Latent trajectories of eating disorder treatment response among female patients in residential care

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.

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.

A preliminary study of latent trajectories of change in dietary restraint during CBT-E for bulimia-spectrum eating disorders and their associations with treatment response

OBJECTIVE

Dietary restraint is a primary target of CBT-E. However, little research has examined how specific types of dietary restraint change during CBT-E for bulimia-spectrum eating disorders (BN-EDs) or the association between changes in dietary restraint and treatment response. This study examined latent trajectories of change in eating enough, eating a range of macronutrients, and following dietary rules during CBT-E for BN-EDs and the relationships between these trajectories and pre- to post-treatment change in BN symptoms and remission.

METHOD

Participants were 56 adults with BN-EDs who received 16 sessions of CBT-E and completed the Eating Disorder Examination and ecological momentary assessments (EMA) of eating behaviors and BN symptoms. Latent growth mixture modeling identified trajectories of change in dietary restraint, which were compared on pre- to post-treatment BN symptom change and remission.

RESULTS

Three trajectories of change were identified for eating enough, eating a range of macronutrients, and food rules. Trajectories of change in eating enough were differentially associated with pre- to post-treatment change in BN symptoms, and trajectories of change in eating a range of macronutrients and food rules were differentially associated with remission.

CONCLUSIONS

CBT-E yields heterogeneous trajectories of change in dietary restraint, which are associated with treatment response.

Outcomes and associated clinical features of people with eating disorders participating in residential treatment facilities: a scoping review

Residential treatment programs for eating disorders (EDs) have gained popularity in recent years, expanding beyond the United States to countries such as Canada, Italy, and the United Kingdom. These programs offer a "home-like" environment where individuals reside for several weeks or months, emphasising both physical restoration and psychological recovery. This scoping review aimed to provide an update since the most recent reviews on the literature regarding outcomes of residential treatment programs for EDs and to explore clinical features that were associated with these outcomes. Methods used followed the Joanna Briggs Institute guidelines for scoping reviews. A systematic search of electronic databases was conducted, and 12 studies met the inclusion criteria. All studies reported improvements in various outcomes from admission to discharge, including changes in eating psychopathology, weight restoration, depression, anxiety, and quality of life. Additionally, three studies reported positive outcomes at intervals after discharge and three predictive factors (self-compassion, personality organisation, and resistance to emotional vulnerability) were reported in a small number of studies. While residential treatment facilities consistently showed positive outcomes, the review highlights the need for randomised controlled studies to establish the efficacy of these programs for EDs. Future research should include controlled studies comparing residential facilities to other treatment settings and incorporate long-term follow-up outcomes and further studies of emergent predictive factors identified in this review.

Recovery Trajectories in Adolescent Girls with Anorexia Nervosa

Background: This study aimed to document recovery trajectories among adolescents with anorexia nervosa (AN) based on three markers of remission, namely changes in body weight, food restriction, and excessive exercise, and to identify predictors of these trajectories. Methods: One hundred twenty-six adolescent girls (14.7 ± 1.3 years) were recruited during initial assessment visits at specialized eating disorder (ED) programs in five University Health Centers across the province of Quebec, Canada. z-BMI and AN symptom severity (food restriction and excessive exercise) were assessed at initial assessment visits and subsequently reassessed at each quarterly follow-up over a 12-month period to identify recovery trajectories. Results: Considering the three markers of remission, three distinct trajectories emerged: Group 1, rapid responders; Group 2, gradual responders; and Group 3, unstable responders. At initial visits, a difference between groups was found regarding the type of treatment (p = 0.01) and weight suppression (p = 0.02). Group 1 had a higher number of youths hospitalized than Group 2 and Group 3, and a greater weight suppression than Group 3. Furthermore, individuals with atypical AN were more likely to belong to Group 2 than to Group 1 and Group 3 (p < 0.0001). Conclusions: This study contributes to a better understanding of the heterogeneity of recovery trajectories in adolescent girls with AN.

Childhood trauma and outcome trajectories in patients with longstanding eating disorders across 17 years

BACKGROUND

A large proportion of patients with eating disorders (ED) report experiences of childhood trauma. Latent trajectory analysis in ED samples reveals the complexities in course and outcome and can explore the long-term impact of adverse experiences in childhood.

METHOD

A total of 84 patients with longstanding ED were included. ED symptoms were assessed by the Eating Disorder Examination interview at discharge from inpatient treatment, and at 1-, 2-, 5-, and 17-year follow-up, respectively. Change over time was examined using growth mixture modeling, allowing the number of trajectories to emerge through the data. Prevalence of childhood trauma was assessed, and its relation to class membership was tested.

RESULTS

We identified four distinct classes: patients with (a) a continuous improvement in the entire follow-up period, and scores within normal range at the end, "continuous improvement" (54.8%); (b) a high symptom level at baseline and moderate decrease over time, "high and declining" (22.6%); (c) initial ED scores below clinical cut-off and stable symptoms throughout the course, "consistently low" (14.3%); and (d) with high scores initially, and a significant increase in symptoms over time, "high and increasing" (8.3%). A history of childhood sexual abuse (CSA) was overrepresented in classes with persistently high symptom levels and poor long-term outcome DISCUSSION: Patients with longstanding ED displayed considerable diversity in trajectories of symptom change across 17 years. To improve long-term outcome, enhanced treatment of sequelae from CSA seems essential.

PUBLIC SIGNIFICANCE

Patients with longstanding eating disorders displayed four different trajectories of change in a 17-year follow-up study. Although there were significant changes over time, the majority of patients remained within similar symptom levels as they presented with at discharge from inpatient treatment. Exposure to childhood maltreatment was common within the sample. Childhood sexual abuse predicted poor long-term outcome, which highlights the importance of trauma informed care.

A baseline comparison of three diagnostic groups using the Progress Monitoring Tool for Eating Disorders

Utilisation of intensive inpatient treatment for eating disorders (EDs) has climbed in the last decade, illuminating a need for better consensus on what constitutes effective treatment and context-appropriate progress/outcome monitoring during residential stays. The novel Progress Monitoring Tool for Eating Disorders (PMED) measure is specifically designed for inpatient settings. Previous research supports the factorial validity and internal consistency of the PMED; however, additional work is needed to determine its appropriateness for complex patient populations. This study used measurement invariance (MI) testing to determine if the PMED administered at programme admission measures the same items in similar ways across patients with anorexia nervosa restricting- and binge-purge subtypes (AN-R; AN-BP) and bulimia nervosa (BN, N = 1121; M_age  = 24.33 years, SD = 10.20; 100% female). Progressively constrained models were used to determine the level of invariance upheld between the three groups. Results indicated that, while the PMED meets configural and metric MI, it does not display scalar invariance. Said otherwise, the PMED similarly assesses constructs and items across AN-R, AN-BP, and BN, however the same score overall may reflect different levels of psychopathology for patients in one diagnostic category versus another. Comparisons of severity between different EDs should be made with caution, however the PMED appears to be a sound tool for understanding the baseline functioning of patients with EDs in an inpatient setting.

Modelling trajectories of change in psychopathology and well-being during eating disorder outpatient treatment

Objective: There are considerable differences in how eating disorder (ED) patients respond to treatment. This study aimed to identify change trajectories of mental health during treatment. Method: Longitudinal data of 442 patients was used with five time points during a year of outpatient treatment. ED psychopathology and well-being were used as primary measures. A series of latent growth mixture models were applied to model trajectories of change. Results: Three latent classes were found for ED psychopathology and well-being. For ED psychopathology, a high baseline severity and slow recovery class (55.9% of the patients), a high baseline severity followed by a substantial recovery class (19.9%) and a moderate baseline severity and no significant recovery class (24.2%) were found. For well-being, a low baseline followed by a slow growth class (44.6%), a low baseline and substantial growth class (9.5%) and a moderate and stable well-being class (45.9%) was found. General psychopathology, early symptom change, hope for recovery, intrinsic motivation and the ED type were predictive of class membership in either ED psychopathology or well-being. Conclusions: This study shows variability in ED psychopathology and well-being change trajectories, modelled in meaningful latent recovery classes. These results may have clinical implications, such as adjusting patients' treatment based on change trajectories.

Early weight gain trajectories in first episode anorexia: predictors of outcome for emerging adults in outpatient treatment

BACKGROUND

Early response to treatment has been shown to be a predictor of later clinical outcomes in eating disorders (EDs). Specifically, early weight gain trajectories in anorexia nervosa (AN) have been shown to predict higher rates of later remission in inpatient treatment. However, no study has, as of yet, examined this phenomenon within outpatient treatment of first episode cases of AN or in emerging adults.

METHODS

One hundred seven patients with AN, all between the ages of 16 and 25 and with an illness duration of < 3 years, received treatment via the first episode rapid early intervention in eating disorders (FREED) service pathway. Weight was recorded routinely across early treatment sessions and recovery outcomes (BMI > 18.5 kg/m2 and eating psychopathology) were assessed up to 1 year later. Early weight gain across the first 12 treatment sessions was investigated using latent growth mixture modelling to determine distinct classes of change. Follow-up clinical outcomes and remission rates were compared between classes, and individual and clinical characteristics at baseline (treatment start) were tested as potential predictors.

RESULTS

Four classes of early treatment trajectory were identified. Three of these classes (n = 95), though differing in their early change trajectories, showed substantial improvement in clinical outcomes at final follow-up. One smaller class (n = 12), characterised by a 'higher' start BMI (> 17) and no early weight gain, showed negligible improvement 1 year later. Of the three treatment responding groups, levels of purging, depression, and patient reported carer expressed emotion (in the form of high expectations and low tolerance of the patient) determined class membership, although these findings were not significant after correcting for multiple testing. A higher BMI at treatment start was not sufficient to predict optimal clinical outcomes.

CONCLUSION

First episode cases of AN treated via FREED fit into four distinct early response trajectory classes. These may represent subtypes of first episode AN patients. Three of these four trajectories included patients with substantial improvements 1 year later. For those in the non-response trajectory class, treatment adjustments or augmentations could be considered earlier, i.e., at treatment session 12.

Prediction of eating disorder treatment response trajectories via machine learning does not improve performance versus a simpler regression approach

OBJECTIVE

Patterns of response to eating disorder (ED) treatment are heterogeneous. Advance knowledge of a patient's expected course may inform precision medicine for ED treatment. This study explored the feasibility of applying machine learning to generate personalized predictions of symptom trajectories among patients receiving treatment for EDs, and compared model performance to a simpler logistic regression prediction model.

METHOD

Participants were adolescent girls and adult women (N = 333) presenting for residential ED treatment. Self-report progress assessments were completed at admission, discharge, and weekly throughout treatment. Latent growth mixture modeling previously identified three latent treatment response trajectories (Rapid Response, Gradual Response, and Low-Symptom Static Response) and assigned a trajectory type to each patient. Machine learning models (support vector, k-nearest neighbors) and logistic regression were applied to these data to predict a patient's response trajectory using data from the first 2 weeks of treatment.

RESULTS

The best-performing machine learning model (evaluated via area under the receiver operating characteristics curve [AUC]) was the radial-kernel support vector machine (AUCRADIAL = 0.94). However, the more computationally-intensive machine learning models did not improve predictive power beyond that achieved by logistic regression (AUCLOGIT = 0.93). Logistic regression significantly improved upon chance prediction (MAUC[NULL] = 0.50, SD = .01; p <.001).

DISCUSSION

Prediction of ED treatment response trajectories is feasible and achieves excellent performance, however, machine learning added little benefit. We discuss the need to explore how advance knowledge of expected trajectories may be used to plan treatment and deliver individualized interventions to maximize treatment effects.

FOOD ADDICTION AS A PROXY FOR ANOREXIA NERVOSA SEVERITY: NEW DATA BASED ON THE YALE FOOD ADDICTION SCALE 2.0

The contribution of an addictive process to anorexia nervosa (AN) is an area of growing interest. Yet, little is known about how the food addiction concept (FA) may be of interest in understanding AN. This study investigates prevalence of FA diagnostic and its association with markers of severity in individuals with AN. We conducted a retrospective study in a sample of 73 patients with AN. We assessed FA with the Yale Food Addiction Scale 2.0, depressive and anxiety disorders, impulsivity (Beck Depression Inventory, STAI, BIS-11) and eating behavior (BITE, EDE-Q). Prevalence of FA in our sample was 47%. FA was significantly associated and positively correlated with the binge-eating/purging subtype of AN, higher levels of depression, anxiety and greater eating psychopathology. FA was not associated with level of impulsivity nor leptin and IGF-1 blood levels. The relationship between FA severity and AN severity was mediated by the severity of binge eating behaviors. Our results suggest that the presence of FA may represent a more severe variant of AN. Longitudinal studies are needed to better understand the etiologic process between FA and AN.