Implicit attitudes toward dieting and thinness distinguish fat-phobic and non-fat-phobic anorexia nervosa from avoidant/restrictive food intake disorder in adolescents

Latent profile analysis reveals overlapping ARFID and shape/weight motivations for restriction in eating disorders

BACKGROUND

DSM-5 differentiates avoidant/restrictive food intake disorder (ARFID) from other eating disorders (EDs) by a lack of overvaluation of body weight/shape driving restrictive eating. However, clinical observations and research demonstrate ARFID and shape/weight motivations sometimes co-occur. To inform classification, we: (1) derived profiles underlying restriction motivation and examined their validity and (2) described diagnostic characterizations of individuals in each profile to explore whether findings support current diagnostic schemes. We expected, consistent with DSM-5, that profiles would comprise individuals endorsing solely ARFID or restraint (i.e. trying to eat less to control shape/weight) motivations.

METHODS

We applied latent profile analysis to 202 treatment-seeking individuals (ages 10-79 years [M = 26, s.d. = 14], 76% female) with ARFID or a non-ARFID ED, using the Nine-Item ARFID Screen (Picky, Appetite, and Fear subscales) and the Eating Disorder Examination-Questionnaire Restraint subscale as indicators.

RESULTS

A 5-profile solution emerged: Restraint/ARFID-Mixed (n = 24; 8% [n = 2] with ARFID diagnosis); ARFID-2 (with Picky/Appetite; n = 56; 82% ARFID); ARFID-3 (with Picky/Appetite/Fear; n = 40; 68% ARFID); Restraint (n = 45; 11% ARFID); and Non-Endorsers (n = 37; 2% ARFID). Two profiles comprised individuals endorsing solely ARFID motivations (ARFID-2, ARFID-3) and one comprising solely restraint motivations (Restraint), consistent with DSM-5. However, Restraint/ARFID-Mixed (92% non-ARFID ED diagnoses, comprising 18% of those with non-ARFID ED diagnoses in the full sample) endorsed ARFID and restraint motivations.

CONCLUSIONS

The heterogeneous profiles identified suggest ARFID and restraint motivations for dietary restriction may overlap somewhat and that individuals with non-ARFID EDs can also endorse high ARFID symptoms. Future research should clarify diagnostic boundaries between ARFID and non-ARFID EDs.

Measuring implicit associations between food and body stimuli in anorexia nervosa: a Go/No-Go Association Task

PURPOSE

The present study aimed to explore the implicit associations between food and bodily stimuli in patients with anorexia nervosa (AN) and control subjects (HC).

METHODS

A Go/No-Go Association Task was administrated to 55 participants (28 AN and 27 HC), using food stimuli (low-calorie food vs. high-calorie food) and body stimuli (underweight vs. overweight bodies).

RESULTS

We evidenced an implicit association between food and body stimuli in the AN group, whereas the HC group only showed a tendency. AN and HC groups also exhibited different categorization strategies: the AN group tended to categorize stimuli as low-calorie foods and underweight bodies less than the HC group, and they tended to categorize stimuli as high-calorie foods and overweight bodies more than the HC group.

CONCLUSION

The present study revealed for the first time specificities of the AN population's implicit association between food and body stimuli in terms of association strength and categorization strategy. Furthermore, the results suggest that combining implicit methodologies with other methods could contribute to a better characterization of the physiopathology of AN.

LEVEL OF EVIDENCE

Level I, experimental study.

Scurvy and food selectivity in childhood: a case report

Despite its rarity, symptomatic micronutrient deficiency remains a public health problem. Scurvy is the differential diagnosis for bleeding disorders and hematological and rheumatological diseases, especially in patients with eating disorders. However, it is unrelated to autism spectrum disorders or other neurodevelopmental disorders. A previously healthy 10-year-old boy living in São Paulo, Brazil, had a history of significant food selectivity unrelated to autism spectrum disorder, resulting in symptomatic ascorbic acid deficiency (scurvy). This resulted in pain and purpuric lesions on the lower limbs, gingival edema, bleeding during tooth brushing, asthenia, weakness, malaise, and sadness. Therefore, dietary anamnesis is important for routine monitoring of child growth and development. This process helps prevent nutritional deficiencies, facilitates early diagnosis of eating disorders, and enables multidisciplinary follow-up for these patients.

Oxytocin response to food intake in avoidant/restrictive food intake disorder

OBJECTIVE

To investigate the response of anorexigenic oxytocin to food intake among adolescents and young adults with avoidant/restrictive food intake disorder (ARFID), a restrictive eating disorder characterized by lack of interest in food or eating, sensory sensitivity to food, and/or fear of aversive consequences of eating, compared with healthy controls (HC).

DESIGN

Cross-sectional.

METHODS

A total of 109 participants (54 with ARFID spectrum and 55 HC) were instructed to eat a ∼400-kcal standardized mixed meal. We sampled serum oxytocin at fasting and at 30-, 60-, and 120-min postmeal. We tested the hypothesis that ARFID would show higher mean oxytocin levels across time points compared with HC using a mixed model ANOVA. We then used multivariate regression analysis to identify the impact of clinical characteristics (sex, age, and body mass index [BMI] percentile) on oxytocin levels in individuals with ARFID.

RESULTS

Participants with ARFID exhibited greater mean oxytocin levels at all time points compared with HC, and these differences remained significant even after controlling for sex and BMI percentile (P = .004). Clinical variables (sex, age, and BMI percentile) did not show any impact on fasting and postprandial oxytocin levels among individuals with ARFID.

CONCLUSIONS

Consistently high oxytocin levels might be involved in low appetite and sensory aversions to food, contributing to food avoidance in individuals with ARFID.

Exploring latent profiles of disordered eating using an indicator of dietary restriction in an undergraduate sample of men and women

OBJECTIVE

Latent class or latent profile analysis (LPA) studies in patients with eating disorders consistently identify a low-weight, restrictive eating subgroup that does not endorse weight/shape concerns. To date, similar studies in samples unselected for disordered eating symptoms have not identified a high restriction-low weight/shape concerns group, which may be due to a lack of inclusion of measures of dietary restriction.

METHOD

We conducted an LPA using data from 1623 college students (54% female) recruited across three different studies. The Eating Pathology Symptoms Inventory Body Dissatisfaction, Cognitive Restraint, Restricting, and Binge Eating subscales were used as indicators, and body mass index, gender, and dataset were covaried. Purging, excessive exercise, emotion dysregulation, and harmful alcohol use were compared across resulting clusters.

RESULTS

Fit indices supported a 10-class solution, including five disordered eating groups (largest to smallest): "Elevated General Disordered Eating", "Body Dissatisfied Binge Eating," "Most Severe General Disordered Eating," "Non-Body Dissatisfied Binge Eating," and "Non-Body Dissatisfied Restriction." The "Non-Body Dissatisfied Restriction" group scored as low on other measures of traditional eating pathology and harmful alcohol use as non-disordered eating groups but scored as high on a measure of emotion dysregulation as other disordered eating groups.

DISCUSSION

This study is the first to identify a latent restrictive eating group that does not endorse traditional disordered eating cognitions in an unselected sample of undergraduate students. Results underscore the importance of using measures of disordered eating behaviors without implied motivation to capture overlooked problematic eating patterns in the population that are distinct from our "traditional" understanding of disordered eating.

PUBLIC SIGNIFICANCE

We identified a group of individuals with high levels of restrictive eating but low body dissatisfaction and intent to diet in an unselected adult sample of men and women. Results underscore the need to investigate restrictive eating outside of the traditional lens of body shape concerns. Findings also suggest that individuals with nontraditional eating difficulties may struggle with emotion dysregulation, putting them at risk of poor psychological and relational outcomes.

Proposal for increasing diagnostic clarity in research and clinical practice by renaming and reframing atypical anorexia nervosa as "Restrictive Eating Disorder" (RED)

Atypical anorexia nervosa (AAN) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), is characterized by meeting all criteria for anorexia nervosa (AN) except for weight being within or above the "normal" range despite significant weight loss. The current definition is plagued by several problems, resulting in widely heterogeneous operationalizations in research and clinical practice. As such, the poorly defined diagnosis of AAN negatively impacts affected individuals and frustrates research attempts to better understand the syndrome. We consider conceptual flaws in the AAN description and contend that the undefined weight range and nature of weight loss renders these two factors functionally inapplicable in research and practice. They also represent a departure from the originally intended use of the AAN category, i.e., arresting a negative weight trajectory likely to result in AN, making the target population, and the application of the label, unclear. We propose revised criteria and a new name, restrictive eating disorder (RED), intended to reduce stigma and encompass a wide but better-defined range of presentations. The RED criteria focus on clinically significant restrictive behavior that disrupts normal living (i.e., impairment), and cognitive symptoms of overevaluation, disturbed experience, and lack of recognition of illness seriousness. We believe that RED may enable more appropriate clinical application, but also inspire coordinated research toward a more valid psychiatric nosology in the eating disorders field.

Validation of the Nine-Item Avoidant/Restrictive Food Intake Disorder Screen Among Transgender and Nonbinary Youth and Young Adults

Purpose

The purpose of the study was to provide initial evidence for the internal consistency and convergent validity of the nine-item avoidant/restrictive food intake disorder screen (NIAS) in a sample of transgender and nonbinary (TGNB) youth and young adults.

Methods

Returning patients at a Midwestern gender clinic (n=164) ages 12-23 completed the NIAS, sick, control, one stone, fat, food (SCOFF), patient health questionnaire 9 (PHQ-9), and generalized anxiety disorder 7 (GAD-7) during their clinic visit. Age, sex assigned at birth, gender identity, weight, and height were also collected. Confirmatory factor analysis was used to establish the hypothesized three-factor structure of the NIAS in this sample. Relationships between the NIAS subscales and anthropometric data, SCOFF, PHQ-9, GAD-7, and sex assigned at birth were explored for convergent and divergent validity, and proposed screening cutoff scores were used to identify the prevalence of likely avoidant/restrictive food intake disorder (ARFID) in this population.

Results

The three-factor structure of the NIAS was an excellent fit to the current data. Approximately one in five (22%) of the participants screened positive for ARFID. Approximately one in four participants scored above the picky eating (27.4%) or appetite (23.9%) cutoffs. Assigned female at birth participants scored significantly higher on the NIAS-Total, Appetite, and Fear subscales than those assigned male at birth. NIAS-Total was significantly related to all convergent validity variables other than age, with a moderate-strong correlation with other symptom screeners (SCOFF, PHQ-9, GAD-7), and a small negative correlation with body mass index percentile.

Conclusions

Evidence supports the NIAS as a valid measure to screen for ARFID among TGNB youth and young adults.

Evaluating individual- and sample-level response to treatment for inpatients with eating disorders: Is change clinically significant?

OBJECTIVE

Evaluating treatment efficacy solely on whether sample-level change is statistically significant does not indicate whether clinically significant change (CSC) has occurred at the individual-level. We assessed whether change in measures of eating disorder psychopathology was statistically significant at the sample-level and clinically significant at the individual-level for inpatients treated in a hospital-based eating disorder program.

METHOD

Participants (N = 143) were consecutive underweight distinct admissions diagnosed with anorexia nervosa or other specified feeding and eating disorder. The Eating Disorder Examination Questionnaire (EDEQ) and Eating Disorder Recovery Self-efficacy Questionnaire (EDRSQ) were assessed at admission and program discharge. CSC was defined as individual score change that was both statistically reliable and shifted from dysfunctional to normative.

RESULTS

Mean EDRSQ and EDEQ scores significantly improved with treatment across the sample; effect sizes were moderate to large. Individual-level analyses demonstrated that 85%, 50%, and 20-35% of participants had CSC or statistically reliable change in BMI, eating symptomatology, and body image respectively. One-third of participants showed CSC on BMI and on at least one self-report measure.

DISCUSSION

Individual-level analyses offer more nuanced outcome data that could identify patients at higher risk of relapse who may benefit from adjunctive interventions during or immediately post-discharge.

PUBLIC SIGNIFICANCE STATEMENT

This study examined change in eating pathology for inpatients with eating disorders using sample- and individual-level analyses, including whether change was statistically reliable and clinically significant (scores statistically improved and moved into the healthy range). Only half of patients responded robustly to treatment, which may be related to high relapse rates following discharge. Individual-level analyses provided a detailed view of treatment response and may identify patients at higher relapse risk.

Differential comorbidity profiles in avoidant/restrictive food intake disorder and anorexia nervosa: Does age play a role?

OBJECTIVE

Research comparing psychiatric comorbidities between individuals with avoidant/restrictive food intake disorder (ARFID) and anorexia nervosa (AN) is limited. ARFID often develops in childhood, whereas AN typically develops in adolescence or young adulthood. Understanding how age may impact differential psychological comorbidity profiles is important to inform etiological conceptualization, differential diagnosis, and treatment planning. We aimed to compare the lifetime frequency of psychiatric comorbidities and suicidality between females with ARFID (n = 51) and AN (n = 40), investigating the role of age as a covariate.

METHOD

We used structured interviews to assess the comparative frequency of psychiatric comorbidities/suicidality.

RESULTS

When age was omitted from analyses, females with ARFID had a lower frequency of depressive disorders and suicidality compared to AN. Adjusting for age, only suicidality differed between groups.

DISCUSSION

This is the first study to compare comorbidities in a similar number of individuals with ARFID and AN, and a structured clinical interview to confer ARFID and comorbidities, covarying for age, and the first to compare suicidality. Although suicidality is at least three times less common in ARFID than AN, observed differences in other psychiatric comorbidities may reflect ARFID's relatively younger age of presentation compared to AN.

PUBLIC SIGNIFICANCE

Our results highlight that, with the exception of suicidality, which was three times less common in ARFID than AN irrespective of age, observed differences in psychiatric comorbidities in clinical practice may reflect ARFID's younger age at clinical presentation compared to AN.

Visualizing Emotional Arousal within the Context of Body Size Evaluation: A Pilot Study of Steady-State Visual Evoked Potentials in Women with Anorexia Nervosa and Healthy Controls

Maladaptive body size evaluation processes and body dissatisfaction are known as central risk factors for the development and maintenance of anorexia nervosa (AN). This study aimed to experimentally test potential key facets, such as (psycho)physiological, cognitive-verbal and behavioral mechanisms, within the context of these evaluation processes. Twenty-two females with AN (AN-G) and 22 healthy controls (HC-G) looked at pictures of their body gradually increasing in weight using a morphing technique. Implicit emotional arousal was assessed using steady-state visual evoked potentials (SSVEP) in electroencephalography. Additionally, in a forced-choice body size evaluation task, participants were asked to classify pictures of their own body as not big or big while reaction times were captured. A significantly earlier increase in SSVEPs emerged in AN-G compared to HC-G (p <.05), with AN-G evaluating their bodies in the morphing process as big at a significantly thinner body size (p <.05). The AN-G showed faster reaction times in the categorical evaluation of body stimuli (p <.05). Findings from this multimodal paradigm underline the importance of body size evaluation mechanisms and underlying emotional arousal for AN. A differentiated understanding of these processes is essential, since the effectiveness of therapeutic interventions for AN is limited and relapses are frequent.

Traditional Machine Learning Models and Bidirectional Encoder Representations From Transformer (BERT)-Based Automatic Classification of Tweets About Eating Disorders: Algorithm Development and Validation Study

BACKGROUND

Eating disorders affect an increasing number of people. Social networks provide information that can help.

OBJECTIVE

We aimed to find machine learning models capable of efficiently categorizing tweets about eating disorders domain.

METHODS

We collected tweets related to eating disorders, for 3 consecutive months. After preprocessing, a subset of 2000 tweets was labeled: (1) messages written by people suffering from eating disorders or not, (2) messages promoting suffering from eating disorders or not, (3) informative messages or not, and (4) scientific or nonscientific messages. Traditional machine learning and deep learning models were used to classify tweets. We evaluated accuracy, F1 score, and computational time for each model.

RESULTS

A total of 1,058,957 tweets related to eating disorders were collected. were obtained in the 4 categorizations, with The bidirectional encoder representations from transformer-based models had the best score among the machine learning and deep learning techniques applied to the 4 categorization tasks (F1 scores 71.1%-86.4%).

CONCLUSIONS

Bidirectional encoder representations from transformer-based models have better performance, although their computational cost is significantly higher than those of traditional techniques, in classifying eating disorder-related tweets.

Therapists' Experiences of Working with Ethnic Minority Females with Eating Disorders: A Qualitative Study

Ethnic minority females are less likely to receive a diagnosis or treatment for an eating disorder (ED). This study captured the experiences of therapists who have worked with ethnic minority females to improve outcomes for this group. Twelve therapists in the United Kingdom, London were recruited for semi-structured interviews and thematic analysis was used to analyse the data. Shame was cited as a barrier to accessing help. This influenced therapeutic work such as not challenging shame or linking this to a negative interpretation of parents. Emotional and interpersonal factors were thought to be more common risk factors for the ED. The minimising of weight and shape concern and non-fat-phobic anorexia was thought to lead to a complex and delayed route to accessing ED services. Therapists felt restricted by service management who they felt required them to deliver a narrow range of therapies that had not necessarily demonstrated therapeutic outcomes in ethnic minority females. Nevertheless, therapists reported using curiosity to guide their cultural adaptations when feeling uncertain. When working with ethnic minority females, therapists face challenges from the therapeutic and diagnostic framework that services are aligned to. Creative solutions to address this include adapting the patient care pathway, referral guides, cultural reflective practice, and the use of cultural genograms and scripts in therapeutic work to address unmet needs.

Cultural shifts in the symptoms of Anorexia Nervosa: The case of Orthorexia Nervosa

Orthorexia Nervosa (ON) is a term describing a fixation on food purity, involving ritualized eating patterns and a rigid avoidance of "unhealthy foods." Those self-identified as having ON tend to focus on food composition and feel immense guilt after eating food deemed "unhealthy." Although not formally recognized as a psychiatric disorder by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ON has received increasing attention since its identification in 1997. There is ongoing work to establish diagnostic and empirical tools for measuring ON; embedded in this is the question as to whether or not ON is a new eating disorder. In this paper, we argue ON is not a new psychiatric disorder but rather a new cultural manifestation of anorexia nervosa (AN). We begin by providing an overview of historical representations and classification of eating disorders, with a specific focus on AN. This is followed by discussion of the rise in diet culture and healthism since the 19th century. We conclude by examining the diagnostic validity and utility of ON through a discussion of empirical evidence. Classifying ON under the diagnostic umbrella of AN may improve our understanding of factors underlying restrictive eating behaviors.

Validation of the nine item ARFID screen (NIAS) subscales for distinguishing ARFID presentations and screening for ARFID

OBJECTIVE

The Nine Item Avoidant/Restrictive Food Intake Disorder (ARFID) Screen (NIAS) has three subscales aligned with ARFID presentations but clinically validated cutoff scores have not been identified. We aimed to examine NIAS subscale (picky eating, appetite, fear) validity to: (1) capture clinically-diagnosed ARFID presentations; (2) differentiate ARFID from other eating disorders (other-ED); and (3) capture ARFID symptoms among individuals with ARFID, individuals with other-ED, and nonclinical participants.

METHOD

Participants included outpatients (ages 10-76 years; 75% female) diagnosed with ARFID (n = 49) or other-ED (n = 77), and nonclinical participants (ages 22-68 years; 38% female, n = 40). We evaluated criterion-related concurrent validity by conducting receiver operating curve (ROC) analyses to identify potential subscale cutoffs and by testing if cutoffs could capture ARFID with and without use of the Eating Disorder Examination-Questionnaire (EDE-Q).

RESULTS

Each NIAS subscale had high AUC for capturing those who fit versus do not fit each ARFID presentation, resulting in proposed cutoffs of ≥10 (sensitivity = .97, specificity = .63), ≥9 (sensitivity = .86, specificity = .70), and ≥ 10 (sensitivity = .68, specificity = .89) on the NIAS-picky eating, NIAS-appetite, and NIAS-fear subscales, respectively. ARFID versus other-ED had high AUC on the NIAS-picky eating (≥10 proposed cutoff), but not NIAS-appetite or NIAS-fear subscales. NIAS subscale cutoffs had a high association with ARFID diagnosis, but only correctly classified other-ED in combination with EDE-Q Global <2.3.

DISCUSSION

To screen for ARFID, we recommend using a screening tool for other-ED (e.g., EDE-Q) in combination with a positive score on any NIAS subscale (i.e., ≥10, ≥9, and/or ≥10 on the NIAS-picky eating, NIAS-appetite, and NIAS-fear subscales, respectively).

Implicit bias to food and body cues in eating disorders: a systematic review

BACKGROUND

Rigid, restrictive eating patterns, fear of gaining weight, body image concerns, but also binge eating episodes with loss of control leading to overweight, at times followed by compensatory measures to control weight, are typical symptoms in eating disorders (EDs). The regulation of food intake in EDs may underlie explicit processes that require cognitive insight and conscious control or be steered by implicit mechanisms that are mostly automatic, rapid, and associated with affective-rather than cognitive-processing. While introspection is not capable of assessing implicit responses, so-called indirect experimental tasks can assess implicit responses underlying a specific behavior by-passing the participant's consciousness. Here, we aimed to present the current evidence regarding studies on implicit biases to food and body cues in patients with EDs.

METHODS

We performed a systematic review (PRISMA guidelines). We included controlled studies performed in clinical ED cohorts (vs. healthy control subjects or another control condition, e.g., restrictive vs. binge/purge AN) and using at least one indirect assessment method of interest.

RESULTS

Out of 115 screened publications, we identified 29 studies fulfilling the eligibility criteria, and present a synthesis of the essential findings and future directions.

CONCLUSION

In this emerging field of research, the present work provides cornerstones of evidence highlighting aspects of implicit regulation in eating disorders. Applying both direct (e.g., self-reports) and indirect measures for the assessment of both explicit and implicit responses is necessary for a comprehensive investigation of the interplay between these different regulatory mechanisms and eating behavior. Targeted training of implicit reactions is already in use and represents a useful future tool as an add-on to standard psychotherapeutic treatments in the battle against eating disorders.

EVIDENCE LEVEL

1 (systematic review).

Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders

Eating disorders (ED) are complex mental illnesses and are not a result of personal choice. Full recovery from an ED is possible. The severity and inherent lethality of an ED is undisputed, and the role of the registered dietitian nutritionist (RDN) is essential. Clinical symptomology presents at varying developmental milestones and is perpetuated through a sociocultural evaluation of beauty and drive for ascetic idealism. ED are globally prevalent in 4.4% of the population aged 5 to 17 years, yet affect individuals across the entire lifespan, including all cultures and genders. The Behavioral Health Nutrition Dietetic Practice Group, along with the Academy of Nutrition and Dietetics Quality Management Committee, revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs in Eating Disorders. Including the RDN in ED treatment is vital for all levels of care. The RDN must be perceptive to negative symptoms indicative of psychological triggers when exploring food belief systems, patterns of disinhibition, and nutrition misinformation with clients. Through a conscious awareness of medical, psychological, and behavioral strategies, the implementation of the SOP and SOPP supports a dynamic and holistic view of ED treatment by the RDN. The SOP and SOPP are complementary resources for RDNs and are intended to be used as self-evaluation tools for assuring competent practice in ED and for determining potential education, training, supervision, and mentorship needs for advancement to a higher practice level in a variety of settings.

Overcoming limitations of self-report: an assessment of fear of weight gain in anorexia nervosa and healthy controls using implicit association tests

BACKGROUND

Fear of weight gain is a characteristic feature of anorexia nervosa (AN), and reducing this fear is often a main target of treatment. However, research shows that 20% of individuals with AN do not report fear of weight gain. Studies are needed that evaluate the centrality of fear of weight gain for AN with a method less susceptible to deception than self-report.

METHODS

We approximated implicit fear of weight gain by measuring implicit drive for thinness using implicit association tests (IATs). We asked 64 participants (35 AN, 29 healthy controls [HCs]) to categorize statements as pro-dieting vs. non-dieting and true vs. false in a questionnaire-based IAT, and pictures of underweight vs. normal-weight models and positive vs. negative words in a picture-based IAT using two response keys. We tested for associations between implicit drive for thinness and explicitly reported psychopathology within AN as well as group differences between AN and HC groups.

RESULTS

Correlation analyses within the AN group showed that higher implicit drive for thinness was associated with more pronounced eating disorder-specific psychopathology. Furthermore, the AN group showed a stronger implicit drive for thinness than HCs in both IATs.

CONCLUSION

The results highlight the relevance of considering fear of weight gain as a continuous construct. Our implicit assessment captures various degrees of fear of weight gain in AN, which might allow for more individually tailored interventions in the future.

Estimated prevalence of eating disorders in Singapore

OBJECTIVE

There is a lack of research on the prevalence of eating disorders (EDs) in Singapore. The aims of our study were to (a) estimate the prevalence of EDs, risk status, and help-seeking behaviors among adults in Singapore, (b) examine gender differences between ED status groups, and (c) characterize clinical profiles of ED status groups.

METHOD

We administered a cross-sectional survey that included a validated EDs screening tool to adults in Singapore.

RESULTS

A total of 797 Singaporean adults ages 21-77 years completed the ED screen. The majority of participants screened positive for a current DSM-5 clinical ED (6.2%), other specified feeding or ED (37.0%) or at high risk of developing an ED (19.5%). Only 1.6% of those who screened positive for an ED reported currently being in treatment. The ratio of males to females who screened positive for an ED was nearly 1:1. The clinical profiles of ED groups were consistent with the clinical presentations found in Western nations.

DISCUSSION

This is the first study in Singapore to estimate the prevalence of EDs in a large sample of adults. Results highlight the urgent need for more ED research and expansion of prevention and treatment programs to address the high prevalence of ED psychopathology in Singapore.

Avoidant/restrictive food intake disorder: Psychopathological similarities and differences in comparison to anorexia nervosa and the general population

INTRODUCTION

Avoidant/restrictive food intake disorder (ARFID) categorises patients with selective and/or restrictive eating patterns in the absence of distorted cognition concerning weight, food, and body image.

OBJECTIVE

To examine the sociodemographic and clinical profile of patients with ARFID in comparison to those with anorexia nervosa (AN) and to a non-clinical group (NCG).

METHOD

A descriptive, observational, comparative study made up of three groups (ARFID, AN and NCG). Ninety-nine children and adolescents were analyzed by means of a semi-structured diagnostic interview and questionnaires on depression, anxiety, clinical fears and general psychopathology.

RESULTS

The ARFID group was significantly younger (10.8 vs. 14.1 years of age), with a greater proportion of males (60.6% vs. 6.1%), an earlier onset of illness (6.2 vs. 13.4 years of age), and a longer period of evolution of the illness (61.2 vs. 8.4 months) compared to the AN group. Clinically, patients with ARFID showed greater medical (42.4% vs. 12.1%) and psychiatric (81.8% vs. 33.3%) comorbidity-assessed with a semi-structured diagnostic interview-greater clinical fear (p < 0.005), more attention problems (p < 0.005) and fewer symptoms of anxiety and depression (p < 0.005)-measured with self-report questionnaires.

CONCLUSIONS

ARFID is a serious disorder with a significant impact on the physical and mental health of the pediatric population. Likewise, some of these physical and mental conditions may be a risk factor in developing ARFID. Attention problems and clinical fears in ARFID, and the greater presence of internalised symptoms in AN, were the main differences found in the psychopathological profiles.

A Systematic Review Of Implicit Attitudes And Their Neural Correlates In Eating Behaviour

An increasing number of studies suggests that implicit attitudes toward food and body shape predict eating behaviour and characterize patients with eating disorders (EDs). However, literature has not been previously analysed, thus differences between patients with EDs and healthy controls and the level of automaticity of the processes involved in implicit attitudes are still matters of debate. The present systematic review aimed to synthetize current evidence from papers investigating implicit attitudes towards food and body in healthy and EDs populations. PubMed, EMBASE (Ovid), PsycINFO, Web of Science and Scopus were systematically screened and 183 studies using different indirect paradigms were included in the qualitative analysis. The majority of studies reported negative attitudes towards overweight/obese body images in healthy and EDs samples and weight bias as a diffuse stereotypical evaluation. Implicit food attitudes are consistently reported as valid predictors of eating behaviour. Few studies on the neurobiological correlates showed neurostimulation effects on implicit attitudes, but the automaticity at brain level of implicit evaluations remains an open area of research. In conclusion, implicit attitudes are relevant measures of eating behaviour in healthy and clinical settings, although evidence about their neural correlates is limited.

Developmental stage-dependent relationships between ghrelin levels and hippocampal white matter connections in low-weight anorexia nervosa and atypical anorexia nervosa

INTRODUCTION

Disruptions in homeostatic and hedonic food motivation are proposed to underlie anorexia nervosa (AN) and atypical AN, restrictive eating disorders which commonly onset in puberty. Ghrelin, a neuroprotective hormone that drives hedonic eating is increased in AN and is expressed in the hippocampus. White matter (WM) undergoes significant change during puberty in regions involved in food motivation, particularly WM tracts connected with the hippocampus. The association between ghrelin and WM region of interest (ROI) with hippocampal connections in restrictive eating disorders, particularly in adolescence during key neurodevelopmental growth, is unknown.

METHODS

We evaluated fasting plasma ghrelin and WM microstructure (measured by free-water corrected fractional anisotropy (FA-t)) in WM ROIs with hippocampal connections - the fornix and the hippocampal portion of the cingulum - in 56 adolescent females (age range: 11.9 - 22.1 y; mean: 19.0 y) with low-weight eating disorders including AN and atypical AN (N = 36) and healthy controls (N = 20).

RESULTS

FA-t in the fornix or hippocampal portion of the fornix did not differ between groups. Ghrelin was higher in AN/atypical AN vs. HC and was positively correlated with puberty stage in the AN/atypical AN group, but not the HC group. The correlation between ghrelin and FA-t in the fornix was significantly different in females with AN/atypical AN compared to controls. In AN/atypical AN, pubertal stage moderated the relation between fasting plasma ghrelin and FA-t in the fornix: higher fasting ghrelin was associated with lower FA-t in the fornix in late-post-puberty, but was not associated with FA-t in the early to mid stages of puberty.

CONCLUSIONS

In post-pubertal females with low-weight AN/atypical AN, higher levels of ghrelin are associated with lower FA-t in the fornix. This relationship is not evident in the early to mid stages of puberty in AN/atypical AN or in HC, and may reflect a lack of possible neuroprotective effects of ghrelin in late-post puberty only. Understanding the effects of ghrelin on WM microstructure longitudinally and following recovery from AN/Atypical AN and how this differs across pubertal stages will be an important next step. These findings could ultimately inform treatment staging and aid in diagnosis and detection of AN/atypical AN.

Preliminary development of an implicit association test to measure body dissatisfaction and predict disordered eating behaviors

We conducted a preliminary test of a novel implicit association test for body dissatisfaction (BD-IAT). We predicted that BD-IAT would correlate with self-reported BD and predict later eating disorder (ED) attitudes. Female undergraduates (N = 145) self-reported BD and ED attitudes. In the BD-IAT, participants sorted words related to "satisfaction" and "dissatisfaction" to opposite sides of a computer screen. Participants categorized pictures of themselves to the side of the screen with the word "Me," which appeared with the "satisfied" or "dissatisfied" category in separate blocks. The BD-IAT measured the strength of the association between a participant's own body and dissatisfaction. The BD-IAT correlated positively with the EDI-BD (r = 0.21, p < 0.05), supporting its convergent validity. The BD-IAT predicted ED attitudes at one-week follow-up, controlling for explicit BD and baseline ED (b = 0.58, SE = 0.23, t = 2.57, p = .01); IAT scores uniquely accounted for 4.7 % of the variance in ED at one-week follow-up. These results provide preliminary evidence for the BD-IAT as an implicit measure of BD and suggest that it may predict future ED attitudes above and beyond explicit BD. Directions for future work aimed at continued development of this task are discussed.

Fat-Phobic and Non-Fat-Phobic Anorexia Nervosa: A Conjoint Analysis on the Importance of Shape and Weight

With the introduction of new diagnostic criteria in DSM-5, fear of weight gain no longer represents a sine qua non-criterion for the diagnosis of anorexia nervosa (AN). This is of relevance as a subgroup of individuals with AN denies fear of weight gain as the reason for restrictive eating but still remain at a very low weight. As self-reports are susceptible to bias, other methods are needed to confirm the existence of the subtype in order to provide adapted treatment. Therefore, we aimed to measure fear of weight gain using a novel method in clinical psychology, the conjoint analysis (CA). Relative importance and preference scores for various life aspects, including appearance/shape and weight were assessed in women with fat-phobic AN (FP-AN, n = 30), NFP-AN (n = 7), and healthy controls (n = 29). Individuals with FP-AN showed a significant lower preference for weight gain versus weight maintenance than HC (p = 0.011, ηp2 = 0.107). Correlation between explicitly assessed drive for thinness and CA score was low. As expected, in FP-AN the explicitly endorsed fear of weight gain was confirmed by the marked preference for weight maintenance compared to HC, while for NFP-AN explicit and implicit measures diverged, indicating that against their self-report they may experience at least some fear of weight gain. The utility of CA as a tool to measure fear of weight gain — and potentially other psychopathological constructs —requires further confirmation.

Characteristics and clinical trajectories of patients meeting criteria for avoidant/restrictive food intake disorder that are subsequently reclassified as anorexia nervosa

OBJECTIVE

To examine the initial assessment profiles and early treatment trajectories of youth meeting the criteria for avoidant/restrictive food intake disorder (ARFID) that were subsequently reclassified as anorexia nervosa (AN).

METHOD

A retrospective cohort study of patients assessed and treated in a tertiary care eating disorders (ED) program was completed.

RESULTS

Of the 77 included patients initially meeting criteria for ARFID, six were reclassified as having AN (7.8%) at a median rate of 71 days after the first assessment. Patients in this cohort presented at very low % treatment goal weight (median 71.6%), self-reported abbreviated length of illness (median 6 months), and exhibited low resting heart rates (median 46 beats per minute). Nutrition and feeding focused worries related more to general health as opposed to specific weight and shape concerns or fears at assessment in half of those reclassified with AN. Treatment at the 6-month mark varied among patients, but comprised family and individual therapy, as well as prescription of psychotropic medication.

CONCLUSION

Prospective longitudinal research that utilizes ARFID-specific as well as traditional eating disorder diagnostic measures is required to better understand how patients with restrictive eating disorders that deny fear of weight gain can be differentiated and best treated.

Cognitive Behavioral Therapy Management of a Patient with Atypical Anorexia Nervosa

Eating disorders are becoming more common in nonwestern societies and some of these presentations are atypical variants such as atypical anorexia nervosa. There is very little data on how to treat these patients. This case study reports the treatment of a young adult female in Sri Lanka who presented with atypical anorexia nervosa and moderate depressive disorder. She was successfully treated with nine sessions of enhanced cognitive-behavioural therapy (CBT-E). According to our knowledge this is the first case report that describes the management of a patient with atypical anorexia nervosa using psychological therapy specifically adapted to nonwestern context.

Introduction to a special issue on child and adolescent feeding and eating disorders and avoidant/restrictive food intake disorder

OBJECTIVE

We are very pleased to introduce a special issue of the International Journal of Eating Disorders on child and adolescent feeding and eating disorders and avoidant/restrictive food intake disorder (ARFID).

METHOD

Contributions focused on five main themes: (1) the definition and assessment of ARFID; (2) the clinical phenomenology of ARFID; (3) similarities and differences between ARFID and anorexia nervosa (AN); (4) novel treatments for ARFID; and (5) new ideas for improving treatment outcomes in AN.

RESULTS

These papers highlight the importance of clear operationalization and measurement of the ARFID diagnostic criteria. ARFID phenotypes bear both similarities and important differences in clinical profile, course, and outcome from AN. Findings suggest the utility of adapting existing treatments for restrictive eating disorders to apply to ARFID and engender clinical creativity to move beyond existing treatments and develop novel interventions that address the heterogeneity of ARFID. Furthermore, burgeoning understanding of ARFID offers the potential that novel treatments for ARFID may also be applied to improve outcomes for AN.

DISCUSSION

This collection of papers features child and adolescent feeding and eating disorder patient groups that have been understudied and we hope that this catalyzes clinical research in these important presentations.