Predictors of outcome among young adult patients with anorexia nervosa in a randomised controlled trial

Factors predicting long-term weight maintenance in anorexia nervosa: a systematic review

PURPOSE

Eating disorder recovery is a poorly defined concept, with large variations among researchers' definitions. Weight maintenance is a key aspect of recovery that remains relatively underexplored in the literature. Understanding the role of weight maintenance may help guide the development of treatments. This paper aims to address this by (1) investigating the factors predicting long-term weight maintenance in anorexia nervosa (AN) patients; (2) exploring differences in predictive factors between adolescent and adult populations; and (3) exploring how weight maintenance is conceptualised in the literature.

METHODS

We conducted a systematic review following PRISMA guidelines to address our research questions. Five databases were searched and filtered according to our exclusion criteria.

RESULTS

From the search, 1059 studies were yielded, and 13 studies were included for review. A range of weight, biological and psychological factors were found to predict weight maintenance among these papers. BMI at admission and discharge from inpatient treatment was the most common predictor among the papers. Few studies investigated biological factors and mixed evidence was found for psychological factors. We found no observable differences between adult and adolescent populations. Finally, weight maintenance was defined and measured differently across studies.

CONCLUSION

This review's findings can help contribute to a well-rounded understanding of weight maintenance, and ultimately, of recovery. This can help support clinicians in tailoring interventions to improve long-term outcomes in AN. Future research should aim to replicate studies to better understand the relationship between the factors identified and weight maintenance.

LEVEL I

Systematic review.

Sensory processing across eating disorders: A systematic review and meta-analysis of self-report inventories

OBJECTIVE

This review investigated the extant literature regarding the relationship between eating disorder diagnoses and sensory processing as measured by validated and reliable self-report inventories. Increasing evidence highlights the role of sensory processing in cognitive functions. Sensory processing is implicated in mental-ill health, including eating disorders (ED) and body image disturbances. However, the pathophysiological underpinnings of sensory processing, encompassing exteroception and interoception, in relation to ED remain underexplored.

METHOD

We included studies involving participants aged 15 years or older with an eating disorder diagnosis confirmed by semi-structured or structured interviews. We further limited inclusion to articles using validated and reliable self-report instruments to measure sensory processing. Our meta-analysis focused on studies using the interoceptive awareness subscale from the second version of the Eating Disorder Inventory. We used the Critical Appraisal checklist for quasi-experimental studies to assess the quality of included articles.

RESULTS

There were 19 studies that met our inclusion criteria. Most studies showed moderate-to-high quality. Anorexia nervosa (AN) and bulimia nervosa (BN) were associated with heightened exteroception. Moreover, people with AN reported a heightened sense of taste compared to those with BN. Our meta-analysis comprising 10 studies, 19 samples, and 6382 participants revealed that AN (binge-purge subtype) and BN were associated with increased interoceptive difficulties compared to AN (restrictive subtype) or binge-eating disorder.

DISCUSSION

Overall, this review emphasizes the need for a deeper investigation into sensory processing, spanning both exteroception and interoception, in relation to ED. This may prove important for individualizing person-centered care.

PUBLIC SIGNIFICANCE

How people process internal, for example, hunger, and external, for example, taste and sensations is known to influence cognition and mental-ill health, including ED and body image disturbances. However, the ways in which sensory processing may contribute to ED are incompletely understood. We found that individuals with AN or BN experienced heightened exteroception, while people with an eating disorder characterized by purging reported increased interoceptive difficulties. These patterns could inform the development of more personalized treatments.

Systemic therapy in children and adolescents with mental disorders: a systematic review and meta-analysis

BACKGROUND

Systemic therapy (ST) is a psychotherapeutic intervention in complex human systems (both psychological and interpersonal). Cognitive behavioural therapy (CBT) is an established treatment for children and adolescents with mental disorders. As methodologically rigorous systematic reviews on ST in this population are lacking, we conducted a systematic review and meta-analysis to compare the benefit and harm of ST (and ST as an add-on to CBT) with CBT in children and adolescents with mental disorders.

METHODS

We searched MEDLINE, Embase, PsycINFO and other sources for randomised controlled trials in 14 mental disorder classes for the above comparisons in respect of effects on patient-relevant outcomes (search date: 7/2022). Where possible, meta-analyses were performed and results were graded into 3 different evidence categories: "proof", "indication", or "hint" (or none of these categories). PRISMA standards were followed.

RESULTS

Fifteen studies in 5 mental disorder classes with usable data were identified. 2079 patients (mean age: 10 to 19 years) were analysed. 12/15 studies and 29/30 outcomes showed a high risk of bias. In 2 classes, statistically significant and clinically relevant effects in favour of ST were found, supporting the conclusion of a hint of greater benefit of ST for mental and behavioural disorders due to psychoactive substance use and of ST as an add-on to CBT for obsessive-compulsive disorders. In 2 other classes (eating disorders; hyperkinetic disorders), there was no evidence of greater benefit or harm of ST. For affective disorders, a statistically significant effect to the disadvantage of ST was found for 1 outcome, supporting the conclusion of a hint of lesser benefit of ST.

CONCLUSIONS

Our results show a hint of greater benefit of ST (or ST as an add-on to CBT) compared with CBT for 2 mental disorder classes in children and adolescents (mental and behavioural disorders due to psychoactive substance use, obsessive compulsive disorders). Given the importance of CBT as a control intervention, ST can therefore be considered a beneficial treatment option for children and adolescents with certain mental disorders. Limitations include an overall high risk of bias of studies and outcomes and a lack of data for several disorders.

Effects of family-based treatment on adolescent outpatients treated for anorexia nervosa in the Eating Disorder Unit of Helsinki University Hospital

BACKGROUND

Family therapy for adolescent anorexia nervosa (AN) has stronger evidence of efficacy in comparison with individual therapy, and family-based treatment (FBT) is the most evaluated in numerous randomized clinical trials. However, few studies have focused on how FBT performs outside of research settings. The current study is the first to assess clinical outcomes of FBT for adolescent AN in Finland, in a specialized outpatient clinic.

AIM

The naturalistic outcome of outpatient FBT for adolescent AN was investigated.

METHODS

Fifty-two female patients and their families who received FBT at a tertiary eating disorders unit participated in the study. Data on their pre-treatment parameters, treatment details, and condition at the end of treatment (EOT) was collected from their medical records.

RESULTS

At EOT, a majority (61.5%) had achieved a full weight restoration [percentage of expected body weight (%EBW) ≥ 95%]. Participants with an %EBW ≥ 95 at EOT had a significantly higher pre-treatment %EBW than those with an EBW < 95% at EOT. Participants with an EBW ≥ 95% at EOT showed significantly higher total weight gain during the treatment period, a higher rate of regular menstrual periods at EOT, significantly lower rates of dietary restrictions, and less cognitive or behavioral symptoms of the eating disorder overall, compared to participants who did not achieve a normal body weight. In 22 cases (42.3%), there was no need for further treatment at the end of FBT. Participants who needed further treatment after FBT, compared to those who did not, showed significantly higher rates of psychiatric comorbidity, history of mental health treatment, and need for psychopharmacological treatment.

CONCLUSIONS

In this naturalistic study, and in line with previous studies, FBT for AN appeared to be an effective and sometimes sufficient intervention, especially for patients with milder weight deficit and less severe psychiatric comorbidities. The results show that FBT can be successfully implemented in Finland and suggest that training more ED clinicians in FBT would be beneficial.

TRIAL REGISTRATION

The study was retrospectively registered on February 8th, 2023, in ClinicalTrials.gov Protocol Registration and Results System, identifier: NCT05734573.

Impact of LEAP and CBT-AN Therapy on Improving Outcomes in Women with Anorexia Nervosa

Anorexia nervosa (AN) is a mental health disorder that has serious physical, emotional and social consequences. Whilst cognitive behavioural therapy for AN (CBT-AN) has demonstrated efficacy, there remains a global need to improve AN treatment. Compulsive exercise activity therapy (LEAP) is an active therapy consisting of the addition to CBT-AN of eight specific sessions that focus on exercise and motivation for behavioural change. This paper presents a secondary analysis of 74 female participants in a randomised control trial of LEAP plus CBT-AN versus CBT-AN alone. The main aim of this study was to explore putative predictors and to estimate the magnitude of changes due to LEAP for specific outcome measures. Participants (LEAP: n = 36; CBT-AN: n = 38) were assessed at three successive surveys: baseline, end of therapy, and 6 months post-therapy. The overall effect sizes for changes between baseline to end of therapy and baseline to 6-month follow-up assessment showed large effect sizes (Cohen's d > = 0.80) for mental-health-related quality of life (MHRQoL), weight concern, dietary restraint, eating concern, AN stage change, and psychological distress (all p < 0.05). The results also indicated that several pre-treatment characteristics, including body mass index (BMI), level of eating disorder (ED) symptoms, and MHRQoL are important for identifying whether a treatment is likely to be effective. Future treatment programs should aim to optimise early improvements in BMI, ED symptoms, and MHRQoL.

Predictors of Treatment Outcome in Eating Disorders: A Roadmap to Inform Future Research Efforts

PURPOSE OF REVIEW

With the current review, we provide a brief summary of recent literature that tests clinically observable characteristics at baseline that may impact treatment response, across eating disorder diagnoses. We then provide a critical discussion regarding how researchers may shift their approach to this research to improve treatment implications and generalizability of these findings.

RECENT FINDINGS

Recent work has broadly replicated prior findings suggesting a negative impact of lower weight status, poor emotion regulation, and early-life trauma on eating disorder treatment outcomes. Findings are more mixed for the relative contributions of illness duration, psychiatric comorbidity, and baseline symptom severity. Recent studies have begun to explore more specific domains of previously tested predictors (e.g., specific comorbidities) as well as previously neglected identity-related and systemic factors. However, recent research continues to use similar sampling techniques and approaches to analysis used in prior work. We propose that resolving remaining questions and illuminating predictors of treatment outcome in eating disorders requires a new approach to research sampling and study design. Suggested changes that can be applied within a traditional clinical trial framework may yield new insights with relevance across transdiagnostic eating disorder presentations.

Systematic review: Exploring the monitoring and reporting of unwanted events in psychotherapy trials for anorexia nervosa

OBJECTIVE

If a psychotherapeutic intervention has the capacity to produce positive change, the "deterioration effect" theory holds that it must also have the potential for negative effects. However, the definition, measurement, and reporting of unwanted events in psychotherapy is a topic of ongoing discussion. At present this area is under-explored in interventions for anorexia nervosa (AN), a severe mental illness associated with high medical and psychiatric risks. The aim of this article was to undertake a systematic review of published randomized controlled trials (RCTs) evaluating psychotherapeutic interventions for AN, and to assess how unwanted events were defined, monitored, and reported alongside the trial's key findings.

METHOD

Using a systematic review methodology, this article identified 23 RCTs through database searches meeting eligibility criteria. Results are presented using a narrative summary approach.

RESULTS

Unwanted event reporting varied widely, both regarding definitions of key unwanted events (such as non-compliance or symptom deterioration) and in the amount of detail captured in each paper.

DISCUSSION

The review identified two key issues: firstly, a lack of consistent definitions and unclear causality made it difficult to distinguish between unwanted events, and adverse events caused by the interventions. Secondly, it highlighted the difficulty of defining unwanted events where different studies have different populations and goals. Recommendations are made around how the area of defining, monitoring, and reporting unwanted events in RCTs for AN can be taken forward.

PUBLIC SIGNIFICANCE

Whilst psychotherapies can be effective in treating mental health conditions, negative or unwanted events can sometimes occur. This review explored how RCTs examining psychotherapy for AN report how they monitor the safety of participants, and how they report unwanted events. We found that the reporting was often inconsistent or hard to interpret, and we have made recommendations for how this can be improved in the future.

Seeing Through the Façade of Anorexia: A Grounded Theory of Emotional Change Processes Associated With Recovery From Anorexia Nervosa

OBJECTIVES

Difficulties in managing emotions have been implicated in the development and maintenance of anorexia nervosa (AN), and psychological treatment models seek to address this in putative targets of change. Yet the field of psychotherapy remains unclear and insufficiently evidenced about the process of change and how this is actually achieved, including in what steps and in what order within clinical treatment. This qualitative study sought to develop theory about the process of emotional change during recovery from anorexia.

METHODS

Semi-structured interviews were carried out with nine women currently engaged in psychological treatment for anorexia. Interviews included questions pertaining to participants' experience of anorexia, emotions, and emotion management. A constructivist version of grounded theory was employed.

RESULTS

The analysis produced 10 major categories, comprising over 60 focused codes. Categories were clustered together into three super categories, reflecting 3 distinct but interrelated phases of participants' journeys toward recovery. The phases were: (1) Coping in a world of uncertainty, (2) Seeing through the façade of anorexia, and (3) Recovery and growth. Whilst movement toward later positions often appeared to be contingent on earlier ones, the analysis suggests that this was not an entirely linear process and that participants moved between positions as they grappled with the process of change. Participants came to view behaviors associated with anorexia as emotion-management strategies that were not working and as a façade. As they moved toward recovery and growth, they became less confined by their need for safety, and to see emotions as meaningful and valuable. Becoming more connected to emotional experience and expression, coincided with positive shifts in their intra and interpersonal relationships.

CONCLUSION

These findings support the recent shift toward emotion-focused models of anorexia. They also highlight an important focus in supporting individuals with AN to connect with, and be guided by, emotional experiences in their relationships with themselves and the world around them. This new grounded theory offers a putative process of change that could be utilized to guide intervention development.

Predictors of improvement in a family-based partial hospitalization/intensive outpatient program for eating disorders

The efficacy of family-based treatment (FBT) in outpatient settings has led to efforts to incorporate FBT principles into higher levels of care. The present study examined predictors of improvement in an FBT-based partial hospitalization program/intensive outpatient program (PHP/IOP) as measured by the Eating Disorder Examination-Questionnaire. Participants were 113 patients with anorexia nervosa (AN) or eating disorder not otherwise specified (EDNOS) consecutively participating in an FBT-based PHP/IOP. Multilevel modeling was used to investigate predictors for adolescents and young adults separately. Predictors considered included illness duration, previous hospitalization, hospitalization immediately prior to treatment, previous outpatient therapy, hospitalization during treatment, diagnosis, gaining 4 pounds in 4 weeks, and family status as time-invariant variables. Time-varying variables considered included depression symptoms and mothers'/fathers' ratings of parental self-efficacy and expressed emotion. For adolescents, depression by time and diagnosis by time interactions were statistically significant. At all levels of depression, adolescent patients with AN demonstrated greater reductions in eating disorder symptoms compared to patients with EDNOS. For young adults, depression and gaining 4 pounds in 4 weeks were significant predictors. The relationships for young adults were curvilinear such that, while lower eating disorder symptoms were found during treatment, these gains were not maintained at follow up.

The effect of group cognitive behavior therapy on Chinese patients with anorexia nervosa: an open label trial

BACKGROUND

The high cost of treatment for anorexia nervosa (AN) and lack of trained specialists have resulted in limited accessibility of effective treatment to patients with AN, which is particularly problematic in China. To increase the accessibility of evidence-based treatment and reduce the cost of treatment, this study aimed to explore the feasibility and efficacy of group cognitive behavior therapy (G-CBT) adapted from enhanced cognitive behavior therapy for eating disorders (CBT-E) in Chinese AN patients.

METHOD

A total of 78 patients with AN were assigned to G-CBT or individual outpatient treatment (IOT) and received three months of treatment for AN in each condition. Measures of eating pathology, depression and anxiety were administrated to both intervention groups at three time points: baseline, one month of treatment, and end of treatment; results were compared between groups and over time.

RESULTS

There were 70 participants included in the final analysis. Both G-CBT and IOT groups showed significant improvement in eating pathology and associated psychopathology (ps < .001) over the course of treatment, but no significant difference in symptom improvement was found between the two groups (ps > .05). G-CBT resulted in additional significant improvement in ED psychopathology over the last two months of treatment, and its overall therapeutic effect was influenced by baseline weight and early symptom improvement.

CONCLUSION

Preliminary findings from this open label trial suggest that G-CBT adapted from CBT-E is feasible in an outpatient setting and as effective as IOT in facilitating weight regain and reducing psychopathology in Chinese AN patients with little evidence for the superiority of either intervention.

TRIAL REGISTRATION

The current study was registered at clinical trials.gov on September 23, 2018 (registration number NCT03684239). People with anorexia nervosa (AN) are known to be unmotivated for treatment and prone to relapse. Recovery from AN often needs intensive, long-term treatment from a specialized multidisciplinary team, which is not accessible for most people in China. Given the increasing incidence of AN and lack of eating disorder (ED) specialists in China, it is important to develop short-term cost-effective treatments for AN. In this study, we explored the feasibility and efficacy of group cognitive behavior therapy (G-CBT) adapted from enhanced cognitive behavior therapy (CBT-E) for people with AN from China. We found that G-CBT was as effective as individual outpatient treatment (IOT) typically provided to AN patients at the research site in facilitating weight regain, improving eating behaviors, and reducing ED and other symptoms. We also found that patients receiving G-CBT made more improvements in cognitive symptoms of the ED, which might help maintain treatment gains and prevent relapse in the long run. This potential long-term advantage of G-CBT needs to be verified in long-term follow-up.

Is personality the key in cognitive-behavioural therapy for eating disorders? A review

The efficacy of individual cognitive-behavioural therapy (CBT) for eating disorders can be assessed by investigating the potential predictors, mediators and moderators of treatment. The present review focused on personality since its crucial role has been emphasized both by research and practice. Sixteen studies were collected, and data were extracted through a highly operationalized coding system. Overall, personality disorders were the most investigated construct; however, their influence was somewhat contradictory. A more cogent result occurred for borderline personality disorder (BPD) when considered as a moderator (not a predictor nor a mediator). Patients with a more disturbed borderline personality benefited to a greater extent from treatments including booster modules on affects, interpersonal relationships and mood intolerance, rather than symptoms exclusively. Nine additional personality dimensions, beyond BPD, were investigated sparsely, and results regarding them were barely indicative in this review. However, some of these dimensions (e.g., affective lability and stimulus-seeking behaviours) could be traced back to BPD, thereby strengthening evidence of the role of borderline disorder as a moderator. Although research on the relationship between personality and eating disorders needs to be increased and methodologically improved, personality, taken as a whole, emerged as a promising variable for enhancing the efficacy of CBT.

Cognitive and emotional regulation in adolescents and young women with eating disorders

BACKGROUND

Eating disorders (EDs) are associated with a reduced ability to regulate emotion and impulses during the life span. Working memory and executive functions (EFs) are cognitive regulatory systems supported by networks involving the pre-frontal cortex. Studies in EDs found impaired functioning in these domains, showing an association between EDs and the reduced ability to control emotions and impulses.

OBJECTIVE

To investigate EF in adolescents and young women with eating disorders (ED) using a quasi-experimental design, focusing on cognitive efficiency, emotional regulation (ER) and behavioural outcomes also taking into account pharmacological treatment and duration of illness.

METHODS

A sample of 151 females belonging to two groups took part in this study. Twenty-six girls and young women (M_age 22;8 years) with ED and 125 typically developed girls and young women (M_age 17;4 years) completed a battery of cognitive tasks (Go-no-go, Stop-signal task, Symmetry span, Reading Span) and the Youth Self-Report and the Difficulties in Emotional Regulation Scale Performance. A series of ANOVA with the Brown-Forsythe test was used to compare the groups.

RESULTS

Participants with ED and controls did not show significant differences in EF tasks, whereas differences between younger and older participants with ED emerged. Moreover, ER difficulties seem to be associated with mainly internalizing problems in EDs. Further analysis on the full ED sample did not reveal any significant differences associated with the disorder persistence. Considering pharmacological treatment effects over cognitive, emotional and behavioural measures emerged.

CONCLUSIONS

The present study documented no specific differences in EF between control and participants with EDs, whereas important differences emerged in ER and behavioural outcomes perception in the clinical sample, together with a partial influence of pharmacological treatment.

LEVEL OF EVIDENCE

No level of evidence.