Treatment outcomes for anorexia nervosa: a systematic review and meta-analysis of randomized controlled trials

Effectiveness of the Maudsley Model of Anorexia Nervosa Treatment for Adults: A systematic review

BACKGROUND

Maudsley Model of Anorexia nervosa (AN) Treatment for Adults (MANTRA) is recommended by NICE for the treatment of adults with AN. However, despite this fact, the approach remains relatively understudied. The aim of this study was to systematically update the research evidence regarding the use of the MANTRA in the treatment of Eating Disorders (ED).

METHOD

The databases used were Web of Science, Scopus, and PsycInfo, including studies up to 31 May 2023. PRISMA guidelines were followed, and Cochrane tools were used to assess the risk of bias. The search focused on identifying published articles that discussed the usefulness of MANTRA as a component of treatment for ED, following PICO criteria.

RESULTS

Nine studies spanning the period from 2011 to 2023 were included. Findings suggested that MANTRA was effective in improving body mass index (BMI), eating symptomatology and emotional state. There were generally no significant differences compared to other treatment conditions. Limitations to interpreting this systematic review include the methodological quality of included studies and the elevated risk of bias.

CONCLUSIONS

This review was the first to examine the effectiveness of MANTRA. The results indicate that MANTRA has shown effectiveness similar to other treatments for adults AN patients in addressing key clinical variables. It has been used in different populations (adolescents, males, inpatients) and formats (group, online) However, more research is needed to determine its effectiveness.

Assessing midbrain neuromelanin and its relationship to reward learning in anorexia nervosa: Stage 1 of a registered report

INTRODUCTION

Anorexia nervosa (AN) is a debilitating and potentially chronic eating disorder, characterized by low hedonic drive toward food, which has been linked with perturbations in both reward processing and dopaminergic activity. Neuromelanin-sensitive magnetic resonance imaging (MRI) is an emerging method to index midbrain neuromelanin-a by-product of dopaminergic synthesis. The assessment of midbrain neuromelanin, and its association with AN psychopathology and reward-related processes, may provide critical insights into reward circuit function in AN.

METHODS

This study will incorporate neuromelanin-sensitive MRI into an existing study of appetitive conditioning in those with AN. Specifically, those with acute and underweight AN (N = 30), those with weight-restored AN (N = 30), and age-matched healthy controls (N = 30) will undergo clinical assessment of current and previous psychopathology, in addition to structural neuromelanin-sensitive MRI, diffusion MRI, and functional MRI (fMRI) during appetitive conditioning.

CONCLUSION

This study will be among the first to interrogate midbrain neuromelanin in AN-a disorder characterized by altered dopaminergic activity. Results will help establish whether abnormalities in the midbrain synthesis of dopamine are evident in those with AN and are associated with symptomatic behavior and reduced ability to experience pleasure and reward.

The efficacy of transcranial direct current stimulation in the treatment of anorexia nervosa: a randomized double-blind clinical trial

Background

Anorexia nervosa (AN) is a life-threatening disease with a low effectiveness of treatment. The high relapse and mortality rate indicate new treatment approaches are needed. Here, we represent the protocol for randomized clinical trial (RCT) of transcranial direct current stimulation (tDCS) efficiency in the AN treatment. The main purpose of the 3-week RCT is to determine the effect of tDCS on the mental state and advances in nutritional rehabilitation in patients with AN.

Methods

50 female inpatients (13-25 years old, body mass index (BMI) 17.5 kg/m2 or less) will be randomly allocated into groups: active (n=25) and sham (n=25) tDCS. Thirty 25-minute tDCS sessions (applied current at 2mA) will be given to DLPFC (F3 anode/F4 cathode) twice a day for 3 weeks on working days parallel to treatment as usual. The primary outcome measures include changes in symptoms related to eating disorders, as assessed by the Eating Attitudes Test (EAT-26), following tDCS sessions over a 3-week trial period. The secondary outcome measures include changes in: brain bioelectric activity, anthropometric measurements, mood, nutritional status, neurocognition, psychological symptoms, selected biological markers related to stress, food intake, inflammation and neurotrophins.

Discussion

This paper describes the evaluation of a 3-week tDCS-based intervention for AN patients. The study design was developed by a multidisciplinary research team to assess the treatment effect, taking into account various types of variables. This approach could help in better understanding the potential therapeutic tDCS strategy in AN.

Clinical trial registration

www.ClinicalTrials.gov, identifier NCT05814458.

Testing the role of associative learning in evidence-based treatments for anorexia nervosa

Treatments for anorexia nervosa (AN) remain ineffective for many patients. Processes that can account for differential treatment outcomes remain mostly unknown. We propose that the field test the role of associative learning in current psychological treatments. We hold that this line of research could yield actionable information for understanding non-response and improving long-term outcomes. To make this argument, we define associative learning and outline its proposed role in understanding psychiatric disorders and their treatment. We then briefly review data exploring associative learning in AN. We argue that associative learning processes are implicitly implicated in existing treatments; by this rationale, baseline differences in learning may interfere with treatment response. Finally, we outline future research to test our hypotheses. Altogether, future research aimed at better understanding how associative learning may contribute to AN symptom persistence has the potential to inform novel directions in intervention research. PUBLIC SIGNIFICANCE: There is a pressing need to improve outcomes in treatments for anorexia nervosa (AN). We propose that individual differences in associative learning-the ability to form and update associations between cues, contexts, behaviors, and outcomes-may account for differential response to existing treatments. Undertaking this research could provide an understanding of how current treatments work and inform new approaches for those who may be at risk of poor outcomes.

Psilocybin therapy and anorexia nervosa: a narrative review of safety considerations for researchers and clinicians

BACKGROUND

Clinical trials using psilocybin therapy to treat anorexia nervosa (AN) are currently underway. The safety and tolerability of psilocybin is of utmost importance in individuals with AN who may present unique medical vulnerabilities. The purpose of this review is to describe how the common physiologic adverse effects of psilocybin may impact medical complications experienced by individuals with AN in clinical trials of psilocybin therapy.

MAIN BODY

The physiologic underpinnings of common adverse effects following psilocybin administration are described, including tachycardia, hypertension, electrocardiogram changes, nausea, headache, and lightheadedness. These anticipated physiologic changes are described in relation to the common medical correlates seen in individuals with AN. Risk mitigation strategies for each adverse effect are proposed.

CONCLUSION

Early evidence suggests that psilocybin therapy is well-tolerated in individuals with AN. Understanding the unique medical complications of AN, and how they may be impacted by common physiologic adverse effects of psilocybin administration, leads to tailored risk mitigation strategies to enhance safety and tolerability of this novel intervention.

Cognitive Impulsivity in Anorexia Nervosa in Correlation with Eating and Obsessive Symptoms: A Comparison with Healthy Controls

Impulsivity in eating disorders (ED) has been historically focused on bingeing-purging symptoms, evidencing lower levels in restricting subtypes. In the recent literature, obsessive-compulsive disorder (OCD) has been described as characterized by high cognitive impulsivity. This specific impulsivity factor has been rarely studied in anorexia nervosa (AN). In this study, 53 inpatients with anorexia nervosa and 59 healthy controls completed the following questionnaires: the Barratt Impulsiveness Scale (BIS-11), the Obsessive-Compulsive Inventory (OCI), the Eating Disorders Inventory-2 (EDI-2), the State-Trait Anxiety Inventory (STAI), and the Beck Depression Inventory (BDI). AN individuals showed significantly increased levels of cognitive instability but no difference in global score and other subscales of impulsivity compared to the healthy controls. Among AN individuals, cognitive instability emerged as being associated with the global score and obsession subscale of the OCI. It was also significantly associated with interoceptive awareness and impulse regulation. Cognitive instability was the main predictor of obsessive thoughts and behaviors in AN. Our study supports the hypothesis of AN as being characterized by high cognitive instability and adds the result that the cognitive domain of impulsivity may be associated with the presence of obsessive symptoms, specifically obsessive thoughts.

Change in food choice during acute treatment and the effect on longer-term outcome in patients with anorexia nervosa

BACKGROUND

Restriction of food intake is a central pathological feature of anorexia nervosa (AN). Maladaptive eating behavior and, specifically, limited intake of calorie-dense foods are resistant to change and contribute to poor long-term outcomes. This study is a preliminary examination of whether change in food choices during inpatient treatment is related to longer-term clinical course.

METHODS

Individuals with AN completed a computerized Food Choice Task at the beginning and end of inpatient treatment to determine changes in high-fat and self-controlled food choices. Linear regression and longitudinal analyses tested whether change in task behavior predicted short-term outcome (body mass index [BMI] at discharge) and longer-term outcome (BMI and eating disorder psychopathology).

RESULTS

Among 88 patients with AN, BMI improved significantly with hospital treatment (p < 0.001), but Food Choice Task outcomes did not change significantly. Change in high-fat and self-controlled choices was not associated with BMI at discharge (r = 0.13, p = 0.22 and r = 0.10, p = 0.39, respectively). An increase in the proportion of high-fat foods selected (β = 0.91, p = 0.02) and a decrease in the use of self-control (β = -1.50, p = 0.001) predicted less decline in BMI over 3 years after discharge.

CONCLUSIONS

Short-term treatment is associated with improvement in BMI but with no significant change, on average, in choices made in a task known to predict actual eating. However, the degree to which individuals increased high-fat choices during treatment and decreased the use of self-control over food choice were associated with reduced weight loss over the following 3 years, underscoring the need to focus on changing eating behavior in treatment of AN.

Differentiation between atypical anorexia nervosa and anorexia nervosa using machine learning

OBJECTIVE

Body mass index (BMI) is the primary criterion differentiating anorexia nervosa (AN) and atypical anorexia nervosa despite prior literature indicating few differences between disorders. Machine learning (ML) classification provides us an efficient means of accurately distinguishing between two meaningful classes given any number of features. The aim of the present study was to determine if ML algorithms can accurately distinguish AN and atypical AN given an ensemble of features excluding BMI, and if not, if the inclusion of BMI enables ML to accurately classify between the two.

METHODS

Using an aggregate sample from seven studies consisting of individuals with AN and atypical AN who completed baseline questionnaires (N = 448), we used logistic regression, decision tree, and random forest ML classification models each trained on two datasets, one containing demographic, eating disorder, and comorbid features without BMI, and one retaining all features and BMI.

RESULTS

Model performance for all algorithms trained with BMI as a feature was deemed acceptable (mean accuracy = 74.98%, mean area under the receiving operating characteristics curve [AUC] = 74.75%), whereas model performance diminished without BMI (mean accuracy = 59.37%, mean AUC = 59.98%).

DISCUSSION

Model performance was acceptable, but not strong, if BMI was included as a feature; no other features meaningfully improved classification. When BMI was excluded, ML algorithms performed poorly at classifying cases of AN and atypical AN when considering other demographic and clinical characteristics. Results suggest a reconceptualization of atypical AN should be considered.

PUBLIC SIGNIFICANCE

There is a growing debate about the differences between anorexia nervosa and atypical anorexia nervosa as their diagnostic differentiation relies on BMI despite being similar otherwise. We aimed to see if machine learning could distinguish between the two disorders and found accurate classification only if BMI was used as a feature. This finding calls into question the need to differentiate between the two disorders.

Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with atypical anorexia nervosa

OBJECTIVE

The StRONG trial demonstrated the safety and efficacy of higher calorie refeeding (HCR) in hospitalized adolescents and young adults with malnutrition secondary to restrictive eating disorders. Here we compare refeeding outcomes in patients with atypical anorexia nervosa (atypical AN) versus anorexia nervosa (AN) and examine the impact of caloric dose.

METHOD

Patients were enrolled upon admission and randomized to meal-based HCR, beginning 2000 kcal/day and advancing 200 kcal/day, or lower calorie refeeding (LCR), beginning 1400 kcal/day and advancing 200 kcal every other day. Atypical AN was defined as %median BMI (mBMI) > 85. Independent t-tests compared groups; multivariable linear and logistic regressions examined caloric dose (kcal/kg body weight).

RESULTS

Among n = 111, mean ± SD age was 16.5 ± 2.5 yrs; 43% had atypical AN. Compared to AN, atypical AN had slower heart rate restoration (8.7 ± 4.0 days vs. 6.5 ± 3.9 days, p = .008, Cohen's d = -.56), less weight gain (3.1 ± 5.9%mBMI vs. 5.4 ± 2.9%mBMI, p < .001, Cohen's d = .51) and greater hypomagnesemia (29% vs. 11%, p = .03, OR = 3.29). These suboptimal outcomes were predicted by insufficient caloric dose (32.4 ± 6.9 kcal/kg in atypical AN vs. 43.4 ± 9.8 kcal/kg in AN, p < .001, Cohen's d = 1.27). For every 10 kcal/kg increase, heart rate was restored 1.7 days (1.0, 2.5) faster (p < .001), weight gain was 1.6%mBMI (.8, 2.4) greater (p < .001), and hypomagnesemia odds were 70% (12, 128) lower (p = .02).

DISCUSSION

Although HCR is more efficacious than LCR for refeeding in AN, it contributes to underfeeding in atypical AN by providing an insufficient caloric dose relative to the greater body weight in this diagnostic group.

PUBLIC SIGNIFICANCE

The StRONG trial previously demonstrated the efficacy and safety of higher calorie refeeding in patients with malnutrition due to restrictive eating disorders. Here we show that higher calorie refeeding contributes to underfeeding in patients with atypical anorexia nervosa, including poor weight gain and longer time to restore medical stability. These findings indicate these patients need more calories to support nutritional rehabilitation in hospital.

Family Meals and Social Eating Behavior and Their Association with Disordered Eating among Spanish Adolescents: The EHDLA Study

PURPOSE

The aim of this study was to examine the association of family meals and social eating behavior with disordered eating behavior in Spanish adolescents.

METHODS

This was a cross-sectional study that included 706 adolescents (43.9% boys) from the Eating Habits and Daily Life Activities (EHDLA) study (aged 12 to 17) from Valle de Ricote, Region of Murcia, Spain. The frequency of family meals was assessed by asking participants to report how often their family, or most household members, had shared meals in the past week. Social eating behavior was evaluated using three statements: "I enjoy sitting down with family or friends for a meal", "Having at least one meal a day with others (family or friends) is important to me", and "I usually have dinner with others". To evaluate disordered eating, two psychologists administered the Sick, Control, One, Fat and Food (SCOFF) questionnaire.

RESULTS

After adjusting for several covariates, for each additional family meal, the likelihood of having disordered eating behavior was lower (odds ratio (OR) = 0.96; 95% confidence interval (CI) 0.93 to 0.9997, p = 0.049). On the other hand, a lower likelihood of having disordered eating behavior was observed for each additional point in the social eating behavior scale (OR = 0.85; 95% CI 0.77 to 0.93, p = 0.001). The likelihood of having disordered eating behavior was 0.7% lower for each additional family meal (95% CI 0.01% to 1.4%, p = 0.046). Furthermore, for each additional point in the social eating behavior scale, a lower probability of having disordered eating behavior was observed (3.2%; 95% CI 1.4% to 5.0%, p < 0.001).

CONCLUSIONS

While disordered eating behavior is complex and can be shaped by various factors, both family meals and social eating behavior emerge as significant factors inversely associated with this condition among adolescents. Promoting regular engagement in family meals and fostering positive social eating experiences could serve as effective strategies in public health initiatives aimed at mitigating the incidence of disordered eating behavior among the young population.

Facing Eating Disorder Fears: An Open Trial Adapting Prolonged Exposure to the Treatment of Eating Disorders

Eating disorders (EDs) are maintained by core fears, which lead to avoidance behaviors, such as food avoidance or compensatory behaviors. Previously tested exposure-based treatments for EDs have generally focused on proximal outcomes (e.g., food), rather than addressing core fears (e.g., fear of weight gain and its consequences). The current study tested the feasibility and initial clinical efficacy of 10 sessions of imaginal and in vivo exposure for core ED fears (termed "Facing Eating Disorder Fears"), mainly fear of weight gain and its associated consequences. Participants were 36 adults with anorexia nervosa (AN), bulimia nervosa, or other specified feeding and eating disorders determined by semistructured diagnostic interviews. ED symptoms, fears, and body mass index (BMI) were assessed at pretreatment, posttreatment, and 1-month follow-up. Treatment involved 10 sessions of imaginal and in vivo exposure to ED fears in combination with in vivo exposures to feared and avoided situations as homework. ED symptoms and fears decreased from pre- to posttreatment and at 1-month follow-up. BMI increased significantly from pre- to posttreatment, particularly for those with AN. Effect sizes ranged from small to very large. ED symptoms and fears decreased and BMI increased following exposure. Increases in BMI occurred without any direct intervention on eating, suggesting that weight gain can be achieved without a specific focus on food during ED treatment. Facing Eating Disorder Fears may be a feasible stand-alone intervention for EDs. Future research must test comparative efficacy through randomized controlled trials.

A multi-modal assessment of fear conditioning in adolescent anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a pernicious psychiatric disorder which is principally characterized by a fear of weight gain. Notwithstanding the centrality of fear in the psychopathology of AN, controlled assessments of negative valence systems are lacking. Herein we assess fear conditioning in adolescent females with AN.

METHOD

Adolescent girls (Mage  = 14.6 years, ±1.57) with DSM-5 diagnoses of AN (N = 25) and age-matched control girls (Mage  = 14.8 years, ±1.46) with no DSM-5 diagnoses (N = 25) completed structured clinical interviews and participated in a classical three-phase Pavlovian fear conditioning paradigm. Participants with comorbid anxiety disorders were excluded. Skin conductance response (SCR) was measured, alongside self-reported fear, valence, and fear expectancy ratings.

RESULTS

Both groups demonstrated significant differential acquisition across all four measures. Regarding group comparisons, no differences emerged for self-reported fear, valence, and fear expectancy ratings during acquisition, although for SCR, those with AN demonstrated reduced physiological arousal relative to controls. Both groups demonstrated significant differential extinction for unconditioned stimuli (US) expectancy, self-report fear, and self-report valence. No statistically significant group differences were evident during extinction to the conditioned stimuli (CS)+, on any outcome measure. However, controls reported more positive valence to the CS- than those with AN.

CONCLUSIONS

Contrary to our hypotheses, our preliminary assessment did not find support for elevated fear responding among adolescent girls with AN with regards to fear acquisition or extinction. These data suggest that AN in adolescent girls may not be associated with a heightened propensity to acquire fear, but conversely, may suggest that exposure treatments for AN may be helpful, since extinction learning is intact in AN.

PUBLIC SIGNIFICANCE

AN is characterized by fear-related symptoms, including food and weight-related fear, and behavioral avoidance, yet controlled studies assessing fear learning are limited. Our preliminary assessment of adolescent AN indicates no abnormalities in fear learning among adolescents with AN. These findings may inform existing mechanistic models of AN psychopathology, and the development of exposure-based treatments for AN.

The Efficacy of Cognitive Remediation Therapy for Anorexia Nervosa: A Systematic Review of Systematic Reviews

BACKGROUND

Cognitive remediation therapy (CRT) for anorexia nervosa (AN) is an intervention specifically focused on addressing cognitive difficulties associated with the eating disorder. This systematic review of systematic reviews and meta-analysis aimed to provide a summary of the existing literature examining the efficacy of CRT in improving the neuropsychological, psychological, and clinical parameters of patients with AN.

METHODS

Systematic reviews and meta-analyses were sought in electronic databases, encompassing studies that explored the impact of CRT on AN. Three eligible reviews were identified based on the inclusion criteria. The Revised Assessment of Multiple SysTemAtic Reviews (R-AMSTAR) was employed to evaluate the methodological quality of the reviews, and all included reviews demonstrated satisfactory methodological quality with an R-AMSTAR score of ≥22. Relevant information was extracted from each review and qualitatively compiled.

RESULTS

Findings suggest that CRT can help people increase their awareness of cognitive styles and information processing and have a positive effect on patients' responses to treatment.

CONCLUSIONS

Further research is required to better understand its impact on other relevant outcomes, including psychological variables, to optimize the treatment's benefits.

'Physically it was fine, I'd eat what normal people do. But it's never like this in my head': A qualitative diary study of daily experiences of life in recovery from an eating disorder

OBJECTIVE

High eating disorder (ED) relapse rates stress the need for clearer understanding around how recovery is experienced and maintained. Recent research endorses the concept of recovery as a process rather than an endpoint. This study aimed to investigate daily experiences of living in recovery from an ED.

METHOD

Fourteen participants who self-identified as recovered from a formally diagnosed ED were recruited online. A qualitative diary app was used for data collection. Participants completed written or audio open-ended diary entries every other day for 2 weeks describing their experiences, thoughts, and feelings. Diaries were analysed using reflexive thematic analysis.

RESULTS

Four themes were developed. 'Ever-present eating disordered thoughts' highlights how pervasive these thoughts remain for participants. 'Impact of social discourses' unpacks the challenges of maintaining recovery while surrounded by unhelpful social discourses about food and body image. 'Recovery is precarious' highlights how a combination of stressors can build up to threaten recovery. 'Finding balance in recovery' illustrates the many ways participants try to manage their recovery each day.

CONCLUSIONS

The findings make it clear that living in recovery from an ED is a complex process that must be navigated daily. Recommendations for treatment and recovery support are discussed.

Targeting intolerance of uncertainty in treatment: A meta-analysis of therapeutic effects, treatment moderators, and underlying mechanisms

OBJECTIVE

Anxiety-related disorders are among the most prevalent psychiatric conditions and cause significant impairment. Intolerance of uncertainty (IU) contributes to the emergence, maintenance, and symptom severity of anxiety-related disorders, yet information regarding treatment-related changes in IU is limited. This systematic review and meta-analysis examined the efficacy of evidence-based treatments for anxiety-related disorders on IU, explored factors moderating treatment effects of IU, and examined whether therapeutic improvement in IU corresponded with improvements in anxiety symptom severity.

METHODS

PubMED and PsycINFO were searched for randomized controlled trials (RCTs) using the terms "intolerance of uncertainty" AND "treatment" OR "therapy." Data for pre and post-treatment measures and patient, intervention, and trial-level characteristics were extracted from 28 RCTs. Separate random effects models examined the treatment efficacy of interventions on IU and symptom severity. Moderators of therapeutic effects were analyzed via method-of-moments meta-regression or an analog to the analysis of variance.

RESULTS

Across RCTs, interventions exhibited a large therapeutic effect on IU compared to control conditions (g = 0.89). Treatment effects on IU positively corresponded with improved symptom severity and accounted for 36 % of the variance. Interestingly, comorbid depression and certain treatment approaches were associated with larger improvements in IU.

CONCLUSION

Evidence-based treatments are effective in improving IU, highlighting the importance of IU in the treatment of anxiety-related disorders. Moderator analyses identified patient and intervention-level factors to inform approaches to improve therapeutic effects on IU. Future research is needed to optimize interventions targeting IU and evaluate long-term efficacy of interventions on IU for anxiety-related disorders.

Challenges and priorities for researching the gut microbiota in individuals living with anorexia nervosa

OBJECTIVE

The gut microbiota is implicated in several symptoms and biological pathways relevant to anorexia nervosa (AN). Investigations into the role of the gut microbiota in AN are growing, with a specific interest in the changes that occur in response to treatment. Findings suggest that microbial species may be associated with some of the symptoms common in AN, such as depression and gastrointestinal disturbances (GID). Therefore, researchers believe the gut microbiota may have therapeutic relevance. Whilst research in this field is rapidly expanding, the unique considerations relevant to conducting gut microbiota research in individuals with AN must be addressed.

METHOD

We provide an overview of the published literature investigating the relationship between the gut microbiota and symptoms and behaviors present in AN, discuss important challenges in gut microbiota research, and offer recommendations for addressing these. We conclude by summarizing research design priorities for the field to move forward.

RESULTS

Several ways exist to reduce participant burden and accommodate challenges when researching the gut microbiota in individuals with AN.

DISCUSSION

Recommendations from this article are foreseen to encourage scientific rigor and thoughtful protocol planning for microbiota research in AN, including ways to reduce participant burden. Employing such methods will contribute to a better understanding of the role of the gut microbiota in AN pathophysiology and treatment.

PUBLIC SIGNIFICANCE

The field of gut microbiota research is rapidly expanding, including the role of the gut microbiota in anorexia nervosa. Thoughtful planning of future research will ensure appropriate data collection for meaningful interpretation while providing a positive experience for the participant. We present current challenges, recommendations for research design and priorities to facilitate the advancement of research in this field.

Novel treatments for anorexia nervosa: Insights from neuroplasticity research

OBJECTIVE

Treatment for anorexia nervosa (AN) remains challenging; there are no approved psychopharmacological interventions and psychotherapeutic strategies have variable efficacy. The investigation of evidence-based treatments has so far been compounded by an underdeveloped understanding into the neurobiological changes associated with the acute stages of AN. There is converging evidence of deficiencies in neuroplasticity in AN.

METHOD

This paper provides an overview of neuroimaging, neuropsychological, molecular and qualitative findings relating to neuroplasticity in AN, translating these findings to the identification of novel biological and psychotherapeutic strategies.

RESULTS

Novel psychopharmacological approaches that may ameliorate deficiencies in neuroplasticity include medications such as ketamine, psilocybin and human recombinant leptin. Anti-inflammatory medications and brain-derived neurotrophic factor mimetics may emerge as potential treatments following further research. Psychotherapeutic strategies that may target neuroplastic deficiencies, as well as having wider effects on identity, include imagery rescripting, memory specificity training, cognitive remediation therapy, exposure therapies, narrative therapies, cultural interventions (e.g. music and arts therapies) and yoga/mindfulness-based interventions.

CONCLUSIONS

Treatments specifically targeted towards mitigating the neurobiological sequalae of AN are warranted, and emerging neurobiological and neuropsychological research utilising longitudinal designs and large sample sizes, as well as initial feasibility studies, are necessitated to bolster translational efforts.

Can you learn to starve yourself? Inducing food avoidance in the laboratory

The restriction of energy intake is a central and persistent symptom of anorexia nervosa. Recent models of the disorder suggest that food restrictions are learned avoidance behaviours, which are acquired and maintained by classical and operant conditioning. The present study aims to test this learning model of food restriction. It investigates whether introducing negative consequences for the intake of tasty high-calorie food and introducing positive consequences for its avoidance can create food avoidance, increase fear of food, and decrease eating desires in healthy individuals. 104 women were randomly assigned to an experimental or control condition and completed an appetitive conditioning and avoidance learning task. While the experimental condition received money after avoiding the tasty high-calorie food item and heard an aversive sound after not avoiding food intake, the control condition never received these consequences. In the extinction phase, reward and punishment discontinued for both conditions. We measured avoidance frequency, mouse movements, fear, eating desires and stimulus liking. Participants in the experimental condition avoided the food more often than controls and showed increased fear, reduced eating desires and less liking for cues associated with food intake. These results support the notion that food avoidance behaviours, reduced eating desires and fear of food can be learned via classical and operant conditioning. Conditioning paradigms might be a useful tool to study the development and maintenance of food restriction in anorexia nervosa.

A systematic review of people's lived experiences of inpatient treatment for anorexia nervosa: living in a "bubble"

BACKGROUND

Treatment for anorexia nervosa (AN) is typically delivered on a continuum of care, starting with outpatient treatment, and moving onto intensive outpatient, day or residential treatment and/or inpatient hospitalisation. However, minimal attention has been afforded to the lived experiences of persons undergoing inpatient treatment for AN. In particular, qualitative literature pertaining to the lived experiences of specialist inpatient or residential treatment of AN remains fragmented and incomplete. The aim of this review was to synthesise current literature exploring patients' lived experiences of residential and inpatient treatment for AN within eating disorder-specific treatment services.

METHODS

Five databases were searched and a qualitative thematic systematic review and meta-synthesis of 11 studies were conducted.

RESULTS

Eleven studies of 159 participants were included. Four meta-themes were constructed from the data: (1) a medical discourse-"I don't think it's individualised here"; (2) restrictive practice-living in a "bubble"; (3) myself, others and "a similar demon"; and (4) I am "not just another anorexic". The data also revealed two cross-cutting themes: (1) more than a single experience; and (2) meaning making and identity.

CONCLUSIONS

These findings highlight the complex and multifaceted nature of the inpatient treatment experience as well as the inherent conflicts in balancing the necessity of medical and psychological intervention with person-centred treatment approaches in the treatment of AN.

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.

Brain-based gene expression of putative risk genes for anorexia nervosa

The etiology of anorexia nervosa (AN) remains elusive. Recent genome-wide association studies identified the first genes liked to AN which reached genome-wide significance, although our understanding of how these genes confer risk remains preliminary. Here, we leverage the Allen Human Brain Atlas to characterize the spatially distributed gene expression patterns of genes linked to AN in the non-disordered human brain, developing whole-brain maps of AN gene expression. We found that genes associated with AN are most expressed in the brain, relative to all other body tissue types, and demonstrate gene-specific expression patterns which extend to cerebellar, temporal and basal ganglia structures in particular. fMRI meta-analyses reveal that AN gene expression maps correspond with functional brain activity involved in processing and anticipating appetitive and aversive cues. Findings offer novel insights around putative mechanisms through which genes associated with AN may confer risk.

Using health administrative data to model associations and predict hospital admissions and length of stay for people with eating disorders

BACKGROUND

Eating disorders are serious mental illnesses requiring a whole of health approach. Routinely collected health administrative data has clinical utility in describing associations and predicting health outcome measures. This study aims to develop models to assess the clinical utility of health administrative data in adult eating disorder emergency presentations and length of stay.

METHODS

Retrospective cohort study on health administrative data in adults with eating disorders from 2014 to 2020 in Sydney Local Health District. Emergency and admitted patient data were collected with all clinically important variables available. Multivariable regression models were analysed to explore associations and to predict admissions and length of stay.

RESULTS

Emergency department modelling describes some clinically important associations such as decreased odds of admission for patients with Bulimia Nervosa compared to Anorexia Nervosa (Odds Ratio [OR] 0.31, 95% Confidence Interval [95%CI] 0.10 to 0.95; p = 0.04). Admitted data included more predictors and therefore further significant associations including an average of 0.96 days increase in length of stay for each additional count of diagnosis/comorbidities (95% Confidence Interval [95% CI] 0.37 to 1.55; p = 0.001) with a valid prediction model (R² = 0.56).

CONCLUSIONS

Health administrative data has clinical utility in adult eating disorders with valid exploratory and predictive models describing associations and predicting admissions and length of stay. Utilising health administrative data this way is an efficient process for assessing impacts of multiple factors on patient care and predicting health care outcomes.

When eating disorder attitudes and cognitions persist after weight restoration: An exploratory examination of non-cognitive responders to family-based treatment for adolescent anorexia nervosa

OBJECTIVE

Family-based treatment (FBT) is a well-established intervention for adolescent anorexia nervosa (AN). Although FBT is efficacious in promoting weight gain and improvements in psychological symptoms, for some adolescents, cognitive/attitudinal recovery lags behind weight gain. This study conducted an exploratory post hoc analysis of outcomes of adolescents who achieved weight gain by the end of FBT but continued to experience elevated psychological symptoms post-treatment.

METHODS

Data were drawn from two randomised controlled trials (RCTs) testing two forms of FBT (conjoint/whole family and parent-focussed). Descriptive statistics and generalised estimating equations were used to examine differences in treatment outcomes between non-cognitive responders (NCRs) (those who regained weight but continued to experience psychological symptoms) and full responders (FRs) (those who achieved both weight and cognitive restoration by the end of treatment) (n = 80; 83.7% female, Agemean [SD] = 14.66 [1.73]).

RESULTS

By 12 months post-treatment, there were no differences in weight between NCRs and FRs. However, NCRs had a slower trajectory of weight gain than FRs and continued to have elevated levels of psychological symptoms throughout the follow-up period.

CONCLUSIONS

A subset of adolescents appear to continue to experience clinically significant levels of eating pathology up to 12 months after FBT even when weight restoration is achieved.

More than an outcome: a person-centered, ecological framework for eating disorder recovery

BACKGROUND

Eating disorder recovery is a complex phenomenon. While historical understandings focused on weight and behaviours, the importance of psychological factors is now widely recognized. It is also generally accepted that recovery is a non-linear process and is impacted by external factors. Recent research suggests a significant impact of systems of oppression, though these have not yet been named in models of recovery. BODY: In this paper, we propose a research-informed, person-centered, and ecological framework of recovery. We suggest that there are two foundational tenets of recovery which apply broadly across experiences: recovery is non-linear and ongoing and there is no one way to do recovery. In the context of these tenets, our framework considers individual changes in recovery as determined by and dependent on external/personal factors and broader systems of privilege. Recovery cannot be determined by looking solely at an individual's level of functioning; one must also consider the broader context of their life in which changes are being made. To conclude, we describe the applicability of the proposed framework and offer practical considerations for incorporating this framework in research, clinical, and advocacy settings.

Systematic review: Exploring the monitoring and reporting of unwanted events in psychotherapy trials for anorexia nervosa

OBJECTIVE

If a psychotherapeutic intervention has the capacity to produce positive change, the "deterioration effect" theory holds that it must also have the potential for negative effects. However, the definition, measurement, and reporting of unwanted events in psychotherapy is a topic of ongoing discussion. At present this area is under-explored in interventions for anorexia nervosa (AN), a severe mental illness associated with high medical and psychiatric risks. The aim of this article was to undertake a systematic review of published randomized controlled trials (RCTs) evaluating psychotherapeutic interventions for AN, and to assess how unwanted events were defined, monitored, and reported alongside the trial's key findings.

METHOD

Using a systematic review methodology, this article identified 23 RCTs through database searches meeting eligibility criteria. Results are presented using a narrative summary approach.

RESULTS

Unwanted event reporting varied widely, both regarding definitions of key unwanted events (such as non-compliance or symptom deterioration) and in the amount of detail captured in each paper.

DISCUSSION

The review identified two key issues: firstly, a lack of consistent definitions and unclear causality made it difficult to distinguish between unwanted events, and adverse events caused by the interventions. Secondly, it highlighted the difficulty of defining unwanted events where different studies have different populations and goals. Recommendations are made around how the area of defining, monitoring, and reporting unwanted events in RCTs for AN can be taken forward.

PUBLIC SIGNIFICANCE

Whilst psychotherapies can be effective in treating mental health conditions, negative or unwanted events can sometimes occur. This review explored how RCTs examining psychotherapy for AN report how they monitor the safety of participants, and how they report unwanted events. We found that the reporting was often inconsistent or hard to interpret, and we have made recommendations for how this can be improved in the future.

Eating disorders in young people

OBJECTIVE

Eating disorders (EDs) have their onset most frequently in adolescence and young adulthood. Treatment for EDs lack efficacy, and we have made little progress in improving outcomes for patients over the course of the last several decades. As with other mental health conditions, early intervention may greatly improve outcomes, yet, little research exists in this area.

CONCLUSIONS

More effective evidence-based treatments are sorely needed for EDs, particularly for early stages of the illness to minimise the potential harms of treatment and long-standing illness. Treatment service models would also benefit from taking an approach that ensures continuation of care from adolescence to young adulthood.

Updates in the treatment of Eating Disorders in 2022: a year in review in Eating Disorders: The Journal of Treatment & Prevention

A broad array of important and diverse studies surrounding the treatment of eating disorders were published in Eating Disorders: The Journal of Treatment & Prevention in 2022. Novel interventions such as neurosurgical and neuromodulatory treatments were discussed, as evidence continues to mount around their potential utility in treating eating disorders, in particular namely anorexia nervosa. Important pragmatic and theoretical developments around feeding and refeeding approaches emerged, and are also discussed. In this review, we carefully review evidence alluding to the potential efficacy of exercise in partially ameliorating binge eating disorder symptomatology, while examining broader evidence underscoring the importance of therapeutically ameliorating compulsive exercise in anorexia nervosa and bulimia nervosa. In addition, we overview evidence relating to the risk and sequelae associated with premature discharge from intensive eating disorder treatment, as well as the efficacy of CBT versus group therapy-based maintenance treatments. Finally, important developments around the use of open versus blind weighing in treatment are assessed. Overall, the articles published in Eating Disorders: The Journal of Treatment & Prevention in 2022 evidence the promise of treatment advances in the field and requires further work to address the development of efficacious treatments to achieve greater outcomes for those with eating disorders.

Transdiagnostic fears and avoidance behaviors in self-reported eating disorders

BACKGROUND

Fears and avoidance behaviors are common symptoms of eating disorders. It was investigated whether different eating disorder diagnoses are equally characterized by similar fears and avoidance behaviors.

METHODS

Individuals with self-reported eating disorders (n = 250) and healthy controls (n = 95) completed online questionnaires assessing general fears, eating related fears, and avoidance behaviors.

RESULTS

All self-reported eating disorder diagnoses showed more eating related fears, general fears, and avoidance behaviors than healthy controls. Individuals with binge eating disorder showed less specific and general fears on some but by no means all scales, yet they showed less food avoidance behaviors than all other eating disorders and less eating restraint than anorexia nervosa and bulimia nervosa.

CONCLUSIONS

Eating related fears, general fears, and food avoidance behaviors were found to be transdiagnostic symptoms in self-reported eating disorders. Individuals with binge eating disorder also exhibit more fears and avoidance behaviors than healthy controls, but to a lesser extent than the other eating disorders. Specialized interventions targeting fears and avoidance may be promising add-on interventions not only in the treatment of anorexia nervosa, but in the treatment of all eating disorders.

Learned industriousness as a translational mechanism in anorexia nervosa

It remains unexplained why some behaviours persist despite being non-hedonic and ostensibly aversive. This phenomenon is especially baffling when such behaviours are taken to excess in the form of psychopathology. Anorexia nervosa is one psychiatric disorder in which effortful behaviours that most people find unpleasant (suchas restrictive eating) are persistently performed. We propose thatthe social psychology theory of learned industriousness providesa novel mechanistic account for such phenomena. This theoryposits that high-effort behaviour can be conditioned to acquire secondary reinforcing properties through repeated pairing with reward. Accordingly, effort sensations become less aversive andmore appetitive, increasing willingness to engage in effortful behaviour. In this Perspective, we review pre-clinical behaviouraland biological data that support learned industriousness, contrast learned industriousness with other models of non-hedonic persistence (such as habit learning), highlight evidence that supports learned industriousness in individuals with anorexia nervosa and consider implications of the model, including translation to other psychiatric presentations.

Hair-Based Assessment of Sex Steroid Hormones in Patients with Anorexia Nervosa

Anorexia nervosa (AN) is a complex psychiatric disorder accompanied by a variety of endocrine effects. Altered levels of the sex steroid hormones progesterone and dehydroepiandrosterone (DHEA) have been shown to occur in patients with AN using short-term hormonal measurement methods based on blood, saliva, and urine samples. However, since sex steroid hormone levels fluctuate during the menstrual cycle, these measurement methods require a great deal of effort due to the need to collect multiple samples in order to correctly determine the basal level of sex hormones. In contrast, hair-based assessments provide a marker of accumulated longer-term hormone exposure using a single, non-invasive sample. The aim of this study was to investigate sex steroid hormone levels via hair-based assessments in acutely underweight AN in comparison with healthy, age-matched, female control participants. Additionally, we compared progesterone and DHEA hair levels longitudinally during inpatient treatment in AN. Collected hair samples were analyzed using liquid chromatography-mass spectrometry (LC-MS/MS) to determine a monthly hormone level of progesterone and DHEA. Our results indicate that DHEA hair hormone levels were similar across groups but progesterone was suppressed in underweight AN compared with healthy controls. In the longitudinal design, no significant change in hair hormone levels during partial weight restoration in patients with AN was observed. Our findings suggest that hair analysis can be used to detect suppressed progesterone levels in severe AN, and that progesterone does not increase during short-term weight restoration.

Comparing randomized controlled trials of outpatient family-based or inpatient multimodal treatment followed by outpatient care in youth with anorexia nervosa: Differences in populations, metrics, and outcomes

OBJECTIVE

Various approaches exist to treat youth with anorexia nervosa (AN). Family-based treatment (FBT) has never been compared to long inpatient, multimodal treatment (IMT) in a randomized controlled trial (RCT). The aim of this study was to compare data on body weight trajectories, change in eating disorder psychopathology, hospital days and treatment costs in RCTs delivering FBT or IMT.

METHOD

Review of RCTs published between 2010 and 2020 in youth with AN, delivering FBT or IMT.

RESULTS

Four RCTs delivering FBT (United States, n = 2; Australia, n = 2), one RCT delivering Family Therapy for AN (United Kingdom) and two RCTs delivering IMT (France, n = 1; Germany, n = 1) were identified from previous meta-analyses. The comparison of studies was limited by (1) significant differences in patient baseline characteristics including pretreated versus non-pretreated patients, (2) use of different psychometric and weight measures and (3) different initial velocity of weight recovery. Minimal baseline and outcome reporting standards for body weight metrics and nature/dose of interventions allowing international comparison are needed and suggestions to developing these standards are presented.

DISCUSSION

An RCT should investigate, whether FBT is a viable alternative to IMT, leading to comparable weight and psychopathology improvement with less inpatient time and costs.

The sight of one’s own body: Could qEEG help predict the treatment response in anorexia nervosa?

Aims of the study

The study aims to identify the differences in brain activity between participants with anorexia nervosa and healthy control using visual stimulus conditions combined with the quantitative dense-array EEG recording analysis method called Brain Activation Sequences (BAS).

Materials and methods

23 participants with anorexia nervosa and 21 healthy controls were presented with visual stimuli, including the subject’s facial expressions and body images. The 128-channel EEG data were processed using BAS and displayed as activity in up to 66 brain regions. Subsequent cluster analysis was used to identify groups of participants exhibiting area-specific activation patterns.

Results

Cluster analysis identified three distinct groups: one including all healthy controls (HC) and two consisting of all participants with anorexia (AN-I with 19 participants and AN-II with four participants). The AN-I and AN-II groups differed in their response to treatment. Comparisons of HC vs. AN confirmed the dominance of the right cerebral hemisphere in participants with anorexia nervosa in two of the three reported conditions. The facial expressions condition, specifically the facial reaction expressing disgust, indicates the existence of a social attentional bias toward faces, whereas emotions remained undetected in participants. High limbic activity, medial frontal gyrus involvement, low fusiform cortex activity, and milder visual cortex activity in healthy controls compared to participants indicate that the facial expression stimulus is perceived by healthy subjects primarily as an emotion, not as the face itself. In the body image condition, participants showed higher activity in the fusiform gyrus and right insula, indicating activation of the brain’s “fear network.”

Conclusion

The study describes a specific pattern of brain activation in response to facial expression of disgust and body images that likely contributes to social-cognitive and behavioral impairments in anorexia. In addition, the substantial difference in the pattern of brain activation within the participants with AN and its association with treatment resistance deserves special attention because of its potential to develop a clinically useful prediction tool and identify potential targets for, for example, neuromodulatory treatments and/or individualized psychotherapy.

Implementing service transformation for children and adolescents with eating disorders across England: the theory, politics, and pragmatics of large-scale service reform

BACKGROUND

Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial.

OVERVIEW OF PAPER

This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people.

Phase 2 of family-based treatment: an exploratory assessment of clinician practices

PURPOSE

In manualized family-based treatment (FBT) for eating disorders, phase 1 of the 3-phase treatment-during which parents are put in control of eating-related issues-is perhaps the most critical phase, and is comprehensively addressed in the manual. Phase 2, during which control over eating is gradually returned to the patient, is more variable and the manual dedicates less space to this phase. The purpose of the current exploratory study was to assess Phase 2 practices of clinicians providing FBT and to compare these practices to the guidance offered in the manual.

METHODS

In the current study, a survey assessing Phase 2 practices was sent to clinicians. Twenty-seven providers responded. Two providers reported that they did not provide FBT in an outpatient setting. One reported not currently providing outpatient FBT but had in the past. The remaining providers were currently providing FBT in an outpatient setting.

RESULTS

No items addressing the core interventions of Phase 2, including encouraging age-appropriate independent eating, were endorsed by 100% of respondents as being addressed 100% of the time in Phase 2.

CONCLUSION

Responses reflected some adherence to the manual, along with examples of therapist drift and incorporation of therapeutic interventions that are not described in the FBT manual. Adherence to manualized treatments may improve outcome for some patients, while allowing for flexibility to address clinical situations that are not addressed in the manual.

LEVEL OF EVIDENCE

V. Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

Modified metacognitive therapy for anorexia nervosa: An open trial in an outpatient setting

OBJECTIVE

Current evidence indicates treatment for adults with anorexia nervosa (AN) requires improvement given recovery rates are low to moderate, and relapse rates are high. Metacognitive therapy (MCT) is an effective treatment for anxiety and depressive disorders. This study evaluates if MCT can be successfully modified to treat AN in a naturalistic clinical setting.

METHOD

Twenty-four patients with AN participated in an open trial of modified metacognitive therapy (MCT-AN). Twelve of the 24 patients (50%) completed treatment. MCT was modified to include components specific to eating disorders. The MCT-AN was delivered by clinical psychologists who had undertaken training in MCT in a specialist outpatient service. Group and single participant data analyses were undertaken on those who completed treatment.

RESULTS

As well as statistically significant differences from pre- to posttreatment in the group data there were also clinically significant improvements at the individual patient level for eating disorder and depressive symptoms, as well as weight. The mean number of therapy sessions was 18.

DISCUSSION

These findings indicate that MCT-AN may be a promising intervention in the treatment of AN, warranting further investigation.

PUBLIC SIGNIFICANCE

Treatment for anorexia nervosa in adults requires improvement. Research indicates that Metacognitive therapy (MCT) is an effective treatment for anxiety and depression and may be applicable to the eating disorders. This small open trial suggests that MCT can be modified successfully to treat patients with anorexia nervosa (AN). The results are preliminary and require further research to provide more evidence on the effectiveness of this treatment for AN.

Neural, physiological, and psychological markers of appetitive conditioning in anorexia nervosa: a study protocol

BACKGROUND

Anorexia nervosa (AN) is a chronic and disabling psychiatric condition characterized by low hedonic drive towards food, and is thought to be inclusive of altered dimensions of reward processing. Whether there exists a fundamental aberrancy in the capacity to acquire and maintain de novo hedonic associations-a critical component of hedonic responding-has never been studied in AN.

METHODS

This multi-modal study will employ a 2-day Pavlovian appetitive conditioning paradigm to interrogate the (1) acquisition, (2) extinction, (3) spontaneous recovery and (4) reinstatement of appetitive learning in adolescents and young adults with AN. Participants will be 30 currently ill, underweight individuals with AN; 30 weight-restored individuals with AN; and 30 age-matched healthy controls, all aged 12-22 years. All subjects will undergo clinical assessment, followed by the 2-day appetitive conditioning task during which fMRI, pupillometry, heart rate deceleration, and subjective ratings will be acquired.

DISCUSSION

This study will be the first to interrogate appetitive conditioning in AN-a disorder characterized by altered hedonic responding to food. Results will help establish objective biomarkers of appetitive conditioning in AN and lay the groundwork for developing novel lines of treatment for AN and other psychiatric disorders involving diminished ability to experience pleasure and reward.

TRIAL REGISTRATION

Pending.

INTENDED REGISTRY

Clinicaltrials.gov.

Potential benefits and limitations of machine learning in the field of eating disorders: current research and future directions

Advances in machine learning and digital data provide vast potential for mental health predictions. However, research using machine learning in the field of eating disorders is just beginning to emerge. This paper provides a narrative review of existing research and explores potential benefits, limitations, and ethical considerations of using machine learning to aid in the detection, prevention, and treatment of eating disorders. Current research primarily uses machine learning to predict eating disorder status from females' responses to validated surveys, social media posts, or neuroimaging data often with relatively high levels of accuracy. This early work provides evidence for the potential of machine learning to improve current eating disorder screening methods. However, the ability of these algorithms to generalise to other samples or be used on a mass scale is only beginning to be explored. One key benefit of machine learning over traditional statistical methods is the ability of machine learning to simultaneously examine large numbers (100s to 1000s) of multimodal predictors and their complex non-linear interactions, but few studies have explored this potential in the field of eating disorders. Machine learning is also being used to develop chatbots to provide psychoeducation and coping skills training around body image and eating disorders, with implications for early intervention. The use of machine learning to personalise treatment options, provide ecological momentary interventions, and aid the work of clinicians is also discussed. Machine learning provides vast potential for the accurate, rapid, and cost-effective detection, prevention, and treatment of eating disorders. More research is needed with large samples of diverse participants to ensure that machine learning models are accurate, unbiased, and generalisable to all people with eating disorders. There are important limitations and ethical considerations with utilising machine learning methods in practice. Thus, rather than a magical solution, machine learning should be seen as an important tool to aid the work of researchers, and eventually clinicians, in the early identification, prevention, and treatment of eating disorders.

Revisiting alexithymia as an important construct in the treatment of anorexia nervosa: a proposal for future research

Consistent research supports altered emotional processing in adult patients with anorexia nervosa (AN), including elevations in alexithymia, or deficits in identifying and describing emotions and other internal experiences. Despite increasing interest in emotion-focused therapies for AN, alexithymia is often not directly addressed within many existing treatments, and little empirical work has moved beyond descriptive, cross-sectional research. In this paper, we propose that refining the field's understanding of alexithymia may provide insights into poor outcomes in existing psychological treatments for AN. First, we provide a brief overview of existing work exploring alexithymia in AN, and then describe several next steps in treatment-relevant research, including differentiating alexithymia from related constructs, considering neurobiological correlates of alexithymia, testing the link between alexithymia and outcome across treatment modalities, and piloting adjunctive treatment techniques focused on emotional identification and description. Altogether, exploring adjunctive treatment approaches targeting alexithymia may offer one promising possibility for improving long-term outcomes.

Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa

PURPOSE

Patients with eating disorders (ED) pose a high-risk group regarding relapse. The understanding of factors contributing to a better outcome is much-needed. Therapeutic alliance (TA) is one important, pantheoretical variable in the treatment process, which has shown to be connected with outcome. This review looks into a possible predictive effect of TA on outcome as well as related variables.

METHODS

A systematic review with pre-determined inclusion criteria following the PRISMA guidelines was conducted for studies published since 2014. Three previous reviews including studies up until 2014 were analyzed for studies matching our inclusion criteria. A total of 26 studies were included.

RESULTS

The results were heterogeneous between different patient groups. Regarding the predictive effect of TA, in adolescent samples, the TA of either the patients or their parents seems to impact outcome as well as completion. For adults, results are mixed, with a tendency to a greater impact of TA for anorexia nervosa (AN) patients, while some samples of adult bulimia nervosa (BN) patients did not find any relation between TA and outcome.

CONCLUSION

The effect of TA on clinical outcome depends on the patient group. TA has a greater impact on adolescents, irrespective of diagnosis, and on adults with AN. The examined studies have different limitations which include small sample sizes and questionable study design. The examination of motivation as a potential influencing factor is recommended.

LEVEL OF EVIDENCE

Level I, systematic review.

Gender-based clinical differences in evidence-based treatment for adolescent anorexia nervosa: analysis of aggregated randomized controlled trials

PURPOSE

Boys represent a small proportion of samples in randomized clinical trials (RCT) investigating evidence-based treatment for adolescents with anorexia nervosa (AN). Consequently, knowledge of potential gender differences in clinical characteristics and treatment response in adolescents is considerably limited.

METHODS

Secondary analyses of aggregated data from two RCTs were used to characterize baseline and end-of-treatment clinical features in male and female adolescents with AN (n = 228, 10.53% male). Mixed analyses of variance were used to investigate potential gender differences in treatment response relative to weight outcomes (% median BMI) and eating disorder cognitions (Eating Disorder Examination Global scores; EDE).

RESULTS

There were no significant gender differences in prior inpatient care, illness duration, psychiatric comorbidity, or psychotropic medication use at baseline. Nor were there significant gender differences in binge eating, purging, or driven exercise at baseline or end-of-treatment. Girls reported elevated weight and shape concern compared to boys at baseline but overall reduction in EDE Global scores over the course of treatment did not differ according to gender. Boys gained more relative weight during treatment than girls, but this difference was statistically non-significant.

CONCLUSION

Overall findings do not suggest significant differences in treatment outcome relative to weight or ED cognitions, by gender. Current evidence suggests that, with the exception of shape and weight concerns, boys present with cognitive and behavioral symptoms as severe as their female counterparts which underscores the need for increased accuracy in assessment of these disorders in boys and young men.

LEVEL OF EVIDENCE

Level 1, secondary data analysis of randomized controlled trials.

Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in female outpatients with anorexia nervosa (ANTOP study): 5-year follow-up of a randomised controlled trial in Germany

BACKGROUND

Anorexia nervosa is a serious illness leading to substantial morbidity and mortality. The Anorexia Nervosa Treatment of Outpatients (ANTOP) study is the largest randomised controlled trial (RCT) globally that uses psychotherapy in outpatients with anorexia nervosa. In this Article, we report the results of the 5-year follow-up.

METHODS

The ANTOP study is an open-label, multicentre RCT involving 242 adult female outpatients with anorexia nervosa. Participants were recruited from ten university hospitals in Germany, had to be aged at least 18 years and female, and have a diagnosis of anorexia nervosa with a body-mass index (BMI) of 15·0-18·5 kg/m². Participants were randomly allocated (1:1:1) to 10 months of treatment with focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual; complete masking of the participants was not possible. The mean duration of the follow-up was 5·96 years (SD 0·2) after randomisation. The primary outcome was change in BMI from baseline at the end of treatment; here, we present the change in BMI from baseline to the 5-year follow-up, using an intention-to-treat approach with a mixed model for repeated measurements. Groups were also compared according to global outcome (based on the combination of BMI and measures of anorexia severity), eating pathology (based on the Eating Disorder Inventory 2), and other secondary mental health outcomes. We did a linear regression analysis to identify the predictors of BMI at follow-up.

FINDINGS

Between May, 2007, and June, 2009, we screened 727 patients for eligibility; at baseline, 242 patients with a mean BMI of 16·7 kg/m² (SD 1·0) were included and randomly allocated to 10 months of treatment with focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual. 154 (64%) of 242 patients completed the 5-year follow-up assessment (53 [66%] of 80 in the focal psychodynamic therapy group, 55 [69%] of 80 in the enhanced cognitive behaviour therapy group, and 46 [56%] of 82 in the optimised treatment-as-usual group), with a mean age of 32·4 years; all reported their ethnicity as White. At the 5-year follow-up, there was an improvement in mean BMI, eating pathology, and global outcome in all treatment groups with no significant differences between treatment groups. Estimated mean BMI was: 18·64 kg/m² (95% CI 18·07-19·21) in the focal psychodynamic therapy group (with an estimated mean BMI gain from baseline to 5-year follow-up of 1·91 kg/m² [1·34-2·48]); 18·70 kg/m² (18·15-19·25) in the enhanced cognitive behaviour therapy group (with an estimated mean BMI gain of 1·98 kg/m² [1·43-2·53]); and 18·99 kg/m² (18·39-19·59) in the optimised treatment-as-usual group (with an estimated mean BMI gain of 2·26 kg/m² [1·67-2·86]). There were no significant differences between treatment groups regarding BMI at the 5-year follow-up; the estimated difference was -0·06 (-0·85 to 0·73) between the focal psychodynamic therapy and enhanced cognitive behaviour therapy groups; -0·35 (-1·18 to 0·47) between the focal psychodynamic therapy and optimised treatment-as-usual groups; and -0·29 (-1·10 to 0·52) between the enhanced cognitive behaviour therapy and optimised treatment-as-usual groups. On the basis of observed data, global outcome at the 5-year follow-up showed 41% (33-49) full recoveries, 41% (33-49) partial recoveries, and 18% (12-24) with full-syndrome anorexia nervosa. One patient initially treated in the enhanced cognitive behaviour therapy group died by suicide between the 1-year and 5-year follow-up. BMI at the 5-year follow-up was predicted by BMI at baseline (p=0·0021), illness duration (p=0·0004), and depression at baseline (p=0·012).

INTERPRETATION

The long-term results of the ANTOP trial confirm the improvement in BMI of patients with anorexia nervosa in all groups; however, a substantial proportion of patients had a poor global outcome. The predictors for the long-term course of anorexia nervosa in our ANTOP study show that we need to treat patients with anorexia nervosa at an earlier stage of the disease, with a clear focus on weight gain and considering other comorbidities (especially depression).

FUNDING

German Federal Ministry of Education and Research.

Satisfaction with normative life domains and the course of anorexia nervosa

OBJECTIVE

Satisfaction with normative life domains has been proposed as an important factor in the persistence of anorexia nervosa (AN). Initial evidence from a cross-sectional study indicated that individuals with AN reported lower satisfaction with normative life domains than individuals without an eating disorder. As an important next step in understanding causal relations, the present study used a longitudinal design to examine whether an improvement in AN symptoms is paralleled by an increase in satisfaction with normative life domains from baseline to follow-up and whether relatively low satisfaction with normative life domains at baseline is related to less improvement in AN symptoms.

METHODS

During baseline and at 1-year follow-up, adolescents with AN (N = 69) completed the Brief Multidimensional Students' Life Satisfaction Scale to measure satisfaction with normative life domains (e.g., friendships, school experience). Furthermore, eating disorder symptoms and BMI were measured.

RESULTS

Improvement in eating disorder symptoms, but not in BMI, was paralleled by an increase in satisfaction with normative life domains. Relatively low satisfaction with normative life domains at baseline was not prospectively related to less improvement in eating disorder symptoms or BMI at follow-up.

DISCUSSION

Our findings provide initial evidence that satisfaction with normative life domains is a malleable factor which fluctuates with symptom severity in AN. The results of this exploratory study point to the relevance of examining whether targeting satisfactory engagement with specific life domains optimizes treatment effectiveness.

PUBLIC SIGNIFICANCE

We explored whether an improvement in anorexia nervosa symptoms from start of treatment to 1-year follow-up would be paralleled by an increase in satisfaction with normative life domains. Improvement in eating disorder symptoms (but not BMI) was indeed related to a concurrent increase in satisfaction with normative life domains. These preliminary results point to the promising possibility that targeting satisfactory engagement with specific life domains may potentially enhance treatment effectiveness.

Updates in the treatment of eating disorders in 2021: a year in review in Eating Disorders: The Journal of Treatment & Prevention

An array of novel and important studies advancing the treatment of eating disorders (EDs) were published in Eating Disorders: The Journal of Treatment & Prevention in 2021. In an unprecedented year of challenges to the delivery of ED treatment, and the volume of patients requiring it, this review summarizes the recent contributions to the literature on the treatment of EDs. Notably, an emphasis on assessing and addressing barriers to collaborative care offers much promise in augmenting treatment delivery and patient outcomes. In keeping with recent data illustrating an elevated risk for increased symptom severity during the COVID-19 pandemic, a focus on further disseminating treatments to higher level of care settings will be critical as the field meets the challenge presented by COVID-19. In addition, we review recent findings relating to the broader assessment and treatment of comorbidities which exacerbate ED symptom severity-which offer critical insights into the development of novel treatments. These recent contributions pave the way for more nuanced approaches to treating EDs across the diagnostic spectrum.

Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders

OBJECTIVE

Only a small proportion of individuals with an eating disorder will receive targeted treatment for their illness. The aim of this study was to examine the length of delay to treatment-seeking and determine the barriers preventing earlier access and utilisation of eating disorder treatment for each diagnostic group - anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding or eating disorder.

METHOD

Participants were recruited as part of the TrEAT multi-phase consortium study. One hundred and nineteen Australians (13-60 years; 96.9% female) with eating disorders currently accessing outpatient treatment for their illness completed an online survey comprised of self-report measures of eating disorder severity, treatment delay and perceived barriers to treatment-seeking. The treating clinician for each participant also provided additional information (e.g. body mass index and diagnosis).

RESULTS

Overall, the average length of delay between onset of eating disorder symptoms and treatment-seeking was 5.28 years. Controlling for age, latency to treatment-seeking was significantly longer for individuals with bulimia nervosa and binge eating disorder compared to anorexia nervosa. However, when perceived barriers to treatment-seeking were investigated, there were no significant differences between the diagnostic groups in regard to the perceived barriers they experienced. Stigma was rated as the most impactful barrier for each diagnostic group.

CONCLUSION

Findings suggest that individuals with eating disorders face substantial delays in accessing appropriate treatment and that latency to treatment-seeking is often magnified for counter-stereotypical eating disorder presentations. Further research is required to investigate other factors contributing to this delay.

Effectiveness of olanzapine in the treatment of anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

Anorexia nervosa (AN) is a severe psychiatric disorder characterized by starvation and malnutrition, a high incidence of coexisting psychiatric conditions, and treatment resistance. The effect of pharmacotherapy has been controversial.

METHOD

A systematic review was conducted for evidence of an effect of olanzapine versus placebo in adults or its effect as adjuvant treatment of AN in adolescents.

RESULTS

A total of seven articles (304 patients with AN) were identified. There were four double-blind, randomized studies examining the effect of olanzapine in the treatment of AN. The mean difference in body mass index (BMI) at the end of treatment between olanzapine and placebo was 0.67 kg/m² (95% confidence interval (CI) 0.15-1.18 kg/m² ; p = 0.01; I²  = 0%, p for heterogeneity < 0.79). The olanzapine groups showed a significant increase in BMI of 0.68 kg/m² (95% CI 0.22-1.13 kg/m² ; p < 0.001; I²  = 0%, p for heterogeneity = 0.74) compared to the placebo groups. Only two studies examined the effect of olanzapine as adjuvant treatment in adolescents and showed an increase in BMI of 0.66 kg/m² (95% CI -0.36 to 1.67 kg/m² ; p = 0.21; I²  = 11%, p for heterogeneity = 0.32).

DISCUSSION

Olanzapine showed efficacy in the treatment of AN with an increased BMI at the end of treatment in adults. The effect of olanzapine as adjuvant treatment in adolescents remains unclear.

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

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