The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM

Psychopathological and Organic Features of Atypical Anorexia Nervosa in Developmental Age: A Systematic Review

PURPOSE

This study aimed to comprehensively report the epidemiological and clinical features of atypical anorexia nervosa (AAN) in children and adolescents.

METHODS

In May 2024, a systematic review was performed using Medline, Cochrane Library, ClinicalTrials.gov, and relevant websites. Following PRISMA guidelines, 234 articles were screened for studies on DSM-5-defined AAN. A standardized checklist-the JBI critical appraisal tool-was adopted in assessing methodology, and 13 retained studies passed the screening and critical appraisal process for the final review. The Newcastle-Ottawa Scale was utilized to assess the risk of bias in cohort and case-control studies, ensuring a comprehensive evaluation of methodological quality.

RESULTS

AAN prevalence in young age groups is 2.8%, with a cumulative 2.8% incidence over 8 years. Incidence is 366 per 100,000 person-years, and the average episode duration is 11.6 months, with a 71% remission rate. Diagnostic persistence for AAN is less stable than other restrictive feeding and eating disorders (FEDs). AAN individuals exhibit higher EDE-Q scores, more severe distress, and distinct BMI differences compared to those with anorexia nervosa and controls. The diagnostic transition from the DSM-IV to the DSM-5 shows that AAN patients are predominantly female, slightly older, and with higher weight.

CONCLUSIONS

This study yields concrete insights into the features of AAN in the developmental age, highlighting demographic variations, clinical presentations, and treatment outcomes. Recognizing the unique challenges faced by AAN individuals is vital for tailoring effective interventions and improving overall care within the FED spectrum.

Latent Profiles of Disordered Eating Among Veterans: Associations With Mental Health Concerns

BACKGROUND

Varying patterns in eating disorder (ED) classification are evident and may impact ED treatment and prevention. However, investigations of patterns of heterogeneity in ED presentations have been limited to civilian samples, despite the high prevalence of EDs in military personnel and veterans. The present study aimed to explore ED-related symptom patterns, including emotional overeating, in women veterans.

METHODS

Participants were 407 women veterans using health care services at a large Veterans Affairs health care system who completed mental health measures via surveys. Latent profile analyses were used to explore distinct ED symptom patterns (binge eating, purging, heavy exercise, positive and negative emotional overeating, dietary restraint, and shape/weight concerns). Subsequent auxiliary models explored associations with mental health concerns (depressive symptoms, posttraumatic stress disorder, anxiety, alcohol misuse, substance misuse), adjusting for age, race and ethnicity, and service branch.

RESULTS

A four-class solution demonstrated the best model fit, characterized as follows: 1) Low ED Concerns, 2) Moderate Dietary Restraint/Negative Emotional Eating, 3) High Binge/Emotional Eating, and 4) High ED Concerns. Although all profiles had moderate or higher levels of negative emotional overeating, the High Binge/Emotional Eating and High ED Concerns profiles were distinct in levels of dietary restraint and had the highest probabilities of positive emotional overeating. The High ED Concerns profile also had the most severe mental health concerns relative to the other profiles.

CONCLUSIONS

The identification of unique ED symptom patterns in women veterans can inform prevention and intervention efforts.

Nutritional Assessment of Children and Adolescents with Atypical Anorexia Nervosa: A Preliminary Longitudinal Investigation Using the 24-h Dietary Recall

BACKGROUND

Atypical Anorexia Nervosa (AAN) is a Feeding and Eating Disorder characterized by fear of gaining weight and body image disturbance, in the absence of significantly low body weight. AAN may present specific clinical and psychopathological features. Nonetheless, the literature lacks data concerning the nutritional characteristics and body composition of children and adolescents with AAN and their variation over time.

METHODS

Case series, including 17 children and adolescents with AAN. All the patients were assessed at the first evaluation (T0) with a standardized dietary assessment (24 h Dietary Recall, 24 hDR). Nutritional data were compared with European dietary reference values (DRVs). Body composition parameters (weight, fat mass, fat-free mass) and their changes over time at two (T1) and six (T2) months were collected as well, using a Bioelectrical impedance analysis (Wunder WBA300 with four poles and foot contact; impedance frequency 50 kHz 500 μA; impedance measurement range 200~1000 Ω/0.1 Ω).

RESULTS

The included individuals presented eating behaviors oriented towards significantly low daily energy intake (p < 0.001) compared with DRVs set by the European Food Safety Authority (EFSA) (with low carbohydrates and fats), and increased proteins (p < 0.001). A longer latency before observation (illness duration before observation) correlated with a negative change in weight. Body composition parameters were described, with no significant changes across the six-month outpatient assessment.

DISCUSSION

This is the first research to systematically assess the body composition and nutritional features of a group of individuals with AAN in the developmental age. Further research should assess the effect of targeted treatment interventions on body composition and nutritional features.

There is nothing as inconsistent as the OSFED diagnostic criteria

Atypical anorexia nervosa (AAN), purging disorder (PD), night eating syndrome (NES), and subthreshold bulimia nervosa and binge-eating disorder (Sub-BN/BED) are the five categories that comprise the 'Other Specified Feeding or Eating Disorder' (OSFED) category in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5). In this review, we examine problems with the diagnostic criteria that are currently proposed for the five OSFED types. We conclude that the existing diagnostic criteria for OSFED are deficient and fall short of accurately describing the complexity and individuality of those with these eating disorders (EDs). Therefore, to enhance the quality of life of people with OSFED, diagnostic criteria for the condition should be applied uniformly in clinical and research settings.

Dynamic relationships among feeling fat, fear of weight gain, and eating disorder symptoms in an eating disorder sample

Feeling fat and fear of weight gain are key cognitive-affective symptoms that are theorized to maintain eating disorders (EDs). Little research has examined the dynamic relationships among feeling fat, fear of weight gain, emotions, cognitions, and ED behaviors. Furthermore, it is unknown if these relations vary by ED diagnosis (e.g., anorexia nervosa (AN) vs other ED). The current study (N = 94 ED participants; AN n = 64) utilized ecological momentary assessments collected four times a day for 18 days (72 timepoints) asking about feeling fat, fear of weight gain, emotions (i.e., anxiety, guilt), cognitions (i.e., feelings of having overeaten, thoughts about dieting), and ED behaviors (i.e., vomiting, diuretic/laxative use, excessive exercise, body checking, self-weighing, binge-eating, restriction) at stressful timepoints (contemporaneous [mealtime], and prospective/temporal [next-meal]). Multilevel modeling was used to test for between and within-person associations. Higher feeling fat and fear of weight gain independently predicted higher next-meal emotions (i.e., anxiety, guilt), cognitions (i.e., feelings of having overeaten, thoughts about dieting, fear of weight gain, feeling fat), and ED behaviors (i.e., body checking, self-weighing [feeling fat]). There were relationships in the opposite direction, such that some emotions, cognitions, and ED behaviors prospectively predicted feeling fat and fear of weight gain, suggesting existence of a reciprocal cycle. Some differences were found via diagnosis. Findings pinpoint specific dynamic and cyclical relationships among feeling fat, fear of weight gain, and specific ED symptoms, and suggest the need for more research on how feeling fat, fear of weight gain and cognitive-affective-behavioral aspects of ED operate. Future research can test if treatment interventions targeted at feeling fat and fear of weight gain may disrupt these cycles.

Eating disorder psychopathology, psychiatric impairment, and symptom frequency of atypical anorexia nervosa versus anorexia nervosa: A systematic review and meta-analysis

OBJECTIVES

Restrictive eating disorders (EDs) occur across the weight spectrum, but historically more focus has been given to anorexia nervosa (AN) than atypical anorexia nervosa (atypAN). AtypAN's relegation to a diagnosis in the "other specified feeding and eating disorder" (OSFED) category and paucity of research surrounding atypAN invariably implies a less clinically severe ED. However, a growing body of research has begun to question the assumption that atypAN is less severe than AN. The current review and meta-analysis aimed to provide a comprehensive review to compare atypAN and AN on measures of eating disorder psychopathology, impairment, and symptom frequency to test whether atypAN is truly less clinically severe than AN.

METHODS

Twenty articles that reported on atypAN and AN for at least one of the variables of interest were retrieved from PsycInfo, PubMed, and ProQuest.

RESULTS

For eating-disorder psychopathology, results indicated that differences were nonsignificant for most indicators; however, atypAN was associated with significantly higher shape concern, weight concern, drive for thinness, body dissatisfaction, and overall eating-disorder psychopathology than AN. Results indicated that atypAN and AN did not significantly differ on clinical impairment or the frequency of inappropriate compensatory behaviors, whereas there was a significantly higher frequency of objective binge episodes in AN (vs. atypAN).

DISCUSSION

Overall, findings indicated that, in contrast to the current classification system, atypAN and AN were not clinically distinct. Results underscore the need for equal access to treatment and equal insurance coverage for restrictive EDs across the weight spectrum.

PUBLIC SIGNIFICANCE

The current meta-analysis found that atypAN was associated with higher drive for thinness, body dissatisfaction, shape concern, weight concern, and overall eating-disorder psychopathology than AN; whereas AN was associated with higher frequency of objective binge eating. Individuals with AN and atypAN did not differ on psychiatric impairment, quality-of-life, or frequency of compensatory behaviors, highlighting the need for equal access to care for restrictive EDs across the weight spectrum.

The absurdity of the latent disease model in mental health: 10,130,814 ways to have a DSM-5-TR psychological disorder

BACKGROUND

Latent disease classification is currently the accepted approach to mental illness diagnosis. In the United States, this takes the form of the Diagnostic and Statistical Manual of Mental Disorders-5-Text Revision (DSM-5-TR). Latent disease classification has been criticized for reliability and validity problems, particularly regarding diagnostic heterogeneity. No authors have calculated the scope of the heterogeneity problem of the entire DSM-5-TR.

AIMS

We addressed this issue by calculating the unique diagnostic profiles that exist for every DSM-5-TR diagnosis.

METHODS

We did this by applying formulas previously used in smaller heterogeneity analyses to all diagnoses within the DSM-5-TR.

RESULTS

We found that there are 10,130,814 ways to be diagnosed with a mental illness using DSM-5-TR criteria. When specifiers are considered, this number balloons to over 161 septillion unique diagnostic presentations (driven mainly by bipolar II disorder). Additionally, there are 1,951,065 ways to present with psychiatric symptoms, yet not meet diagnostic criteria.

CONCLUSIONS

Latent disease classification leads to considerable heterogeneity in possible presentations. We provide examples of how latent disease classification harms research and treatment programs. We echo recommendations for the dismissal of latent disease classification as a mental illness diagnostic program.

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

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

Impairments among DSM-5 eating disorders: A systematic review and multilevel meta-analysis

Previous research revealed that people who did not meet full DSM-IV criteria for anorexia nervosa (AN), bulimia nervosa (BN), or binge-eating disorder (BED) but met criteria for eating disorder not otherwise specified (EDNOS) display high levels of psychiatric and physical morbidity commensurate with full criteria eating disorders. The DSM-5 introduced significant changes to eating disorder diagnostic criteria, so the present study aimed to determine whether the revised diagnostic criteria better distinguish between full criteria eating disorders, and other specified feeding or eating disorder (OSFED) and unspecified feeding or eating disorder (UFED). We present a series of meta-analyses comparing eating pathology, general psychopathology, and physical health impairments among those with AN, BN, and BED, compared to those with OSFED or UFED (n = 69 eligible studies). Results showed significantly more eating pathology in OSFED compared to AN, no difference in general psychopathology, and greater physical health impairments in AN. BN had greater eating pathology and general psychopathology than OSFED, but OSFED showed more physical health impairments. No differences were found between BN and purging disorder or low-frequency BN, or between BED and OSFED. Findings highlight the clinical severity of OSFED and suggest the DSM-5 criteria may not appropriately account for these presentations.

Assessment and Treatment of Avoidant/Restrictive Food Intake Disorder

PURPOSE OF REVIEW

To review the literature pertaining to the assessment and treatment of avoidant/restrictive food intake disorder (ARFID) ten years following its introduction to DSM-5.

RECENT FINDINGS

Several structured clinical interviews for assessing ARFID have been developed, each with its own strengths and limitations. There is no clear leading self-report measure for tracking treatment progress and outcome in ARFID. Medical assessment is comprised of examining anthropometrics, vitamin deficiencies, and other comorbidities. To date, several studies have reported on cognitive behavioral therapy, family-based treatment, and other approaches to the treatment of ARFID. These treatments appear promising; however, they rely on data from clinical case series and very small randomized controlled trials. Several promising assessments and treatments for ARFID are in the early stages of research. Yet, controversies remain. These include (a) overlap with criteria for pediatric feeding disorder; (b) the optimal method for assessing nutrient deficiencies; (c) disciplines involved in treatment. Future research innovation is necessary to improve the psychometric properties of ARFID assessments and evaluate treatment efficacy with larger samples and randomized designs.

Androgens impact on psychopathological variables according to CPRS, and EDI 2 scores: In women with bulimia nervosa, and eating disorder not otherwise specified

Bulimia nervosa (BN) is characterized by binge eating, compensatory behavior, over-evaluation of weight and shape, which often co-occur with symptoms of anxiety and depression. Depression is the most common comorbid diagnosis in women with eating disorders. The role of androgens in the pathophysiology of depression has been recognized in recent years. However, the research on psychopathological comorbidity and androgen levels in bulimic disease is sparse. This study aimed to investigate, if there were any correlations between the androgens, testosterone (T), dehydroepiandrosterone sulphate (DHEAS), androstenedione (A4), 5α-dihydrotestosterone, (5α-DHT), and test scores of psychopathological variables, in women with bulimia nervosa (BN), eating disorder not otherwise specified of purging subtype (EDNOS-P) assessed by CPRS, and EDI 2. Women with DSM-IV diagnosis of BN (n = 36), EDNOS-P (n = 27), and healthy control subjects (n = 58) evaluated for fifteen psychopathological variables, i.a. depressive symptoms, impulsivity, personal traits, as well as serum androgen levels. All women were euthyroid, and polycystic ovarian syndrome (PCOS) diagnosis was excluded. Although androgen levels were almost equal for all three groups, significant correlations between core psychopathological symptoms (9/15) of bulimia nervosa and the most potent endogenous androgen, 5α-DHT, was found only in the EDNOS-P group. The role of 5α-DHT in women is not fully elucidated. Both animal and human studies have shown that the brain is able to locally synthesize steroids de novo and is a target of steroid hormones. Maybe these results can be interpreted in the light of differences in androgen receptor variability, metabolism and origin of T and 5α-DHT.

Eighteen-month Course and Outcome of Adolescent Restrictive Eating Disorders: Persistence, Crossover, and Recovery

OBJECTIVE

In adults, low-weight restrictive eating disorders, including anorexia nervosa (AN), are marked by chronicity and diagnostic crossover from restricting to binge-eating/purging. Less is known about the naturalistic course of these eating disorders in adolescents, particularly atypical AN (atyp-AN) and avoidant/restrictive food intake disorder (ARFID). To inform nosology of low-weight restrictive eating disorders in adolescents, we examined outcomes including persistence, crossover, and recovery in an 18-month observational study.

METHOD

We assessed 82 women (ages 10-23 years) with low-weight eating disorders including AN (n = 40; 29 restricting, 11 binge-eating/purging), atyp-AN (n = 26; 19 restricting, seven binge-eating/purging), and ARFID (n = 16) at baseline, nine months (9 M; 75% retention), and 18 months (18 M; 73% retention) via semi-structured interviews. First-order Markov modeling was used to determine diagnostic persistence, crossover, and recovery occurring at 9 M or 18 M.

RESULTS

Among all diagnoses, the likelihood of remaining stable within a given diagnosis was greater than that of transitioning, with the greatest probability among ARFID (0.84) and AN-R (0.62). Persistence of BP and atypical presentations at follow-up periods was less stable (AN-BP probability 0.40; atyp-AN-R probability 0.48; atyp-AN-BP probability, 0.50). Crossover from binge-eating/purging to restricting occurred 72% of the time; crossover from restricting to binge-eating/purging occurred 23% of the time. The likelihood of stable recovery (e.g., recovery at both 9 M and 18 M) was between 0.00 and 0.36.

CONCLUSION

Across groups, intake diagnosis persisted in about two-thirds, and recovery was infrequent, underscoring the urgent need for innovative treatment approaches to these illnesses. Frequent crossover between AN and atyp-AN supports continuity between typical and atypical presentations, whereas no crossover to ARFID supports its distinction.

A network approach can improve eating disorder conceptualization and treatment

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

Feasibility and Acceptability of a Guided Self-Help, Text-Messaging Intervention to Promote Positive Body Image of Emerging Adult Women

The predominant approach of existing eating disorder prevention programs targets risk factors for development; furthermore, burgeoning evidence suggests that promotion of protective factors against eating disorders (e.g., positive body image) is also a worthy avenue for prevention efforts. The present study considered existing literature gaps in the design of an 8-week guided self-help intervention meant to address the risk for disordered eating through the improvement of positive body image and enhancement of current adaptive functioning. The intervention incorporated elements of weight-inclusive health promotion (e.g., Health at Every Size; HAES) alongside positive psychology and third-wave behavioral interventions [e.g., self-compassion, mindful eating, Acceptance and Commitment Therapy (ACT)] to promote engagement in mindful-self-care. This mixed-methods study evaluated the feasibility and acceptability of the text-messaging based intervention in a diverse sample of cisgender college women (N = 30; 30% Black; 30% bisexual) at risk for disordered eating. Results indicated a high level of engagement and satisfaction with the intervention. Proof of concept was preliminarily supported by the observed significant changes in variables of interest (i.e., body appreciation, positive embodiment, mindful self-care, intuitive eating, self-compassion, disordered eating, and body image dissatisfaction) across the intervention. Overall, results of this study suggest that the use of a guided self-help program based in technology which seeks to reduce risk factors for disordered eating while also supporting adaptive functioning may be indicated for emerging adult women. This article will discuss how the present study provides the groundwork for continued development of innovative and remotely accessible interventions which promote positive body image.

Eating disorders and subsequent risk of substance use disorders involving illicit drugs: a Danish nationwide register-based cohort study

PURPOSE

No study has investigated the ongoing risk of substance use disorders involving illicit drugs (ISUD) after first eating disorder (ED) and whether the pattern of risk differs according to types of ED and ISUD. Therefore, we aimed to longitudinally assess the risk of a subsequent diagnosis of any ISUD (pooled category) and specific ISUD after a first-time diagnosis of anorexia nervosa (AN), bulimia nervosa (BN), or unspecified ED (USED).

METHODS

A retrospective cohort study using data from Danish nationwide registers identified 20,759 ED patients and 83,038 matched controls (1:4 ratio). Risk of any ISUD diagnosis after first ED diagnosis was estimated by generating hazard ratios (HR). Logistic regression was applied to assess associations between each ED and specific ISUD.

RESULTS

Patients with AN, BN, and USED (without a prior ISUD diagnosis) exhibited an increased relative risk of a subsequent diagnosis of any ISUD compared with respective controls, and the elevated risk persisted over 10 years (AN, adjusted HRs ranging from 1.60 [99% CI 1.15-2.24] to 5.16 [3.14-8.47]; BN, 2.35 [1.46-3.79] to 14.24 [6.88-29.47]; USED, 2.86 [1.35-3.79] to 8.56 [3.31-29.47]). The highest estimates were observed during the first year of follow-up. Each ED type was associated with an increased likelihood of all types of ISUD. AN and USED were most strongly associated with sedatives/hypnotics, BN with other illegal substances (e.g., ecstasy and hallucinogens).

CONCLUSIONS

ED patients have a considerable risk for subsequent ISUD. Prevention efforts and treatment targeting ISUD are likely required to improve ED treatment prognosis.

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

Background

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

Method

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

Results

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

Discussion

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

An update on the prevalence of eating disorders in the general population: a systematic review and meta-analysis

OBJECTIVE

To update the prevalence of eating disorders in the general population before 2021 and to analyze the distribution characteristics at different times and in different regions and sexes, as well as the diagnostic criteria.

METHODS

Based on the method from a previous report by the authors, studies were identified from the following databases: PubMed/Medline, PsycINFO, ISI Web of Knowledge, Ovid and the 4 most important Chinese databases. Articles in English and Chinese before 2021 were retrieved. The data retrieved at this time were pooled with the data from a previous report for analyses.

RESULTS

Thirty-three studies were identified, which included 18 studies supplemented in this retrieval. The pooled lifetime and 12-month prevalence of eating disorders were 0.91% (95% CI, 0.48-1.71) and 0.43% (95% CI, 0.18-0.78), respectively. The pooled lifetime and 12-month prevalence of the subgroup EDs (any), which covers all types of eating disorders, were 1.69% and 0.72%, respectively. The lifetime prevalence of AN, BN and BED was 0.16% (95% CI, 0.06-0.31), 0.63% (95% CI, 0.33-1.02) and 1.53% (95% CI, 1.00-2.17), respectively. The lifetime prevalence of EDs in Western countries was 1.89%, and was high at 2.58% in females. Prevalence studies using DSM-5 criteria were scarce.

CONCLUSIONS

The prevalence of eating disorders might be underestimated thus far. Not all types of EDs were included in a majority of epidemiological surveys, and the prevalence rates of the new types of EDs were significantly higher. Eating disorders were especially common in Western countries and in females. New diagnostic criteria should be used to comprehensively assess all types of eating disorders.

LEVEL OF EVIDENCE

1, systematic review and meta-analysis.

Disordered Eating Behaviors in Young Individuals With Idiopathic Intracranial Hypertension

BACKGROUND

The objective of this study was to assess the prevalence of disordered eating behaviors (DEBs) in young individuals with idiopathic intracranial hypertension (IIH) and to identify predictors of DEBs in this population.

METHODS

Individuals with IIH aged eight to 25 years and their matched controls responded to a self-rating survey comprised of the Eating Attitude Test-26 for assessing the presence of DEBs and the Depression, Anxiety and Stress Scale.

RESULTS

Fifty-three subjects with IIH and 106 healthy controls were included. DEBs were significantly more prevalent in individuals with IIH (P < 0.001). Individuals with IIH and DEBs were more likely to have longer periods of treatment [odds ratio: 1.07, 95% CI: 1.02-1.41), P = 0.008] and to have lost a significant amount of weight during the course of treatment [odds ratio: 9.06 (95% CI: 1.30-62.9), P = 0.026]. Depression, anxiety, and stress were more prevalent in the IIH group than in the controls (P = 0.004) and were associated with DEBs in these individuals (P = 0.01).

CONCLUSIONS

There is an increased prevalence of DEBs among young individuals with IIH, which persists even after disease resolution, and is associated with higher reported rates of depression, anxiety, and stress. Medical caregivers should have heightened awareness to DEBs in individuals with IIH with the aim of early identification and intervention.

Attentional biases towards food and body stimuli among individuals with disordered eating versus food allergies

BACKGROUND AND OBJECTIVES

Individuals with disordered eating display heightened attentional biases towards food- and body-related stimuli. However, it is unknown whether these attentional biases reflect maladaptive thinking/eating pathology. We investigated the differences between maladaptive and adaptive ways of thinking about food by assessing food- and body-related attentional biases among individuals with disordered eating, participants with peanut allergies (i.e., individuals who think frequently about food in an adaptive manner), and healthy controls. We also examined the extent to which negative mood and rumination exacerbated attentional biases among those in these groups.

METHOD

Three hundred and twenty-one individuals with disordered eating (n = 139), peanut allergies (n = 60), and healthy controls (n = 122) completed food- and body-based Stroop tasks prior to and following a cognitive rumination task designed to increase negative mood.

RESULTS

Individuals with disordered eating and individuals with peanut allergies had significantly worse performance on the food and body Stroop tasks relative to healthy controls at baseline (ps < .001). However, there were no perceived differences in performance by group following rumination.

LIMITATIONS

The cognitive rumination task heightened negative mood for those in the disordered eating group but not for those in the peanut allergy or healthy control groups.

CONCLUSIONS

Findings suggest that frequent thoughts involving food are associated with attentional biases towards food and body stimuli. This appears to be the case regardless of whether these frequent thoughts are due to disordered eating or to fear of an allergic reaction.

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

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

Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature

OBJECTIVE

Currently, there is debate in the eating disorders field regarding how to define atypical anorexia (AAN), how prevalent it is in community and clinical settings, and how AAN rates compare with low-weight AN. This systematic review assesses AAN literature from 2007 to 2020, to investigate: (a) the demographic characteristics of AAN studies, (b) the prevalence of AAN compared with AN, (c) the range of operational definitions of AAN and the implications of these definitions, and (d) the proportion of patients with AAN and AN represented in consecutive admission and referral samples.

METHOD

PsychINFO, CINAHL, PubMed, Greylit.org, and ProQuest databases were searched according to methods for Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic reviews, yielding 3,184 potential articles. Seventy-five eligible studies were coded for sixty-one variables.

RESULTS

Clinical samples predominantly included younger, female, white samples with limited diversity. In epidemiological designs, AAN was typically as common or more common than AN, and AAN rates varied significantly based on the population studied and operational definitions. In consecutive clinical samples, AAN was frequently less represented.

DISCUSSION

Although AAN appears to occur more frequently than AN in communities, fewer patients with AAN are being referred and admitted to eating disorder specific care, particularly in the United States. Given the significant medical and psychosocial consequences of AAN, and the importance of early intervention, this represents a crucial treatment gap. Additionally, results suggest the need for fine-tuning diagnostic definitions, greater diversity in AAN studies, and increased screening and referral for this vulnerable population.

Reconsidering delay discounting in bulimia nervosa

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

Characterizing fear of weight gain and sensitivity to weight gain in individuals seeking weight loss treatment

PURPOSE

Weight concern, including fear of weight gain and sensitivity to weight gain, is indicative of disordered eating in individuals with underweight or healthy weight. It is unknown, however, whether or how these constructs present in individuals with excess weight, particularly among those with binge-eating disorder (BED). This study sought to characterize fear of weight gain and sensitivity to weight gain and examine their relationship with disordered eating and depression symptoms, in individuals seeking weight loss treatment, both with and without BED.

METHODS

Adults seeking weight loss treatment in an urban primary care clinic (N = 131) completed the Eating Disorder Examination interview and Beck Depression Inventory. Height and weight were collected.

RESULTS

Clinical levels of fear of weight gain and sensitivity to weight gain were present in this sample. Individuals with BED reported experiencing fear of weight gain (48.6%), significantly more than those without BED (20.9%); both groups reported similar and clinically elevated sensitivity to weight gain. Both constructs were related to greater levels of disordered eating and depression symptoms, at times based on BED status. Fear of weight gain was associated with overvaluation of weight and shape for those without BED only. Objective and subjective bulimic episodes were unrelated to fear of weight gain or sensitivity to weight gain, regardless of BED status.

CONCLUSION

Fear of weight gain and sensitivity to weight gain were common in this sample and may be maladaptive, as evidenced by associations with elevated eating psychopathology. Future studies should examine these variables within larger samples and should employ longitudinal designs.

LEVEL OF EVIDENCE

Level III: case-control analytic study.

Health-Related Quality of Life in Spanish Women with Eating Disorders

People with eating disorders show impaired health-related quality of life (HRQoL). We aimed to investigate the relative role of physical and mental factors and stage of change as possible predictors of HRQoL in a group of Spanish women (n = 124) with eating disorders. For this purpose, initial and follow-up data were obtained after 6 months from patients attending an outpatient treatment unit for eating disorders. The determinants of the physical and mental domains of the Medical Outcomes Survey Short-form Health Survey (SF-36) questionnaire were investigated in the total sample and separately based on the eating disorder diagnosis by multiple linear regression. Lower scores in the physical component of the SF-36 questionnaire were associated with the presence of a higher body mass index (BMI) at follow-up as well as a higher score in the "action" component of the Attitudes towards Change in Eating Disorders Questionnaire (ACTA). Conversely, a higher index in the EuroQoL-5D overall quality of life questionnaire (EQ-5D) and the presence of obsessive compulsive disorder were associated with a higher score in the physical dimension. The instrument used demonstrated the ability to assess changes associated with the physical component of these patients over the period studied, and the analysis provided more information and specific data on different aspects of HRQoL, thus allowing a more detailed analysis of the information.

Presence and severity of suicidal thoughts and behaviors across the eating disorder diagnostic spectrum: A pilot study

OBJECTIVES

There is a dearth of research on suicidal thoughts and behaviors among eating disorder patients diagnosed with binge eating disorder (BED) or other specified feeding or eating disorder (OSFED). This pilot study evaluated presence and severity of suicidal thoughts and behaviors by eating disorder diagnosis in a transdiagnostic clinical eating disorder sample.

METHODS

Participants were individuals (N = 257; 91.1% female; 94.6% Caucasian) currently receiving eating disorder treatment for anorexia nervosa (AN), bulimia nervosa (BN), BED, or OSFED. Participants completed online measures of variables.

RESULTS

Lifetime and current presence and severity of suicidal ideation and suicide attempts were statistically similar among diagnostic groups.

CONCLUSION

Though largely overlooked, treatment-utilizing individuals with BED and OSFED may experience elevated rates and severity of suicidal thoughts and behaviors, like those with AN and BN. Attention to suicide-related risk assessment and management is needed when treating individuals with eating disorders, regardless of diagnosis.

A randomised clinical trial to evaluate the acceptability and efficacy of an early phase, online, guided augmentation of outpatient care for adults with anorexia nervosa

BACKGROUND

Outpatient interventions for adult anorexia nervosa typically have a modest impact on weight and eating disorder symptomatology. This study examined whether adding a brief online intervention focused on enhancing motivation to change and the development of a recovery identity (RecoveryMANTRA) would improve outcomes in adults with anorexia nervosa.

METHODS

Participants with anorexia nervosa (n = 187) were recruited from 22 eating disorder outpatient services throughout the UK. They were randomised to receiving RecoveryMANTRA in addition to treatment as usual (TAU) (n = 99; experimental group) or TAU only (n = 88; control group). Outcomes were measured at end-of-intervention (6 weeks), 6 and 12 months.

RESULTS

Adherence rates to RecoveryMANTRA were 83% for the online guidance sessions and 77% for the use of self-help materials (workbook and/or short video clips). Group differences in body mass index at 6 weeks (primary outcome) were not significant. Group differences in eating disorder symptoms, psychological wellbeing and work and social adjustment (at 6 weeks and at follow-up) were not significant, except for a trend-level greater reduction in anxiety at 6 weeks in the RecoveryMANTRA group (p = 0.06). However, the RecoveryMANTRA group had significantly higher levels of confidence in own ability to change (p = 0.02) and alliance with the therapist at the outpatient service (p = 0.005) compared to the control group at 6 weeks.

CONCLUSIONS

Augmenting outpatient treatment for adult anorexia nervosa with a focus on recovery and motivation produced short-term reductions in anxiety and increased confidence to change and therapeutic alliance.

Muscle dysmorphia: A systematic and meta-analytic review of the literature to assess diagnostic validity

OBJECTIVE

Although muscle dysmorphia (MD) is a new addition to DSM-5 as a specifier of body dysmorphic disorder (BDD), previous studies have treated MD as a stand-alone diagnosis. We aimed to assess the validity of MD as a stand-alone diagnosis via systematic and meta-analytic review of MD literature using both Robins and Guze criteria and additional criteria from Kendler.

METHOD

We performed a systematic search of ProQuest, PsycInfo, and PubMed databases for the period of January 1993 to October 2019 resulting in 40 papers to examine Robins and Guze's criteria (clinical picture) as well as those added by Kendler (antecedent validators; concurrent validators; predictive validators).

RESULTS

We identified two distinct symptomatic presentations of MD using cluster analysis, a behavioral type and cognitive/behavioral type. For examining the concurrent validators, quantitative meta-analyses differentiated MD populations from controls; however, results were inconclusive in delineating MD from existing disorders. For assessing antecedent and predictive validators, the symptomatic profiles, treatment response, and familial links for MD were similar to those for BDD and for eating disorders.

DISCUSSION

We found preliminary support for MD as a clinically valid presentation, but insufficient evidence to determine whether it is best categorized as a specifier of BDD or unique psychiatric condition.

Behavioral symptoms of eating disorders among adopted adolescents and young adults in the United States: Findings from the Add Health survey

OBJECTIVE

More adopted individuals report experiencing general psychopathology, poor parental attachment, and early childhood eating difficulties than nonadopted individuals, yet little is known about disordered eating in this population. This study sought to describe the relationship between adoption status and behavioral eating-disorder (ED) symptoms, and to examine potential correlates of ED symptoms that are unique to adopted individuals.

METHOD

We examined data from adolescents and young adults from Waves 1 (n adopted = 561, nonadopted = 20,184), 2 (n adopted = 211, nonadopted = 14,525), and 3 (n adopted = 416, nonadopted = 14,754) of the National Longitudinal Study of Adolescent to Adult Health. ED symptom items included dieting, breakfast skipping, binge eating, extreme weight loss behaviors (EWLBs; i.e., self-induced vomiting, laxative use, diet pill use) and lifetime ED diagnosis.

RESULTS

Compared to nonadopted individuals, adopted individuals were more likely to report EWLBs at Wave 2 and binge eating and lifetime ED diagnosis at Wave 3 (ps < .05). Among adopted individuals, contact with a biological parent was associated with higher rates of binge eating and lifetime ED diagnosis at Wave 3 (ps < .05), whereas age at adoption and having ever been in foster care were not associated with rates of ED symptoms.

DISCUSSION

This study provides preliminary evidence that being adopted may be a risk factor for certain behavioral symptoms of EDs. Given the benefits of early detection and treatment of ED symptoms, mental health professionals working with adopted individuals should assess for disordered eating.

Associations of self-reported eating disorder behaviors and personality in a college-educated sample

OBJECTIVE

In order to better understand factors motivating eating disorder (ED) behaviors and better identify persons at-risk for these behaviors, we sought to identify which personality domains and facets were associated with behaviors for weight control.

METHODS

ED behavior information was gathered from the University of North Carolina Alumni Heart Study using the question, "have you ever used any of the following to lose weight?" Respondents endorsed any combination of the following: "Vomiting," "Fasting," "Laxatives," "Excessive physical exercise." Personality was measured using the Revised NEO Personality Inventory (NEO-PI-R). One-way ANOVAs were performed comparing personality domains and facets to reported ED behaviors, computed both as separate behaviors and the number of cumulative behaviors.

RESULTS

Of 3496 respondents, 9.41% endorsed ever having used at least one ED behavior, with the majority endorsing only a single ED behavior. For both sexes, endorsing greater numbers of ED behaviors was associated with higher scores on Neuroticism and Openness. For women, the strongest associations for behaviors with personality were: excessive exercise with high Impulsiveness; fasting with high Impulsiveness and low Gregariousness; laxative use/purging with high scores on Activity and Feelings. For men, the strongest associations were: excessive exercise with high Impulsiveness; fasting with high Ideas; laxative use/purging with low Modesty.

DISCUSSION

Data collected from this sample showed a sex-modulated pattern of association between personality domains and facets with ED behaviors. Our findings support that obtaining personality profiles of individuals exhibiting subclinical eating behaviors will enhance our understanding of who is at risk of developing an ED diagnosis.

Eating disorders in a community-based sample of women with alcohol use disorder and nicotine dependence

BACKGROUND

Studies consistently report a higher prevalence of substance use disorders (SUDs) among women with eating disorders than control women. However, limited research exists on the prevalence of eating disorder symptoms and diagnoses in women with SUDs, especially in community-based populations. We examined the prevalence of eating disorder symptoms and diagnosis by the presence or absence of lifetime alcohol use disorder (AUD) and/or nicotine dependence (ND) in a community-based sample of women.

METHODS

3756 women (median age = 22 years) from the Missouri Adolescent Female Twin Study completed a modified semi-structured interview assessing lifetime DSM-IV psychiatric disorders and SUDs. Logistic regression models adjusted for demographic characteristics and other psychopathology, and robust standard errors accounted for the non-independence of twin data.

RESULTS

In general, women with comorbid AUD and ND had a higher prevalence of eating disorder symptoms and diagnoses than women with AUD or ND Only, who in turn had a higher prevalence than those without either SUD. After adjustment for covariates, women with AUD and ND had significantly greater risk of broad anorexia nervosa (RRR = 3.17; 99 % CI = 1.35, 7.44), purging disorder (2.59; 1.24, 5.43), and numerous eating disorder symptoms than women with neither disorder. Significant differences emerged between individuals with both AUD and ND versus women with AUD Only or ND Only for some eating disorder symptoms.

CONCLUSIONS

Women with lifetime AUD or ND diagnoses are at high risk for eating disorder symptoms and diagnoses, underscoring the importance of assessing eating disorder symptoms among women with these disorders.

The Feasibility of Using Guided Self-Help in Anorexia Nervosa: An Analysis of Drop-Out From the Study Protocol and Intervention Adherence

The implementation of online technologies to promote wellbeing is increasingly becoming a worldwide priority. This study includes secondary analyses of data and examined drop-out rates in an online guided self-help intervention for patients with anorexia nervosa. Specifically, rates of drop-out at end of treatment (i.e., 6 weeks assessment), as well as intervention adherence (minimum of four of six online guided sessions) and differences between completers and drop-outs were examined. Motivation to change and associated patient variables were assessed as predictors of drop-out using structural equation modeling. Ninety-nine patients were randomized to the intervention arm of the trial. Data were available for 82 individuals, 67 of whom completed the 6 weeks assessment and attended a minimum of four online sessions. No significant differences were found between completers and drop-outs at baseline. At the end of the first week of participation, drop-outs from the 6 weeks assessment or the intervention reported less satisfaction with their work with the mentor delivering online guidance. Greater confidence in own ability to change and higher controlled motivation (willingness to change due to pressure from others) predicted lower drop-out rates from the 6 weeks assessment. Stronger alliance with the therapist at the treatment center and lower psychological distress were associated with greater autonomous motivation (self-directed motivation) and importance and ability to change. Data demonstrate that a novel online guided self-help intervention for patients with anorexia nervosa is feasible. Early satisfaction with the program and external pressure to change have a protective role against drop-out rates.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT02336841.

Reduced automatic approach tendencies towards task-relevant and task-irrelevant food pictures in Anorexia Nervosa

BACKGROUND AND OBJECTIVES

Anorexia Nervosa (AN) patients are characterized by an excessive restriction of their food-intake. Prior research using an Affective Simon Task (AST) with food as a task-irrelevant feature, provided evidence for the view that AN patients' ability to refrain from food is facilitated by reduced automatic approach tendencies towards food. However, because food was task-irrelevant (i.e., participants had to base their reaction on the perspective of the picture and not on its content), the findings may in fact reflect a relatively strong ability to ignore the content of the food stimuli rather than weakened approach towards food per se. Therefore, this study also included a Stimulus Response Compatibility (SRC) task with food as task-relevant feature that could not be ignored, because the required response depended on the [food vs non-food] content of the pictures.

METHODS

AN spectrum patients (n = 63), and a comparison group of adolescents without eating pathology (n = 57) completed both a SRC task with food as task-relevant feature, and an Affective Simon Task AST with food as task-irrelevant feature.

RESULTS

AN patients showed reduced approach tendencies for high caloric food. Only the SRC uniquely predicted the presence of AN.

LIMITATIONS

Comparison between tasks was hampered because the SRC only included high caloric food stimuli, whereas the AST included high and low caloric food stimuli.

CONCLUSION

Patients with AN are characterized by weakened automatic approach of high caloric food. This might 'help' restrict their food-intake even in a condition of starvation.

Interview-based assessment of avoidant/restrictive food intake disorder (ARFID): A pilot study evaluating an ARFID module for the Eating Disorder Examination

OBJECTIVE

Although avoidant/restrictive food intake disorder (ARFID) has been included as a new diagnostic entity of childhood feeding and eating disorders, there is a lack of measures to reliably and validly assess ARFID. In addition, virtually nothing is known about clinical characteristics of ARFID in nonclinical samples.

METHOD

The present study presents the development and validation of an ARFID module for the child and parent version of the Eating Disorder Examination (EDE) in a nonclinical sample of N = 39 children between 8 and 13 years with underweight and/or restrictive eating behaviors. For evaluating the ARFID module's reliability, the convergence of diagnoses between two independent raters and between the child and parent module was determined. The module's validity was evaluated based on the full-length child version of the EDE, a 24 h food record, parent-reported psychosocial functioning and self-reported quality of life, and objective anthropometric measures.

RESULTS

In total, n = 7 children received an ARFID diagnosis. The ARFID module showed high interrater reliability, especially for the parent version, and high convergence between child and parent report. Evidence for the module's convergent, divergent, and discriminant validity was provided. Specifically, children with versus without ARFID reported significantly less macro- and micronutrient intake and were more likely to be underweight.

DISCUSSION

This pilot study indicates the child and parent version of the EDE ARFID module to be promising for diagnosing ARFID in a structured way but still necessitates a validation in a larger clinical and community-based sample.

Pre-treatment patient characteristics as predictors of drop-out and treatment outcome in individual and family therapy for adolescents and adults with anorexia nervosa: A systematic review and meta-analysis

Understanding variables predicting drop-out or unfavourable outcome following treatment for anorexia nervosa (AN) may help to improve upon intervention efforts. However, the current literature has demonstrated sparse and inconsistent significant findings. The current systematic review and meta-analysis summarised the evidence base examining baseline predictors of drop-out and outcome in AN treatment. A literature search was conducted to identify research investigating predictors of drop-out and outcome in individuals treated for AN. Four online databases were searched, and predictors were organised by category and dependent variable (outcome versus drop-out). 27 studies were included. Lower motivation, lower BMI, and having the binge-purge subtype of AN predicted drop-out. Greater ED pathology and poorer motivation predicted poorer outcome. Clinical recommendations include taking particular care during assessment stages to identify patients at risk of drop-out and/or poor outcome based on their clinical profile and level of motivation for recovery. At-risk patients should be receiving tailored treatment to enhance engagement and reduce risk of drop-out. In conclusion, there's some evidence that motivation, BMI, subtype, and ED pathology predicts drop-out and/or outcome in individual and family-based therapy for AN amongst adolescents and adults; however, research incorporating carefully designed multi-site studies is required to further examine these findings.

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

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

Predictors of Complications in Anorexia Nervosa and Atypical Anorexia Nervosa: Degree of Underweight or Extent and Recency of Weight Loss?

PURPOSE

Adolescents with atypical anorexia nervosa (AAN) can experience severe physical complications despite not being underweight, posing questions about the contribution of weight loss to complications experienced in restrictive eating disorders (EDs). This study compared total weight loss and recent weight loss with admission weight as predictors of physical and psychological complications.

METHODS

Retrospective (2005-2010) and prospective (2011-2013) studies were undertaken of 12- to 19-year-old hospitalized adolescents with anorexia nervosa (AN) or AAN, defined as meeting criteria for AN except underweight (≥85% median body mass index). Predictors were total weight loss (from lifetime maximum), recent weight loss (past 3 months), and admission weight. Outcomes were hypophosphatemia, clinical, anthropometric, and psychometric markers during admission.

RESULTS

In 171 participants (AN, 118 [69%]; AAN, 53 [31%]), there was little evidence of an association between weight measures and hypophosphatemia. Greater total weight loss (regression coefficient [Coeff]: -1.70, 95% confidence interval [CI]: -2.77, -.63, p = .002) and greater recent weight loss (Coeff: -3.37, 95% CI: -5.77, -.97, p = .006), but not admission weight, were associated with a lower pulse rate nadir. Greater total weight loss (odds ratio [OR]: 1.70, 95% CI: 1.19, 2.24, p = .003) and greater recent weight loss (OR: 2.12, 95% CI: 1.11, 4.02, p = .02) were also associated with a higher incidence of bradycardia.

CONCLUSIONS

In adolescents with restrictive EDs, total weight loss and recent weight loss were better predictors than admission weight of many physical complications. This suggests that future diagnostic criteria for AN place greater emphasis on weight loss.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Other Specified Feeding or Eating Disorders (OSFED): Clinical heterogeneity and cognitive-behavioral therapy outcome

BACKGROUND

with the DSM-5 new eating disorders (EDs) diagnostic subtypes were identified within the Other Specified Feeding or Eating Disorders (OSFED) category, which have so far been under-researched. Objectives of this study were to examine differential features among OSFED subtypes, exploring short-term cognitive-behavioral therapy (CBT) response and identifying clinical predictors of therapy outcome.

METHODS

the sample included 176 female patients diagnosed with OSFED [82 atypical anorexia nervosa (atypical-AN), 57 purging disorder (PD), and 37 subthreshold bulimia nervosa (sub-BN)]. Assessment included eating-related, psychopathological and personality measures.

RESULTS

results showed similar clinical and personality profiles between the diagnostic subtypes, with hardly any differences, only observable in the core symptoms of each diagnosis. The sub-BN group was the one which showed more social impairment. Regarding treatment outcome, the three groups did not reveal significant differences in remission rates, therapeutic adherence or dropout rates, reaching rates of dropout from 36.8% to 50% (p = .391). However, different ED subtype predictors appear related with full remission or dropout risk, specifically personality traits.

CONCLUSIONS

our results suggest that OSFED patients may benefit similarly from the same CBT outpatient group approach. However, high dropout rates and low motivation seems to be an important limitation and challenge for future approaches.

Reciprocal Associations Between Eating Pathology and Parent-Daughter Relationships Across Adolescence: A Monozygotic Twin Differences Study

This prospective study explored longitudinal, bidirectional associations between eating pathology and perceptions of the parent-child relationship (i.e., parent-child regard and involvement) across adolescence. Specifically, this study examined whether twin differences in mother-daughter and father-daughter relationship problems emerged as a risk factor for, or outcome of, twin differences in eating pathology. By examining twin differences, this study explored associations between variables while controlling for shared environmental and genetic effects. A population-based sample of 446 monozygotic twin girls and their mothers completed questionnaires when twins were approximately 11, 14, and 17 years. Responses were analyzed using longitudinal cross-lagged models. Overall, few strong longitudinal associations were observed. Where longitudinal associations emerged, overall patterns indicated reciprocal associations that shifted across adolescence. Whereas twin differences in parent-daughter relationship variables more often predicted later twin differences in eating pathology across early adolescence, conversely, twin differences in eating pathology more often predicted later twin differences in parent-daughter relationship variables across later adolescence. In particular, the twin who reported greater eating pathology later reported more negative perceptions of the father-daughter relationship, as compared to her co-twin. Findings raise questions for future research regarding parental-in particular, paternal-responses to adolescent eating pathology and suggest the potential importance of efforts to support the parent-daughter relationship within the context of adolescent eating pathology.

Are socio-emotional and neurocognitive functioning predictors of therapeutic outcomes for adults with anorexia nervosa?

BACKGROUND

Emotional, social, and neurocognitive factors are theorised to maintain anorexia nervosa (AN). Yet whether they predict outcomes or relate to clinical change remains unclear.

METHODS

Seventy-one consecutive adult outpatient eating disorder service referrals presenting with AN, who participated in a randomised controlled trial comparing 2 psychotherapies, were assessed for emotional processing, social cognition, and neurocognition pretherapy and posttherapy. Intention-to-treat analysis employed maximum-likelihood methods to model missing data. Baseline self-reported emotional processing, social cognitive, or neurocognitive task performance was entered into forward stepwise regression models with posttreatment clinical outcomes (weight, eating disorder psychopathology, psychosocial functioning) as dependent variables. Correlation analyses examined relationships between clinical and self-report/task score change.

RESULTS

Self-reported emotional avoidance (behavioural/cognitive avoidance, low acceptance) and submissive behaviour predicted clinical outcomes. Social cognitive (emotion recognition, emotional theory of mind) and neurocognitive performance (set-shifting, detail focus) had limited predictive ability.

CONCLUSIONS

Emotional avoidance and submissiveness may represent maintenance factors for AN.

Implications of DSM-5 for the diagnosis of pediatric eating disorders

OBJECTIVE

The aim of the study was to compare the DSM-IV, DSM-5, and ICD-10 eating disorders (ED) nomenclatures to assess their value in the classification of pediatric eating disorders. We investigated the prevalence of the disorders in accordance with each system's diagnostic criteria, diagnostic concordance between the systems, and interrater reliability.

METHOD

Participants were 1062 children and adolescents assessed at intake to a specialist Eating Disorders Program (91.6% female, mean age 14.5 years, SD = 1.75). Measures were collected from routine intake assessments.

RESULTS

DSM-5 categorization led to a lower prevalence of unspecified EDs when compared with DSM-IV. There was almost complete overlap for specified EDs. Kappa values indicated almost excellent agreement between the two coders on all three diagnostic systems, although there was higher interrater reliability for DSM-5 and ICD-10 when compared with DSM-IV.

DISCUSSION

DSM-5 nomenclature is useful in classifying eating disorders in pediatric clinical samples.

Preoccupation with shape or weight, fear of weight gain, feeling fat and treatment outcomes in patients with anorexia nervosa: A longitudinal study

OBJECTIVE

The study aimed to evaluate the trajectories of change over time in body-image concern components in patients with anorexia nervosa treated by means of intensive enhanced cognitive behavioural therapy. Moreover, it aimed to study the role of body-image concern components in changes in eating and general psychopathology as well as work and social functioning.

METHOD

Sixty-six adult patients with anorexia nervosa were recruited. Body mass index (BMI); Eating Disorder Examination 'Dietary Restraint' and 'Eating Concern' subscales; Brief Symptom Inventory (BSI); and Work and Social Adjustment Scale (WSAS) scores were recorded at admission, end of treatment, and at 6- and 12-month follow-ups. The trajectories of change of three components of body image concern, namely 'preoccupation with shape or weight', 'fear of weight gain' and 'feeling fat', were assessed.

RESULTS

The treatment was associated with a significant improvement in outcome variables and body-image concern components. Baseline 'preoccupation with shape or weight' predicted improvement in Eating Concern, BSI and WSAS scores, while the change in 'fear of weight gain' was associated with improvement in dietary restraint. Baseline and end-of-therapy scores for all three measured body-image concern components predicted achievement of BMI ≥18.5 kg/m² at 6- and 12-month follow-ups.

DISCUSSION

These findings highlight the importance of assessing and addressing body-image concern in the management of patients with anorexia nervosa.

The relative associations of shape and weight over-evaluation, preoccupation, dissatisfaction, and fear of weight gain with measures of psychopathology: An extension study in individuals with anorexia nervosa

Recent research has demonstrated that certain components of body image (i.e., shape and weight over-evaluation, preoccupation, and dissatisfaction) in secondary school students shared a distinct clinical significance because of their differential relation to measures of psychopathology. The present study aimed to replicate and extend on these findings by examining the distinctiveness of these body image constructs, in addition to a fear of weight gain, in individuals with anorexia nervosa (AN)-a disorder this is facilitated and maintained by extreme body image concerns. Treatment-seeking females with AN (n = 124) completed a questionnaire battery that measured these constructs. Findings demonstrated that once any shared variance between body image components was removed in regression analyses, fear of weight gain was the only unique predictor of eating disorder psychopathology (e.g., dietary restraint and compulsive exercise), while over-evaluation and preoccupation were the only unique predictors of general psychopathology (e.g., depressive and anxiety symptoms). Overall, these findings demonstrate certain components of body image may operate differently in AN, and reinforce previous calls to consider and assess for distinct facets of body image in this population.

Rumination and eating disorder psychopathology: A meta-analysis

Rumination is a cognitive process involving repetitive thoughts about negative experiences and emotions and is associated with psychopathology. Rumination has been implicated in mood and anxiety disorders, and there is a growing body of research on rumination in relation to eating disorder (ED) psychopathology. The current meta-analytic review focused on the literature addressing rumination and ED psychopathology. A comprehensive search process identified 38 studies, which primarily used cross-sectional designs with non-clinical samples. Results demonstrated that rumination was concurrently (r = 0.33) and prospectively (r = 0.22-0.23) associated with ED psychopathology, and that groups with ED psychopathology evidenced higher levels of rumination compared to non-ED control groups (g = 0.95), though no significant differences in rumination were observed when comparing anorexia nervosa to bulimia nervosa groups (g = 0.09). In addition, a narrative review of five experimental studies suggested that rumination in response to ED-related stimuli was related to increased negative affect and negative body-related cognitions across clinical and non-clinical samples. The type of rumination and sample population emerged as moderators of effect sizes, such that larger effects were observed among samples using ED-specific measures of rumination and heterogeneous samples compared to only non-clinical samples. Taken together, this literature demonstrates that rumination is a salient process in ED psychopathology, though the literature is characterized by methodological limitations and the need for more fully elaborated theories on the role of rumination in EDs. Findings are discussed in the context of existing models of rumination and ED psychopathology, with suggestions for future research in this area.

A review of purging disorder through meta-analysis

Although a growing body of research has examined Purging Disorder (PD), there remains a lack of conclusive evidence regarding the diagnostic validity of PD. This meta-analysis compared PD to DSM-5 eating disorders (i.e., Anorexia Nervosa [AN], Bulimia Nervosa [BN], and Binge Eating Disorder [BED]) and controls. A comprehensive literature search identified 38 eligible studies. Group differences on indicators of course of illness and both general and eating psychopathology were assessed using standardized effect sizes. Results supported the conceptualization of PD as a clinically significant eating disorder, but findings were less clear regarding its distinctiveness from other eating disorder diagnoses. More specifically, PD significantly differed from BN and BED in natural course of illness (g = .40-.54), and PD significantly differed from AN in treatment outcome (g = .27), with PD characterized by a better prognosis. Overall, PD was more similar to AN and BED on many dimensional measures of general and eating-related psychopathology, though PD was less severe than BN in most of these domains. PD, BN, and BED groups also evidenced similar frequencies of subjective binge episodes (SBEs), yet PD evidenced less frequent SBEs than AN. There is a clear need for future studies of PD to assess validators that have not been reported comprehensively in the literature, such as mortality, medical morbidity, and course of illness. Additionally, empirical classification studies are needed to inform future classifications of PD, particularly with regard to categorical differences between PD and other eating disorders. (PsycINFO Database Record

Is the diagnostic threshold for bulimia nervosa clinically meaningful?

The DSM-5 differentiates full- and sub-threshold bulimia nervosa (BN) according to average weekly frequencies of binge eating and inappropriate compensatory behaviors. This study was the first to evaluate the modified frequency criterion for BN published in the DSM-5. The purpose of this study was to test whether community-recruited adults (N=125; 83.2% women) with current full-threshold (n=77) or sub-threshold BN (n=48) differed in comorbid psychopathology and eating disorder (ED) illness duration, symptom severity, and clinical impairment. Participants completed the Clinical Impairment Assessment and participated in semi-structured clinical interviews of ED- and non-ED psychopathology. Differences between the sub- and full-threshold BN groups were assessed using MANOVA and Chi-square analyses. ED illness duration, age-of-onset, body mass index (BMI), alcohol and drug misuse, and the presence of current and lifetime mood or anxiety disorders did not differ between participants with sub- and full-threshold BN. Participants with full-threshold BN had higher levels of clinical impairment and weight concern than those with sub-threshold BN. However, minimal clinically important difference analyses suggested that statistically significant differences between participants with sub- and full-threshold BN on clinical impairment and weight concern were not clinically significant. In conclusion, sub-threshold BN did not differ from full-threshold BN in clinically meaningful ways. Future studies are needed to identify an improved frequency criterion for BN that better distinguishes individuals in ways that will more validly inform prognosis and effective treatment planning for BN.