One hundred twenty-six adolescent girls (14.7 ± 1.3 years) were recruited during initial assessment visits at specialized eating disorder (ED) programs in five University Health Centers across the province of Quebec, Canada. z-BMI and AN symptom severity (food restriction and excessive exercise) were assessed at initial assessment visits and subsequently reassessed at each quarterly follow-up over a 12-month period to identify recovery trajectories. Results: Considering the three markers of remission, three distinct trajectories emerged: Group 1, rapid responders; Group 2, gradual responders; and Group 3, unstable responders. At initial visits, a difference between groups was found regarding the type of treatment (p = 0.01) and weight suppression (p = 0.02). Group 1 had a higher number of youths hospitalized than Group 2 and Group 3, and a greater weight suppression than Group 3. Furthermore, individuals with atypical AN were more likely to belong to Group 2 than to Group 1 and Group 3 (p < 0.0001). Conclusions: This study contributes to a better understanding of the heterogeneity of recovery trajectories in adolescent girls with AN.

The impact of genetic risk for schizophrenia on eating disorder clinical presentations

A growing body of literature recognizes associations between eating disorders (EDs) and schizophrenia and suggests that familial liability to schizophrenia in individuals with anorexia nervosa (AN) reveals distinct patterns of clinical outcomes. To further investigate the influence of schizophrenia genetic liability among individuals with EDs, we evaluated the associations between schizophrenia polygenic risk scores (PRS) and clinical presentations of individuals with EDs including their overall health condition and ED-related symptoms. Using data from two previous studies of the genetics of EDs comprising 3,573 Anorexia Nervosa Genetics Initiative (ANGI) cases and 696 Binge Eating Genetics Initiative (BEGIN) cases born after 1973 and linked to the Swedish National Patient Register, we examined the association of schizophrenia PRS on ED clinical features, psychiatric comorbidities, and somatic and mental health burden. Among ANGI cases, higher schizophrenia PRS was statistically significantly associated with higher risk of major depressive disorder (MDD) measured by hazard ratio (HR) with 95% confidence interval (CI) (HR [95% CI]: 1.07 [1.02, 1.13]) and substance abuse disorder (SUD) (HR [95% CI]: 1.14 [1.03, 1.25]) after applying multiple testing correction. Additionally, higher schizophrenia PRS was associated with decreased clinical impairment assessment scores (-0.56, 95% CI: [-1.04, -0.08]) at the conventional significance level (p < 0.05). Further, in BEGIN cases, higher schizophrenia PRS was statistically significantly associated with earlier age at first ED symptom (-0.35 year, 95% CI: [-0.64, -0.06]), higher ED symptom scores (0.16, 95% CI: [0.04, 0.29]), higher risk of MDD (HR [95% CI]: 1.18 [1.04, 1.34]) and SUD (HR [95% CI]: 1.36 [1.07, 1.73]). Similar, but attenuated, patterns held in the subgroup of exclusively AN vs other eating disorder (OED) cases. These results suggest a similar pattern of influence of schizophrenia PRS for AN and OED cases in terms of psychiatric comorbidities, but a different pattern in terms of ED-related clinical features. The disparity of the effect of schizophrenia PRS on AN vs OED merits further investigation.

Severe-Enduring Anorexia Nervosa (SE-AN): a case series

BACKGROUND

Anorexia Nervosa (AN) poses significant therapeutic challenges, especially in cases meeting the criteria for Severe and Enduring Anorexia Nervosa (SE-AN). This subset of AN is associated with severe medical complications, frequent use of services, and the highest mortality rate among psychiatric disorders.

CASE PRESENTATION

In the present case series, 14 patients were selected from those currently or previously taken care of at the Eating Disorders Outpatients Unit of the Maggiore Hospital in Bologna between January 2012 and May 2023. This case series focuses on the effects of the disease, the treatment compliance, and the description of those variables that could help understand the great complexity of the disorder.

CONCLUSION

This case series highlights the relevant issue of resistance to treatment, as well as medical and psychological complications that mark the life course of SE-AN patients. The chronicity of these disorders is determined by the overlapping of the disorder's ego-syntonic nature, the health system's difficulty in recognizing the problem in its early stages, and the presence of occupational and social impairment.

Fracture Risk in Patients with Anorexia Nervosa Over a 40-Year Period

Researchers have reported increased fracture risk in patients with anorexia nervosa (AN), but more knowledge on the long-term risk and the effects of age, male sex, and time-related changes is still needed. We examined the long-term (up to 40 years) fracture risk among patients with AN compared to a matched comparison cohort from the general population. We utilized data from the Danish Health Care Registers to identify 14,414 patients with AN (13,474 females and 940 males) diagnosed between 1977 and 2018, with a median age of 18.6 years and median follow-up time of 9.65 years. We calculated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) using Cox regression analysis for overall and site-specific fracture risks. The overall aHR of any fracture was 1.46 [95% CI: 1.36 to 1.48], with an aHR of 1.50 [95% CI: 1.43 to 1.57] for females and 0.95 [95% CI: 0.82 to 1.1] for males. For specific fractures we found an association with femur fractures both in females 4.06 [95% CI: 3.39 to 4.46] and in males 2.79 [95% CI: 1.45 to 2.37] and for fractures of the spine (females 2.38 [95% CI: 2.00 to 2.84], males 2.31 [95% CI: 1.20 to 4.42]). The aHR of any fracture decreased from 1.66 [95% CI: 1.52 to 1.81] in the period from 1977 to 1997 to 1.40 [95% CI: 1.33 to 1.40] from 1998 to 2018. In conclusion, we found that AN was associated with a 46% increased risk of any fracture up to 40 years after diagnosis. We found no overall increased risk in males, but in both sexes we found a particularly high site-specific fracture risk in the spine and femur. Fracture risk decreased in recent decades, indicating that more patients with AN have been diagnosed with presumably less severe disease and that the earlier detection and intervention of AN in recent years may translate into a lower facture risk. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Individuals with restrictive eating disorders' experience of the introduction of calories on menus in England: An interpretative phenomenological analysis study

OBJECTIVE

In April 2022 the Calorie Labelling (Out of Home) Regulations came into effect in England where cafés, restaurants, and takeaways with over 250 employees were required to provide calorie labelling on menus. Concerns have been raised regarding the potential negative impact this could have on individuals with eating disorders (EDs), yet this has not been explored using qualitative methodology.

METHOD

Eleven participants with a current or previously diagnosed restrictive ED were interviewed in September 2022. Interpretative Phenomenological Analysis (IPA) was used to explore their experience of the introduction of calories on menus.

RESULTS

Using IPA we established six themes and seven subordinate themes. These included the introduction of calories on menus as an 'attack' on individuals with EDs; the prominent visual display of calories as an attentional pull; normalising of calories counting; the impact on behaviour; and associated strategies for managing.

CONCLUSION

This contributes to research surrounding the implications for public health policies on individuals with EDs, especially their ability to reinforce and amplify disordered thoughts and behaviours, and the need for greater consideration of how to minimise impact and potential harm of large public health campaigns.

Predictors for and duration of hospitalization among children and adolescents with eating disorders

OBJECTIVE

The objective of this study was to investigate the predictive value of sex, age, body mass index (BMI), Eating Disorder Examination (EDE) score, social risk factors, and psychiatric comorbidities for hospitalization and hospitalization duration among children and adolescents suffering from eating disorders.

METHOD

This prospective cohort study involved 522 consecutive patients who had been referred to a specialized eating disorder unit between January 1, 2009 and December 31, 2015; participants were followed up until August 1, 2016 by medical records. We used regression analyses to evaluate the prognostic value of sex, age, BMI, EDE, eating disorder diagnoses, social risk factors, and psychiatric comorbidities concerning inpatient hospitalization and hospitalization duration.

RESULTS

We found that younger age, higher EDE global score, lower BMI percentile, anorexia nervosa, a higher number of social risk factors, and the presence of diagnosed self-harm increased the odds of being hospitalized, while being female and having a comorbid autism spectrum condition increased the duration of hospitalization. No other psychiatric comorbidity was found to significantly predict hospitalization or duration of hospitalization.

DISCUSSION

The odds of being hospitalized were predicted by the severity of anorexia nervosa and indicators of social risk factors in the family, whereas the duration of hospitalization was predicted by having a comorbid autism spectrum condition, indicating a difference between the factors affecting the risk of hospitalization and the factors affecting the duration of hospitalization. This calls for further exploration of tailored treatments for eating disorders.

PUBLIC SIGNIFICANCE STATEMENT

This study finds that hospitalization for an eating disorder is predicted by the severity of the illness, self-harm, and social risk factors. Duration of hospitalization is predicted by having a comorbid autism spectrum condition. These findings indicate that the treatment of eating disorders may require different treatment approaches depending on the presentation of the individual patient to reduce both the need for hospitalization and the length of inpatient stay.

Anorexia Nervosa in Adolescence: A Comprehensive Study of Multidimensional Factors Associated with Symptom Severity 1 Year Following the Diagnosis

The overarching goal of this study was to examine the unique contribution of psychological, familial, and friendship factors in explaining anorexia nervosa (AN) symptom severity 1 year following diagnosis among a sample of adolescent girls. A second objective was to determine whether friendship factors mediated the association between psychological and/or familial factors and AN symptom severity. This study included 143 adolescent girls under the age of 18 diagnosed with AN (M = 14.84, SD = 1.31). Participants were recruited from specialized eating disorder treatment programs. At admission (T1), participants completed a set of self-report questionnaires measuring psychological, familial, and friendship factors. AN symptom severity was assessed 1 year later (T2). Results of hierarchical regression analysis revealed that greater general psychological maladjustment at T1 (b = .26; se = .03; p = .00) was associated with greater AN symptom severity at T2. Greater alienation from friends at T1 (b = 1.20, se = .53, p = .03) also predicted greater AN symptom severity at T2, above and beyond the influence of adolescent girls' general psychological maladjustment. Finally, the mediating role of alienation from friends in the association between general psychological maladjustment at T1 and AN symptom severity at T2 was also identified. AN is a multidimensional disorder with a prognosis that involves both psychological and social factors. The results stemming from the present study shed light on the role of peer as a mechanism through which general psychological maladjustment is linked to AN symptom severity 1 year following diagnosis.

Efficacy of educational interventions in adolescent population with feeding and eating disorders: a systematic review

BACKGROUND

Educational interventions are a key element in the care of young patients with feeding and eating disorders, forming part of the majority of therapeutic approaches. The aim of this review is to evaluate the impact of educational interventions in adolescents with feeding and eating disorders.

METHODS

Following the PRISMA recommendations electronic databases were searched up to 29 June 2023. Studies related to educational interventions in young population diagnosed with feeding and eating disorders (anorexia nervosa, avoidant/restrictive food intake disorder, bulimia nervosa, pica and ruminative disorders and binge- eating disorder) in Spanish and English language, without temporal limitation, were located in the databases: PubMed, Scopus, CINAHL, Cochrane Library, PsycINFO, CUIDEN, DIALNET, and ENFISPO. A search in the databases of grey literature was performed in OpenGrey and Teseo. The review protocol was registered in PROSPERO (CRD42020167736).

RESULTS

A total of 191 articles were selected from the 9744 citations screened. Ten publications were included. The results indicated variability between educational programs, including individual and group interventions, learning techniques and various research methodologies. Variables such as learning, attitudinal and perceptual changes, anthropometric parameters, symptom improvement, normalization of eating patterns, evaluation of the program and cognitive flexibility were identified. The risk of bias was high due to the low methodological quality of a large number of studies analyzed.

CONCLUSION

The results indicate that educational interventions can influence the improvement of knowledge level and have a positive effect on health outcomes. Although education is a common practice in the treatment of these pathologies, high-quality studies were not identified. Thus, this review concludes that additional evidence is needed to evaluate the effectiveness of educational programs, with further research studies, especially randomized controlled trials, to confirm these results.

LEVEL OF EVIDENCE

Level I: Systematic review.

Mortality and mental health funding-do the dollars add up? Eating disorder research funding in Australia from 2009 to 2021: a portfolio analysis

Background

Eating Disorders (EDs) are among the deadliest of the mental disorders and carry a sizeable public health burden, however their research and treatment is consistently underfunded, contributing to protracted illness and ongoing paucity of treatment innovation.

Methods

We compare absolute levels and growth rates of Australian mental health research funding by illness group for the years 2009-2021, with a specific focus on eating disorders analysed at the portfolio level.

Findings

Actual and adjusted data obtained from Australia's three national medical research funding bodies (NHMRC, ARC and MRFF) shows eating disorders receive a disproportionately low allocation of mental health research funding despite having amongst the highest mortality rates. Forty-one category one research grants totalling $AUD28.1 million were funded for eating disorders over the period. When adjusted for inflation, this equates to $2.05 per affected individual, compared with $19.56 for depression, $32.11 for autism, and $176.19 for schizophrenia. Half of all research funded for eating disorders was 'basic' research (e.g., illness underpinning), with little investment in the development of innovative treatment models, novel therapeutics or translation, well reflected by recovery rates of less than 50% in individuals with Anorexia Nervosa.

Interpretation

Significant discrepancy remains between research funding dollars and disease burden associated with the mental health disorders. The extent to which eating disorders are underfunded may in part be attributable to inaccuracies in epidemiological and burden of disease data.

Funding

This work was in-part funded by the Australian Government Department of Health and the National Eating Disorder Research & Translation Strategy. The funder was not directly involved in informing the development of the current study.

A pilot randomized controlled trial of transdiagnostic network-informed personalized treatment for eating disorders versus enhanced cognitive behavioral therapy

OBJECTIVE

Eating disorders (EDs) are serious mental illnesses with high mortality and relapse rates and carry significant societal and personal costs. Nevertheless, there are few evidence-based treatments available. One aspect that makes treatment difficult is the high heterogeneity in symptom presentation. This heterogeneity makes it challenging for clinicians to identify pertinent treatment targets. Personalized treatment based on idiographic models may be well-suited to address this heterogeneity, and, in turn, presumably improve treatment outcomes.

METHODS

In the current randomized controlled trial, participants will be randomly assigned to either 20 sessions of enhanced cognitive behavioral therapy (CBT-E) or transdiagnostic network-informed personalized treatment for EDs (T-NIPT-ED). Assessment of ED symptoms, clinical impairment, and quality of life will occur at pre-, mid-, posttreatment, and 1-month follow-up.

RESULTS

We will examine the acceptability and feasibility of T-NIPT-ED compared to CBT-E. We also will test the initial clinical efficacy of T-NIPT-ED versus CBT-E on clinical outcomes (i.e., ED symptoms and quality of life). Finally, we will test if the network-identified precision targets are the mechanisms of change.

DISCUSSION

Ultimately, this research may inform the development and dissemination of evidence-based personalized treatments for EDs and serve as an exemplar for personalized treatment development across the broader field of psychiatry.

PUBLIC SIGNIFICANCE

Current evidence-based treatments for eating disorders result in low rates of recovery, especially for adults with AN. Our study aims to test the feasibility, acceptability, and clinical efficacy of a data-driven, individualized approach to ED treatment, network-informed personalized treatment, compared to the current evidence-based treatment for EDs, Enhanced CBT. Findings have the potential to improve treatment outcomes for EDs by identifying and targeting core symptoms maintaining EDs.

Psilocybin therapy for females with anorexia nervosa: a phase 1, open-label feasibility study

Anorexia nervosa (AN) is a deadly illness with no proven treatments to reverse core symptoms and no medications approved by the US Food and Drug Administration. Novel treatments are urgently needed to improve clinical outcomes. In this open-label feasibility study, 10 adult female participants (mean body mass index 19.7 kg m-2; s.d. 3.7) who met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for AN or pAN (partial remission) were recruited to a study conducted at an academic clinical research institute. Participants received a single 25-mg dose of synthetic psilocybin in conjunction with psychological support. The primary aim was to assess safety, tolerability and feasibility at post-treatment by incidences and occurrences of adverse events (AEs) and clinically significant changes in electrocardiogram (ECG), laboratory tests, vital signs and suicidality. No clinically significant changes were observed in ECG, vital signs or suicidality. Two participants developed asymptomatic hypoglycemia at post-treatment, which resolved within 24 h. No other clinically significant changes were observed in laboratory values. All AEs were mild and transient in nature. Participants' qualitative perceptions suggest that the treatment was acceptable for most participants. Results suggest that psilocybin therapy is safe, tolerable and acceptable for female AN, which is a promising finding given physiological dangers and problems with treatment engagement. ClinicalTrials.gov identifier NCT04661514 .

Gut microbiota metabolites mediate the interplay between childhood maltreatment and psychopathology in patients with eating disorders

Eating disorders (EDs) are syndromes with a multifactorial etiopathogenesis, involving childhood traumatic experiences, as well as biological factors. Human microbiome has been hypothesised to play a fundamental role, impacting on emotion regulation, as well as with eating behaviours through its metabolites such as short chain fatty acids (SCFAs). The present study investigated the interactions between psychopathology of EDs, the gut microbiome and SCFAs resulting from bacterial community metabolic activities in a population of 47 patients with Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder and in healthy controls (HCs). Bacterial gut microbiota composition differences were found between subjects with EDs and HCs, especially in association with different pathological behaviours (binge-purge vs restricting). A mediation model of early trauma and ED-specific psychopathology linked reduction of microbial diversity to a typical microbiota-derived metabolite such as butyric acid. A possible interpretation for this model might be that childhood trauma represents a risk factor for gut dysbiosis and for a stable modification of mechanisms responsible for SCFAs production, and that this dysfunctional community is inherited in the passage from childhood to adulthood. These findings might open the way to novel interventions of butyric acid-like compounds as well as faecal transplant.

Risk factors of disordered eating in adolescent girls from a community sample: a multidimensional approach

BACKGROUND

Eating disorders (ED) are severe, chronic, and complex in nature mental illnesses that are difficult to treat. One of the ways to stave off EDs is by screening among adolescents to preempt the development of clinical forms of ED in risk groups.

AIM

1) to investigate the prevalence of ED risk among adolescent girls and compare subgroups at high and low risk of ED; 2) to investigate using a multidimensional approach those variables that can interact with temperament and character traits to predict ED symptomatology.

METHODS

The cross-sectional observational self-report study of a community sample of adolescent girls 1217 years old (n=298; M=14.771.13) was carried out in the city of Ryazan, Russia. The Russian versions of Eating Attitudes Test and Cloningers Temperament and Character Inventory-Revised were used. In addition, an original questionnaire (Risk Factors of Eating Disorders) was developed. Regression models (to test for significant moderation) and path analysis (to test for significant mediations) were used.

RESULTS

Girls at risk of developing EDs are characterized by a heightened level of concern about weight and dissatisfaction with their body, tend to suffer from low self-directedness, higher novelty seeking and tendency to higher harm avoidance, display high alexithymia, experience self-distrust, negative emotionality and are dissatisfied with family relationships. They also suffer from low self-esteem and tend to be perfectionism and engage in risk behavior. Significant moderating effects were uncovered between the following ED risk factors: (1) self-distrust/risk behavior and BMI; (2) alexithymia/negative emotionality/self-esteem and cooperativeness; and (3) negative emotionality/risk behavior and self-transcendence. Family relationship dissatisfaction mediates the association between self-directedness/cooperativeness/self-transcendence and disordered eating.

CONCLUSION

There are various mutual influences between the numerous ED risk and prevention factors, which all together determine the paths between the predictors and final outcome.

Differences and similarities in personality functioning across different types of eating disorders

Objective

The classification of anorexia nervosa (AN) into subtypes is relevant due to their different symptomatology. However, subtypes (restricting type: AN-R; purging type: AN-P) differ also in terms of their personality functioning. Knowledge about these differences would allow for better treatment stratification. A pilot study indicated differences in structural abilities that can be assessed by the operationalized psychodynamic diagnosis (OPD) system. The aim of this study was therefore to systematically explore differences in personality functioning and personality between the two AN subtypes and bulimia nervosa (BN) using three personality (functioning) constructs.

Methods

A total of N = 110 inpatients with AN-R (n = 28), AN-P (n = 40), or BN (n = 42) were recruited in three clinics for psychosomatic medicine. Assignment to the three groups was performed using a comprehensive questionnaire validated for diagnostic purposes (Munich-ED-Quest). Personality functioning was examined using OPD Structure Questionnaire (OPD-SQ), personality by using the Personality Inventory for DSM-5-Brief Form and Big Five Inventory-10. (M)ANOVAs were used to examine differences across eating disorder groups. In addition, correlation and regression analyses were conducted.

Results

We observed differences on several sub- and main scales of the OPD-SQ. Whereas patients with BN showed the lowest levels, AN-R patients displayed the highest levels of personality functioning. On some sub- and main scales, such as "affect tolerance," the subtypes of AN differed from BN, whereas on the scale "affect differentiation," AN-R, differed from the other two groups. The total eating disorder pathology score of the Munich-ED-Quest best predicted overall personality structure [stand. β = 0.650; t(104) = 6.666; p < 0.001] and self-regulation [stand. β = 0.449; t(104) = 3.628; p < 0.001].

Discussion

Our findings confirm most of the results of the pilot study. These findings can facilitate the development of stratified treatment approaches for eating disorders.

Decision-making difficulties mediate the association between poor emotion regulation and eating disorder symptoms in adolescence

BACKGROUND

The emergence of eating problems during childhood increases the risk for eating disorders (EDs) during young adulthood. Previous studies highlight a relationship between poor self-regulation and onset of eating pathology. In this study, we investigated whether this association is mediated by decision-making difficulties.

METHODS

To test this hypothesis, we used data from the Millennium Cohort Study. Decision-making performance was assessed with the Cambridge Gambling Task at age 11. Principal components analysis was used to derive an index of ED symptoms at age 14. The trajectories of scores of two subscales of the Child Social Behaviour Questionnaire, Independence and Self-Regulation (ISR) and Emotional Dysregulation (EmotDy), were modelled from ages 3 to 7 years in a latent growth curve analysis. The individual predicted values of the intercept (set at baseline, 3 years) and the slope (rate of annual change) were then used in the mediation analysis.

RESULTS

In our sample of 11 303 individuals, there was evidence for mediation by three measures of decision-making at age 11 (poor quality of decision-making, delay aversion and low risk-adjustment) in the association between EmotDy across ages 3-7 and ED symptoms at age 14 even after the adjustment for relevant covariates. We found no evidence of association between ISR and ED symptoms.

CONCLUSION

Our findings suggest that emotion regulation processes during childhood may be relevant for the future onset of ED symptoms via their association with decision-making skills. These findings, obtained from a large, representative, sample, shed light on the relationship between self-regulation, decision-making and symptoms of EDs.

Eating disorder symptoms among children and adolescents in Germany before and after the onset of the COVID-19 pandemic

Background

Disordered eating is highly prevalent among children and adolescents. Since the outbreak of the COVID-19 pandemic, hospitalizations due to eating disorders have peaked and overweight has risen. The aim of this study was to determine differences in the prevalence of eating disorder symptoms among children and adolescents in Germany before and after the onset of the COVID-19 pandemic and to identify associated factors.

Materials and methods

Eating disorder symptoms and associated factors were examined in a sample of n = 1,001 participants of the nationwide population-based COPSY study in autumn 2021. Standardized and validated instruments were used to survey 11-17-year-olds along with a respective parent. To identify differences in prevalence rates, logistic regression was used to compare results with data from n = 997 participants of the prepandemic BELLA study. Multiple logistic regression analyses were performed to examine associations with relevant factors in the pandemic COPSY sample.

Results

Eating disorder symptoms were reported by 17.18% of females and 15.08% of males in the COPSY study. Prevalence rates were lower overall in the COPSY sample compared to before the pandemic. Male gender, anxiety, and depressive symptoms were associated with increased odds for eating disorder symptoms in the pandemic.

Conclusion

The pandemic underscores the importance of further research, but also prevention and intervention programs that address disordered eating in children and adolescents, with a focus on age - and gender-specific differences and developments. In addition, screening instruments for eating disorder symptoms in youths need to be adapted and validated.

Gut-Associated Lymphatic Tissue in Food-Restricted Rats: Influence of Refeeding and Probiotic Supplementation

Anorexia nervosa (AN) is a severe and often chronic eating disorder that leads to alterations in the gut microbiome, which is known to influence several processes, such as appetite and body weight regulation, metabolism, gut permeability, inflammation, and gut-brain interactions. Using a translational activity-based anorexia (ABA) rat model, this study examined the effect of chronic food starvation, as well as multistrain probiotic supplementation and refeeding, on the structure of the gut and gut-associated lymphatic tissue (GALT). Our results indicated that ABA had an atrophic influence on intestinal morphology and increased the formation of GALT in the small bowel and colon. Higher formation of GALT in ABA rats appeared to be reversible upon application of a multistrain probiotic mixture and refeeding of the starved animals. This is the first time that increased GALT was found following starvation in the ABA model. Our results underscore a potential role of gut inflammatory alterations in the underlying pathophysiology of AN. Increased GALT could be linked to the gut microbiome, as probiotics were able to reverse this finding. These results emphasize the role of the microbiome-gut-brain axis in the pathomechanisms of AN and point to probiotics as potentially beneficial addendum in the treatment of AN.

An integrative model as a step toward increasing the awareness of eating disorders in the general population

Eating disorders (EDs) represent a contradictory chapter of clinical psychiatry, i.e., although they are associated with significant prevalence and risks in the long term (including vital risk, especially for anorexia nervosa), the therapeutic resources are minimal and based on low-quality data. Another contradiction arose in the last few decades, i.e., a variety of new EDs have been described, either by clinicians or signaled by mass media, but their systematic exploration is progressing very slowly. Entities like "food addiction," "orthorexia nervosa," or "emotional eating disorder" still require intensive exploration in order to find the most accurate diagnostic instruments, diagnosis criteria, prevalence data, vulnerability factors, and therapeutic approaches. This article is focused on integrating into a comprehensive model a variety of EDs not specified or loosely defined by the current international classifications of psychiatric disorders. This framework is intended as an instrument for stimulating clinical and epidemiological research, with potential favorable consequences for therapeutic research. The dimensional model suggested here includes four main categories that accommodate the already recognized EDs (i.e., anorexia nervosa, bulimia nervosa, and binge eating disorder) as well as ten EDs that still need intensive research to find their clinical and pathophysiological characteristics. More good-quality studies are urgently required regarding this topic, based on the mental and physical negative impact these EDs may have in the short and long term, especially in vulnerable populations (e.g., pregnant women, athletes, adolescents, etc.).

Closed-Loop Deep Brain Stimulation for Psychiatric Disorders

ABSTRACT

Deep brain stimulation (DBS) is a well-established approach to treating medication-refractory neurological disorders and holds promise for treating psychiatric disorders. Despite strong open-label results in extremely refractory patients, DBS has struggled to meet endpoints in randomized controlled trials. A major challenge is stimulation "dosing"-DBS systems have many adjustable parameters, and clinicians receive little feedback on whether they have chosen the correct parameters for an individual patient. Multiple groups have proposed closed loop technologies as a solution. These systems sense electrical activity, identify markers of an (un)desired state, then automatically deliver or adjust stimulation to alter that electrical state. Closed loop DBS has been successfully deployed in movement disorders and epilepsy. The availability of that technology, as well as advances in opportunities for invasive research with neurosurgical patients, has yielded multiple pilot demonstrations in psychiatric illness. Those demonstrations split into two schools of thought, one rooted in well-established diagnoses and symptom scales, the other in the more experimental Research Domain Criteria (RDoC) framework. Both are promising, and both are limited by the boundaries of current stimulation technology. They are in turn driving advances in implantable recording hardware, signal processing, and stimulation paradigms. The combination of these advances is likely to change both our understanding of psychiatric neurobiology and our treatment toolbox, though the timeframe may be limited by the realities of implantable device development.

Trauma Experiences Are Common in Anorexia Nervosa and Related to Eating Disorder Pathology but Do Not Influence Weight-Gain during the Start of Treatment

OBJECTIVE

The main characteristics of Anorexia Nervosa (AN) in adults are restriction of energy intake relative to requirements leading to significant weight loss, disturbed body image, and intense fear of becoming fat. Traumatic experiences (TE) have been reported as common, although less is known about the relationship with other symptoms in severe AN. We investigated the presence of TE, PTSD, and the relation between TE, eating disorder (ED) symptoms, and other symptoms in moderate to severe AN (n = 97) at admission to inpatient weight-restoration treatment. All patients were enrolled in the Prospective Longitudinal all-comer inclusion study on Eating Disorders (PROLED).

METHODS

TE were assessed using the Post-traumatic stress disorder checklist, Civilian version (PCL-C), and ED symptoms using the Eating Disorder Examination Questionnaire (EDE-Q); depressive symptoms were assessed using the Major Depression Inventory (MDI), and the presence of Post-traumatic Stress Disorder (PTSD) was diagnosed according to ICD-10 criteria.

RESULTS

The mean score on PCL-C was high (mean 44.6 SD 14.7), with 51% having a PCL-C score at or above 44 (n = 49, suggested cut-off for PTSD), although only one individual was clinically diagnosed with PTSD. There was a positive correlation between baseline scores of PCL-C and EDE-Q-global score (r = 0.43; p < 0.01) as well as of PCL-C and all EDE-Q subscores. None of the included patients were admitted for treatment of TE/PTSD during the first 8 weeks of treatment.

CONCLUSIONS

In a group of patients with moderate to severe AN, TE were common, and scores were high, although only one had a diagnosis of PTSD. TE were related to ED symptoms at baseline, but this association diminished during the weight restoration treatment.

Gaining consensus on clinical quality outcomes for eating disorders: Framework for the development of an Australian national minimum dataset

OBJECTIVES

Eating disorders (EDs) are complex psychiatric illnesses requiring multidisciplinary care across both mental and medical healthcare settings. Currently, no nationally comprehensive, consistent, agreed on or mandated data set or data collection strategy exists for EDs in Australia: thus, little is known about the outcomes of care nor treatment pathways taken by individuals with EDs. InsideOut Institute was contracted by the Australian Government Department of Health to develop a minimum dataset (MDS) for the illness group with consideration given to data capture mechanisms and the scoping of a national registry.

DESIGN

A four-step modified Delphi methodology was used, including national consultations followed by three rounds of quantitative feedback by an expert panel.

SETTING

Due to social distancing protocols throughout the global SARS-CoV-2 pandemic, the study was conducted online using video conferencing (Zoom and Microsoft Teams) (Step 1), email communication and the REDCap secure web-based survey platform (Steps 2-4).

PARTICIPANTS

14 data management organisations, 5 state and territory government departments of health, 2 Aboriginal and Torres Strait Islander advising organisations and 28 stakeholders representing public and private health sectors across Australia participated in consultations. 123 ED experts (including lived experience) participated in the first quantitative round of the Delphi survey. Retention was high, with 80% of experts continuing to the second round and 73% to the third.

MAIN OUTCOME MEASURES

Items and categories endorsed by the expert panel (defined a priori as >85% rating an item or category 'very important' or 'imperative').

RESULTS

High consensus across dataset items and categories led to the stratification of an identified MDS. Medical status and quality of life were rated the most important outcomes to collect in an MDS. Other items meeting high levels of consensus included anxiety disorders, depression and suicidality; type of treatment being received; body mass index and recent weight change.

CONCLUSIONS

Understanding presentation to and outcomes from ED treatment is vital to drive improvements in healthcare delivery. A nationally agreed MDS has been defined to facilitate this understanding and support improvements.

Public perceptions of people with eating disorders: Commentary on results from the 2022 Australian national survey of mental health-related stigma and discrimination

Mental illness is highly prevalent in the community. As such, significant attention has been paid in recent years to raising awareness of the mental health disorders (including eating disorders). This includes efforts to normalise help-seeking, campaigns to reduce stigma and discrimination, targeted research funding and advocacy for improved and accessible mental health service provision. But have these initiatives changed public attitude? The 2022 National Survey of Mental Health-Related Stigma and Discrimination is the first of four national surveys canvassing the general public's perceptions of people with mental health disorders (including stigmatising and discriminatory beliefs) conducted since 1995 to include eating disorders. It finds significant prejudice against those with mental health disorders still exists within the community, particularly among younger Australians. For eating disorders, this is primarily related to attributions of blame and personal weakness. Findings from the survey are discussed in this commentary.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level V, narrative review.

Anorexia nervosa and muscle health: A systematic review of our current understanding and future recommendations for study

OBJECTIVE

Conduct a systematic review on muscle size and strength in individuals with anorexia nervosa (AN).

METHOD

In accordance with PRISMA guidelines, we searched Pubmed for articles published between 1995 and 2022 using a combination of search terms related to AN and muscle size, strength, or metabolism. After two authors screened articles and extracted data, 30 articles met inclusion criteria. Data were coded, and a risk bias was conducted for each study.

RESULTS

The majority of studies focused on muscle size/lean mass (60%, n = 18) and energy expenditure (33%, n = 9), with few studies (17%, n = 5) investigating muscle function or possible mechanisms underlying muscle size (20%, n = 6). Studies supported that individuals with AN have smaller muscle size and reduced energy expenditure relative to controls. In some studies (33%, n = 10) recovery from AN was not sufficient to restore muscle mass or function. Mechanisms underlying short and long-term musculoskeletal alterations have not been thoroughly explored.

DISCUSSION

Muscle mass and strength loss may be an unexplored component of physiological deterioration during and after AN. More research is necessary to understand intramuscular alterations during AN and interventions to facilitate muscle mass and functional gain following weight restoration in AN.

PUBLIC SIGNIFICANCE

Muscle health is important for optimal health and is reduced in individuals with AN. However, we do not understand how muscle is altered at the cellular level throughout the course of AN. Here we review what is currently known regarding muscle health during AN and with weight restoration.

Risk factors for eating disorders: findings from a rapid review

BACKGROUND

Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders.

METHODS

The current review forms part of a series of Rapid Reviews to be published in a special issue in the Journal of Eating Disorders, funded by the Australian Government to inform the development of the National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2021, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, or population studies). Data pertaining to risk factors for eating disorders were synthesised and outlined in the current paper.

RESULTS

A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms.

CONCLUSION

Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.

Sizing up the crowd: Assessing spatial integration difficulties in body size judgements across eating disorder symptomatology

Introduction

Body size judgements are frequently biased, or inaccurate, and these errors are further exaggerated for individuals with eating disorders. Within the eating disorder literature, it has been suggested that exaggerated errors in body size judgements are due to difficulties with integration. Across two experiments, we developed a novel integration task, named the Ebbinghaus Illusion for Bodies in Virtual Reality (VR), to assess whether nearby bodies influence the perceived size of a single body. VR was used to simulate the appearance of a small crowd around a central target body.

Method and Results

In Experiment 1 (N = 412), participants were required to judge the size of a central female target within a crowd. Experiment 1 revealed an Ebbinghaus Illusion, in which a central female appeared larger when surrounded by small distractors, but comparatively smaller when surrounded by large distractors. In other words, the findings of Experiment 1 demonstrate that surrounding crowd information is integrated when judging an individual's body size; a novel measure of spatial integration (i.e., an Ebbinghaus Illusion for Bodies in VR). In Experiment 2 (N = 96), female participants were selected based on high (n = 43) and low (n = 53) eating disorder symptomatology. We examined whether the magnitude of this illusion would differ amongst those with elevated versus low eating disorder symptomatology, in accordance with weak central coherence theory, with the high symptomatology group displaying less spatial integration relative to the low group. The results of Experiment 2 similarly found an Ebbinghaus Illusion for Bodies in VR. However, illusion magnitude did not vary across high and low symptomatology groups.

Discussion

Overall, these findings demonstrate that surrounding crowd information is integrated when judging individual body size; however, those with elevated eating disorder symptomatology did not show any integration deficit on this broader measure of spatial integration.

'It makes you not want to eat': Perceptions of anti-obesity public health campaigns in individuals diagnosed with an eating disorder

OBJECTIVE

Recent research has highlighted the potentially deleterious effects of anti-obesity public health campaigns on vulnerable audiences such as those at risk of, or diagnosed with, eating disorders (ED). The qualitative experiences of campaigns in this population group have been little explored.

METHODS

Twelve interviews were conducted with participants either currently or previously diagnosed with an ED using the Interpretative Phenomenological Analysis approach. Participants were shown a series of real-world public health campaigns and, using a semi-structured interview guide, asked about their responses to the images used.

RESULTS

Several themes emerged from the data, including the effect of campaigns on participants, perceived effect on others, and general campaign attributes. It was evident that participants felt that anti-obesity campaigns had the potential to confirm ED thoughts and behaviours, and could act as potential triggers. Participants also felt that they could impact vulnerable groups (e.g., young audiences) and stigmatise those living in larger bodies.

CONCLUSION

Campaigns addressing overweight and obesity should consider reframing these conditions and care must be taken to avoid causing potential harm to vulnerable audiences.

Considerations in Evidence-Based Treatment of Adolescents With Atypical Anorexia Nervosa

There is emerging evidence suggesting atypical anorexia nervosa (AAN), an eating disorder (ED) introduced in the DSM-5, is as serious an ED as anorexia nervosa (AN) in terms of medical risk and ED pathology. Medical hospitalizations among individuals with AAN have significantly increased over the years and individuals with AAN are noted to have longer illness durations and greater weight loss prior to receiving care than individuals with AN. Additionally, AAN is noted to be two to three times more common than AN in community samples of adolescents. Given that AAN is a newer diagnosis, research knowledge and evidence-based treatment guidelines are emerging, yet pivotal. Thus, this article discusses specific considerations during assessment and treatment using Family Based Treatment (FBT) among adolescents diagnosed with AAN and clinical and ethical concerns involved while providing effective care and mitigating any weight bias or stigma related to historical and current weight status.

Integrating clinician and patient case conceptualization with momentary assessment data to construct idiographic networks: Moving toward personalized treatment for eating disorders

Eating disorders are serious psychiatric illnesses with treatments ineffective for about 50% of individuals due to high heterogeneity of symptom presentation even within the same diagnoses, a lack of personalized treatments to address this heterogeneity, and the fact that clinicians are left to rely upon their own judgment to decide how to personalize treatment. Idiographic (personalized) networks can be estimated from ecological momentary assessment data, and have been used to investigate central symptoms, which are theorized to be fruitful treatment targets. However, both efficacy of treatment target selection and implementation with 'real world' clinicians could be maximized if clinician input is integrated into such networks. An emerging line of research is therefore proposing to integrate case conceptualizations and statistical routines, tying together the benefits from clinical expertise as well as patient experience and idiographic networks. The current pilot compares personalized treatment implications from different approaches to constructing idiographic networks. For two patients with a diagnosis of anorexia nervosa, we compared idiographic networks 1) based on the case conceptualization from clinician and patient, 2) estimated from patient EMA data (the current default in the literature), and 3) based on a combination of case conceptualization and patient EMA data networks, drawing on informative priors in Bayesian inference. Centrality-based treatment recommendations differed to varying extent between these approaches for patients. We discuss implications from these findings, as well as how these models may inform clinical practice by pairing evidence-based treatments with identified treatment targets.

Models of care for eating disorders: findings from a rapid review

BACKGROUND

Delayed diagnosis, gaps in services and subsequent delays in specialist care and treatment lead to poorer health outcomes for individuals with eating disorders (EDs) and drive significant government healthcare expenditure. Given the significant disease burden associated with EDs, it is imperative that current implementation research is summarised to identify gaps in care and enable refinement for optimal patient outcomes. This review aimed to provide an updated synthesis on models of care for EDs in developed healthcare systems.

METHODS

This paper was conducted as part of a series of Rapid Reviews (RRs) to be published in a special series in the Journal of Eating Disorders. To provide a current and rigorous review, peer-reviewed articles published in the English language between 2009 and 2021 across three databases (ScienceDirect, PubMed and Ovid/Medline) were searched, with priority given to higher level evidence (e.g., meta-analyses, large population studies, Randomised Control Trials (RCTs)). The current review synthesises data from included studies investigating models of care for people with EDs.

RESULTS

Sixty-three studies (4.5% of the original RR) were identified, which included several diagnostic populations, the most common being Anorexia Nervosa (AN) (30.51%). Across EDs, specialist care was found to improve patient outcomes, with many patients effectively being treated in outpatient or day programs with multi-disciplinary teams, without the need for lengthy inpatient hospitalisation. Few studies investigated the interaction of different ED services (e.g., inpatient, community services, primary care), however stepped care models emerged as a promising approach to integrate ED services in a targeted and cost-effective way. Issues surrounding low treatment uptake, underdiagnosis, long waiting lists and limited hospital beds were also evident across services.

CONCLUSION

Findings suggested further research into alternatives to traditional inpatient care is needed, with partial and shorter 'hospitalisations' emerging as promising avenues. Additionally, to tackle ongoing resource issues and ensure timely detection and treatment of EDs, further research into novel alternatives, such as active waiting lists or a greater role for primary care clinicians is needed. This paper is part of a larger Rapid Review series carried out to guide Australia's National Eating Disorders Research and Translation Strategy 2021-2031. Rapid reviews aim to thoroughly summarise an area of research over a short time period, typically to help with policymaking in this area. This Rapid Review summarises the evidence relating to how we care for people with eating disorders in Western healthcare systems. Topics covered include inpatient/hospital care, residential care, day programs, outpatient/community care, and referral pathways. Findings suggested specialist eating disorder services may enhance detection, referral, and patient care. Stepped care models presented as a cost-effective approach which may help with linkage between different eating disorder services. There was a trend towards shorter hospital stays and approaches which allow for greater connection with the community, such as day programs. Evidence was also found of treatment delays, due to system issues (long waiting lists, lack of accurate assessment and diagnosis) and patient-related barriers (stigma, recognition). Upskilling and involving primary care clinicians in diagnosis and referral as part of a stepped care model may help to address some of these concerns. Further efforts to improve mental health literacy and de-stigmatise help-seeking for eating disorders are needed.

A century of research on psychedelics: A scientometric analysis on trends and knowledge maps of hallucinogens, entactogens, entheogens and dissociative drugs

A scientometric analysis was realized to outline clinical research on psychedelics over the last century. Web of Science Core Collection was searched up to March 18, 2022, for publications on psychedelics. Network analyses and bibliometrics were combined, to identify research themes and trends with Bibliometrix and CiteSpace. The primary aim was to measure research trends evolution over time, and the secondary aims were to identify bibliometric performance and influence networks of publications, authors, institutions, and countries. Sensitivity analyses were conducted for 2016-2022, and 2021 time periods. We included 31,687 documents (591,329 references), which aggregated into a well-structured network with credible clustering. Research productivity was split into an early less productive period mainly focusing on safety issues, and a "psychedelic renaissance" after the 1990s. Major trends were identified for hallucinogens/entheogens, entactogens, novel psychoactive substances (NPS), and on dissociative substances. There was a translational evolution from the bench to the bedside, with phase 2 and 3 trials and/or evidence synthesis in particular. The most recent trends concerned NPS, ketamine-associated brain changes, and ayahuasca-assisted psychotherapy. The USA and Canada were the most productive settings for the research overall, and more recently this geographical distribution became more prominent, reflecting legislative context/policy making. A translational evolution of psychedelics has been occurring, that has brought approval of esketamine for depression and will likely lead to approval of additional psychedelics across mental and physical conditions. Toxicology screening tools for NPS are urgently needed, which in turn might follow the same translational evolution of psychedelics in the future.