Outcomes of eating disorders: a systematic review of the literature

A comprehensive review on the co-occurrence of scurvy and anorexia nervosa

Scurvy, a rare disease resulting from vitamin C deficiency, can occur in individuals with restrictive eating disorders like anorexia nervosa (AN), leading to severe health complications. This review explores the complex relationship between scurvy and AN, highlighting the overlapping symptoms and challenges in diagnosis and treatment. Vitamin C is essential for collagen synthesis, immune function, and neurotransmitter production, and its deficiency manifests as fatigue, gingival bleeding, joint pain, and perifollicular hemorrhages. AN exacerbates these symptoms through extreme food restriction, causing severe nutritional deficiencies. Analyzing nine case reports, this review reveals that patients with co-occurring AN and scurvy often present with gastrointestinal, psychiatric, and dermatological symptoms. Treatment with vitamin C supplementation typically results in rapid symptom improvement. However, the malnutrition inherent in AN complicates the clinical picture, making timely diagnosis and intervention crucial. This review underscores the importance of a comprehensive, multidisciplinary approach to managing these conditions, emphasizing the need for early recognition and treatment to prevent severe complications. Future research should include a more diverse patient population to enhance understanding of the interplay between AN and scurvy, aiming to improve patient outcomes through tailored treatment strategies.

Body weight and eating attitudes influence improvement of depressive symptoms in children and pre-adolescents with eating disorders: a prospective multicenter cohort study

BACKGROUND

Pediatric patients with eating disorders in a multicenter joint study on 11 facilities were enrolled and prospectively investigated to determine whether improvement in body weight, eating attitudes, and psychosocial factors in children with eating disorders would also improve depressive symptoms.

METHODS

In this study, 91 patients were enrolled between April 2014 and March 2016. The severity of underweight was assessed using the body mass index-standard deviation score (BMI-SDS), eating behavior was assessed using the children's eating attitude test (ChEAT26), the outcome of childhood eating disorders was assessed using the childhood eating disorder outcome scale, and depressive symptoms were assessed using the Children's Depression Inventory (CDI) score.

RESULTS

After 12 months of treatment, depressive symptoms were evaluated in 62 of the 91 cases where it was evaluated at the initial phase. There was no difference in background characteristics between the included patients and the 29 patients who dropped out. A paired-sample t-test revealed a significant decrease in CDI scores after 12 months of treatment (p < 0.001, 95% CI: 2.401-7.373) and a significant increase in the BMI-SDS (p < 0.001, 95% CI: - 2.41973-1.45321). Multiple regression analysis revealed that BMI-SDS and ChEAT26 scores at the initial phase were beneficial in CDI recovery. In addition, BMI-SDS at the initial phase was useful for predicting BMI-SDS recovery after 12 months of treatment.

CONCLUSIONS

Depressive symptoms in children with eating disorders improved with therapeutic intervention on body weight and eating attitudes.

TRIAL REGISTRATION

The Clinical Trial Number for this study is UMIN000055004.

Overall and cause-specific mortality in anorexia nervosa; impact of psychiatric comorbidity and sex in a 40-year follow-up study

OBJECTIVE

This study investigates the overall and cause-specific mortality in males and females with anorexia nervosa (AN) from 1977 to 2018, focusing on the impact of psychiatric comorbidity on mortality risk, a less explored aspect despite a high prevalence in patients with AN.

METHOD

We conducted a nationwide population-based cohort study in Denmark including all patients with AN (n = 14,774) with a median follow-up time of 9.1 years and a 1:10 age- and sex-matched general population comparison cohort. Using Cox proportional hazard model, we calculated adjusted hazard ratios (aHR) for death stratified by psychiatric comorbidity, sex, and age at AN onset and evaluated the causes of death using Fine and Gray sub-distribution hazard ratios (SHR).

RESULTS

In patients with AN, the weighted average aHR for all-cause mortality was 4.5 [95% CI 4.1-4.9] with up to 40 years follow-up. Psychiatric comorbidity was present in 47% of patients with AN at index date, which was associated with a 1.9-fold increase in 10-year mortality compared with patients without comorbidity and a notably four-fold increase, when diagnosed at age 6-25 years. The mortality risk was similar according to sex. 13.9% of all deaths in patients with AN were due to suicide (SHR 10.7 [8.1-14.2]). The risk of dying of natural causes was increased with a SHR of 3.8 [95% CI 3.4-4.2].

DISCUSSION

The increased mortality risk in both males and females with AN and psychiatric comorbidity, particularly when diagnosed at young age, underscores the need for comprehensive treatment addressing both AN and coexisting psychiatric conditions.

PUBLIC SIGNIFICANCE

The mortality in patients with anorexia nervosa (AN) is high and we show in our study that the mortality is doubled in the presence of psychiatric comorbidity particularly the first 10 years after diagnosis seen in both sexes and with suicide as a major cause of death. These findings stress the importance of detection and treatment of psychiatric comorbidities alongside the eating disorder to prevent fatal outcome.

Exploring the associations between muscularity teasing and eating and body image disturbances in Chinese men and women

This study described muscularity teasing in both men and women and explored its associations with eating and body image disturbances in adults from China. A total of 900 Chinese adults (50% women) were recruited online. Correlation and regression analyses were conducted to examine the relationships between muscularity teasing and a battery of measures on eating and body image disturbances. Gender differences in the associations were examined. Men reported more muscularity teasing than women (31.6% men vs. 15.6% women; χ2(1,N = 900) = 31.99, p < .001). Muscularity teasing was significantly and positively correlated with all measures in both men and women. Muscularity teasing explained significant, unique variance in all measures for men and women, except for body fat dissatisfaction in women, beyond covariates (i.e., age, body mass index, and weight teasing). The relationships between muscularity teasing and eating and body image disturbances were generally stronger in men than women. Findings further suggest that muscularity teasing is an important factor related to eating and body image disturbances in men and women, but muscularity teasing might be more detrimental to men's eating behaviors and body image. Future research is needed to further explore the directionality and mechanisms of the links between muscularity teasing and eating and body image disturbances.

Care pathways for longstanding eating disorders must offer paths to recovery, not managed decline

Eating disorders are historically underserved in healthcare, but are increasingly prevalent and recognised for their high costs regarding mortality, quality of life and the economy. Those with longstanding eating disorders are commonly labelled 'severe and enduring' (SEED), which has been challenged for its conceptual vagueness and potential to discourage patients. Attempts to define individuals from this cohort as having 'terminal' illness have also gained traction in recent years. This paper is grounded in lived/living experience and relevant research. It challenges the logical coherence and utility of SEED, arguing that the word 'enduring' unhelpfully situates intractability of longstanding illness within patients themselves and the nature of their illness. This risks a sense of inevitability and overlooks the important role of contextual factors such as lacking resources and insufficient evidence for withholding active treatment. Recommendations suggest approaches to dismantling unhelpful binaries between early intervention and intensive support, recovery and decline.

Remote family education and support program for parents of patients with adolescent and early adulthood eating disorders based on interpersonal psychotherapy: study protocol for a pilot randomized controlled trial

BACKGROUND

In cases of adolescent and early adulthood eating disorders, despite the importance of the patients' relationship with their parents, conflict and confusion frequently occur among them. Interpersonal psychotherapy (IPT) is a present-focused psychotherapy that emphasizes the interpersonal context of symptoms. We developed a remote family education and support program exclusively for parents of patients with eating disorders, based on the principle of IPT. The use of IPT is expected to reduce conflicts in the patient-parent relationship. Consequently, parents will be better able to listen to patients, and patients will be better able to express their thoughts and desires. In this study, we describe the protocol for a randomized controlled trial designed to examine the effectiveness of this program in promoting effective communication in their home based on active listening skills of parents of patients with adolescent and early adulthood eating disorders.

METHODS

Participants will be parents of patients aged 12-29 years with adolescent and early adulthood eating disorders. Individually randomized, parallel-group trial design will be employed. Seventy participants will be allocated to one of two treatment conditions: (1) remote family education and support program (four, 150 min weekly group sessions) for parents plus treatment-as-usual for patients (consultation by physicians or no treatment), or (2) waiting for the control condition (parents will wait to start the program for 8 weeks) plus treatment-as-usual for patients. The primary outcome measure will be parents' active listening ability as measured by the Active Listening Attitude Scale at 8 weeks after randomization. Additionally, perception of social support (Social Provision Scale-10 item), loneliness (UCLA Loneliness Scale), mental health status (K6), family function (Family Assessment Device), and parent-evaluated eating disorder symptoms (Anorectic Behavior Observation Scale) will be assessed. Data from the intention-to-treat sample will be analyzed 8 weeks after randomization.

DISCUSSION

This is the first study to evaluate the effectiveness of a family education and support program for parents of patients with adolescent and early adulthood eating disorders based on IPT. If this type of intervention is effective, although indirect, it could be a new support method for this patient population.

TRIAL REGISTRATION

Clinical Trials. gov ID NCT05840614.

Inpatient admissions and mortality of anorexia nervosa patients according to their preceding psychiatric and somatic diagnoses

OBJECTIVE

Anorexia nervosa (AN) is associated with increased risk of mortality, but little is known about the risk of inpatient admissions and mortality outcomes in individuals with diagnoses of both AN and other psychiatric and somatic conditions. We aimed to investigate the inpatient admissions and mortality among people with AN and other diagnosed conditions using Danish national registers.

METHOD

This retrospective cohort study included individuals diagnosed with AN in Denmark, born 1977-2010. We identified other mental and somatic conditions in this population. We used Cox proportional hazards regression to estimate the risk of inpatient admission and mortality, focusing on (i) the number of other diagnosed conditions, and (ii) specific combinations of conditions diagnosed prior to the AN diagnosis. Categories of inpatient admissions considered were due to: (i) AN, (ii) any psychiatric disorder, and (iii) any somatic disorder. Additionally, competing risks survival analysis was used to calculate the cumulative incidence of inpatient admission and all-cause mortality over the follow-up period.

RESULTS

The study population included 11,489 individuals. The most common conditions individuals had prior to their AN diagnosis were other eating disorders (34.5%) and anxiety disorders (32.7%). During the follow-up, 3184 (27.7%), 4604 (40.1%), and 6636 (57.8%) individuals were admitted for AN, any psychiatric disorder, and any somatic disorder, respectively; and in total 106 (0.9%) died. The risk of all outcomes was highest among those who had received a higher number of other diagnoses. For most combinations, the risks of admission and mortality were increased.

DISCUSSION

Our study presents the prevalence of other conditions in patients with AN in Denmark and elucidates their association with higher rates of inpatient admission and mortality. Our findings highlight the need for comprehensive, multidisciplinary care of patients with AN considering the spectrum of other diagnosed conditions to improve health outcomes.

The United Kingdom Eating Disorders Genetics Initiative

OBJECTIVE

The United Kingdom Eating Disorders Genetics Initiative (EDGI UK), part of the National Institute for Health and Care Research (NIHR) Mental Health BioResource, aims to deepen our understanding of the environmental and genetic etiology of eating disorders. EDGI UK launched in February 2020 and is partnered with the UK eating disorders charity, Beat. Multiple EDGI branches exist worldwide. This article serves the dual function of providing an in-depth description of our study protocol and of describing our initial sample including demographics, diagnoses, and physical and psychiatric comorbidities.

METHOD

EDGI UK recruits via media and clinical services. Anyone living in England, at least 16 years old, with a lifetime probable or clinical eating disorder is eligible to sign up online: edgiuk.org. Participants complete online questionnaires, donate a saliva sample for genetic analysis, and consent to medical record linkage and recontact for future studies.

RESULTS

As of September 2022, EDGI UK recruited 7435 survey participants: 98% female, 93.1% white, 97.8% cisgender, 65.9% heterosexual, and 52.1% have a university degree. Over half (57.8%) of these participants have returned their saliva DNA kit. The most common diagnoses are anorexia nervosa (48.3%), purging disorder (37.8%), bulimia nervosa (37.5%), binge-eating disorder (15.8%), and atypical anorexia nervosa (7.8%).

CONCLUSION

EDGI UK is the largest UK eating disorders study and efforts to increase its diversity are underway. It offers a unique opportunity to accelerate eating disorder research. Researchers and participants with lived experience can collaborate on projects with unparalleled sample size.

PUBLIC SIGNIFICANCE STATEMENT

Eating disorders are debilitating and costly for society but are under-researched due to underfunding. EDGI UK is one of the largest eating disorder studies worldwide with ongoing recruitment. The collected data constitute a resource for secondary analysis. We will combine data from all international EDGI branches and the NIHR BioResource to facilitate research that improves our understanding of eating disorders and their comorbidities.

A systematic review of weight stigma and disordered eating cognitions and behaviors

Weight stigma is persistent across contexts and is associated with disordered eating cognitions and behaviors. This systematic review aimed to examine the existing literature that has explored the relationship between weight stigma and disordered eating cognitions and behaviors. We specifically examined three dimensions of weight stigma - experienced, anticipated, and internalized - and adopted an inclusive conceptualization of outcomes related to disordered eating (including constructs such as binge eating, body dissatisfaction, and other cognitions and behaviors such as dietary restraint, unhealthy weight control behaviors, and drive for thinness). We searched PubMed, Embase, CINAHL, Web of Science, Sociological Abstracts, and PsycINFO for English-language, peer-reviewed articles and dissertations with quantitative methodology published through October 2023. The search resulted in 242 articles meeting inclusion criteria. A narrative review found a consistent relationship between greater weight stigma and more disordered eating cognitions and behaviors. Methodological and theoretical limitations are discussed, as are critical avenues for future research and potential clinical implications stemming from this body of research. Given the widespread nature and impact of weight stigma on disordered eating, it is imperative that we intervene to address weight stigma at all levels, from the structural to the intrapersonal.

Performing well but not appreciating it - A trait feature of anorexia nervosa

Background

Despite advances in the etiology of anorexia nervosa (AN), a large subgroup of individuals does not profit optimally from treatment. Perfectionism has been found to be a risk factor predicting the onset, severity, and duration of AN episodes. To date, perfectionism has been studied predominantly by the use of self-report questionnaires, a useful approach that may, however, be impacted by demand characteristics, or other distortions of introspective or metacognitive access.

Methods

Here we circumvent these problems via a behavioral paradigm in which participants perform a modified Go/NoGo task, whilst self-evaluating their performance. We compared a group of 33 adolescent females during their first episode of AN (age = 16.0) with 29 female controls (age = 16.2), and 23 adolescent girls recovered from AN (age = 18.3) with 23 female controls (age = 18.5). The controls were closely matched by intelligence quotient and age to the two clinical groups.

Results

First-episode AN and control participants performed equally well on the task (reaction time and errors of commission), whereas the recovered group displayed significantly faster reaction times but incurred the same error rate. Despite performing at least as good as and predominantly better than control groups, both clinical groups evaluated their performances more negatively than controls.

Conclusion

We offer a novel behavioral method for measuring perfectionism independent of self-report, and we provide tentative evidence that this behavioral manifestation of perfectionism is evident during first-episode AN and persists even after recovery.

An Update on Eating Disorders

Abstract:

It is no surprise that eating disorders (EDs) are increasing all over the planet. With the emergence of global westernization, development in technology, and societal changes, nearly all regions of the globe have been influenced by the concept of a perfect body image and height. EDs are a considerable public concern, a bewilderment for psychologists and a challenge for physicians. The primary EDs include anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). AN is an ED that is psychological and possibly life-threatening. Usually, people with AN experience an exceedingly low body weight due to their height and body shape. The highest rate of occurrence is between 14 and 17 years of age. BN is an extreme, lifethreatening, neurological ED in which you have binge eating cycles. You may not have any sense of balance in your diet throughout these binges. The weight-control engagement of patients with AN and BN results in various physiological shifts. EDs can control your lives and can be quite hard to cope with. Yet you will develop a better understanding of who you are by therapy, return to healthy eating and exercise, and undo any of the severe complications of AN. Investigation into EDs has yielded valuable new information over the past few decades, notably involving the psychological features and care of patients. The purpose of this study/review is to expand the knowledge of the people about these EDs, their global burden, diagnostic criteria, risk factors, medical complications, management, and the newly added avoidant/restrictive food intake disorder.

Which Symptoms Bridge Symptoms of Depression and Symptoms of Eating Disorders?: A Network Analysis

ABSTRACT

Depression is a common comorbid mental illness in eating disorders (EDs). Network theory focuses on interactions between symptoms, but findings from network analyses of EDs and depression need to be replicated to make reliable claims about the nature of symptomatic interplay. We used cross-sectional data of 366 online-recruited participants with clinically elevated ED symptomatology and constructed a regularized partial correlation network with ED and depression symptoms. To determine each symptom's influence, we calculated expected influence (EI) and bridge EI to identify symptoms that bridged symptoms of depression and ED. Concerns that others see one eat, fear of weight gain, and fear of loss of control over eating were especially important among the ED symptoms. Loss of interest and feeling sad were the key depression symptoms. Eating in secret and low self-esteem emerged as potential bridge symptoms between clusters. These findings regarding bridge symptoms partially overlap with prior network analyses in nonclinical and clinical samples. Future studies that investigate symptom interplay via a longitudinal design to deduce causality are needed.

Development and validation of a prognostic index for mental health and substance use disorder burden

OBJECTIVE

To develop an accessible index which quantifies MHSUD burden among patients of Veterans Affairs hospitals.

METHOD

We used 21 disorder categories provided by the diagnostic and statistical manual (DSM) to characterize diagnoses among primary care (PC) patients. For each patient, we generated counts of unique disorder categories present during the PC encounter or in the year prior. We used these counts to generate multiple indexes, which we compared in a 60% training sample of our population. Using model fit statistics generated from ordered multinomial logistic regressions, we identified the subset of DSM categories which, structured as index, were most predictive of MHSUD hospitalization and death. We validated and fine-tuned the form of the selected index in the full population using measures of calibration and discrimination.

RESULTS

In model development, the index (I-6) which best fit the data (R2 = 0.191) included the following six disorder categories: substance use, depressive, psychotic, bipolar, trauma, and personality. When applied in the full population and weighted by disorder severity, this index demonstrated good predictive discrimination for MHSUD death (C = 0.66) and hospitalization (C = 0.88) and was well calibrated in comparisons of observed versus predicted outcomes.

CONCLUSIONS

We recommend the I-6 as a parsimonious and effective tool for MHSUD burden risk adjustment.

Beyond generalized anxiety: the association of anxiety sensitivity with disordered eating

BACKGROUND

Anxiety and eating disorders (EDs) are rising at alarming rates. These mental health disorders are often comorbid, yet the factors associated with their comorbidity are not well understood. The present study examined a theoretical model of the pathways and relative associations of anxiety sensitivity (AS) with different dimensions of ED risk, controlling for generalized anxiety.

METHODS

Participants (N = 795) were undergraduate students with an average age of 21 (SD = 4.02), predominantly female (71%), and Hispanic (71.8%). Participants completed an online survey with established measures of AS (i.e., Anxiety Sensitivity Index-3; ASI-3), general anxiety (i.e., Beck Anxiety Inventory; BAI), and eating behaviors (i.e., Eating Attitudes Test-26; EAT-26).

RESULTS

The results of our structural equation models indicated that AS subscales were significantly associated with dimensions of the EAT-26, even when controlling for generalized anxiety. Specifically, the ASI-3 factors reflecting cognitive and social concerns provided the most consistent significant associations with EDs. Whereas reporting higher cognitive concerns was associated with higher ED symptoms (e.g., reporting the urge to vomit after a meal), reporting higher social concerns was associated with fewer ED symptoms. These differential results may suggest risk and resilience pathways and potential protective or buffering effects of social concerns on ED risk.

DISCUSSION

Findings advance understanding of the role of AS in the comorbidity of anxiety and EDs, demonstrating the strong association of AS with ED pathology. These findings provide cognitive indicators for transdiagnostic therapeutic intervention in order to reduce the risk of EDs.

Narrative review of inpatient nutritional management of anorexia nervosa with management recommendations for Australian tertiary health services

BACKGROUND

Patients with anorexia nervosa (AN) may experience life-threatening malnutrition-related complications requiring inpatient medical stabilisation. Several management guidelines have been developed but discrepancies exist because of limited high-level evidence.

AIMS

To review the evidence base for recommendations contained in Victorian health services guidelines for the nutritional management of inpatients with AN.

METHODS

MEDLINE and Embase databases were searched for published studies on the nutritional management of inpatients with AN, combined with a manual search through citations. Studies including patients with AN aged 16 years and older were included. Case reports, small case series of <10 patients, studies of nonmedical management and studies with an exclusive paediatric population were excluded. The search results were compared with AN inpatient medical management guidelines sourced from large tertiary health services across Victoria, Australia.

RESULTS

The search yielded 584 studies, subsequently reduced to nine studies using the inclusion and exclusion criteria. The results suggest that commencing refeeding at a higher caloric value allows faster weight gain and shorter hospitalisation. Enteral tube feeding is preferential to parenteral nutrition because of infrequent and milder complications. Zinc supplementation showed a doubled rate of body mass index increase compared with placebo. Comparison with Victorian health services guidelines revealed inconsistent recommendations for high-calorie refeeding and micronutrient supplementation.

CONCLUSION

The evidence supports high-calorie refeeding of 2000 kcal/day in AN inpatient medical management and zinc supplementation in improving the rate of weight restoration. This is inconsistently reflected in different Victorian health services guidelines. Updated national consensus guidelines could assist in improving consistency of evidence-based health care.

When the clinic becomes home: on the limits of kinship care in an eating disorder treatment centre in Italy

Drawing on fieldwork in a public residential facility for eating disorders in central Italy, the paper examines the relational temporalities of therapeutics by looking at how time affects treatment at the intersection of professional and family care practices. In arguing that 'chronic cases' put into question the specific kind of kinship care that is at the basis of treatment, the paper contributes to the anthropological literature on eating disorders by bringing time under the analytical lens, and to the literature on 'chronicity' by complicating simplified assumptions about structural care problems. In addition, the paper draws on and goes beyond anthropological works that have highlighted the potentially harmful side of kinship - including those that have explored how kinship can be framed as a source of mental distress and at the same time as a therapeutic tool. Kinship as a therapeutic tool here becomes risky because professionals need to borrow from kinship practices in their own work with patients, balancing those with the necessary clinical detachment. The paper shows that the time chronic patients need in residential treatment generates a particularly complex mix between what is seen as 'functional' and what is seen as 'dysfunctional' in kinship care, because the 'efficacy' of the kinship work that is at the basis of treatment rests on that being partial and temporary. Long term care in the facility complicates what otherwise allows clinical detachment: the treatment team ends up literally substituting the patient's family, with professional and family care mixing 'too much' with one another.

Risk factors for anorexia nervosa: A population-based investigation of sex differences in polygenic risk and early life exposures

OBJECTIVE

To examine sex differences in risk factors for anorexia nervosa (AN).

METHOD

This population-based study involved 44,743 individuals (6,239 AN cases including 5,818 females and 421 males, and 38,504 controls including 18,818 females and 19,686 males) born in Denmark between May 1981 and December 2009. Follow-up began on the individual's sixth birthday and ended at AN diagnosis, emigration, death, or December 31, 2016, whichever occurred first. Exposures included socioeconomic status (SES), pregnancy, birth, and early childhood factors based on data from Danish registers, and psychiatric and metabolic polygenic risk scores (PRS) based on genetic data. Hazard ratios were estimated using weighted Cox proportional hazards models stratified by sex (assigned at birth), with AN diagnosis as the outcome.

RESULTS

The effects of early life exposures and PRS on AN risk were comparable between females and males. Although we observed some differences in the magnitude and direction of effects, there were no significant interactions between sex and SES, pregnancy, birth, or early childhood exposures. The effects of most PRS on AN risk were highly similar between the sexes. We observed significant sex-specific effects of parental psychiatric history and body mass index PRS, though these effects did not survive corrections for multiple comparisons.

CONCLUSIONS

Risk factors for AN are comparable between females and males. Collaboration across countries with large registers is needed to further investigate sex-specific effects of genetic, biological, and environmental exposures on AN risk, including exposures in later childhood and adolescence as well as the additive effects of exposures.

PUBLIC SIGNIFICANCE

Sex differences in the prevalence and clinical presentation of AN warrant examination of sex-specific risk factors. This population-based study indicates that the effects of polygenic risk and early life exposures on AN risk are comparable between females and males. Collaboration between countries with large registers is needed to further investigate sex-specific AN risk factors and improve early identification of AN.

Can neuroimaging measures differentiate the disease course of anorexia nervosa? A systematic review

Anorexia nervosa (AN) entails many uncertainties regarding the clinical outcome, due to large heterogeneity in the disease course. AN is associated with global decrease in brain volumes and altered brain functioning during acute illness. However, it is unclear whether structural and functional brain alterations can predict clinical outcome. We aimed to systematically review the predictive value of volumetric and functional brain outcome measures of structural and functional brain magnetic resonance imaging (MRI) on the disease course of AN. Four databases (Embase, Medline, Psycinfo, and Cochrane Central Register) were systematically searched. A total of 15 studies (structural MRI: n = 6, functional MRI: n = 9) were reviewed. In total 464 unique AN patients, and 328 controls were included. Follow-up time ranged between 1 and 43 months. Structural neuroimaging studies showed that lower brain volumes of the cerebellum, subcortical grey matter, and cortical white matter at admission predicted a worse clinical outcome. A smaller increase of the anterior cingulate cortex volume in the early phase of the disease predicted a worse clinical outcome. Lower overall gyrification, and a higher clustering coefficient predicted a worse clinical outcome. Functional MRI studies showed that frontal, parietal and temporal activity during task-based algorithms predicted follow-up body mass index, although results were bidirectional possibly due to the large heterogeneity in methodological approaches. Neuroimaging measures may predict the clinical outcome of AN. However, there is a lack of replication studies. Future studies are needed to validate the prognostic utility of neuroimaging measures in AN patients, and should harmonize demographic, clinical and neuroimaging features in order to enhance comparability.

Longitudinal Coupling between Eating Disorder Psychopathology and Depression in Patients with Anorexia Nervosa and Bulimia Nervosa Treated with Enhanced Cognitive Behavior Therapy: A One-Year Follow-Up Study

BACKGROUND

The relationship between eating disorder (ED) specific psychopathology and depressive symptomatology in EDs is often debated. The aim of this study was to provide an explicative model regarding the mechanisms by which enhanced cognitive-behavior therapy (CBT-E) might determine an amelioration of depressive symptoms in patients with anorexia nervosa (AN) or bulimia nervosa (BN).

METHODS

A total of 157 women with AN or BN and no history of childhood trauma or bipolar disorder were evaluated before treatment and after 12 months of CBT-E. Self-administered questionnaires were used to measure ED psychopathology and depressive symptoms.

RESULTS

All psychopathological measures improved after treatment, with no significant additional improvement with the concomitant use of antidepressants. Structural equation modeling using the bivariate latent change score approach showed that higher levels of depressive symptoms at baseline were associated with a worse longitudinal trend of ED psychopathology, and vice versa. Finally, the amelioration of ED psychopathology predicted the improvement in depressive symptoms at follow-up, whereas data did not support the inverse path.

CONCLUSION

This study elucidated the complex longitudinal interplay between ED psychopathology and depression during CBT-E, underlining the importance of addressing ED symptoms as a primary target in the case of comorbidity between AN or BN and depressive symptoms.

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.

Binge Eating, Purging, and Restriction Symptoms: Increasing Accuracy of Prediction Using Machine Learning

Eating disorders are severe mental illnesses characterized by the hallmark behaviors of binge eating, restriction, and purging. These disordered eating behaviors carry extreme impairment and medical complications, regardless of eating disorder diagnosis. Despite the importance of these disordered behaviors to every eating disorder diagnosis, our current models are not able to accurately predict behavior occurrence. The current study utilized machine learning to develop longitudinal predictive models of binge eating, purging, and restriction in an eating disorder sample (N = 60) using real-time intensive longitudinal data. Participants completed four daily assessments of eating disorder symptoms and emotions for 25 days on a smartphone (total data points per participant = 100). Using data, we were able to compute highly accurate prediction models for binge eating, restriction, and purging (.76-.96 accuracy). The ability to accurately predict the occurrence of binge eating, restriction, and purging has crucial implications for the development of preventative interventions for the eating disorders. Machine learning models may be able to accurately predict onset of problematic psychiatric behaviors leading to preventative interventions designed to disrupt engagement in such behaviors.

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

Introduction

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

Method and Results

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

Discussion

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

Therapeutic uses of psychedelics for eating disorders and body dysmorphic disorder

BACKGROUND

Clinical use of psychedelics has gained considerable attention, with promising benefits across a range of mental disorders. Current pharmacological and psychotherapeutic treatments for body dysmorphic disorder (BDD) and eating disorders (EDs) have limited efficacy. As such, other treatment options such as psychedelic-assisted therapies are being explored in these clinical groups.

AIMS

This systematic review evaluates evidence related to the therapeutic potential of psychedelics in individuals diagnosed with BDD and EDs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of all study designs published to the end of February 2022 that identified changes in ED/BDD symptom severity from psychedelics using validated measures to assess symptom changes.

RESULTS

Our search detected a total of 372 studies, of which five met inclusion criteria (two exploratory studies, two case reports, and one prospective study). These were included in the data evaluation. Effects of psychedelics on BDD and various ED symptoms were identified mostly through thematic analyses and self-reports.

CONCLUSIONS

Our findings highlight that more research is needed to determine the safety and efficacy of psychedelics in BDD and EDs and we suggest avenues for future exploration.

Subjective disgust and facial electromyography responses towards unedited and morphed overweight self-pictures in women with varying levels of eating disorder symptomatology

Individuals with an eating disorder (ED) often report to be disgusted by their body. Body-related self-disgust could play an important role in the development and maintenance of EDs. We investigated if women with relatively high ED symptom scores indeed respond with disgust upon exposure to their body as indexed by facial electromyography (fEMG) of the m. levator labii superioris and self-report. Given that one's self-disgust may increase/decrease depending on the relative distance of the own body to the thin ideal, we also assessed women's disgust for overweight- and thin-morphs of their body. Female undergraduate students (N = 104) were photographed and presented with their (morphed) body pictures, next to disgust-relevant and overweight body control pictures. Higher levels of ED symptoms were associated with stronger self-reported disgust to unedited body-pictures and overweight-morphs. Disgust to thin-morphs was unrelated to ED symptoms. Participants generally showed heightened facial disgust towards overweight morphs, yet the strength of facial disgust was unrelated to ED symptoms. Thus, the findings provide evidence for the involvement of heightened body-related self-disgust in ED symptomatology, albeit only on the basis of self-report.

The effect of body image dissatisfaction on goal-directed decision making in a population marked by negative appearance beliefs and disordered eating

Eating disorders are associated with one of the highest mortality rates among all mental disorders, yet there is very little research about them within the newly emerging and promising field of computational psychiatry. As such, we focus on investigating a previously unexplored, yet core aspect of eating disorders-body image dissatisfaction. We continue a freshly opened debate about model-based learning and its trade-off against model-free learning-a proxy for goal-directed and habitual behaviour. We perform a behavioural study that utilises a two-step decision-making task and a reinforcement learning model to understand the effect of body image dissatisfaction on model-based learning in a population characterised by high scores of disordered eating and negative appearance beliefs, as recruited using Prolific. We find a significantly reduced model-based contribution in the body image dissatisfaction task condition in the population of interest as compared to a healthy control. This finding suggests general deficits in deliberate control in this population, leading to habitual, compulsive-like behaviours (body checking) dominating the experience. Importantly, the results may inform treatment approaches, which could focus on enhancing the reliance on goal-directed decision making to help cope with unwanted behaviours.

A benchmark study of a combined individual and group anorexia nervosa therapy program

OBJECTIVE

Anorexia nervosa (AN) is a treatment-resistant illness. Up to half of the patients show limited or no significant treatment response. First, we aimed to describe a new stepped-care outpatient treatment combining group and individual therapy (CIGAN) with a strong focus on normalizing eating and weight and in vivo meal support for adults with moderate to severe AN. Second, we aimed to compare CIGAN with specialized treatments of Specialized Supportive Clinical Management (SSCM) and the Maudsley model of AN (MANTRA).

METHOD

The study includes 137 adults with moderate to severe AN and the primary outcome (BMI) at six and twelve months was compared with the outcomes published for SSCM and MANTRA using the Chi-squared test and Student's t-test. The paired t-test and Cohen's d were used to compare the within-group follow-up data with the baseline data.

RESULTS

CIGAN patients changed significantly on all outcome measures at 6 and 12 months, with effect sizes on BMI of 1.37 and 1.51 and on the weight of 1.36 and 1.60, respectively. Except for the 12-month comparison with MANTRA, patients had a higher BMI and larger BMI increase at both 6 and 12 months than SSCM (BMI p = 0.002 and 0.023, BMI increase p < 0.001 and 0.003) and MANTRA (BMI p = 0.031 and 0.168, BMI increase p < 0.001 and 0.037).

DISCUSSION

CIGAN, including a stepped care approach, is a promising treatment, and further research on the effective elements is warranted.

Lived experience perspectives on a definition of eating disorder recovery in a sample of predominantly white women: a mixed method study

BACKGROUND

There has recently been a push for recovery-focused research in the eating disorder (ED) field, starting with a consensus definition of recovery. One definition, in particular, proposed by Bardone-Cone et al. [21] has received considerable attention given its transdiagnostic nature and validation studies. However, no studies to date have elicited lived experience views of this definition. The goal of the current study was to examine perspectives on this definition of recovery from individuals with a past or present ED and to determine whether participant agreement with the model differed based on diagnostic history or current symptom severity.

METHODS

Sixty-two individuals (95.2% women; 91.9% White/European) participated in a 1-2 h interview aimed at capturing their perspectives on ED recovery. Transcripts were analyzed using qualitative content analysis and codebook thematic analysis to examine agreement with and thoughts on Bardone-Cone's definition of recovery, respectively. Chi-squared tests of independence and binary logistic regression were computed to determine whether agreement with the definition differed across diagnostic history and self-reported symptoms.

RESULTS

Although some participants indicated acceptance of the definition, the majority expressed concerns related to its categorical nature, proposed criteria, feasibility, language, and applications. There were no differences in acceptance based on diagnostic history or current symptom severity.

CONCLUSION

A single definition of recovery does not seem to fit individuals' lived ED experience. Future research may benefit from distinguishing between recovery as an individually-defined phenomenon and related constructs such as remission (i.e., loss of diagnosis or absence of clinical symptoms). A more comprehensive multi-faceted, and person-centered model of recovery may have merit in clinical settings.

Different pathways, same goals: A large-scale qualitative study of autistic and non-autistic patient-generated definitions of recovery from an eating disorder

BACKGROUND

Definitions of recovery from an eating disorder (ED) have generally been formulated around clinical conceptualisations, rather than based on the views of patients. This paper therefore asked those with lived experience of ED for their own definitions of recovery.

METHOD

Data were collected as part of an online study looking at EDs, autism and relationships. About 173 participants identified as recovered from ED and gave free-response definitions of recovery. Responses were subject to thematic analysis.

RESULTS

Seven major themes were identified: Weight restoration, lack of ED behaviours, thoughts and behaviours, cognitions, emotional responses, getting on with life, and ongoing challenges.

CONCLUSIONS

Many definitions of recovery given by those who have lived experience of ED echoed those used by clinicians and researchers. There were also points of divergence around the ongoing challenges of recovery. Our findings highlight the need for continuing support post-weight restoration to facilitate the successful long-term recovery for those with ED.

Parent-Focused Psychotherapy for the Preventive Management of Chronicity in Anorexia Nervosa: A Case Series

Background: Anorexia nervosa (AN) is a complex eating disorder where involvement of family plays a central role in first line treatment in adolescents, but which is not so for adults where poor response to treatment is frequent. Given the reluctance of some patients to receive treatment, we set out to explore the hypothesis that certain family dynamics may be involved in the maintenance of the disorder. Methods: We aimed to understand what is underlying in the cases of patients who present clinical improvement with their parents, but not the ones who received a parent-focused psychotherapeutic intervention. We conducted a mixed methods study. On the one hand we performed a case series of 14 patients who dropped out of treatment while their parents actively attended the intervention, and on the other hand, we followed the evolution of the parents of those patients reluctant to continue treatment, through non-participant observation. Results: We present preliminary evidence where we found the parent-focused psychotherapeutic intervention was able to elicit a reflective function of the parents. We also observed that the intervention modified certain family dynamics that could be related to maintaining factors of the disorder. In patients, we found that in parallel to the assistance of their parents to psychotherapeutic treatment, and even when they were receiving no intervention, they showed significant clinical improvement of symptomatology and global functioning; we observed 9 of 14 of them who voluntarily decided to return to pharmacological treatment. Conclusions: This parent-focused intervention elicited changes in reflective functioning of participant parents; the intervention produced favorable changes in family dynamics, which we believe is probably related to improvement of global functioning, symptomatology, and insight of patients.

Self-Harm in Eating Disorders (SHINE): a mixed-methods exploratory study

INTRODUCTION

Self-harm is highly prevalent among young people with eating disorders. However, why a young person may develop and continue to experience both an eating disorder and self-harm is unclear. This study will investigate the frequency, intensity, duration, function, context and processes of self-harm among people aged 16-25 diagnosed with an eating disorder. It will explore participants' perspectives on the genesis and functions of both their self-harm and eating disorder, as well as their support needs. The study was designed with the input of members of a Young Persons' Advisory Group, who will be key to study delivery and dissemination.

METHODS AND ANALYSIS

This exploratory study has a sequential mixed-methods explanatory design. Between 70 and 100 young people aged 16-25 with both an eating disorder diagnosis and self-harm thoughts and/or behaviours will be recruited from three NHS Eating Disorder outpatient services in England. Phase 1: a 14-day (six prompts per day) ecological momentary assessment (EMA) of participants' feelings, thoughts, motivations, behaviours and experiences of self-harm. Phase 2: 20-30 participants from phase 1 will be reapproached to take part in an in-depth qualitative interview on the psychological, emotional and social factors that underlie their self-harm and eating disorder as well as their support needs. EMA data from phase 1 will be analysed using descriptive and multilevel statistics. Qualitative interview data from phase 2 will be analysed using inductive and deductive thematic analysis. Results from both phases will be integrated using a mixed-methods matrix, with each participant's data from both phases compared alongside comparative analysis of the datasets as a whole.

ETHICS AND DISSEMINATION

The study gained ethical approval from the NHS HRA West Midlands-Black Country Research Ethics Committee (number: 296032). We anticipate disseminating findings to clinical, academic and lived experience audiences, at academic conferences, through peer-reviewed articles, and through various public engagement activities (eg, infographics, podcasts).

Adolescent experience of radically open dialectical behaviour therapy: a qualitative study

BACKGROUND

Radically Open Dialectical Behaviour Therapy (RO DBT) is a novel transdiagnostic treatment that targets 'maladaptive overcontrol'; a transdiagnostic cluster of traits associated with excessive emotional and behavioural inhibitory control. Outcomes are promising for adults with a range of psychiatric disorders. No study to date has explored the adolescent experience of RO DBT.

METHODS

Of the 25 eligible adolescents who received RO DBT between March 2015 and April 2017, 15 (14-17 years) consented and completed a semi-structured interview about their experience of treatment within 1 month of discharge. Interviews were recorded and then transcribed manually. Free text responses were analysed using reflexive thematic analysis.

RESULTS

The majority (n = 13) had a primary diagnosis of anorexia nervosa, although comorbidity was the norm, with 80.0% having two or more predicted comorbid psychiatric diagnoses. All had received some prior psychological treatment. Four themes were identified from analysis of transcripts: 1) Broadening Horizons, 2) Building Connections, 3) Flexibility, 4) Information Overload. Generally, RO DBT was perceived as helpful in both content and process. The focus on social and broader well-being, rather than specific mental health symptoms, was considered beneficial by many. Adolescents appreciated the group-based format of skills classes and reported benefiting from learning and practicing skills each week. The fourth theme, Information Overload, highlighted that for some, the amount of content felt overwhelming and that it was hard to remember and digest all the information, suggesting that adaptations, or simplifications, may be required to ensure accessibility for adolescents.

CONCLUSIONS

RO DBT is perceived as a relevant and beneficial new treatment for adolescents with maladaptive overcontrol. The broad treatment focus is perceived as unique and of particular benefit. It is reported to help with general and social functioning and foster cognitive and behavioural flexibility. Nevertheless, the amount and complexity of material was felt to be very large by some and may suggest the need for modified adolescent-specific materials.

Broad and Narrow Transdiagnostic Risk Factors in Eating Disorders: A Preliminary Study on an Italian Clinical Sample

Eating disorders are multifaceted psychopathologies and the transdiagnostic approach is currently considered a useful framework to understand their complexity. This preliminary study aimed to investigate both broad (i.e., intolerance of uncertainty and emotion dysregulation) and narrow (i.e., extreme body dissatisfaction) transdiagnostic risk factors underlying eating disorders. 50 Italian female patients seeking treatment for an eating disorder were involved (M_age = 31.6 years ± 12.8, 18–65). They completed self-report measures assessing emotion regulation difficulties, intolerance of uncertainty, extreme body dissatisfaction, general psychological distress, and eating disorder symptomatology. To explore whether the abovementioned transdiagnostic factors predicted patients’ psychological distress and eating disorder symptoms, two linear regressions were performed. Emotion dysregulation emerged as the only significant predictor of distress, while extreme body dissatisfaction was the only significant predictor of overall eating disorder symptomatology. Then, to analyze the differences between patients with anorexia nervosa and bulimia nervosa in intolerance of uncertainty and emotion regulation problems, t-tests were conducted. The two groups differed significantly in intolerance of uncertainty levels only, with higher scores obtained by patients with anorexia nervosa. Overall, our findings suggest that emotion dysregulation and extreme body dissatisfaction may be relevant constructs in eating disorders in general, while intolerance of uncertainty may be more involved in restrictive eating disorders. The clinical implications of such results are discussed.

The role of the lateral septum in neuropsychiatric disease

The lateral septum (LS) is a structure in the midline of the brain that is interconnected with areas associated with stress and feeding. This review highlights the role of the LS in anxiety, depression, and eating disorders and their comorbidity. There is a prevailing view that the LS is anxiolytic. This review finds that the LS is both anxiolytic and anxiogenic. Furthermore, the LS can promote and inhibit feeding. Given these shared roles, the LS represents a common site for the comorbidity of neuropsychiatric disorders, and therefore a potential pharmacological target. This is crucial since currently available treatments are not always effective. Corticotrophin-releasing factor 2 antagonists are potential drugs for the treatment of anxiety and anorexia and require further research. Furthermore, other drugs currently in trials for binge eating, such as alpha-adrenergic agonists, may in fact promote food intake. It is hoped that the advancements in chemo- and optogenetic techniques will allow future studies to profile the specific neural connections of the LS and their function. This information could facilitate our understanding of the underlying mechanisms, and therefore pharmacological targets, of these psychiatric conditions.

Imaginal Exposure for Disordered Eating Related Fears: An Initial Randomized Controlled Trial

Exposure therapy has been investigated as a treatment for eating disorders, but prior research has largely neglected core fears underlying the disorder such as rejection, abandonment, disgust, and loss of control. We tested the feasibility and acceptability of using imaginal exposure to target disordered eating related fears by randomizing participants (N = 47) with disordered eating to: imaginal exposure (IE), imaginal exposure preceded by a brief food exposure (IE + Food), or an assessment control. Participants attended two in-person visits and completed pretreatment, posttreatment, and one-month follow-up questionnaires. IE was rated more acceptable than IE + Food. Retention was high across conditions. Habituation occurred for subjective distress and believability of feared outcomes, suggesting that imaginal exposure effectively activates core fears. Distress tolerance and confidence in ability to change improved. Disordered eating symptoms, fears, preoccupations, and rituals decreased in all conditions, indicating that IE was not specifically responsible for improvement.

The Mediating Effect of Negative Appearance Evaluation on the Relationship Between Eating Attitudes and Sociocultural Attitudes Toward Appearance

Objective

Body-image disturbance and eating disorders are significant physical and mental health problems in China. Attitudes toward the body are thought to work in conjunction with other established risk factors for dietary pathology, which include body dissatisfaction, dieting, and negative effects. Negative appearance evaluation may be valuable for extending our understanding of measuring factors and potential causal relationships associated with body image and eating problems. Therefore, this study aimed to determine the association between negative appearance evaluation and a combination of eating attitudes and sociocultural attitudes toward appearance and the mediating effect of negative appearance evaluation on the relationship between eating attitudes and sociocultural attitudes toward appearance.

Methods

We invited 339 Chinese adults to undergo the Eating Attitudes Test (EAT-26), the Fear of Negative Appearance Evaluation Scale (FNAES), and the Sociocultural Attitudes toward Appearance (SATAQ-3) scale, and used AMOS 24.0 for model construction and mediating effects testing.

Results

There was a significant positive correlation between EAT-26 scores and FNAES (p < 0.001) and SATAQ-3 scores (p < 0.001), and all dimensions except internalization general were significantly positively correlated (p < 0.05). There was a significant positive correlation between FNAES and SATAQ-3 scores for all dimensions (p < 0. 01). There was no significant direct effect of eating attitude on sociocultural attitude toward appearance; however, there was a significant mediating effect of fear of negative appearance evaluation.

Conclusion

Our results demonstrate that negative appearance evaluation fully mediates the relationship between eating attitudes and sociocultural attitudes toward appearance. An individual's attitude toward eating affects negative body perceptions and thus their perception of their own body shape. Our exploration of the specific effects of eating attitudes on body perception provides a psychological basis for guidance and developing interventions regarding attitudes toward the body.

Polygenic association with severity and long-term outcome in eating disorder cases

About 20% of individuals with anorexia nervosa (AN) remain chronically ill. Therefore, early identification of poor outcome could improve care. Genetic research has identified regions of the genome associated with AN. Patients with anorexia nervosa were identified via the Swedish eating disorder quality registers Stepwise and Riksät and invited to participate in the Anorexia Nervosa Genetics Initiative. First, we associated genetic information longitudinally with eating disorder severity indexed by scores on the Clinical Impairment Assessment (CIA) in 2843 patients with lifetime AN with or without diagnostic migration to other forms of eating disorders followed for up to 16 years (mean = 5.3 years). Second, we indexed the development of a severe and enduring eating disorder (SEED) by a high CIA score plus a follow-up time ≥5 years. We associated individual polygenic scores (PGSs) indexing polygenic liability for AN, schizophrenia, and body mass index (BMI) with severity and SEED. After multiple testing correction, only the BMI PGS when calculated with traditional clumping and p value thresholding was robustly associated with disorder severity (β_PGS = 1.30; 95% CI: 0.72, 1.88; p = 1.2 × 10^-5) across all p value thresholds at which we generated the PGS. However, using the alternative PGS calculation method PRS-CS yielded inconsistent results for all PGS. The positive association stands in contrast to the negative genetic correlation between BMI and AN. Larger discovery GWASs to calculate PGS will increase power, and it is essential to increase sample sizes of the AN GWASs to generate clinically meaningful PGS as adjunct risk prediction variables. Nevertheless, this study provides the first evidence of potential clinical utility of PGSs for eating disorders.

From efficacy to effectiveness: child and adolescent eating disorder treatments in the real world (Part 2): 7-year follow-up

BACKGROUND

Eating disorders are often characterised as disabling, chronic or relapsing conditions with high mortality rates. This study reports follow-up outcomes for patients seen at the Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED), whose end of treatment outcomes are reported in a separate paper.

METHODS

Three-hundred-and-fifty-seven former patients, who received evidence-based treatment for an eating disorder as a child or adolescent in MCCAED between 2009 and 2014 were eligible to participate. Current contact information was available for 290, of whom 149 (51.4%) consented to follow-up. Participants were sent links to online questionnaires, with additional demographic information extracted from medical records. Descriptive analyses of key socioeconomic and health outcomes were performed on data collected.

RESULTS

Mean length of follow-up was 6 years 11 months. Ten (6.7%) participants reported a current diagnosis of an eating disorder at follow-up. The great majority reported no (63.8%) or minimal (26.8%) interference from eating disorder difficulties. More than half (53.6%) reported other mental health diagnoses with most reporting no (33.8%) or minimal (50.7%) interference from those difficulties. One third (33.3%) had sought help for an eating disorder and around 20% received prolonged/intensive treatment during the follow-up period. Approximately 70% had sought treatment for other mental health difficulties (mostly anxiety or depression) and 35.4% had substantial treatment. At follow-up more than half (55.5%) reported doing generally well, and around two-thirds reported general satisfaction with their social well-being (65%). The majority (62.7%) had a good outcome on the Morgan Russell criteria, which was consistent with low self-reported ratings on EDE-Q, and low impact of eating disorder or mental health symptoms on work and social engagement. Most of the former patients who had day and/or inpatient treatment as a part of their comprehensive integrated care at MCCAED did well at follow-up.

CONCLUSIONS

Young people seen in specialist eating disorder services do relatively well after discharge at longer-term follow-up especially regarding eating disorders but less favourably regarding other mental health difficulties. Few reported a diagnosable eating disorder, and the great majority went on to perform similarly to their peers in educational and vocational achievements.

Genome-Wide Analysis of Disordered Eating Behavior in the Mexican Population

Alterations in eating behavior characterized eating disorders (ED). The genetic factors shared between ED diagnoses have been underexplored. The present study performed a genome-wide association study in individuals with disordered eating behaviors in the Mexican population, blood methylation quantitative trait loci (blood-meQTL), summary data-based Mendelian randomization (SMR) analysis, and in silico function prediction by different algorithms. The analysis included a total of 1803 individuals. We performed a genome-wide association study and blood-meQTL analysis by logistic and linear regression. In addition, we analyzed in silico functional variant prediction, phenome-wide, and multi-tissue expression quantitative trait loci. The genome-wide association study identified 44 single-nucleotide polymorphisms (SNP) associated at a nominal value and seven blood-meQTL at a genome-wide threshold. The SNPs show enrichment in genome-wide associations of the metabolic and immunologic domains. In the in silico analysis, the SNP rs10419198 (p-value = 4.85 × 10-5) located on an enhancer mark could change the expression of PRR12 in blood, adipocytes, and brain areas that regulate food intake. Additionally, we found an association of DNA methylation levels of SETBP1 (p-value = 6.76 × 10-4) and SEMG1 (p-value = 5.73 × 10-4) by SMR analysis. The present study supports the previous associations of genetic variation in the metabolic domain with ED.

Impact of eating disorders on paid or unpaid work participation and performance: a systematic review and meta-analysis protocol

BACKGROUND

Eating disorders (ED) can reduce quality of life by limiting participation and performance in social and occupational roles, including paid or unpaid work. The association between ED pathologies and work participation and performance must be well understood to strengthen vocational rehabilitation programmes and prevent occupational disruptions in the ED population. The aims of this study are: (1) to examine the degree of association between ED pathologies and work participation and performance in 15-year-olds and older; (2) to highlight the specific ED symptoms that are most correlated with changes in work performance and participation; (3) to compile the most common metrics and assessments used to measure work participation and performance with ED.

METHODS

Medline, Embase, CINAHL, Web of Science, PsycINFO, and Cochrane Library will be searched for observational and experimental studies that meet the following criteria: (1) a clinical sample of typical or atypical ED; (2) paid or unpaid employment or training; (3) an association between ED pathologies and work participation or performance. Unpublished data will also be examined. Title and abstract, and full-text screening will be conducted in duplicate. Risk of bias and quality of evidence assessments will be completed. A random-effect meta-analysis will be performed.

DISCUSSION

This synthesis can clarify knowledge and gaps around the impact of ED on work functioning, thereby allowing better evaluation, improvements and development of current workplace assessments, interventions, and policies.

TRIAL REGISTRATION

The registration number for this systematic review on PROSPERO is CRD42021255055.

Self-disgust as a potential mechanism underlying the association between body image disturbance and suicidal thoughts and behaviours

This study examined whether self-disgust added incremental variance to and mediated the multivariate association between measures of body image disturbance and suicidal thoughts and behaviours. We hypothesized that self-disgust would be associated with suicidal ideation above the effects of body image disturbance, and that self-disgust would mediate the relationship between body image disturbance and suicidal ideation. A total of N=728 participants completed The Body Image Disturbance Questionnaire, The Self-Disgust Scale, and the Suicidal Behaviours Questionnaire-Revised. Suicidality was significantly related to increased levels of self-disgust and body image disturbance, whereas self-disgust was associated with greater body image disturbance. Linear regression analysis showed that self-disgust was associated with suicidal thoughts and behaviours, over and above the effects of body image disturbance. Multiple mediation modelling further showed that self-disgust mediated the relationship between body image disturbance and suicidal thoughts and behaviours. Our findings highlight the role of self-disgust in the context of body image disturbance and support the notion that body image disturbance is associated with aversive self-conscious emotions. Interventions aiming to reduce the risk of suicidality in people with body image disturbance may address self-disgust and negative self-conscious emotions.

Recruitment, adherence and attrition challenges in internet-based indicated prevention programs for eating disorders: lessons learned from a randomised controlled trial of ProYouth OZ

BACKGROUND

Growing evidence supports the effectiveness of Internet-based prevention programs for eating disorders, but the adjunctive benefit of synchronous peer support has yet to be investigated. In the current study, a randomised controlled trial was conducted to evaluate the effectiveness of an indicated Internet-based prevention program (ProYouth OZ) with and without peer-to-peer support in reducing disordered eating behaviours and attitudes.

METHOD

Fifty young adults (18-25 years) with eating disorder symptoms were randomised to one of three study conditions: (1) ProYouth OZ (without peer-to-peer support), (2) ProYouth OZ Peers (with peer-to-peer support), and (3) a waitlist control group. Outcomes were assessed at three different time points. Eating disorder symptoms (primary outcome) were measured with the Eating Disorder Examination Questionnaire.

RESULTS

Of 415 screened participants, 73 (17.6%) were eligible and 213 (51.3%) excluded due to severe eating disorder symptoms. Fifteen participants (30%) completed the post-intervention survey. Of the two intervention groups, 20.6% failed to access any component of the program. Of 17 ProYouth OZ Peers participants, 58.8% attended at least one chat session, 20% attended 2-5 sessions, and 11.8% attended all six sessions. Due to limited outcome data, it was not possible to statistically examine between-group differences in outcomes. Visual inspection of individual profiles revealed that both ProYouth OZ Peers participants who completed the post-intervention survey showed a decrease in disordered eating compared with only one of the six completers in ProYouth OZ.

CONCLUSION

Findings highlight the challenges of trialling Internet-based eating disorder prevention programs in the community. The study identified a large group of emerging adults with eating disorders who were interested in an Internet-based program, suggesting a high level of unmet need. Future research on synchronous peer-to-peer support in Internet-based prevention for eating disorders is warranted. Further studies are required to identify optimal strategies for reaching this population (e.g., online vs. offline) and evaluating the effectiveness of a range of strategies for promoting engagement. Finally, there is an urgent need to develop innovative widely accessible interventions for individuals who experience clinically relevant eating disorder symptomatology but may not be ready or able to seek professional face-to-face treatment.

TRIAL REGISTRATION

ACTRN12615001250527, Registered 16 November 2015, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12615001250527.

Autism Spectrum Disorder and Obesity in Children: A Systematic Review and Meta-Analysis

INTRODUCTION

Children and adolescents with autism spectrum disorder (ASD) appear to be at greater risk of excess weight gain. The aim of this systematic review and meta-analysis was to examine whether children with ASD have a greater prevalence of obesity and whether the prevalence of ASD is higher in children with obesity.

METHODS

We conducted a systematic search on PubMed, Scopus, and PsychINFO until May 21, 2021. We used the meta package in the R in order to calculate the pooled prevalence and relative risk of obesity in children with ASD.

RESULTS

We found 20 eligible studies investigating the prevalence of obesity in children with ASD, with the prevalence ranging from 7.9 to 31.8% and from 1.4 to 23.6% among controls. All but three studies originated from the USA. The proportion of children with obesity in ASD populations was 17% (95% confidence interval [CI]: 13-22). The relative risk of obesity in children with ASD compared with control children was 1.58 (95% CI: 1.34-1.86). There were no controlled studies reporting on the prevalence of ASD in children with obesity.

CONCLUSION

Children and adolescents with ASD have a higher prevalence of obesity than healthy controls. There is a need for further prevalence studies of obesity in children with ASD, especially outside the USA, since the few European studies carried out have failed to show a significant difference between obesity prevalence in children with and without ASD. There is no knowledge at all regarding the prevalence of ASD among children with obesity.

Outcomes for infants whose mothers had an eating disorder in the perinatal period: A systematic review of the evidence

OBJECTIVE

To establish any health outcomes for infants to age one, associated with their mother having a diagnosis of an active eating disorder during pregnancy or the 12-month postnatal period.

METHOD

A qualitative systematic literature review of numerous databases (Medline, PsycINFO, CINAHL, Scopus, Cochrane Library, MedNar, PsycExtra, National Institute for Health and Care Excellence and Open Grey) was performed examining any infant health outcomes.

RESULTS

This resulted in 22 included studies (17 cohort, 3 cross-sectional, 1 case controlled and 1 mixed methods study). A range of adverse infant outcomes including poor birth, growth and interactional feeding outcomes were identified.

DISCUSSION

Antenatal identification and treatment for women with an eating disorder during the perinatal period and their infants are vital. Optimizing pregnancy nutrition, maternal eating disorder symptoms and feeding interactions appear particularly important.

The ACAMTO study-impact of add-on osteopathic treatment on adolescent patients with anorexia nervosa: study protocol for a randomized controlled trial

Background

Anorexia nervosa (AN) mainly affects women (sex ratio 1/10) and most often starts during adolescence. The prognosis of AN remains poor (10% of deaths and high risk of chronicity). Body dissatisfaction, disturbances in recognition and identification of body sensations are some of the key symptoms of AN. However, there is a contrast between this consensual observation of body image disorders in AN, and the relative deficit of specifically targeted body treatments. Our proposal for a body approach specifically dedicated to AN is based on the understanding that posture, breathing, muscle tension and body perception are closely linked to our psychological and emotional state and are therefore disturbed in patients with AN. The purpose of this monocentric randomized controlled trial is to evaluate if a targeted osteopathic protocol treatment for AN in addition to treatment as usual (TAU) is significantly more effective than TAU alone.

Methods

In total, 72 patients meeting the inclusion criteria will be randomly assigned to one of the two treatment groups: one receiving the specific osteopathic treatment targeted for AN in addition to the TAU (group A) and the other one, receiving TAU only (group B). The patients in group A will receive 5 30-min osteopathic treatment sessions. Soft specific palpatory techniques on the diaphragm, digestive system and cervical region will be performed. The TAU is defined by the multidisciplinary approach recommended by the French health high authority. The primary outcome is the evaluation of interoceptive sensibility and secondary outcomes include clinical and psychopathology-related symptoms with assessment of somatic dysfunctions’ evolution. A qualitative study will also be carried out, applying the Interpretative Phenomenological Analysis method. Patients will be included for a maximum of 14 weeks between the inclusion time and the last evaluation.

Discussion

If the results of the study are positive (statistically significant efficacy of this osteopathic treatment protocol), the study will provide arguments in favor of osteopathic sessions as a possible non-invasive additional treatment option in the multidisciplinary care approach for patients with AN.

Trial registration

ClinicalTrials.gov ID: NCT04666415, Release Date: December 11, 2020; N° ID-RCB: 2019-A02613-54.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05810-8.

Prevalence and management of people with eating disorders presenting to primary care: A national study

OBJECTIVE

Primary care practitioners are well placed to support diagnosis and appropriate treatment of eating disorders as they are often the first point of contact with the health care system. However, little is known about management of eating disorders in primary care. We aimed to estimate the prevalence of management of eating disorders in primary care and identify how these disorders are managed.

METHODS

This study used data from the Bettering the Evaluation of Care of Health programme, which annually surveys 1000 randomly sampled general practitioners in Australia who each record details of 100 successive patient encounters. In total, data were utilised from 1,568,100 primary care encounters between 2000/2001 and 2015/2016.

RESULTS

Eating disorders were managed in less than 1% of primary care encounters between 2000/2001 and 2015/2016. When extrapolated to the Australian population, up to 0.32% of the population were managed in primary care for a primary or probable eating disorder. In the majority of encounters where an eating disorder was managed (58.5%), the encounter was initiated for reasons other than the eating disorder itself. Of a group of patients identified with a clinically significant low body mass index (N = 5917), a small number (n = 118) had either no other diagnosis or a related condition that may be indicative of an eating disorder. In encounters where an eating disorder was managed, referrals to a mental health specialist/service, medical specialist and nutritionist/dietician were provided in 20%, 8% and 6% of encounters, respectively. Mental health treatment plans, which provide subsidised access to mental health services, were ascribed in approximately 7.7% of encounters where an eating disorder was managed.

CONCLUSION

Primary care provides an opportunity to improve detection and management of eating disorders, particularly when patients present for 'other' issues or with unexplained low body mass index and one or more symptoms related to an eating disorder.

Network intervention analysis to assess the trajectory of change and treatment effects associated with the use of online guided self-help for anorexia nervosa

AIM

The aim of this study was to use the innovative technique of Network Intervention Analysis (NIA) to examine the trajectory of symptom change associated with the use of a digital guided self-help intervention (RecoveryMANTRA) to augment treatment as usual in adult anorexia nervosa.

METHODS

Self-reported eating disorder symptoms and mood (stress, anxiety and depression), work and social adjustment, motivation and treatment (Treatment as usual + RecoveryMANTRAand Treatment as usual) were included as nodes in the network and examined using NIA. Networks were computed at baseline (n = 88, 99), at end of treatment (6 weeks, n = 71, 75) and at 6- (n = 58, 63) and 12-month (n = 52, 63) follow-up.

RESULTS

RecoveryMANTRA was associated with a direct effect on anxiety, shape concern and restraint at the end of the intervention. This effect was not maintained at follow-up. There were no direct effects of RecoveryMANTRA on motivation, stress and depression.

CONCLUSIONS

These findings indicate that RecoveryMANTRA exerts a direct effect on eating disorder symptoms and anxiety. NIA is a promising method to evaluate trajectories of clinical change and direct and indirect effects of a therapeutic intervention compared to a control condition.

Radically open dialectical behaviour therapy adapted for adolescents: a case series

BACKGROUND

Overcontrol is a transdiagnostic cluster of traits associated with excessive psychological, behavioural and social inhibitory control. It is associated with psychiatric diagnoses of depression, restrictive eating disorders and/or obsessive-compulsive personality disorder. Radically Open Dialectical Behaviour Therapy is a transdiagnostic treatment for maladaptive overcontrol. This case series evaluates an adolescent adaption (RO-A) for a transdiagnostic group of adolescents identified as overcontrolled.

METHODS

Twenty-eight adolescents were consecutively referred for RO-A from two different National and Specialist Child and Adolescent Mental Health Services between June 2017 and February 2020. Baseline self-report measures assessed overcontrol characteristics, relationship and attachment quality and mental health symptoms of depression and eating disorders, which were repeated at discharge.

RESULTS

Adolescents in this case series reported high rates of depression (78.6%), self-harm (64.3%) and eating disorders (78.6%). Most (85.7%) had two or more mental health diagnoses and all had previous mental health treatments before starting RO-A. The mean number of RO-A sessions attended was 18 group-based skills classes and 21 individual sessions over a mean period of 34 weeks. Significant improvements with medium and large effect sizes were reported in cognitive flexibility (d = 1.63), risk aversion (d = 1.17), increased reward processing (d = .79) and reduced suppression of emotional expression (d = .72). Adolescents also reported feeling less socially withdrawn (d = .97), more connected to others (d = 1.03), as well as more confident (d = 1.10) and comfortable (d = .85) in attachment relationships. Symptoms of depression (d = .71), eating disorders (d = 1.06) and rates of self-harm (V = .39) also significantly improved. Exploratory correlation analyses suggest improvements in overcontrol are moderately to strongly correlated with improvements in symptoms of depression and eating disorders.

CONCLUSIONS

This case series provides preliminary data that RO-A may be an effective new treatment for adolescents with overcontrol and moderate to severe mental health disorders like depression and eating disorders. RO-A led to improved management of overcontrol, improved relationship quality and reduced mental health symptoms. Further evaluation is indicated by this case series, particularly for underweight young people with eating disorders. More rigorous testing of the model is required as conclusions are only tentative due to the small sample size and methodological limitations.

Pilot outcomes from a multidisciplinary telehealth versus in-person intensive outpatient program for eating disorders during versus before the Covid-19 pandemic

INTRODUCTION

Eating disorders (EDs) are serious mental illnesses with high rates of mortality, morbidity, and personal and societal costs. Onset of the Covid-19 pandemic led to increased ED diagnoses in the general public, as well as worsening of ED symptoms in those with an existing ED diagnosis. Heightened prevalence and severity of EDs during the pandemic is complicated by the fact that traditional modes of ED care (specialty intensive treatment provided by a multidisciplinary team) have been difficult to access during the pandemic.

METHODS

The current between-groups study (N = 93 ED) tested a multidisciplinary intensive outpatient program (IOP) delivered via in-person (pre-pandemic; n = 60) and virtually via telehealth (during the pandemic; n = 33).

RESULTS

We found no differences in outcomes via delivery mode, such that regardless of in-person versus telehealth programming, ED symptoms, depression, and perfectionism significantly decreased and body mass index significantly increased.

CONCLUSIONS

Our findings suggest that a multi-disciplinary telehealth ED IOP program is feasible and has comparable outcomes to in-person IOP treatment. These findings have implications for treatment beyond the pandemic, suggesting that adoption of telehealth IOPs is warranted. Such delivery modes of intensive treatments for EDs could be expanded to reach underserved populations, especially in rural areas where treatment is often difficult to access.