Quality of life impairment in a community sample of women with eating disorders

Direct and indirect effects of psychological well-being and therapeutic alliance on therapy outcome in eating disorders

Introduction

Outcome research in eating disorders (EDs) is commonly focused on psychopathological dysfunction. However, Ryff's model of psychological well-being (PWB) has shown promising-yet preliminary-results with ED patients. Additionally, despite substantial evidence highlighting the association between the therapeutic alliance and treatment outcome, findings in ED samples remain unclear. The present study aimed at exploring the direct effect of PWB dimensions and the early therapeutic alliance on ED patients' individual treatment responses, as well as the mediating role played by the early therapeutic alliance in the relationship between PWB dimensions and overall pre-post symptom change.

Methods

A sample of N = 165 ED patients assigned female at birth, who were receiving treatment in a residential program, completed the Psychological Well-Being Scale at treatment intake and the Working Alliance Inventory after the first four psychotherapy sessions. Patients also completed the Outcome Questionnaire-45.2 at the same time point and during the week prior to discharge.

Results

The PWB dimensions of autonomy, positive relations, and self-acceptance were associated with clinically significant change, while the dimensions of personal growth and self-acceptance were associated with reliable change. The early therapeutic alliance showed both direct and indirect effects on therapy outcome, predicting clinically significant and reliable symptom reduction. It also emerged as a significant mediator in the relationship between all PWB dimensions and overall symptomatic change.

Conclusion

The identification of individual, adaptive characteristics in ED patients that might influence their development of an early therapeutic alliance may help therapists to predict relationship ruptures and tailor their interventions to enhance treatment effectiveness.

Examining the placement of atypical anorexia nervosa in the eating disorder diagnostic hierarchy relative to bulimia nervosa and binge-eating disorder

OBJECTIVE

Some individuals meet the criteria for atypical anorexia nervosa and another eating disorder simultaneously. The current study evaluated whether allowing a diagnosis of atypical anorexia nervosa to supersede a diagnosis of bulimia nervosa (BN) or binge-eating disorder (BED) provided additional information on psychological functioning.

METHODS

Archival data from 650 university students (87.7% female, 69.4% white) who met Eating Disorder Diagnostic Survey for DSM-5 eating disorder criteria and completed questionnaires assessing quality of life, eating disorder-related impairment, and/or eating pathology at a single time point. Separate regression models used diagnostic category to predict quality of life and impairment. Two diagnostic schemes were used: the DSM-5 diagnostic scheme and an alternative scheme where atypical anorexia nervosa superseded all diagnoses except anorexia nervosa. Model fit was compared using the Davidson-Mackinnon J test. Analyses were pre-registered (https://osf.io/2ejcd).

RESULTS

Allowing an atypical anorexia nervosa diagnosis to supersede a BN or BED diagnosis provided better fit to the data for eating disorder-related impairment (p = .02; n = 271), but not physical, psychological, or social quality of life (p's ≥ .33; n = 306). Allowing an atypical anorexia nervosa diagnosis to supersede a BN or BED diagnosis provided a better fit in cross-sectional models predicting purging (p = .02; n = 638), but not body dissatisfaction, binge eating, restricting, or excessive exercise (p's ≥ .08; n's = 633-647).

DISCUSSION

The current data support retaining the DSM-5 diagnostic scheme. More longitudinal work is needed to understand the predictive validity of the atypical anorexia nervosa diagnosis.

PUBLIC SIGNIFICANCE

The current study examined how changes to the diagnostic categories for eating disorders may change how diagnoses are associated with quality of life and impairment. Overall, findings suggest that the diagnostic hierarchy should be maintained.

Epidemiology of eating disorders: population, prevalence, disease burden and quality of life informing public policy in Australia-a rapid review

BACKGROUND

Understanding of the epidemiology and health burden of eating disorders has progressed significantly in the last 2 decades. It was considered one of seven key areas to inform the Australian Government commissioned National Eating Disorder Research and Translation Strategy 2021-2031, as emerging research had highlighted a rise in eating disorder prevalence and worsening burden-of-illness. The aim of this review was to better understand the global epidemiology and impact of eating disorders to inform policy decision-making.

METHODS

Using a systematic Rapid Review methodology, ScienceDirect, PubMed and Medline (Ovid) were searched for peer-reviewed studies published between 2009 and 2021. Clear inclusion criteria were developed in consultation with experts in the field. Purposive sampling of literature was conducted, which predominately focused on higher-level evidence (meta-analyses, systematic reviews, and large epidemiological studies), synthesised, and narratively analysed.

RESULTS

135 studies were deemed eligible for inclusion in this review (N = 1324). Prevalence estimates varied. Global Lifetime prevalence of any eating disorder ranged from 0.74 to 2.2% in males, and 2.58-8.4% in females. Australian 3-month point-prevalence of broadly defined disorders was around 16% in females. Eating disorders appeared more prevalent in young people and adolescents, particularly females (in Australia: eating disorders ~ 22.2%; disordered eating ~ 25.7%). Limited evidence was found on sex, sexuality and gender diverse (LGBTQI +) individuals, particularly males, who had a six-fold increase in prevalence compared to the general male population, with increased illness impact. Similarly, limited evidence on First Australian's (Aboriginal and Torres Strait Islander) suggests prevalence rates similar to non-Indigenous Australians. No prevalence studies were identified specifically assessing culturally and linguistically diverse populations. Global disease burden of any eating disorder was 43.4 age-standardised disability-adjusted-life-years per 100,000; increasing by 9.4% between 2007 and 2017. Australian's total economic cost was estimated at $84 billion from years-of-life lost due to disability and death, and annual lost earnings ~ $1.646 billion."

CONCLUSIONS

There is no doubt that eating disorder prevalence and impact are on the rise, particularly in at-risk and understudied populations. Much of the evidence came from female-only samples, and Western, high-income countries which more readily have access to specialised services. Future research should examine more representative samples. There is an urgent need for more refined epidemiological methods to better understand these complex illnesses over time, to guide health policy and development-of-care.

Ketamine as a Novel Psychopharmacotherapy for Eating Disorders: Evidence and Future Directions

Eating disorders (EDs) are serious, life-threatening psychiatric conditions associated with physical and psychosocial impairment, as well as high morbidity and mortality. Given the chronic refractory nature of EDs and the paucity of evidence-based treatments, there is a pressing need to identify novel approaches for this population. The noncompetitive N-methyl-D-aspartate receptor (NMDAr) antagonist, ketamine, has recently been approved for treatment-resistant depression, exerting rapid and robust antidepressant effects. It is now being investigated for several new indications, including obsessive–compulsive, post-traumatic, and substance use disorder, and shows transdiagnostic potential for EDs, particularly among clinical nonresponders. Hence, the aim of this review is to examine contemporary findings on the treatment of EDs with ketamine, whether used as a primary, adjunctive, or combination psychopharmacotherapy. Avenues for future research are also discussed. Overall, results are encouraging and point to therapeutic value; however, are limited to case series and reports on anorexia nervosa. Further empirical research is thus needed to explore ketamine efficacy across ED subgroups, establish safety profiles and optimize dosing, and develop theory-driven, targeted treatment strategies at the individual patient level.

Does comparison of self with others influence body image among adult women? An experimental study in naturalistic settings

BACKGROUND AND OBJECTIVES

It has been suggested that body comparison is a safety behavior in eating disorders. This experimental study investigates the causal impact of upward and downward body comparison on body image, eating pathology, self-esteem, anxiety and mood. It also considers whether trait body comparison and eating pathology are associated with responsiveness to upward and downward comparison.

METHODS

Thirty-nine women participated. Each completed trait comparison and eating pathology measures. Following this, each participant spent an hour (on different days) making an upward, downward or neutral comparison in a naturalistic setting. After each condition, the participant completed measures of body satisfaction, self-esteem, anxiety, depression and eating pathology.

RESULTS

Participants were significantly less satisfied with their bodies following upward comparison. Both upward and downward comparison were associated with particularly negative effects if an individual had greater trait eating concerns. The effects of downward comparison were correlated with increased anxiety.

LIMITATIONS

The sample was lacking in diversity. Compliance with the experimental tasks was not strictly monitored.

CONCLUSIONS

Upward comparison resulted in lower body satisfaction, but downward comparison did not result in positive effects. However, trait eating concerns and comparison influenced the impact of both forms of comparison. Body comparison should be a target for treatment in CBT for eating disorders, particularly where the individual has a strong tendency to make comparisons with other people.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Women of diverse sexual identities admit to eating disorder treatment with differential symptom severity but achieve similar clinical outcomes

OBJECTIVE

Sexual minority (SM) women may be at increased risk for certain eating disorder (ED) symptoms and report distinct body image concerns compared to heterosexual women. However, it is unclear how such symptoms differ across sexual orientations in treatment-seeking women, or if there are differences in treatment outcomes. This study examined group differences in (1) ED symptomatology at admission in a disaggregated sample of SM and heterosexual women presenting for ED treatment and (2) treatment outcomes.

METHODS

Adult women who admitted to higher levels of ED treatment across 48 locations of one treatment center between 2015 and 2018 completed self-report measures of ED symptomatology and quality of life (QOL) at admission and discharge. Participants identified their sexualities as heterosexual (n = 2,502, 80.2%), lesbian/gay (n = 134, 4.3%), bisexual (n = 270, 8.7%), "other" (n = 136, 4.4%), and unsure (n = 78, 2.5%). Objectives 1 and 2 were tested using one-way and repeated measures analyses of variance, respectively.

RESULTS

Group differences at admission emerged between lesbian/gay and heterosexual, bisexual and heterosexual, and bisexual and "other"-identified women on preoccupation and restriction, fasting, self-induced vomiting, shape and weight concern, and QOL. Bisexual women, in particular, admitted with the highest severity and at younger ages compared to heterosexual women. Despite such differences, women across groups achieved similar treatment outcomes at discharge.

DISCUSSION

Study findings underscore the importance of subgroup analyses of ED symptoms in SM women and have both clinical and research implications related to ED symptomatology in this population.

Predicting probable eating disorder case-status in men using the Clinical Impairment Assessment: Evidence for a gender-specific threshold

The Clinical Impairment Assessment (CIA) is a widely used self-report measure of the psychosocial impairment associated with eating-disorder symptoms. Past studies recommended a global CIA score of 16 to identify clinically significant impairment associated with a probable eating disorder (ED). However, to date, research on the properties of the CIA has been conducted in majority-women samples. Preliminary research on gender differences in CIA scores suggested men with EDs report less impairment on the CIA relative to women with EDs. Thus, the purpose of this study was to test if a different impairment threshold is needed to identify cases of men with EDs. We hypothesized that a lower CIA threshold, relative to that identified in majority-women samples, would most accurately identify men with EDs. Participants (N = 162) were men from our university-based and general community-based ED participant registry who completed the CIA and Eating Disorder Diagnostic Scale. Both precision-recall and receiver operating characteristic curves assessed what CIA global score threshold most accurately identified men with EDs. Both analytic approaches indicated that a CIA global score of 13 best predicted ED case-status in men. Consistent with past research, men with a clinically significant ED appear to report lower impairment on the CIA. Results have implications for screening and assessing for substantial ED-related impairment in men. Additionally, past research using the CIA to identify men with EDs may have under-identified men with clinically significant symptoms.

Rumination and perceived social support from significant others interact to predict eating disorder attitudes and behaviors in university students

University students are at a greater risk for eating disorder attitudes and behaviors (EDAB) compared to the general population. This study examined the roles of rumination and perceived social support (PSS) from three domains in the occurrence of EDAB. Participants: A sample of students (N= 300) attending a rural Midwestern university. Methods: Participants completed online surveys which collected demographic information and assessed eating disorders, rumination, and PSS. Pearson's correlation and moderated regression were performed for analysis. Results: Of the sample, 63.6% of participants identified as women, 34.8% as men, and 1.7% with another gender. PSS from family and friends was negatively associated with EDAB. Rumination was positively associated with EDAB. High rumination and high PSS from significant others interacted to predict eating, shape, and weight concerns, but not dietary restraint. Conclusions: Findings support incorporating screening tools for PSS and rumination at on-campus counseling sessions to identify students at risk for EDAB.

"The Food Matches the Mood": Experiences of Eating Disorders in Bipolar Disorder

Approximately 33% of those with bipolar disorder (BD) have a comorbid eating disorder (ED). However, the trajectory of these conditions has received little research attention. Nine participants who met criteria for BD and an ED participated in qualitative interviews exploring experiences of illness onset, the interaction of these conditions, and service provision. Almost all participants in the sample reported minimal to no screening of ED problems, despite their health professionals' frequent discussion of obesity. Findings suggested that ED features were diverse and evolved over time. Mania and depression were connected to ED features such as overeating and restricting, but this differed between and within participants. Most participants disclosed historic trauma which they considered central to their mental health concerns. This clinical group appears to be underserviced. Clinicians and researchers should routinely screen for ED features when treating and diagnosing BD to inform their physical and mental health interventions.

ANZAED eating disorder treatment principles and general clinical practice and training standards

INTRODUCTION

Eating disorders are complex to manage, and there is limited guidance around the depth and breadth of knowledge, skills and experience required by treatment providers. The Australia & New Zealand Academy for Eating Disorders (ANZAED) convened an expert group of eating disorder researchers and clinicians to define the clinical practice and training standards recommended for mental health professionals and dietitians providing treatment for individuals with an eating disorder. General principles and clinical practice standards were first developed, after which separate mental health professional and dietitian standards were drafted and collated by the appropriate members of the expert group. The subsequent review process included four stages of consultation and document revision: (1) expert reviewers; (2) a face-to-face consultation workshop attended by approximately 100 health professionals working within the sector; (3) an extensive open access online consultation process; and (4) consultation with key professional and consumer/carer stakeholder organisations.

RECOMMENDATIONS

The resulting paper outlines and describes the following eight eating disorder treatment principles: (1) early intervention is essential; (2) co-ordination of services is fundamental to all service models; (3) services must be evidence-based; (4) involvement of significant others in service provision is highly desirable; (5) a personalised treatment approach is required for all patients; (6) education and/or psychoeducation is included in all interventions; (7) multidisciplinary care is required and (8) a skilled workforce is necessary. Seven general clinical practice standards are also discussed, including: (1) diagnosis and assessment; (2) the multidisciplinary care team; (3) a positive therapeutic alliance; (4) knowledge of evidence-based treatment; (5) knowledge of levels of care; (6) relapse prevention; and (7) professional responsibility.

CONCLUSIONS

These principles and standards provide guidance to professional training programs and service providers on the development of knowledge required as a foundation on which to build competent practice in the eating disorder field. Implementing these standards aims to bring treatment closer to best practice, and consequently improve treatment outcomes, reduce financial cost to patients and services and improve patient quality of life.

Compulsão alimentar periódica: aspecto negligenciado na abordagem de pacientes com síndrome metabólica

A obesidade, um dos principais componentes da síndrome metabólica frequentemente associa-se à compulsão alimentar periódica (CAP). O objetivo do presente estudo foi avaliar a presença da CAP em mulheres com SM e a possível associação com parâmetros sociodemográficos, clínicos e comportamentais. Em estudo transversal foram selecionados 124 indivíduos com SM, distribuídos em dois grupos: Grupo 1 (ausência de CAP) e Grupo 2 (presença de CAP). A avaliação clínica incluiu medidas de peso e altura, circunferência da cintura e pressão arterial de consultório. Foram também avaliados parâmetros comportamentais, como presença de compulsão alimentar periódica, nível de atividade física, consumo de álcool, imagem corporal, sintomas depressivos e qualidade de vida. A avaliação laboratorial incluiu as dosagens de glicose e insulina, hormônio tiroestimulante, perfil lipídico e taxa de filtração glomerular estimada. Aplicou-se análise estatística através dos testes Qui Quadrado e t de Student. A média de idade das participantes foi 41±10,9 anos e a totalidade da amostra apresentava obesidade abdominal, com média da circunferência da cintura de 110±11,0 cm, 70% eram hipertensas, com média de Pressão Arterial Sistólica de 133±13,0 mmHg e Pressão Arterial Diastólica de 89±11,0 mmHg. Além disso, 95% eram sedentárias, 7% eram fumantes, 12% faziam uso nocivo do álcool, 98% declararam insatisfação com a imagem corporal e 62% apresentavam depressão. Observou-se presença de CAP em 57% das mulheres avaliadas. Houve associação entre CAP e idade, com predomínio na faixa etária entre 20 a 39 anos (p=0,010) e entre CAP e qualidade de vida (p=0,039). Quanto aos parâmetros laboratoriais, não foi observada diferença significativa entre os grupos. Em conclusão, a presença de CAP foi achado frequente em indivíduos com SM, sendo observada associação da CAP com faixa etária mais jovem e com pior qualidade de vida.Palavras-chave: Obesidade; Síndrome metabólica; Transtorno da compulsão alimentar.

Having an Eating Disorder and Still Being Able to Flourish? Examination of Pathological Symptoms and Well-Being as Two Continua of Mental Health in a Clinical Sample

Introduction: Eating Disorders (EDs) are serious psychiatric disorders, impacting physical and psychosocial functioning, often with a chronic course and high mortality rates. The two continua model of mental health states that mental health is a complete state, that is, not merely the absence of mental illness, but also the presence of mental health. This model was studied among ED patients by examining the presence and correlates of well-being and psychopathology. In addition, the levels of well-being were compared to the Dutch general population. Method: A total of 468 female ED patients participated in this study during application and intake at a specialized ED treatment Center in the Netherlands. They filled out questionnaires about well-being (MHC-SF), general psychopathology (OQ-45), and ED psychopathology (EDE-Q). Categorical andmean well-being levels were calculated. Also, the relationships between these variables were examined with Pearson correlation and multiple hierarchical regression analysis. Results: ED patients showed lower levels of emotional, psychological, and social well-being on average compared to the general population. About 26% of the ED patients experienced low levels of well-being (languishing). However, also 13% experienced high levels of well-being (flourishing), varying between 9% in Anorexia Nervosa to 25% in Binge Eating Disorder. ED psychopathology and general well-being showed a moderate negative correlation. For patients with Bulimia Nervosa and Binge Eating Disorder however no such correlation was found. Lower general psychopathology, not having a history of hospitalization for the ED, and adaptive personal functioning were correlated with well-being among ED patients. Conclusion: This study shows initial support for the two continua model of mental health among ED patients. Psychopathology and well-being should be considered as related, but distinct dimensions of mental health in ED patients. Further research should focus on the possible reciprocal relationships between psychopathology and well-being during recovery. It is recommended to monitor well-being during treatment and to implement interventions for well-being to realize complete recovery for those patients with inadequate levels of well-being.

Implementation of a Positive Technology Application in Patients With Eating Disorders: A Pilot Randomized Control Trial

Background: Positive psychological interventions (PPIs) have been suggested to produce benefits in patients with eating disorders (ED) by improving well-being, which might act as a buffer of the harmful effects caused by the disorder. Best Possible Self (BPS) is a PPI which consists of writing and envisioning a future where everything has turned out in the best possible way. In this regard, positive technology (PT) can be of considerable benefit as it allows to implement specific PPIs that have already shown efficacy.

Objective: This study tested the preliminary efficacy of the BPS exercise implemented through a PT application and carried out for 1 month, in improving positive functioning measures, compared to a control condition, in patients with ED. Follow-up effects were also explored at 1 and 3 months later.

Methods: This is a pilot randomized controlled trial, with two experimental conditions. Participants were 54 outpatients, who were receiving ongoing specialized treatment in ED services. 29 participants were randomly allocated to the BPS intervention and 25 to the control exercise. The sample was composed mostly by females and the mean age was 27 years. In the intervention group, participants had to write about their BPS. In the control group participants had to write about their daily activities. The exercise was conducted through the Book of Life, which is a PT application that allows users to add multimedia materials to the written content. Measures of future expectations, affect, dispositional optimism, hope and self-efficacy were assessed at different time frames.

Results: Findings showed that all participants improved over time and there were no statistically significant differences between conditions on the specific measures. These effects were not influenced by prior levels of ED severity. Within-group effect sizes indicate a greater benefit for the participants in the BPS condition, compared to the control condition, on nearly all the measures.

Conclusion: Results indicated that PT produced modest improvements in patients with EDs that are receiving current treatment for ED. More empirical attention is needed to explore the potential benefits of PPIs as supporting tools in the prevention and treatment of EDs.

Trial registration: clinicaltrails.gov Identifier: NCT03003910, retrospectively registered December 27, 2016.

Identifying fundamental criteria for eating disorder recovery: a systematic review and qualitative meta-analysis

BACKGROUND

Outcome studies for eating disorders regularly measure pathology change or remission as the only outcome. Researchers, patients and recovered individuals highlight the importance of using additional criteria for measuring eating disorder recovery. There is no clear consensus on which additional criteria are most fundamental. Studies focusing on the perspectives of recovered patients show criteria which are closely related to dimensions of positive functioning as conceptualized in the complete mental health model. The aim of this study was to identify fundamental criteria for eating disorder recovery according to recovered individuals.

METHODS

A systematic review and a qualitative meta-analytic approach were used. Eighteen studies with recovered individuals and meeting various quality criteria were included. The result sections of the included papers were searched for themes that were stated as criteria for recovery or 'being recovered'. All themes were analyzed using a meta-summary technique. Themes were labeled into criteria for recovery and the frequency of the found criteria was examined.

RESULTS

In addition to the remission of eating disorder pathology, dimensions of psychological well-being and self-adaptability/resilience were found to be fundamental criteria for eating disorder recovery. The most frequently mentioned criteria were: self-acceptance, positive relationships, personal growth, decrease in eating disorder behavior/cognitions, self-adaptability/resilience and autonomy.

CONCLUSIONS

People who have recovered rate psychological well-being as a central criterion for ED recovery in addition to the remission of eating disorder symptoms. Supplementary criteria, besides symptom remission, are needed to measure recovery. We recommend including measurements of psychological well-being and self-adaptability/resilience in future research, such as outcome studies and in routine outcome measurement.

Perfectionism, emotion dysregulation, and affective disturbance in relation to clinical impairment in college-age women at high risk for or with eating disorders

Individuals with eating disorders (EDs) demonstrate impaired quality of life; however, less than one-third report severe clinical impairment. Thus, it is important to determine factors that may identify those who are most likely to report marked impairment. Perfectionism, emotion dysregulation, and aspects of affective disturbance, such as anxiety and depression, are independently associated with eating pathology and clinical impairment in eating and other disorders. However, little research has explored these three factors concurrently in relation to eating pathology. It is possible that the combined interaction effect of these constructs could be especially harmful. The current study examined the influence of these constructs and their interactions on clinical impairment in college-aged women at high risk for or with a DSM-5 clinical or subclinical ED. Although the three-way interaction of perfectionism, emotion dysregulation, and affective disturbance (i.e., anxiety or depression) was not significant, the two-way interaction between perfectionism and emotion dysregulation was significant such that those who were high in both perfectionism and emotion dysregulation reported the highest levels of clinical impairment. This suggests that the combination of perfectionism and emotion dysregulation may be especially problematic for those with or at high risk for EDs. Interestingly, perfectionism alone was not a predictor of clinical impairment when accounting for the other constructs, implying that perfectionism may have a greater impact when in conjunction with emotion dysregulation. Understanding the impact of combined perfectionistic tendencies and emotion dysregulation on clinical impairment may better inform treatment and more directly target contributors to impaired quality of life.

Predictors of change in psychosocial impairment secondary to an eating disorder

Eating disorders (ED) can significantly impair psychosocial health in patients. However, no published studies have so far used a standardized and specific instrument to evaluate predictive factors in ED-related psychosocial impairment. This prospective cohort study involved 177 patients receiving outpatient treatment for an ED at baseline and 115 patients at the 1-year follow-up. Patients completed three self-administered questionnaires: the Clinical Impairment Assessment (CIA), the Eating Attitudes Test-12 (EAT-12), and the Health-Related Quality of Life in ED-short form (HeRQoLED-s). Descriptive statistics, ANOVA, chi-square, and Fisher's exact test were applied to examine intervariable relationships. Multivariate linear regression was used to determine predictors of change in CIA scores. An improvement was reported by patients with restrictive anorexia nervosa (AN) compared to those with purgative AN. In the multivariate analysis, employment status, subtype of ED, and the bulimia and food preoccupation factor of the EAT-12 were significant predictors of change in the CIA scores.

Development and Psychometric Validation of the EDE-QS, a 12 Item Short Form of the Eating Disorder Examination Questionnaire (EDE-Q)

Objective

The aim of this study was to develop and validate a short form of the Eating Disorder Examination Questionnaire (EDE-Q) for routine, including session by session, outcome assessment.

Method

The current, 28-item version (6.0) of the EDE-Q was completed by 489 individuals aged 18–72 with various eating disorders recruited from three UK specialist eating disorder services. Rasch analysis was carried out on factors identified by means of principal component analysis, which in combination with expert ratings informed the development of an EDE-Q short form. The shortened questionnaire’s reliability, validity and sensitivity was assessed based on online data collected from students of a UK university and volunteers with a history of eating disorders recruited from a national eating disorders charity aged 18–74 (N = 559).

Results

A 12-item short form, the Eating Disorder Examination Questionnaire Short (EDE-QS) was derived. The new measure showed high internal consistency (Cronbach’s α = .913) and temporal stability (ICC = .93; p < .001). It was highly correlated with the original EDE-Q (r = .91 for people without ED; r = .82 for people with ED) and other measures of eating disorder and comorbid psychopathology. It was sufficiently sensitive to distinguish between people with and without eating disorders.

Discussion

The EDE-QS is a brief, reliable and valid measure of eating disorder symptom severity that performs similarly to the EDE-Q and that lends itself for the use of sessional outcome monitoring in treatment and research.

Incidence of eating disorders in Danish psychiatric secondary healthcare 1970-2008

OBJECTIVE

Is an increased focus on eating disorders during the past few decades reflected by increasing occurrence in the psychiatric health service system.

METHOD

All first-time diagnoses of eating disorders identified in the Danish Central Psychiatric Research Register 1970-2008 constitute the present research database. Age-standardized rates per 100,000 inhabitants were calculated and autoregressive models were fitted for males and females separately as well as for in- and outpatients.

RESULTS

The incidence of eating disorders diagnosed in Danish psychiatric secondary healthcare has increased considerably during a nearly 40-year period of observation both within the general category of eating disorders and also specifically for anorexia nervosa. The steepest increase is seen within females aged 15-19 years, where the highest incidences are also found. Anorexia nervosa constitutes the vast majority of all eating disorders. Throughout the time interval investigated, the number of males, however, is negligible compared to females. Most patients are seen in outpatient services, increasing towards recent years. However, the number of patients being treated as inpatients has increased linearly through the entire four decenniums investigated.

CONCLUSIONS

Changes in registration principles, public awareness and higher acceptance of mental disorders in the public is the most obvious explanation for the incidence increase of anorexia nervosa and other eating disorders. This study does not answer whether there has been an increase in true incidence in the population.

Prevalence of Eating Disorder Risk and Associations with Health-related Quality of Life: Results from a Large School-based Population Screening

OBJECTIVE

The objective of this study was to investigate the prevalence of eating disorder (ED) risk as well as associated psychopathology and health-related quality of life (HrQoL) in a large population sample of Austrian adolescents.

METHOD

A sample of 3610 adolescents aged 10-18 years was recruited from 261 schools representative for the Austrian population. The SCOFF questionnaire was used to identify participants at risk for EDs, and the Youth Self-Report and KIDSCREEN were used to assess general psychopathology and HrQoL.

RESULTS

In total, 30.9% of girls and 14.6% of boys were screened at risk for EDs. SCOFF scores were significantly associated with internalising and externalising behavioural problems as well as HrQoL after controlling for sex, age and body mass index. The SCOFF score further turned out to be an independent predictor of HrQoL.

DISCUSSION

The high prevalence of ED risk among Austrian adolescents points out the need for prevention in this field. Variables indicating eating pathology should be included in general mental health screenings.

Quantitative and Qualitative Analysis of the Quality of Life of Individuals With Eating Disorders

OBJECTIVE

To examine the quality of a broad range of life domains using both quantitative and qualitative methodologies.

METHOD

Forty-eight individuals seeking inpatient treatment for an eating disorder (mean age = 29.8 years, female = 100%, white = 96.4%) from 2007 to 2009 completed the Quality of Life Inventory (QOLI) and the Eating Disorder Examination Questionnaire; a medical chart review confirmed diagnosis and treatment history. Patients diagnosed with anorexia nervosa (n = 24) and bulimia nervosa (n = 24) were compared. Body mass index (kg/m(2)), treatment history, number of comorbid psychiatric conditions, and eating disorder severity were used to predict quality of life. Finally, an inductive content analysis was performed on qualitative QOLI responses to contextualize the quantitative findings.

RESULTS

Participants with anorexia nervosa, compared to those with bulimia nervosa, reported significantly less satisfaction with the domain of relatives (F 1,46 = 5.35; P = .025); no other significant group differences were found. The only significant predictor of QOLI global score was number of previous treatments (F 1,41 = 8.67; P = .005; R (2) = 0.175). Content analysis of qualitative data yielded complementary findings to the quantitative data; interesting group differences emerged for satisfaction with health with implications for measuring quality of life domains.

CONCLUSIONS

Across several life domains, individuals seeking treatment for anorexia nervosa and bulimia nervosa appear to have similar levels of satisfaction, as evidenced by numeric and descriptive responses. Satisfaction with relatives, however, appears to differ between groups and suggests a specific target for intervention among patients in treatment for anorexia nervosa (eg, a family-based intervention such as the Maudsley approach). The use of quantitative and qualitative assessments, such as the QOLI, provides more clinically meaningful, contextualized information about quality of life than traditional self-report assessments alone.

Adaptation and validation of the Spanish version of the Clinical Impairment Assessment Questionnaire

The Clinical Impairment Assessment (CIA) assesses psychosocial impairment secondary to an eating disorder. The aim of this study was to create and validate a Spanish-language version of the CIA. Using a forward-backward translation methodology, we translated the CIA into Spanish and evaluated its psychometric characteristics in a clinical sample of 178 ED patients. Cronbach's alpha values, confirmatory factor analysis (CFA), and correlations between the CIA and the Eating Attitudes Test-12 and the Health-Related Quality of Life in ED-short form questionnaires evaluated the reliability, construct validity, and convergent validity, respectively. Known-groups validity was also studied comparing the CIA according to different groups; responsiveness was assessed by means of effect sizes. Data revealed a three-factor structure similar to that of the original CIA. Cronbach alpha coefficient of 0.91 for the total CIA score supported its internal consistency and correlations with other instruments demonstrated convergent validity. The total CIA score and factor scores also significantly discriminated between employment status, evidencing known-groups validity. Responsiveness parameters showed moderate changes for patients with restrictive eating disorders. These findings suggest that the CIA can be reliably and validly used in Spain in a number of different clinical contexts, by researchers and clinicians alike.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders

OBJECTIVES

This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013-2014.

METHODS

The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008-2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified.

RESULTS

In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice.

CONCLUSIONS

Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management.

EXPERT REVIEWERS

Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.

Exploring health-related quality of life in eating disorders by a cross-sectional study and a comprehensive review

BACKGROUND

People with eating disorders (ED) often report poor health-related quality of life (HRQoL), which is explicitly correlated to illness' severity and its effects on cognitive performance. We aimed to analyze health-related quality of life (HRQoL) in subgroups of eating disorder (ED) patients by using the brief version of WHOQoL questionnaire (WHOQoL-BREF) before treatment administration. Moreover, in order to compare our findings with other published data, we carried out a comprehensive review of the literature on HRQoL in ED patients.

METHODS

Our review was carried out by means of an accurate data mining of PsychInfo and Medline databases and other available sources. In our cross-sectional study, eighty female ED patients (26 with bulimia nervosa, 33 with anorexia nervosa, 7 with binge eating disorder and 14 with ED not otherwise specified) completed the WHOQoL-BREF. HRQoL scores were compared among ED subgroups and clinical information (presence of previous contacts, length of illness, psychiatric comorbidity) was considered in the analysis.

RESULTS

Our review shows that with few exceptions ED patients have a poorer HRQoL than the healthy population of control and sometimes the mental component of HRQoL is the most involved dimension. Moreover, there are no differences in the HRQoL among ED groups, even if AN patients in some studies have a lower HRQoL scores. Furthermore, BED patients have a poorer HRQoL than obese patients who do not have binge episodes. Finally, all treatments were positively correlated with an improvement on general and specific QoL dimensions. In our sample, ED subgroups differed only for Psychological Health HRQoL scores (F = 4.072, df = 3; p = 0.01). No differences were found between inpatients and outpatients, treatment naïve and previously treated patients and patients with or without psychiatric comorbidity. Moreover, HRQoL scores were not correlated to length of illness within each ED subgroup.

CONCLUSIONS

The analysis of the literature adds some relevant information on HRQoL in ED and may address the future research toward the exploration of specific questions. One of these may be the prominent role of Psychological Health domain in HRQoL, since our study confirms that this component is able to differentiate eating disorders.

Quality of life impairment associated with body dissatisfaction in a general population sample of women

Background

In order to elucidate the individual and community health burden of body dissatisfaction (BD), we examined impairment in quality of life associated with BD in a large, general population sample of women.

Methods

Self-report measures of BD, health-related quality of life (SF-12 Physical and Mental Component Summary scales) and subjective quality of life (WHOQOL-BREF Psychological Functioning and Social Relationships subscales) were completed by 5,255 Australian women aged 18 to 42 years.

Results

Most participants (86.9%) reported some level of dissatisfaction with their weight or shape and more than one third (39.4%) reported moderate to marked dissatisfaction. Higher levels of BD were associated with poorer quality of life for all items of both quality of life measures, the degree of impairment being proportional to the degree of BD. Associations were strongest for items tapping mental health and psychosocial functioning, although greater BD was associated with substantially increased risk of impairment in certain aspects of physical health even when controlling for body weight. Post-hoc analysis indicated that the observed associations between BD and quality of life impairment were not accounted for by an association between BD and eating disorder symptoms.

Conclusions

In women, BD is associated with marked impairment in aspects of quality of life relating to mental health and psycho-social functioning and at least some aspects of physical health, independent of its association with body weight and eating disorder symptoms. Greater attention may need to be given to BD as a public health problem. The fact that BD is “normative” should not be taken to infer that it is benign.

Quality of life impairment and the attitudinal and behavioral features of eating disorders

We examined the relative contribution of different forms of eating disorder (ED) pathology to impairment in mental and physical health-related quality of life (QOL) in women with a wide range of ED symptoms. Female participants from an outpatient ED clinic (n = 53) and the local community (n = 214) completed measures of ED features and mental and physical health-related QOL. Across the sample, ED features were significantly associated with most mental and physical domains of QOL. In multiple regression analyses controlling for age and body mass index, ED features significantly predicted impairment in mental and physical QOL. Extreme shape and weight concern significantly and independently predicted most QOL subscales (β range = 0.19-0.44). The prominent contribution of shape and weight concern to both mental and physical QOL impairment underlines the importance of addressing body dissatisfaction in the treatment and prevention of EDs.