Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis

Comparing a novel, virtual, group-based guided self-help to unguided self-help for the treatment of binge-eating disorder in adults: a randomized controlled trial

Binge Focused Therapy (BFT) is a 3-session, group-based, guided self-help treatment for binge-eating disorder (BED). In this parallel-group randomized controlled trial (RCT), adults with BED were randomized to virtual BFT or a traditional unguided self-help approach (Overcoming Binge Eating; Fairburn, 2013). Self-report measures were collected at baseline, week 6, week 10 (posttreatment), 6- and 12-month follow-up. We hypothesized BFT (n = 82) would lead to better BED outcomes and lower dropout than unguided self-help (n = 82). Our intention-to-treat analysis demonstrated a significant effect of treatment group on BED symptomatology (primary outcome; β= - 5.04, p < .001, 95% CI [ - 7.57,  - 2.52]), binge frequency (β= - 3.24, p = .001, 95% CI [ - 5.22,  - 1.26]), general ED symptomatology (β= - 0.91, p < .001, 95% CI [ - 1.17,  - 0.65]), clinical impairment (β= - 6.27, p < .001, 95% CI [ - 8.78,  - 3.77]), confidence to change binge eating (β = 1.22, p < .001, 95% CI [0.56, 1.89]), BED remission (OR = 4.98, p = .003, 95% CI [1.72, 14.40]), and treatment attrition (β = 0.456, p < .001), with the BFT group reporting greater improvements and lower dropout. We did not find evidence of a significant effect of group on binge-eating abstinence (OR = 2.01, p = .103, 95% CI [0.87, 4.64]). BFT may be an effective BED treatment that could overcome common barriers to treatment implementation and accessibility.

Carer Outcomes From a Residential Treatment Service for Eating Disorders

OBJECTIVE

Eating disorders often result in distress, relationship impairment, and emotional, social, and financial burden for family members and other loved ones. However, carer outcomes from eating disorder treatment are under-researched, particularly residential settings. This study aimed to examine carer outcomes from a transdiagnostic residential service for eating disorders, which included therapist-led psychoeducation and peer support for carers.

METHOD

Measures of carer burden, accommodation and enabling of eating disorder symptoms, psychological distress, and health-related quality of life were completed at pre-treatment and three months' post-treatment by 51 carers (66.7% parents).

RESULTS

Linear mixed effects modelling found significant improvement in carer burden (b = -5.80, p = 0.033), accommodation and enabling of eating disorder symptoms (b = -13.32, p = 0.003), and psychological distress (b = -3.19 p = 0.026), with medium to large effect sizes (d = -0.76-1.32). Averaged across time, women reported significantly greater carer burden than men (b = 12.42, p = 0.011).

CONCLUSIONS

Findings support the effectiveness of residential treatment for carers, including improvement in behaviours that are likely to support eating disorder recovery. Future research is needed to determine what elements in residential treatment, the caregiving relationship, and beyond contribute to these positive outcomes.

TRIAL REGISTRATION

The study was prospectively registered on the Australian and New Zealand Clinical Trials Registry in November 2021, registration number ACTRN12621001651875.

The Cognitive Profile in Adolescents With Anorexia Nervosa and the Relationship With Autism and ADHD: A Pilot Study

OBJECTIVE

We aimed to examine the cognitive profile in adolescents with anorexia nervosa (AN) and its association with traits of autism spectrum disorder (ASD) and ADHD. In addition, resemblance in the cognitive profile between youths with AN and their parents was explored.

METHODS

Adolescent females with acute AN (n = 20) and a healthy comparison group (n = 28) completed neuropsychological tasks of set-shifting (Trail making test, Wisconsin Card Sorting Test) and central coherence (Rey Complex Figures Task, Group Embedded Figures Test, object assembly subtest). In the AN group, mothers and fathers (n = 31) also completed the neuropsychological tasks. Traits of ASD and ADHD were assessed. The AN group was reassessed after weight gain.

RESULTS

Weight-restored AN adolescents scored higher on the Group Embedded Figures Test than a comparison group (p < 0.001). No other set-shifting and central coherence differences were found across groups. A father-child correlation emerged in the object assembly subtest (r = 0.53, p = 0.035). ASD and ADHD traits were common in the AN group and not only related to starvation. No associations were found between neuropsychological deficits and traits of ASD and ADHD.

CONCLUSIONS

Scant support was found for weaker central coherence in weight-recovered adolescents with AN. Set-shifting impairments could not be observed in young females with acute AN or after weight recovery.

Unveiling Severity Indicators for Anorexia and Bulimia Nervosa Treatment Success: DSM-5 Versus ICD-11 Versus Drive for Thinness

OBJECTIVE

This study aimed to compare treatment outcomes associated with three severity indicators-DSM-5 for anorexia nervosa (AN) and bulimia nervosa (BN), ICD-11 for AN, and drive for thinness (DT) for AN and BN-within a treatment-seeking population.

METHOD

A total of 628 female participants diagnosed with either AN (n = 266; mean age = 26.71) or BN (n = 362; mean age = 29.49) were recruited from an ED unit. Upon admission, participants were classified based on DSM-5 (AN and BN) and ICD-11 severity categories. They underwent CBT-E comprehensive manualised programs, according to ED subtype, and were categorised into 'full remission', 'partial remission', 'non-remission' or 'drop-out' based on DSM-5 diagnostic criteria at discharge.

RESULTS

Significant associations were found only for ICD-11 AN severity groups (p = 0.03, Cramer's V = 0.18), with 'dangerously low BMI' associated with poorer outcomes than 'significantly low BMI'. No other significant relationships were found with DSM-5 or DT severity groups.

CONCLUSION

This study reveals the limitation of using a single severity indicator and emphasises the necessity of a comprehensive assessment to capture the complexities of AN and BN. Future research should also evaluate the validity of these severity measures across various factors, including biological correlates and psychopathology.

Study protocol for a pre-registered randomised open-label trial of ten-session cognitive behaviour therapy (CBT-T) for eating disorders: does stratified augmented treatment lead to better outcomes?

INTRODUCTION

Further improvement of cognitive-behavioural therapy for eating disorders (CBT-ED) is required that can provide better outcomes. Recent work showed that the length of therapy is not critical in improving outcomes. Rather, stratifying the treatment to individual needs is required to produce significant improvements. The current study adopts the approach of evaluating augmentations to ten-session CBT (CBT-T) where initial response to therapy is gradual rather than rapid.

METHODS AND ANALYSIS

Clients aged 15 years and over presenting to the Flinders University Services for Eating Disorders between January 2025 and June 2028 will be randomised to receive either CBT-T as usual or CBT-T augmented with therapy modules (CBT-TA) matched to obstacles to progress for gradual responders. Rapid response, assessed using the Eating Disorder Examination Questionnaire, is defined as ≥1.13 decrease in global ED psychopathology at session 4. In CBT-TA, the therapist and gradual responder will collaboratively choose at least one of nine augmentations to incorporate into therapy. Rapid responders in this group will be given access to the augmentations for use in their own time. Data for the main intent-to-treat analyses will be collected on five occasions: baseline assessment (T1), immediately preceding session 4 (T2), end of treatment (T3) and 3-month and 6-month follow-up (T4 and T5). The primary outcome is ED psychopathology, and secondary outcomes include behavioural indicators of the ED, impairment caused by the ED, general negative emotion, self-harm and hope. Analyses will be undertaken on an intention-to-treat basis and will include all participants in the group to which they were randomised.

ETHICS AND DISSEMINATION

Ethics approval was provided by the Social and Behavioural Research Ethics Committee at Flinders University (7992). This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12624001495516). The findings arising from the study protocol will be reported to participants and presented at scientific conferences and disseminated by publications submitted to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12624001495516).

Longitudinal Effects of Residential Treatment for Eating Disorders: Symptom Trajectories and Predictors of Functional Outcomes

OBJECTIVE

Residential treatment for eating disorders addresses the gap between inpatient and outpatient care, but evidence for longer-term and functional outcomes remains limited. The current study examined both clinical and functional outcomes from admission to a 6-month follow-up from Australia's first residential service for eating disorders.

METHOD

Measures of eating disorder symptoms, body mass index (BMI), anxiety, depression, general and eating disorder-specific health-related quality of life (HRQoL), and functional disability were completed at pretreatment, posttreatment, and 3- and 6-month follow-ups by 81 individuals with eating disorders (Mage = 25.78 years).

RESULTS

Linear mixed effects modeling found that change in outcomes over time was best modeled by a cubic growth curve, such that participants showed a steep improvement from pretreatment to posttreatment followed by a worsening of symptoms by 3 months post-discharge, which tapered off by 6 months post-discharge. Pairwise comparisons indicated significant improvement between pretreatment and posttreatment for all outcomes, and between pretreatment and 6 months post-discharge for all outcomes except mental HRQoL. Treatment gains were maintained after discharge for shape and weight concerns, anxiety, general and eating disorder-specific HRQoL, and functional disability. Greater in-treatment improvement in eating disorder symptoms predicted steeper in-treatment improvement and posttreatment deterioration in eating disorder-specific HRQoL, mental HRQoL, and functional disability. Greater post-discharge mental health support predicted steeper improvement in functional disability.

DISCUSSION

Results support the longitudinal effectiveness of residential treatment for clinical and functional outcomes. However, not all outcomes may maintain the degree of improvement seen at discharge, highlighting the importance of appropriate step-down care.

TRIAL REGISTRATION

Registration number: ACTRN12621001651875.

Rapid response to behavioral/pharmacological obesity treatments for binge-eating disorder predicts better clinical outcomes

OBJECTIVE

The objective of this study was to examine rapid response and its prognostic significance in participants with binge-eating disorder (BED) and obesity in a randomized clinical trial testing behavioral and pharmacological obesity treatments for BED.

METHODS

A total of 136 participants were randomly assigned (balanced 2 × 2 factorial) to 16-week behavioral and/or pharmacological (naltrexone/bupropion) obesity interventions. Masked assessments occurred monthly throughout treatment and at posttreatment.

RESULTS

Rapid response (≥65% reduction in frequency of binge-eating episodes after 1 month of treatment), observed in 55% (n = 75/136) of participants, was unrelated to baseline sociodemographic and clinical characteristics. Rapid response was more common in behavioral therapy than not and in naltrexone/bupropion than placebo. Rapid response was associated with binge-eating remission. Mixed models revealed that rapid response was associated with greater reductions in binge-eating frequency, eating-disorder psychopathology, percent weight loss, and metabolic variables (total cholesterol, glycated hemoglobin A1c) at posttreatment. Rapid response effects on outcomes did not vary by treatment.

CONCLUSIONS

In a randomized clinical trial testing behavioral and pharmacological obesity treatments for BED with co-occurring obesity, rapid response was a robust prognostic indicator of binge-eating remission and significantly better behavioral, psychological, and metabolic outcomes. Non-rapid response to behavioral and pharmacological obesity treatments could signal a need to switch to alternative treatments.

Indicators of early change in cognitive behaviour therapy that predict eating disorder remission

We examined the utility of three definitions of rapid response to treatment for predicting remission in a transdiagnostic sample receiving 10-session cognitive behaviour therapy (CBT) for an eating disorder. Both efficiency (categorising the greatest number of people as rapid responders) and predictiveness (performs best in predicting outcomes) were compared. The participants (N = 176, 93 % female, 89 % white, mean age 26.65 years) completed measures at baseline and before session 4 of CBT which was used to calculate rapid response. Remission was achieved by 64 participants (36 %) at the end of therapy. A multivariable logistic regression analysis was used to examine the contribution of rapid response, as well as baseline disordered eating, impairment, general negative emotion, to remission status. Two of the rapid response definitions were associated with participants being 2.5 times more likely to achieve remission at end of treatment. In both cases, remission was also associated with a lower level of baseline eating disorder psychopathology. The preferred definition (a reduction of ≥1.13 points on the Eating Disorder Examination Questionnaire) categorised 58 % of participants as rapid responders. These findings can be used to inform clinicians of meaningful early change that predicts positive outcomes in brief CBT for eating disorders. Early change indicators can inform collaborative consideration of barriers to progress and approaches to tackle these, making CBT more effective for more people. The conclusions should be interpreted with caution given remission was only examined at end of treatment and not over longer-term follow-up.

Treating the individual: moving towards personalised eating disorder care

Eating disorders (EDs) are complex and heterogeneous conditions, which are often not resolved with conventional, manualised treatments. Arguments for the development of holistic, person-centred treatments accounting for individual variability have been mounting amongst researchers, clinicians and people with lived experience alike. This review explores the transformative potential of personalised medicine in ED care, emphasising the integration of precision diagnostics and tailored interventions based on individual genetic, biological, psychological and environmental profiles. Building on advancements in genomics, neurobiology, and computational technologies, it advocates for a shift from categorical diagnostic frameworks to symptom-based and dimensional approaches. The paper summarises emerging evidence supporting precision psychiatry, including the development of biomarkers, patient-reported outcomes, predictive modelling, and staging models, and discusses their application in ED research and clinical care. It highlights the utility of machine learning and idiographic statistical methods in optimising therapeutic outcomes and identifies key challenges, such as ethical considerations, scalability and implementation.

Predictors and Moderators of Outcomes in a Trial of Cognitive Behavioural Therapy Integrated with Behavioural Weight Loss for High Weight Individuals with Disorders of Recurrent Binge Eating

Background/Objectives: To inform person-centred clinical practice, it is important to know what features may predict or moderate treatment outcomes. Thus, we investigated pre-treatment clinical features and mid-therapy reduction in loss of control over eating (MTLOCE), including impacts on treatment outcomes of a new manualised psychotherapy, a healthy approach to weight management and food in eating disorders (HAPIFED). HAPIFED was developed as an integrated psychological and behavioural treatment for individuals with bulimia nervosa or binge eating disorder, which are co-morbid with a high body mass index (BMI). Methods: In total, 50 participants were randomised to HAPIFED and 48 were randomised to the control cognitive behaviour therapy-enhanced group. Assessments included mental health-related quality of life (MHRQoL), eating disorder symptom severity, binge-eating frequency, BMI, and loss of control over eating (LOCE) at baseline, mid-treatment, end-treatment, and 6 and 12 months end of follow-up (EndFU). These were measured with the SF-12, the EDE-Q, and the LOCES, respectively. Linear and negative binomial mixed models were used. Missing data were imputed multiple times, assuming intention of treatment for the analysis. Results: Pre-treatment eating disorder symptom severity, MHRQoL, and BMI positively predicted eating disorder symptom severity, MHRQoL, and BMI up to 6 and 12 months end of follow-up. Mid-treatment LOCE MTLOCE predicted improved MHRQoL (coefficient = 0.387, 95% CI 0.0824-0.6921, p = 0.004), reduced binge-eating frequency (IRR = 0.5637, 95% CI 0.3539-0.8977, p = 0.0191), and eating disorder symptom severity (coefficient= -0.65, 95% CI -1.0792--0.2217, p = 0.0139). Neither purging nor illness duration were a significant predictor of any of the outcomes. The effect of HAPIFED was not moderated by baseline weight/BMI but was moderated negatively by MTLOCE for binge-eating frequency (coefficient = -0.636, SE = 0.28, p < 0.05, IRR = 0.529) and eating disorder symptom severity (coefficient = -0.268, SE = 0.13, p < 0.05, Cohen's d = -0.102). Conclusions: Greater control over eating improved MHRQoL and decreased the frequency of binge-eating episodes and eating disorder symptom severity. These positive effects were moderated by being in the HAPIFED group, supporting previous findings of benefits to people's mental health through participation in the HAPIFED trial.

The timing of symptom change and early treatment response in a self-guided digital treatment for obsessive-compulsive disorder

OBJECTIVE

Self-guided digital treatment is effective for many people with OCD-however, little is known about when during treatment people experience significant symptom reductions. In addition, there is substantial variability in the literature regarding what factors predict treatment responding in self-guided digital treatment for OCD. There is preliminary evidence to suggest that adults with OCD may show early treatment responding (i.e., significant symptom reductions within the first month of treatment) and that this early response could be associated with better post-treatment outcomes.

METHODS

In a secondary analysis (n = 123), the current study examined the timing and magnitude of symptom change during self-guided digital CBT, the incidence of early response (at 4-weeks), and whether early treatment response predicted post-treatment response (at 8-weeks). These analyses were conducted for OCD symptoms (primary) and depression symptoms (secondary).

RESULTS

Results indicated a gradual reduction in OCD and depression symptoms across treatment. Although fewer participants experienced an early response in OCD symptoms (22%) compared to depression symptoms (45%), early response was significantly associated with an increased likelihood of post-treatment response in both symptom domains.

CONCLUSIONS

These findings highlight that individuals with OCD symptoms may experience reductions in different symptom types at different points during treatment and that early response may be a prognostic factor for overall treatment response in this population across outcomes.

Latent Trajectories of Change in Dietary Restriction During Treatment in Avoidant/Restrictive Food Intake Disorder and Anorexia Nervosa

OBJECTIVE

Outcomes for low-weight restrictive eating disorders, including anorexia nervosa, restricting type (AN-R) and avoidant/restrictive food intake disorder (ARFID), are sub-optimal. Reducing dietary restriction is a key treatment target. Understanding heterogeneity in patterns of change in dietary restriction may aid in improving outcomes. We examined latent trajectories of change in dietary restriction during treatment and follow-up in AN-R and ARFID.

METHODS

Adolescents and adults with R-EDs (N = 276, 18% ARFID, 90% female, M age = 18) receiving intensive ED treatment completed assessments at five timepoints. Latent growth mixture modeling examined trajectories of change in dietary restriction, measured using the Eating Pathology Symptoms Inventory Restricting subscale. Classes were compared on clinical features at admission to determine characteristics prospectively associated with trajectory.

RESULTS

A 3-class solution emerged: Class 1 comprising individuals with "good response" (n = 138; 33% of those with ARFID in the sample); Class 2 with "good response, rebounding" (n = 81; 41% of ARFID); and Class 3 with "gradual response, low symptoms" (n = 57; 26% of ARFID). Class 3 had lower anxiety and R-ED symptoms than Classes 1 and 2. Class 2 presented with older age than Class 1.

DISCUSSION

No ARFID-specific classes emerged, underscoring similarities in response to intensive treatment between AN-R and ARFID.

Examining Associations of Borderline Personality Disorder Symptoms and Eating Disorder Diagnoses: Results From a US Representative Sample

OBJECTIVES

Borderline personality disorder (BPD) and eating disorders (EDs) are common comorbid diagnoses. Given the various combinations of borderline personality disorder symptoms (BPDS) that can comprise a diagnosis, understanding whether specific BPDS are more likely to be associated with an ED (anorexia nervosa [AN], bulimia nervosa [BN], and binge eating disorder [BED]) is important for the conceptualization and treatment of BPD-ED comorbidity.

METHODS

This study used data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) study, a nationally representative dataset of US adults (N = 36,309). The association of BPDS with EDs, compared with psychiatric and healthy control groups, was examined in two binomial and two multinomial (i.e., with all ED diagnoses) models.

RESULTS

Compared with the healthy control group, affect instability, emptiness, impulsivity, self-injurious behaviors, and unstable relationships were positively associated with any ED diagnosis (AN, BN, or BED). Compared with the psychiatric control group, impulsivity was positively associated with any ED diagnosis. In the multinomial model with the healthy control group, impulsivity and self-injurious behaviors were positively associated with AN, BN, and BED, emptiness was positively associated with AN and BED, and unstable relationships and affect instability were positively associated with BED. In the multinomial model with the psychiatric control group, self-injurious behaviors were positively associated with AN, and impulsivity and affect instability were positively associated with BED.

DISCUSSION

Results suggest certain BPDS may be more common with certain EDs (AN, BN, and BED), even when controlling for other EDs and a psychiatric control group.

Understanding Personalized Dynamics in Eating Disorders: A Dynamic Time Warp Analysis

OBJECTIVE

To enhance our understanding of the processes of change and the interaction of symptoms, we applied a relatively novel method known as Dynamic Time Warp to data from low-threshold internet-based interventions directed at decreasing eating disorder (ED) symptoms and increasing help-seeking.

METHOD

Utilizing data from the Featback study, we examined how various factors such as ED psychopathology, binge eating, vomiting, laxative use, BMI, anxiety, depression, self-efficacy, social support, well-being, and health-related quality of life interplayed over a period of 14 months among 355 individuals at six different time points. Moreover, we explored which symptoms exerted a significant temporal relationship on others (with high out-strength) and which were most affected by other symptoms (with high in-strength).

RESULTS

The sample included participants with different types of ED symptoms and high levels of severity. On a group level, we identified four dimensions with similar within-person trajectories: (1) Depression, anxiety, ED psychopathology, health-related quality of life, and self-rated health; (2) binge eating and vomiting; (3) self-efficacy and social support; (4) BMI, well-being, and laxative use. Directed analyses revealed that social support and anxiety had the highest significant out-strength (i.e., temporal lead), indicating their changes preceded those of other factors, while laxative use and well-being were among those that mostly lagged behind those of other items (with significant in-strength).

DISCUSSION

Depressive and anxiety symptom severity were strongly connected to ED severity. Social support may be an important factor to address first as it may drive other factors and symptoms in patients with EDs.

The Interplay Between Personality and Clinical Syndromes in Eating Disorders: Implications for Personalized Treatment

INTRODUCTION

Eating disorders (EDs) are complex and multifactorial conditions with significant impacts on both physical and mental health. Despite advances in treatment, relapse rates remain high, highlighting the need for improved predictive models for treatment outcomes. This study aims to examine the role of personality traits and clinical syndromes, as assessed by the Millon Clinical Multiaxial Inventory-III (MCMI-III), in predicting treatment outcomes for individuals with EDs.

METHODS

A retrospective evaluation was conducted on 149 women diagnosed with EDs, receiving inpatient treatment at the Eating Disorder Unit of Casa di Cura Villa Margherita-KOS (Arcugnano-Vicenza) between 2020 and 2024. Participants completed the MCMI-III at treatment initiation, with the Eating Disorder Examination Questionnaire (EDE-Q) and Clinical Impairment Assessment (CIA) administered at baseline and discharge.

RESULTS

Regression analyses revealed that maladaptive personality traits (avoidant, dependent and histrionic) and clinical syndromes such as major depression were significant negative predictors of treatment response. In contrast, post-traumatic stress emerged as a positive predictor of improvement. Specific personality and clinical patterns were associated with changes in symptomatology, including reductions in eating concerns, shape concerns and clinical impairment. However, not all dimensions were predictive of treatment outcomes.

CONCLUSION

This study underscores the importance of personalized treatment approaches that account for both personality traits and clinical syndromes in individuals with EDs. Future research should explore how these factors interact over time and inform tailored therapeutic strategies, particularly for those with comorbid traits or disorders.

Eating Disorders, Co-Morbid Disorders and Early Risk Factors Amongst Post-9/11 Veteran Men and Women

OBJECTIVE

To assess, by interview, the rates of eating disorders in a nationally representative sample of recent veterans, describe their DSM-5 eating disorder diagnoses and the occurrence of comorbid psychiatric disorders. To conduct an exploratory case-control analysis of previously documented and additional specific military risk factors before eating disorder onset to inform studies of prospective risk.

METHOD

Using a two-stage design, probable cases and controls were identified by screening questionnaires from a sample of 1494 veterans who completed a survey study and interviewed to establish case status and confirm probable co-morbid psychiatric diagnoses. Previously documented risk factors and military risk factors occurring before disorder onset were investigated.

RESULTS

Ninety-one cases and 51 controls were confirmed. Weighted prevalence for any eating disorder was 5.2%, with estimates for anorexia nervosa, bulimia nervosa, binge eating disorder and other specified eating disorder being 0.01%, 0.6%, 1.4%, and 1.6%, respectively. Seventy-nine (86.8%) confirmed cases had a diagnosis of one or more co-morbid psychiatric disorders. Previously documented risk factors were associated with subsequent case status, while in this sample, military risk factors were not.

DISCUSSION

Rates of eating disorder and co-occurring psychiatric disorders in recent veterans were comparable to those reported for non-veterans, with levels of posttraumatic stress disorder likely higher. As co-occurring psychiatric disorders, particularly posttraumatic stress disorder, may complicate achieving good outcomes with existing evidence-based treatments, there is an urgent need to adapt them where necessary to improve outcomes. Military risk factors may maintain or exacerbate pre-existing problems and need to be investigated alongside other maintaining factors in longitudinal studies.

PUBLIC SIGNIFICANCE

Rates of eating disorder and co-occurring psychiatric disorders in recent veterans were comparable to those reported for non-veterans, highlighting a need to detect eating problems and address unmet treatment need. Co-occurring psychiatric disorders may complicate achieving good outcomes with existing treatments, emphasising a need to adapt them to improve outcomes. Investigating maintaining factors, including military factors in longitudinal studies will likely aid treatment development.

Understanding Early Treatment Response in Brief CBT for Nonunderweight Eating Disorders: A Mixed Methods Study

OBJECTIVE

Early change in eating disorder psychopathology is the most robust predictor of treatment outcomes in eating disorders. However, little is known about what predicts early change. Using mixed-methodology, this study explored predictors of early change in the first four sessions of 10-session cognitive behavioral therapy (CBT-T) for nonunderweight eating disorders.

METHOD

Phase 1: interviews were conducted to explore CBT-T clinicians' perspectives on predictors of early change. Phase 2: robust multiple regressions were undertaken to examine whether any of five variables identified during interviews-diagnosis, wait time, therapeutic alliance, depression, and anxiety-were associated with early change in eating disorder psychopathology. Data were derived from outcome measures for service users (n = 107) receiving CBT-T in a community eating disorder service.

RESULTS

Phase 1: eight themes were identified: attitudes to making change, diagnosis, external mitigating circumstances, therapeutic alliance, therapist confidence, pretreatment variables, CBT-T format, and therapeutic suitability. Phase 2: no significant associations were found between the five predictor variables (diagnosis type, wait time, baseline depression, baseline anxiety, and therapeutic alliance) and early change in EDE-Q scores. These results have been certified as computationally reproducible by an independent statistician.

DISCUSSION

Qualitative findings identified several potential predictors of early change in eating disorder psychopathology in CBT-T, however, quantitative data contradicted qualitative findings, finding no significant association for any of the tested variables. Further research is required to clarify theses conflicting findings and to quantitatively explore the additional predictors highlighted during qualitative analysis.

Residential versus day program treatment for eating disorders: A comparison of post-treatment outcomes and predictors

Both residential and day programs for eating disorders provide options for a step-up from standard outpatient care. However, there have not been any direct comparisons of their effectiveness and limited research on predictors of better outcomes from either setting. This study aimed to compare clinical outcomes and predictors from a transdiagnostic residential and day program for eating disorders. Measures of eating disorder symptoms, body mass index (BMI), anxiety, and depression were completed by 106 participants (n = 82 residential, n = 24 day program) at pre-treatment, after four weeks, and at discharge. Greater improvement from pre- to post-treatment was evident from residential, compared to day program, treatment (all ps ≤ .005, medium effect sizes). After accounting for age, baseline BMI, and treatment duration, lower baseline eating disorder symptoms (β = 0.84, p < .001) and greater early change in eating disorder symptoms (β = -0.88, p < .001) each predicted less severe eating psychopathology at discharge. Longer treatment duration predicted better post-treatment outcomes for the day program, but was less predictive of residential outcomes (β = 0.64, p < .001). Post-treatment outcomes were not predicted by age or baseline BMI, anxiety, or depression. As symptom severity did not differ at baseline, results support residential treatment over day programs for individuals with more severe eating disorder presentations. Future research should examine whether day programs are equally effective as residential treatment at lower baseline symptom severity and compare residential care with more intensive settings such as inpatient services.

Patient-Related Factors Influencing Motivation to Change in Adolescents With First-Onset Anorexia Nervosa: A Cross-Sectional Study

OBJECTIVE

Motivation to change significantly impacts treatment outcomes in eating disorders (EDs). This study investigated patient-related factors associated with motivation to change in adolescents with first-onset anorexia nervosa (AN). Understanding these factors will help tailor interventions to individual needs, enhancing treatment outcomes.

METHOD

Seventy-six female adolescents with first-onset AN completed the Readiness and Motivation Questionnaire (RMQ)-Dutch translation. ED symptoms, body mass index, and comorbidity (depressive, anxiety, obsessive-compulsive, autism spectrum disorder, and attention deficit and hyperactivity disorder symptoms) were analysed using linear regression analyses. As a secondary aim, the association between specific ED behaviours and motivation to change was analysed. This project was preregistered: https://osf.io/vx9ud/.

RESULTS

Adolescents with more severe ED symptoms, depressive symptoms, and obsessive-compulsive symptoms, experienced lower motivation to change. The severity of ED symptoms emerged as the most important factor associated with motivation to change, specifically ED symptoms concerning weight and body shape. Additionally, laxative misuse was associated with greater motivation to change.

CONCLUSIONS

The link between motivation to change and ED symptoms suggests that early treatment can improve outcomes by reducing ED symptoms and facilitating change. Furthermore, addressing depression during treatment might enhance motivation to change.

Exploring Reciprocal Associations Between Self-Reported Anxiety and Eating Disorder Symptoms Longitudinally: A Bivariate Latent Change Score Approach

OBJECTIVE

Consistent data support an association between anxiety and eating disorders (EDs), and theoretical models of EDs suggest that anxiety may be involved in the etiology and maintenance of ED symptoms over time. However, the directionality of relations between these variables remains under-characterized, particularly within treatment settings.

METHOD

We used bivariate latent change score models to explore longitudinal associations between anxiety and ED symptoms in a sample of ED patients (N = 548, 93.2% female, Mage = 21.16, 78.8% White, 79.6% Non-Hispanic/Latinx) throughout intensive treatment and at 6- and 12-month follow-up.

RESULTS

Best-fitting models exploring change in each variable independently (i.e., univariate models) suggested that changes in ED and anxiety symptoms decreased over time, but that change was influenced by an individual's symptom severity at the previous timepoint. Models exploring associations between changes in both variables over time (i.e., bivariate latent change score models) suggested the best fit for a model where both anxiety and ED symptoms at one timepoint were associated with later change in the other. Specifically, parameters within these models suggested that higher levels of anxiety were associated with increased subsequent reductions in ED symptoms, whereas elevations in ED symptoms were associated with decreased later reductions in anxiety.

CONCLUSIONS

Our findings suggest that anxiety and ED symptoms are intricately related both within and outside of intensive treatment. Future multi-modal research exploring real-time links between anxiety and ED symptoms throughout treatment is critical to extend this work and inform improvements in targeted, mechanistic interventions for this population.

Eating-Specific Interpersonal Difficulties: Changes and Impacts on Outcomes During Ten-Session Cognitive Behavioral Therapy for Eating Disorders (CBT-T)

OBJECTIVE

The relationship between self-reported interpersonal difficulties and eating disorder symptoms is well-established. The Interpersonal Relationships in Eating Disorders (IR-ED) is a new measure of eating-specific interpersonal difficulties (food-related isolation, avoidance of body evaluation, foot-related interpersonal tension). This study aims to (1) explore changes in IR-ED scores, eating disorder symptoms, and psychosocial impairment during ten-session cognitive behavioral therapy for eating disorders (CBT-T), (2) assess whether pre-treatment IR-ED scores moderate the trajectory of change in eating disorder symptoms and psychosocial impairment during CBT-T and (3) investigate the relationship between changes in the IR-ED and changes in eating disorder symptoms and psychosocial impairment.

METHOD

Individuals with eating disorders (N = 126, M age = 26.08) received CBT-T and completed questionnaires at pre-, mid-, and post-treatment.

RESULTS

Eating-specific interpersonal difficulties, eating disorder symptoms, and psychosocial impairment reduced during CBT-T. Severity of pre-treatment eating-specific interpersonal difficulties was unrelated to change in eating disorder symptoms or psychosocial impairment, irrespective of diagnosis or body mass index. Changes in interpersonal difficulties were associated with concurrent changes in eating disorder symptoms and psychosocial impairment. Early change in interpersonal difficulties did not predict later change in eating disorder symptoms or psychosocial impairment, and early changes in symptoms or psychosocial impairment did not predict later changes in interpersonal difficulties.

CONCLUSIONS

Eating-specific interpersonal difficulties improve during CBT-T, and individuals benefit from treatment regardless of their pre-treatment interpersonal difficulties. Theoretical and clinical implications are discussed.

The current clinical approach to feeding and eating disorders aimed to increase personalization of management

Feeding and eating disorders (FEDs) are a heterogeneous grouping of disorders at the mind-body interface, with typical onset from childhood into emerging adulthood. They occur along a spectrum of disordered eating and compensatory weight management behaviors, and from low to high body weight. Psychiatric comorbidities are the norm. In contrast to other major psychiatric disorders, first-line treatments for FEDs are mainly psychological and/or nutrition-focused, with medications playing a minor adjunctive role. Patients, carers and clinicians all have identified personalization of treatment as a priority. Yet, for all FEDs, the evidence base supporting this personalization is limited. Importantly, disordered eating and related behaviors can have serious physical consequences and may put the patient's life at risk. In these cases, immediate safety and risk management considerations may at least for a period need to be prioritized over other efforts at personalization of care. This paper systematically reviews several key domains that may be relevant to the characterization of the individual patient with a FED aimed at personalization of management. These domains include symptom profile, clinical subtypes, severity, clinical staging, physical complications and consequences, antecedent and concomitant psychiatric conditions, social functioning and quality of life, neurocognition, social cognition and emotion, dysfunctional cognitive schemata, personality traits, family history, early environmental exposures, recent environmental exposures, stigma, and protective factors. Where possible, validated assessment measures for use in clinical practice are identified. The limitations of the current evidence are pointed out, and possible directions for future research are highlighted. These also include novel and emerging approaches aimed at providing more fine-grained and sophisticated ways to personalize treatment of FEDs, such as those that utilize neurobiological markers. We additionally outline remote measurement technologies designed to delineate patients' illness and recovery trajectories and facilitate development of novel intervention approaches.

Early intervention for adolescents with anorexia nervosa: Pilot evaluation of an outpatient group therapy prior to inpatient treatment

OBJECTIVE

An increasing demand for inpatient treatment for adolescents with anorexia nervosa (AN) during and after the Covid-19 pandemic contrasts with limited capacity and long waiting times. The current pilot study evaluated an outpatient group therapy (GT) as early intervention for adolescents with AN prior to inpatient treatment.

METHODS

Seventeen female adolescents who participated at the GT (intervention group, INT) were compared to 16 adolescents without GT (treatment-as-usual, TAU). BMI, eating disorder psychopathology and motivation of change (MoC) were assessed at three timepoints.

RESULTS

Comparing pre- versus post- group participation, we identified a significant increase of MoC and a trend towards a decreased AN-specific psychopathology. Comparing INT with TAU adolescents, we found a significant lower AN psychopathology at inpatient admission for the INT group and a trend for different BMI courses: While the BMI of the TAU group decreased during waiting time, the INT group did not show a decrease during GT resulting in a higher BMI at admission.

CONCLUSIONS

Results of the current pilot study suggest positive effects of an early outpatient intervention in a group setting for adolescents with AN prior to inpatient treatment. Further research with larger sample sizes is necessary to validate the current pilot results.

The Unmet Treatment Need for Eating Disorders: What Has Changed in More Than 10 Years? An Updated Systematic Review and Meta-Analysis

OBJECTIVE

A minority of individuals with eating disorders seek help from health professionals qualified to provide eating disorder care. This review assessed the proportion of individuals with eating disorders who had sought help or received treatment, as an update to an earlier review conducted more than a decade ago.

METHOD

Three databases were searched for studies that: (1) included a community sample of help-seekers and non-help seekers, (2) used a standardized eating disorder screening instrument, and (3) assessed the percentage of participants who had sought help specifically for eating disorder concerns.

RESULTS

Of 972 articles, 21 studies met inclusion criteria, representing 37,423 participants. The pooled proportion reporting help-seeking from any source (e.g., helpline, support groups, chat rooms as well as health professionals) was 30% and the pooled proportion reporting formal treatment seeking from health professionals (e.g., psychologist) specifically for eating disorder concerns was 32%. However, there was evidence of publication bias across studies.

DISCUSSION

These rates suggest little to no improvement in the unmet need for treatment since the last review with studies continuing to focus on white adult women. Help-seeking rates among other populations remain unclear and there is an urgent need to understand reasons for overall low help-seeking rates. Clear definitions and measures of help-seeking with appropriate distinctions between sources of help are needed to improve our understanding of help-seeking pathways and identify solutions to facilitate help-seeking. Better visibility of health professionals qualified to provide safe and effective eating disorder care could help reduce the substantial treatment gap.

The predictive value of emotion regulation difficulties and negative mood on short and long-term treatment outcomes in an online guided self-help programme for adults with binge-eating disorder

OBJECTIVE

Cognitive behaviour therapy (CBT) online guided self-help programs represent efficacious and accessible treatment options for adults with binge-eating disorder (BED), but research on predictors of treatment outcome is scarce. This study aimed to investigate the predictive value of emotion regulation difficulties relative to that of negative mood on short- and longer-term treatment outcomes in an online guided self-help programme for BED above and beyond other predictors (age, sex, baseline BED severity).

METHODS

Participants were 63 adults (87% female, mean age 37.2 years) with BED. Data was analysed using a hierarchical model approach.

RESULTS

Emotion regulation difficulties better predicted both weekly binge-eating frequency and eating disorder (ED) pathology at posttreatment than negative mood, after controlling for the effect of age, sex and baseline BED severity. At 6-month follow-up, neither emotion regulation difficulties nor negative mood further added to the prediction of weekly binge-eating frequency, whereas negative mood, but not emotion regulation difficulties, did so for ED pathology.

CONCLUSION

These findings indicate that emotion regulation difficulties at treatment begin might be a relevant predictor of immediate treatment outcome in online guided self-help for adults with BED but might have lower impact on longer-term treatment outcome than negative mood.

CLINICAL TRIAL REGISTER NUMBER

The clinical trial register number is not given in this version of the manuscript due to anonymisation.

Network dynamics of self-compassion, anxiety, and depression during eating disorder therapy

BACKGROUND

Recovery processes during residential treatment for eating disorders, especially in patients with a history of maltreatment, are insufficiently understood. This study aimed to explore the temporal relationships among comorbid factors, including depression, anxiety, and self-compassion, with the influence of childhood maltreatment.

METHOD

Using Dynamic Time Warp (DTW), weekly scores from the Symptom Checklist-5, Eating Disorder Examination, and Self-Compassion Scale were analysed over 12 weeks. The study generated undirected and directed networks to identify influential symptoms in a transdiagnostic sample, comparing patients with and without childhood maltreatment.

RESULTS

The study included 124 patients with eating disorders (ED) (97% women), mean age of 30.9 years (SD = 9.7, range 18-61 years). Diagnoses included anorexia nervosa (26%), bulimia nervosa (38%), and other specified feeding and eating disorders (36%). The directed DTW network showed that hopelessness, worrying, and restlessness had the highest out-strength, predicting changes in self-compassion and ED behaviour. In maltreatment cases, hopelessness and low acceptance predicted changes, while worry, restlessness, and nervousness were predictive in non-maltreatment cases.

CONCLUSION

Temporal network analyses suggest that a change in hopelessness, worrying, and restlessness drives symptom improvement in ED behaviour and the development of self-compassion during residential treatment. These processes vary between patients with and without a history of childhood maltreatment separately, indicating the need for further analyses.

Enhancing assessment for eating disorders: the impact of a podcast-based pre-treatment psychoeducation intervention

This study reports the outcome of a low intensity pre-treatment intervention (a guided e-health podcast) for patients with anorexia nervosa and bulimia nervosa, delivered between assessment and the start of the full outpatient treatment programme. A case series design was used. A total of 254 patients at a specialist eating disorder service were offered a pre-treatment three-week psychoeducational intervention (Keeping Myself Safe; KMS), and 203 undertook the intervention. The intervention consisted of six podcasts (107 mins), an accompanying workbook, and a follow-up review appointment. Body Mass Index and Eating Disorder Examination-Questionnaire scores were taken at assessment, end of the KMS intervention (mean duration = 21.9 days) and start of treatment (mean = 79.8 days post KMS intervention). Generalised Linear Mixed Models were used to test main and interaction effects (diagnosis x time). There were improvements on most variables following the KMS intervention. The effects were more pronounced for patients with bulimia nervosa across several measures. Pre-treatment guided e-health psychoeducational interventions can be associated with early attitudinal and behavioural change in patients with bulimia nervosa and anorexia nervosa whilst on the waiting list for treatment. They allow greater, affordable accessibility to effective psychoeducation and enhance potential engagement. More research is required to investigate the longer-term impact on retention and outcome, particularly in anorexia nervosa.

Early response in people with anorexia nervosa receiving cognitive-behavioural therapy for eating disorders (CBT-ED): a latent change study

OBJECTIVE

Early improvement predicts good outcome in psychotherapy for eating disorders. Prior studies have examined change in body mass index (BMI) or Eating Disorder Examination Questionnaire scores (EDE-Q) as indicators of early response, but not both simultaneously. Little research has examined early change among Anorexia Nervosa (AN) samples treated with eating disorder-focussed cognitive behavioural therapy (CBT-ED). We studied the process of early change in a fine-grained way to better understand whether early response predicts later response and post-treatment outcomes in CBT-ED for AN, and how the changes in EDE-Q and BMI are related.

METHOD

Adults (N = 193) diagnosed with AN were treated with outpatient CBT-ED. We used bivariate Latent Change Score models to examine change in BMI and EDE-Q and relations between them.

RESULTS

Early change in BMI was independent of early change in EDE-Q. Larger changes in EDE-Q over the first five weeks of therapy followed smaller ones over the next five weeks, meanwhile smaller changes followed larger ones. Early change was predictive of post-treatment scores.

CONCLUSION

Early change in BMI and EDE-Q during CBT-ED appear to be unrelated and follow different trajectories. Therefore, individuals declared as early responders may differ depending on which variable is used for the decision.

Developing Solutions to the Waitlist Problem for Eating Disorder Treatments

OBJECTIVE

We examine the small amount of research to date that describes and/or evaluates waitlist interventions as a precursor to treatment for an eating disorder (ED) with the intent to provide recommendations for future research that can further test the efficacy and effectiveness of waitlist interventions.

METHOD

A review of published studies showed the standard of proof about the usefulness of waitlist interventions to be slight, with important gaps in our knowledge. One such gap was whether recovered people with lived experience could provide support to adults waiting for treatment. We briefly present new research evaluating this approach (N = 40), where people waiting for treatment were randomized to waitlist as usual or guided self-help with a trainee psychologist or a person with lived experience.

RESULTS

Eight published studies across 10 different programs are described; N = 7 addressed waitlists for children and adolescents, and only three were randomized controlled trials. Our new research did not support the involvement of people with lived experience at this stage of the treatment journey.

DISCUSSION

The results suggest some promise of waitlist interventions. Parents waiting for family-based treatment were able to improve weight and nutritional health in their children and experienced improved self-efficacy with respect to managing the ED. Provision of a waitlist intervention to adults may increase the probability of later engagement in treatment. It is still not possible to conclude whether waitlist interventions improve outcomes over treatment compared to those who did not receive such an intervention. We make five recommendations for future research.

Long-Term Outcome and Mortality in Adolescent Girls 8 Years After Treatment for Anorexia Nervosa

OBJECTIVE

Assessment of the longer-term outcome of anorexia nervosa (AN) in female adolescent inpatients (N = 132).

METHOD

A follow-up (mean 8.2 years) after treatment was conducted. A subsample of 39 patients with at least 10 years of follow-up (mean 14 years) was defined.

RESULTS

Over the 8-year follow-up period, the body mass index (BMI) increased from 14.33 (1.65) to 19.04 kg/m2 (2.97; t[112] = 17.33, p < 0.001, d = 1.63), and BMI percentiles increased from 0.50 (1.14) to 24.96 (26.81; t[112] = 9.83, p < 0.001, d = 0.92). Remission was found in 32.5% (8-year total sample) and 48.6% (14-year subsample). In the 8-year total sample, 15.1% still had AN or had relapsed (8.1% in the 14-year subsample). A cross-over from AN to binge-eating disorder was rare. The main cross-over occurred from AN to an eating disorder not otherwise specified (37.5% and 27.0%, respectively). The standardized mortality ratio was 21.7.

DISCUSSION

In the long run, eating disorder diagnoses decreased significantly. Although a considerable proportion of patients recovered from their eating disorder, the number of recovered patients remained limited, with long-term negative consequences in a large proportion of patients. Standardized mortality was excessive, calling for ever-better therapies. Additional studies are needed to show if improved therapies lead to a better long-term outcome.

An Exploration of Clinical Characteristics and Treatment Outcomes Associated with Dietetic Intervention in Adolescent Anorexia Nervosa

Background: Although dietitians possess expert knowledge on the interplay between nutrition and health, their specific role in family therapy for anorexia nervosa (FT-AN) remains a topic of debate. Some of the literature indicates insufficient evidence to affirm the impact of dietetic interventions, emphasising variability in outcomes and a need for standardised research. This study aimed to identify the clinical characteristics of adolescents requiring dietetic intervention during FT-AN and to assess differences in clinical outcomes between those receiving dietetic support and those who did not. Methods: A retrospective cohort study was conducted at the Maudsley Centre for Child and Adolescent Eating Disorders in London. Patients were selected from electronic records. Inclusion criteria were ICD-10 diagnosis of AN and completion of FT-AN treatment between January 2020 and December 2022. Collected data included weight (kg and %mBMI), eating disorder symptom severity, pre-assessment anxiety (patient and parent), and details of FT-AN sessions (i.e., frequency and amount). The sample was divided into two groups: those who received dietetic input and those who did not. Statistical analyses included Mann-Whitney U tests, χ2 tests, independent t-tests, and a logistic regression to examine differences at baseline, 4-6 weeks post-assessment, and discharge. Results: The study included 92 participants (dietetic group = 33 participants; non-dietetic group = 59 participants). Baseline characteristics were comparable between groups. The logistic regression showed no significant predictors for dietetic input. At 4-6 weeks, those requiring dietetic input exhibited lower %mBMI (83.3% vs. 87.3%, p = 0.027) and poorer weight gain (+2.3 kg vs. +3.1 kg, p = 0.04). By discharge, weight restoration was similar (92% vs. 93% mBMI, p = 0.64), although the dietetic group had more therapeutic treatment sessions (24 vs. 19, p = 0.04). Discussion: This study found no specific predictors for prioritising dietetic input in young people during FT-AN treatment. While those receiving dietetic support struggled with weight gain early and attended more sessions, both groups achieved similar weight outcomes by the end of treatment. Future research should focus on the timing and content of dietetic interventions, as well as perspectives from patients and caregivers, to better understand their role and impact on cognitive and emotional recovery aspects.

Exploring validated strategies for screening for eating disorders in adolescents and adults in primary health care: a scoping review protocol

BACKGROUND

This study will be the first scoping review dedicated to investigating screening strategies for eating disorders specifically performed in the primary health care setting, as no comprehensive examination has been performed to date. Our primary aim is to explore the available literature and assess and identify validated screening strategies for eating disorders in adolescents and adults within the primary care context.

METHODS

The study protocol was developed following the guidance outlined by the Preferred Reporting Items for Systematic reviews and Meta-Analyses Protocols and the Joanna Briggs Institute methodology for scoping reviews. This study will adhere to the PRISMA extension for scoping reviews to report review data. The protocol was registered on the Open Science Framework. The review will include studies that involve validated screening strategies for eating disorders in adolescents and adults utilising primary health care services. Experimental, quasiexperimental, observational, qualitative, and mixed-methods study designs and reviews will be eligible without language or publication year restrictions. Six databases (MEDLINE-PubMed, Embase, LILACS, CINAHL, Web of Science, PsycINFO) and grey literature will be searched. Studies will be selected and extracted by two independent reviewers via online Covidence. The results will be presented in narrative form and through tables and graphs. When possible, descriptive qualitative content analysis will be conducted.

DISCUSSION

The expected results of this scoping review will shed light on validated strategies for screening for eating disorders in primary health care. This will equip health care professionals with well-substantiated empirical evidence. Moreover, it is anticipated to uncover research gaps, nurturing the ongoing development and refinement of screening strategies for eating disorders in primary health care. The results will be widely disseminated to the scientific community, policy-makers, service providers, and the general public.

SYSTEMATIC REVIEW REGISTRATION

This protocol has been registered on the Open Science Framework ( https://osf.io/pybvf ).

Effectiveness and predictors of psychotherapy in eating disorders: state-of-the-art and future directions

PURPOSE OF REVIEW

Psychotherapy is the cornerstone of the multidisciplinary treatment approach for eating disorders. This review examines recent evidence regarding effectiveness, predictors, and mechanisms of change of psychotherapy in eating disorders, providing a road map for clinicians and researchers.

RECENT FINDINGS

Family-based treatments (FBT) are effective in adolescents with anorexia nervosa and bulimia nervosa. Evidence-based psychotherapies for anorexia nervosa have no evidence of superiority compared with treatment as usual (TAU) in adults with anorexia nervosa. Cognitive-behavioural therapy (CBT) is the first-choice psychotherapy recommended for adults with bulimia nervosa and binge-eating disorder (BED). Self-help interventions have some evidence of effectiveness in nonunderweight individuals with eating disorders. Early symptom improvement and adolescent age predict more favourable outcomes.

SUMMARY

Evidence-based psychotherapies can be suggested for eating disorders, although follow-up data are needed. Beyond anorexia nervosa, bulimia nervosa, and BED, there is no evidence of psychotherapy effectiveness in other eating disorders. The effectiveness of novel (e.g. 'third-wave') psychotherapies, treatment delivery modality (e.g. internet-delivered), and adjunctive interventions (e.g. virtual reality) needs to be further explored. A broader definition of recovery is recommended, including behavioural, physical, and psychological criteria. Predictors and mechanisms of changes have not been studied enough: quantitative and qualitative studies are needed to promote more tailored and individualized psychotherapy interventions.

Factor Structure and Psychometric Properties of the ED-15 in People With an Eating Disorder

OBJECTIVE

This study examines the factorial structure and psychometric properties of the Eating Disorder-15 questionnaire (ED-15) in a large clinical sample, as well as the instrument's sensitivity to early clinical change in therapy and ability to measure remission.

METHOD

Participants with eating disorders (N = 278) referred to the Flinders University Services for Eating Disorders in South Australia completed the ED-15 as well as other measures of eating disorder symptoms and co-occurring psychopathology, including depression, anxiety, and stress.

RESULTS

Confirmatory factor analysis (CFA) revealed a two-factor model for the ED-15. The ED-15 had good internal consistency. It showed satisfactory concurrent validity with moderate correlations with the EDE-Q global score and contribution of unique variance to that score. Correlations indicated good convergent validity with clinical impairment and good divergent validity from depression, anxiety, and stress. The ED-15 showed a significant medium effect size change within the first four sessions of therapy. Good discriminant validity was indicated by cut-off scores used for remission, with significantly different levels of ED psychopathology and other impairments between the two groups.

DISCUSSION

This study adds to the four previous psychometric studies of the ED-15, confirming robustness of the English version in a clinical sample. The brevity and psychometric robustness of the ED-15 makes it a preferable measure to the Eating Disorder Examination for sessional assessment of progress in treatment.

Discovering a "sense of community": patient experiences of connection in intentionally remote eating disorder care

BACKGROUND

While some findings indicate high levels of patient satisfaction with remote eating disorder treatment, others reflect feelings of disconnection due to unique telehealth treatment challenges. The COVID-19 pandemic presented circumstances that likely impacted the findings established thus far. As such, the present study sought to understand patient experiences of connection in an intentionally remote eating disorder treatment program, specifically in a context outside of pandemic transition.

METHODS

A secondary analysis of de-identified qualitative data previously obtained for quality improvement purposes via a client satisfaction survey was conducted. Adult patient responses (N = 38) were analyzed via reflexive thematic analysis within a critical realist framework.

RESULTS

Four themes were generated from the data: (1) Embracing one's humanity paves the way for connection, (2) Discovering a "sense of community" in remote care, (3) "They made me feel I was worth recovering": connection as a vehicle for healing, and (4) Aligning expectations and reality: reconceptualizing the journey to connection in remote eating disorder care.

CONCLUSIONS

Overall, findings suggest that it is possible for patients to form strong, impactful connections in remote treatment. Importantly, patient perspectives indicated that there were shifts in how these connections were experienced as a result of the remote care environment (e.g., how support could be provided and by whom). Considerations unique to remote care (e.g., offering training to improve clients' comfort with technology) may be important to fostering connection, thereby contributing to improved patient experiences and treatment outcomes.

Predictors of treatment outcome in higher levels of care among a large sample of adolescents with heterogeneous eating disorders

BACKGROUND

Despite widespread use of higher levels of care in treating eating disorders in adolescents, research supporting the use of these treatments remains limited by small sample sizes and a predominant focus on anorexia nervosa. Further, existing data regarding predictors of outcome have yielded mixed findings. In the current study, we evaluated treatment outcomes and predictors of outcome among a large sample of adolescents with eating disorders presenting to inpatient, residential, partial hospitalization programs, and intensive outpatient programs across the United States.

METHODS

Adolescents (N = 1,971) completed self-report measures of eating disorder symptoms, depression, and anxiety at treatment admission, stepdown, and discharge. Using linear mixed effect models, we evaluated changes in symptoms over treatment separately among youth admitted to inpatient/residential treatment and those admitted to partial hospitalization/intensive outpatient programs, and used established metrics to gauge frequency of reliable (i.e., statistically reliable) and clinically significant change.

RESULTS

Results suggested decreases in eating disorder symptoms, depression, and anxiety from intake to discharge. Around 50% of the sample reported reliable decreases in eating disorder symptoms at stepdown and discharge, with 30% of the sample reporting reliable reductions in depression and anxiety. Psychiatric comorbidity, primary diagnosis, age, and eating disorder symptoms at admission consistently predicted treatment-related change, although patterns in findings varied across symptoms.

CONCLUSIONS

Data from our sample are consistent with past work suggesting that adolescents enrolled in higher levels of care report clinical benefit; however, these effects are heterogenous, and a significant portion of individuals may not report reliable change in symptoms. Ultimately, ongoing work is required to better understand how and for whom higher levels of care may achieve their benefit and to identify the optimal approach for improving outcomes for adolescents with eating disorders.

"The only way that they can access help quickly": a qualitative exploration of key stakeholders' perspectives on guided self-help interventions for children and young people with eating disorders

BACKGROUND

There is a significant unmet treatment need for children and young people (CYP) with eating disorders. Guided self-help interventions have the potential to expand access to evidence-based treatments. Guided self-help is a type of low intensity psychological intervention where individuals engage with a workbook or online programme, with the support of a health professional. Its primary aim is to equip patients and/or their caregivers with self-management skills. However, little is currently known about the acceptability and suitability of guided self-help interventions for CYP with eating disorders. This study aimed to explore the perspectives of three key stakeholder groups - CYP with lived experience of eating disorders, parents/carers, and healthcare professionals - on guided self-help for this population.

METHODS

Qualitative focus groups and semi-structured interviews were conducted with 11 CYP (aged 13-19 years) with lived experience of eating disorders, 12 parents/carers, and 10 healthcare professionals. The study comprised a total of seven focus groups (including 2 with CYP, 3 with parent/carers, and 2 with healthcare professionals), as well as four semi-structured interviews (including 3 with CYP and 1 with a parent/carer). Discussion topics included past experiences of using/delivering guided self-help, the suitability of guided self-help for CYP with eating disorders, and preferences towards the content, structure and modes of guided self-help. Data were analysed using reflexive thematic analysis.

RESULTS

Three themes were generated across all three stakeholder groups. Theme one, Bridging the gap, highlighted the role of guided self-help in increasing access to psychological support for CYP with eating disorders. Theme two, Timing matters, considered the suitability of guided self-help for CYP with eating disorders at different stages of illness and the care pathway. Theme three, One size does not fit all, emphasised the heterogeneity of eating disorders and the need for a personalised and flexible approach in guided self-help.

CONCLUSIONS

Findings from this study lay a foundation for the future design and delivery of guided self-help interventions for CYP with eating disorders. Future work must consider these findings in the context of best available research evidence to optimise the potential utility of guided self-help for this population.

The efficacy of internet-based cognitive behavioral therapy for adult binge spectrum eating disorders: A meta-analysis

OBJECTIVE

Internet-Based Cognitive Behavioral Therapy (iCBT) is an innovative modality of cognitive-behavioral intervention that presents a promising therapeutic strategy for individuals diagnosed with binge spectrum eating disorders. This study employed a meta-analysis methodology to assess the clinical effectiveness and acceptability of iCBT.

METHODS

We conducted searches in databases such as PubMed, Embase, Web of Science, Cochrane Library, and PsycINFO, collecting literature that met the inclusion criteria until August 5, 2023.

RESULTS

A comprehensive analysis was conducted, encompassing a total of 11 randomized controlled studies that satisfied the predetermined criteria for inclusion. The summary results demonstrated that iCBT could significantly improve the pathological features related to eating in patients with binge spectrum eating disorders and also significantly reduce the frequency of binge episodes. Additionally, iCBT could ameliorate the depressive and anxious emotions of patients with binge spectrum eating disorders and boost their self-esteem. Furthermore, a notable disparity in dropout rates was seen in comparison to the control group.

LIMITATION

Heterogeneity across studies，limitations of self-assessment scales and potential publication bias.

CONCLUSION

iCBT can effectively assist patients with binge spectrum eating disorders in improving clinical symptoms. However, it is important to use caution when interpreting the findings of this study, as there are limitations pertaining to the quantity and quality of the included studies.

Differences in treatment trajectory following brief paediatric inpatient admissions for children and young people with eating disorders

OBJECTIVE

Little is known about factors associated with treatment trajectory following brief paediatric admissions for children and young people (CYP) admitted for medical complications of their eating disorder (ED). This project aimed to identify possible factors and ways to improve the usefulness of paediatric admissions.

METHOD

Retrospective NHS data was analysed to explore differences between paediatric admissions followed by community-based care or inpatient psychiatric care. Twelve parents were interviewed to seek feedback about paediatric admissions.

RESULTS

Patients who received subsequent inpatient psychiatric care were unwell for longer, had longer paediatric admissions and more crisis team input, were more likely to have had previous admissions, and had higher parent-reported anxiety and depression. However, the groups did not significantly differ in ED severity. The interviews identified recommendations for improving paediatric admissions, which included improving understanding of EDs, enhancing communication channels, and providing psychological support to parents.

CONCLUSIONS

Factors linked with illness severity (but not illness severity itself) appear to be associated with the difference between CYP either returning to community-based care or requiring more intensive psychiatric input. These factors may help clinicians understand who requires subsequent inpatient care, allowing clinicians to target more intensive support earlier and facilitate smoother transitions between services.

Testing associations between assessments of cognitive flexibility and eating disorder symptoms in adolescent bulimia nervosa

OBJECTIVE

Cognitive rigidity, or difficulty adapting to changing demands, is commonly observed in anorexia nervosa. Less is known, however, about cognitive flexibility (CF) in bulimia nervosa (BN) and, particularly, adolescence. Clarifying this relation and best assessment practices may guide informed clinical decision-making. The current study compared how two measures of CF (i.e., Wisconsin Card Sort Task [WCST] and Trail Making Task [TMT]) relate to BN symptoms among adolescents.

METHODS

Data from a subsample (n = 78) of adolescents with BN were analyzed. Linear and hurdle regressions were used to compare the effects of WCST perseverative errors and TMT performance on Eating Disorder Examination Global Scores, objective binge episodes, and self-induced vomiting episodes (SVEs) at baseline and end-of-treatment (EOT).

RESULTS

Neither CF measure associated with baseline BN symptoms. TMT performance positively associated with the likelihood of engaging in SVEs at EOT (𝛽 = 0.47, p = 0.01, 95% confidence interval [CI] = [0.11-0.84]) and, among adolescents who endorsed ≥1 SVE at EOT, WCST perseverative errors (𝛽 = 0.05, p = 0.005, 95% CI = [0.01-0.08]) positively associated with SVE frequency at EOT.

DISCUSSION

The overall lack of associations between CF and outcomes suggests that cognitive rigidity may not be as relevant to the clinical profile of adolescent BN as for anorexia nervosa. In the few significant associations that emerged, the WCST and TMT uniquely predicted the severity of vomiting at EOT in this sample. Given the lack of CF deficits, future work should aim to test the role of other executive functions (e.g., impulsivity), in addition to CF, to determine which deficits are present in adolescent BN and may predict outcomes.

PUBLIC SIGNIFICANCE

Patients with eating disorders often have difficulties thinking flexibly, which may interfere with their recovery. We tested two ways of measuring flexible thinking in adolescents with BN. Overall, flexible thinking was not associated with symptom-level outcomes. However, less flexible thinking at the start of treatment predicted self-induced vomiting at EOT. If findings are replicable, then assessing and addressing flexible thinking could improve outcomes for adolescents with BN.

Preliminary associations of body weight, weight bias, and dietary restriction with eating disorder diagnosis in women experiencing food insecurity

Understanding the co-occurrence of food insecurity and eating disorders is a pressing concern. Several factors have been hypothesized to increase risk for eating disorders in women with food insecurity including dietary restriction, body weight, and weight-related bias, but few studies have tested these factors simultaneously to determine which are associated most strongly with eating disorder status. We tested cross-sectional associations of dietary restriction, current body mass index (BMI), weight suppression (i.e. the difference between current weight and highest weight), and weight bias with eating disorder diagnosis in a sample of 99 self-identified women with current food insecurity (54% White; mean [SD] age = 40.26 [14.33] years). Participants completed two virtual study visits consisting of electronic questionnaires and interviews. A binary logistic regression model was conducted to test relations between the hypothesized correlates and eating disorder diagnostic status in the past 12 months, controlling for age, food insecurity severity, and body dissatisfaction. Higher levels of weight suppression and weight bias, but not current BMI, were significantly associated with the presence of an eating disorder. Contrary to our hypothesis, greater dietary restriction was associated with lower likelihood of eating disorder diagnosis. Results suggest high levels of weight bias and weight suppression characterize women with food insecurity who meet criteria for an eating disorder. Women who experience food insecurity and have lost a relatively great deal of weight and/or hold biases about high weight should be screened for eating pathology in clinical settings.

The Contribution of Shame to Eating Disorder Treatment Outcomes in a Community Mental Health Clinic

OBJECTIVE

Shame is a powerful self-conscious emotion that is often experienced by individuals with eating disorders (EDs). While the association between EDs and shame is well-established, there is limited research investigating the contribution of pre-treatment shame to clinical outcomes.

METHOD

Participants (N = 273) received outpatient cognitive-behavioral therapy for eating disorders (CBT-ED). We investigated pre-treatment shame as a predictor of dropout and as a moderator of change in ED psychopathology and clinical impairment from pre-treatment to post-treatment. We also explored the potentially moderating roles of body mass index, ED diagnostic category, and co-occurring anxiety and depression diagnoses.

RESULTS

Shame improved substantially (d = 1.28) despite not being explicitly targeted in treatment. Pre-treatment shame did not predict treatment dropout. Individuals high in shame started and ended treatment with higher ED symptoms and impairment than those with low shame. The contribution of pre-treatment shame on the degree of change in symptoms/impairment depended critically on whether analyses controlled for pre-treatment symptoms/impairment. When those were controlled, high pre-treatment shame was associated with substantially less improvement in ED symptoms and impairment. There was some evidence that ED diagnosis and co-occurring depressive diagnoses may moderate the relationship between shame and treatment outcome. Changes in shame were positively associated with changes in ED symptoms and clinical impairment.

DISCUSSION

A high level of shame at pre-treatment is not a contraindication for CBT-ED as good therapeutic outcomes can be achieved. However, outcomes may be enhanced among individuals high in shame by offering adjunctive interventions that explicitly target shame.

Acute Augmentations to Psychological Therapies in Eating Disorders: A Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

The purpose of this systematic review and meta-analysis was to examine the use and efficacy of acute augmentation therapies in eating disorders.

RECENT FINDINGS

A meta-analysis addressing this topic across psychological disorders found augmentation significantly improved therapy outcome with strongest findings for augmentations targeting biological mechanisms; however, only one study examined eating disorders. Our systematic review identified 29 studies examining people with eating disorders (N = 1831 participants, 93.7% female), of which 17 RCTs (n = 1162 participants) were included in the meta-analysis. Small subgroups of acute augmentations were identified. Adding acute augmentations to an intervention was effective in 72.4% of studies, with a significant effect on eating disorder outcomes (Hedges' g = 0.14, 95% CI: [0.02, 0.26]). Acute augmentation looks to be a promising approach regardless of weight status or whether it is added to treatment as usual or a single therapy approach.

Longitudinal Impact of Disordered Eating Attitudes on Depression, Anxiety, and Somatization in Young Women with Anorexia and Bulimia

Background/Objectives: Eating disorders, characterized by severe disturbances in eating behavior, are a public health concern, particularly among young women. This longitudinal study aimed to investigate the relationship between disordered eating attitudes and mental health outcomes, including depression, anxiety, and somatization, among individuals with eating disorders. Methods: A total of 471 young German women hospitalized with anorexia nervosa or bulimia nervosa participated in this study. Assessments were conducted at two points over a two-month interval using the Eating Disorder Inventory-2 (EDI-2) and the Patient Health Questionnaire. Regression analyses were performed to determine predictors of depression, anxiety, and somatization. The study controlled for socio-demographic segmentation using Sinus-Milieus, a social classification system, as a covariate. Results: Regression analyses revealed that interpersonal distrust and impulse regulation were significant predictors of subsequent depression. Impulse regulation strongly predicted subsequent anxiety, while both impulse regulation and social insecurity were strong predictors of subsequent somatization. The Neo-Ecological Milieu emerged as the most prevalent socio-demographic group (34.4% of participants). The Sinus-Milieus segmentation, however, did not significantly impact the health outcomes, suggesting consistent mental health issues across socio-demographic groups. Conclusions: This study's findings underscored the role of disordered eating attitudes in predicting mental health outcomes among young women with eating disorders. Addressing these attitudes in therapeutic settings may help mitigate symptoms of not only the primary condition but also depression, anxiety, and somatization.

Eating disorder risks and psychopathological distress in Italian high school adolescents

BACKGROUND

Psychopathological disorders are often comorbid diagnosis in eating disorders (EDs). We aimed to assess the presence of psychopathological traits and symptoms associated with EDs in an Italian high school adolescent population.

METHODS

A sample of high school adolescents was enrolled, and demographic and clinical data were collected. Two self-report questionnaires, the Eating Disorder Inventory-3 (EDI-3) and the Questionnaire for the Assessment of Psychopathology in Adolescence (Q-PAD), were administered.

RESULTS

548 adolescents (333 F/215 M; 16.89 ± 0.85 years) were included. Symptoms associated with EDs of clinical or high clinical concern were prevalent in a range of individuals, with percentages varying from 26.82% for body dissatisfaction to 51.83% for Interoceptive Deficits. The findings from the Q-PAD assessment indicated the presence of psychological distress, leading to discomfort or challenging situations requiring potential intervention in a percentage of adolescents ranging from 2.93% for psychosocial risks to 23.77% for anxiety. These percentages showed differences between genders (F > M, p < 0.001). Our study also highlighted an association between symptoms of EDs and lifestyle factors within families. We observed correlations between Q-PAD measures and EDI-3 scores, including a positive correlation between Q-PAD and EDI-3 body dissatisfaction (r = 0.7), Q-PAD interpersonal conflicts and EDI-3 interpersonal problems (r = 0.6) and a negative correlation between Q-PAD self-esteem and well-being and EDI-3 ineffectiveness Composite (r=-0.7).

CONCLUSIONS

a substantial prevalence of ED symptoms and psychological distress among high school adolescents were recorded. These conditions are interrelated, suggesting the importance of addressing them comprehensively. Early detection is essential to improve treatment outcomes and to implement preventive strategies.

Self-Esteem and Anxiety as Mediators in the Relationship Between Emotional Intelligence and Eating Disorder Symptoms

This study investigated the relationship between emotional intelligence (EI) and eating disorder symptoms (EDS) by testing the serial mediation model, with self-esteem and anxiety as mediators. A total of 923 participants (61.9% female) aged 15-60 years completed questionnaires assessing their EI, self-esteem, anxiety, and EDS. Correlational analyses were conducted to assess the relationship between the study variables, and a serial mediation analysis was conducted to test the possible mediating role of self-esteem and anxiety in the relationship between EI and EDS. Correlation analyses revealed significant bivariate relationships between EI, self-esteem, and anxiety, but no significant correlation between EI and EDS. The relationship between EI and EDS was serially mediated by self-esteem and anxiety. High levels of EI were associated with higher self-esteem, which, in turn, was associated with lower anxiety and less EDS. The results offer potential mechanisms that could explain the relationship between EI and EDS and highlight the importance of EI in regulating eating behavior through self-esteem and anxiety.

Thought-shape fusion in residential eating disorder treatment: Cognitive defusion as a mediator between thought-action fusion and treatment outcome

An understudied cognitive bias within eating disorder (ED) psychopathology is Thought-Shape Fusion (TSF), which involves irrational beliefs about the likelihood and moral implications of feared outcomes related to shape, weight, and food. This phenomenon has received less attention within the context of ED treatment, with little known about potential processes of change to address TSF and ultimately promote ED recovery. We propose cognitive defusion as a process of change, a metacognitive process that emphasizes observing thoughts objectively rather than appraising thoughts as absolute truth. We explored whether cognitive defusion, that is, reductions in body image-related cognitive fusion, mediated the relationship between trait-level TSF and treatment outcomes in a transdiagnostic ED sample of adult and adolescent females (N = 130) presenting to residential care. We found that reductions in body image-related cognitive fusion mediates the association between trait-level TSF at baseline and ED severity at discharge. However, when the sample was separated into adolescent and adult subgroups, these results only remained significant for adolescents. These findings underscore the relevance of targeting cognitive defusion as a potential mechanism to address the impact of trait levels of TSF cognitions on ED psychopathology.

A randomized controlled trial of an online single session intervention for body image in individuals with recurrent binge eating

OBJECTIVE

Theoretical models highlight body image disturbances as central to the maintenance of eating disorders, with empirical evidence finding negative body image to be a robust predictor of treatment nonresponse, relapse and symptom persistence. Accessible, scalable, and inexpensive interventions that can effectively target negative body image across the eating disorders are needed. We developed an online single session intervention (SSI) for negative body image and evaluated its acceptability and efficacy in a randomized controlled trial in individuals with recurrent binge eating.

METHOD

Participants with recurrent binge eating were randomly assigned to the SSI (n = 99) or a waitlist (n = 101). Assessments were conducted at baseline, 4 week follow-up, and 8 week follow-up.

RESULTS

81% of participants accessed the SSI, demonstrating reasonable uptake. However, issues with attrition were apparent; a 32% study dropout rate was observed at posttest, while a 58% dropout rate was observed at follow-up. 87% of participants who completed satisfaction measures would recommend the SSI. SSI participants experienced greater improvements in negative body image at both 4 (d = -0.65) and 8 week (d = -0.74) follow-up. Significant between-group effects were also observed on most other secondary symptom measures, though no differences were found for motivations and help-seeking beliefs and intentions.

CONCLUSION

Body image-focused self-guided SSIs for recurrent binge are largely accepted by those who are retained in the trial, but are associated with significant attrition. Although SSIs are not intended to replace standard treatment, they may help with short-term symptom management and could play an important role in eating disorder care.

PUBLIC SIGNIFICANCE

Single session interventions (SSI) are a potentially accessible, scalable, and cost-effective way to deliver evidence-based treatment content to people with eating disorders. This study shows that an online (SSI) designed to target body image among people with recurrent binge eating is accepted and produced short-term symptom relief.

Improvements in Quality of Life and Readiness for Change After Participating in an Eating Disorder Psychoeducation Group: A Pilot Study

Psychoeducation groups are an integral part of eating disorder treatment in community programs, yet research on their efficacy remains limited. This study examines the impact of participating in a 10-week psychoeducation group on changes in quality of life and in readiness and motivation. Seventy-five adults who had eating disorders were included in the study. We administered the Eating Disorder Quality of Life Scale (EDQLS) and Readiness and Motivation Questionnaire (RMQ) before and after the group. After participation, respondents reported an 11-point increase in the EDQLS score and 9-, 8-, and 9-point increases, respectively, in the total action, confidence, and internality components of the RMQ score. In group exit evaluations, participants reported that the psychoeducation group improved their quality of life and their readiness and motivation to recover.