Cognitive Behavioural Therapy for anorexia nervosa: A systematic review

Ketogenic Food Ameliorates Activity-Based Anorexia of Adult Female Mice

OBJECTIVE

Genome-wide association studies implicate metabo-psychiatric origins for anorexia nervosa (AN). There are two case reports totaling six adult females who experienced complete remission of AN following a treatment comprised of ketogenic diet (targeting metabolism) with ketamine infusions (targeting psychiatric origins), but no study has determined the efficacy of ketogenic diet, alone. We addressed this gap in knowledge, with exploration of potential molecular mechanisms, using an animal model.

METHOD

Adult C57BL6 female mice underwent 2 or 3 cycles of activity-based anorexia (ABA1, ABA2, ABA3), an animal model of AN relapse, in which AN-like maladaptive behaviors of hyperactivity and voluntary food restriction are elicited when wheel access is combined with food restriction. ABA was categorized as severe, based on weight loss ≥ 20%, food restriction-evoked increase in wheel counts > 10,000/6 h, and crouching/grimace, and compared across two groups: (1) KG, fed ketogenic food continuously (N = 25); and (2) CON, fed standard diet (N = 28).

RESULTS

86% of CON versus none of the KG were crouching with grimace during ABA1. 93% of CON versus 11% of KG lost weight severely during ABA2 (p < 0.001, 8% difference of group mean weights). Severe hyperactivity was prevalent among CON (86%) and rare for KG (4%) during ABA2 (p < 0.001 on all food-restricted days). ABA up-regulated BDNF (brain-derived neurotrophic factor) in the hippocampus of both groups but ketone body, β-hydroxybutyrate, in urine was increased only among KG.

DISCUSSION

Ketogenic diet may reduce severity of AN relapse through reduction of compulsive exercise, via mechanisms that are in addition to BDNF up-regulation and involve β-hydroxybutyrate.

Subanesthetic Ketamine Ameliorates Activity-Based Anorexia of Adult Mice

OBJECTIVE

Anorexia nervosa (AN) is an eating disorder with the second highest mortality of all mental illnesses and high relapse rate, especially among adult females, yet with no accepted pharmacotherapy. A small number of studies have reported that adult females who struggled with severe and relapsing AN experienced sustained remission of the illness following ketamine infusions. Two other reports showed that 30 mg/kg IP ketamine can reduce vulnerability of adolescent mice to activity-based anorexia (ABA), an animal model of AN. However, no study has tested the efficacy of ketamine on adult ABA mice. This study aimed to fill this gap in knowledge.

METHODS

Forty-one female mice underwent three cycles of ABA (ABA1, ABA2, and ABA3) to assess relapse vulnerability in adulthood. Of them, 13 received ketamine injections (30 mg/kg, 3 doses) during ABA2 (KET) in adulthood to assess ketamine's acute effects during ABA2 and ketamine's potential for sustained efficacy during ABA3, 10-13 days later. The remaining 28 received vehicle or no injections during ABA2 (CON).

RESULTS

Severe weight loss (>20% of baseline) during ABA3 was observed for 89% of CON but only 69% of KET. Overall wheel running per day was significantly less for KET than CON (p < 0.01) throughout ABA2, including hours of food availability, and these reductions were sustained through ABA3. Food consumption was not altered significantly by ketamine.

DISCUSSION

These findings suggest that ketamine may reduce adult females' vulnerability to ABA and may protect women from AN relapse by reducing hyperactivity.

Three daily intraperitoneal injections of sub-anesthetic ketamine ameliorate activity-based anorexia vulnerability of adult female mice

OBJECTIVE

To identify ketamine's dosing schedule that ameliorates voluntary food restriction, hyperactivity and body weight loss of adult mice undergoing activity-based anorexia (ABA), an animal model of anorexia nervosa.

METHOD

Female and male C57BL6 mice underwent three cycles of ABA, starting from mid-adolescence. ABA vulnerability was compared within and across two groups of animals: those injected intraperitoneally with 30 mg/kg ketamine for three consecutive days (30mgKetx3) during the second ABA in late adolescence (ABA2) or with vehicle only (Vx3).

RESULTS

Vx3 females and males exhibited individual differences in wheel running and weight retention during first ABA in mid-adolescence (ABA1), ABA2, and third ABA in adulthood (ABA3). Their wheel running correlated with anxiety-like behavior. During ABA1 and ABA3, weight gain of Vx3 females (but not males) after food consumption correlated negatively with food-anticipatory activity (FAA) preceding the feeding hours, indicating that females with higher levels of running restrict feeding more and persistently. This paradoxical relationship confirms earlier findings of ABA females without ketamine treatment, capturing the maladaptive behaviors exhibited by individuals diagnosed with anorexia nervosa. By contrast, 30mgKetx3 had an effect on both sexes of reducing hyperactivity during the feeding hours acutely and reducing anxiety-like behavior's contribution to running. For females, only, 30mgKetx3 acutely improved the extent of compensatory food consumption relative to FAA and improved weight retention during ABA3, 12 days post ketamine in adulthood.

DISCUSSION

Sub-anesthetic ketamine evokes behavior-specific ameliorative effects for adult mice re-experiencing ABA, supporting the notion that multiple doses of ketamine may be helpful in reducing relapse among adults with anorexia nervosa.

PUBLIC SIGNIFICANCE STATEMENT

This study examined whether ketamine reduces anorexia-like behaviors in adult mice. Three daily sub-anesthetic ketamine injections suppress wheel running during and leading up to the hours of food availability and enable animals to compensate better for weight loss associated with excessive exercise by eating more. These findings suggest that ketamine may help adult females diagnosed with anorexia nervosa but also point to sex- and age-related differences in the action of ketamine.

Adapting dose-response methodology to improve clinical trial design for psychotherapies

OBJECTIVE

Conventional randomized controlled trials (RCTs) have long served as the foundation of research in clinical psychology; however, most treatments for eating disorders show only modest effects on reduction of symptoms and maintenance of long-term remission. New options for psychotherapy treatment development research, beyond continuing to pursue additive or subpopulation approaches, are needed.

METHODS

One option is to apply dose-response designs, which are commonplace in studies of pharmacology, toxicology, and medical research, and characterized by the evaluation of the amount of exposure (dose) to an intervention, and the resulting changes in body function or health (response).

RESULTS

Eating disorder interventions are particularly well-suited for dose-response treatment designs. The deadly nature of eating disorders makes it imperative that patients are not turned away for not being "ready" to engage with treatment. By identifying optimal doses, research will likely yield a more parsimonious course of treatment, which will lend itself to reduced costs, greater uptake, and reduced drop-out.

DISCUSSION

Limited use of within-subject designs in trials for patients with eating disorders has produced fast-track efficacy studies and omitted key elements in the treatment development pathway. To decrease reliance on RCT's, dose-response methods should be applied as an alternative study design.

PUBLIC SIGNIFICANCE

Eating disorders are associated with medical and psychiatric comorbidities, poor quality of life, and high mortality. Access to evidence-based services for patients with eating disorders is limited, and identifying additional effective treatment options can be difficult because of challenges inherent to randomized-controlled trials. This manuscript describes an alternative trial methodology to maximize the information that can be gathered prior to utilizing a standard large-scale efficacy design.

Neuromodulation of Eating Disorders: A Review of Underlying Neural Network Activity and Neuromodulatory Treatments

Eating disorders are a group of psychiatric conditions that involve pathological relationships between patients and food. The most prolific of these disorders are anorexia nervosa, bulimia nervosa, and binge eating disorder. The current standard of care involves psychotherapy, pharmacotherapy, and the management of comorbid conditions, with nutritional rehabilitation reserved for severe cases of anorexia nervosa. Unfortunately, many patients often fail to respond, leaving a concerning treatment gap between the current and requisite treatments for eating disorders. To better understand the neurobiology underlying these eating disorders, investigations have been undertaken to characterize the activity of various neural networks, primarily those activated during tasks of executive inhibition, reward processing, and self-reference. Various neuromodulatory techniques have been proposed to stimulate these networks with the goal of improving patients' BMI and mental health. The aim of this review is to compile a comprehensive summarization of the current literature regarding the underlying neural connectivity of anorexia nervosa, bulimia nervosa, and binge eating disorder as well as the numerous neuromodulatory modalities that have been investigated. Importantly, we aimed to summarize the most significant clinical trials to date as well as to provide an updated assessment of the role of deep brain stimulation, summarizing numerous recently published clinical studies that have greatly contributed to the literature. In this review, we found therapeutic evidence for transcranial magnetic stimulation and transcranial direct current stimulation in treating individuals suffering from anorexia nervosa, bulimia nervosa, and binge eating disorder. We also found significant evidence for the role of deep brain stimulation, particularly as an escalatory therapy option for the those who failed standard therapy. Finally, we hope to provide promising directions for future clinical investigations.

The usefulness of an intervention with a serious video game as a complementary approach to cognitive behavioural therapy in eating disorders: A pilot randomized clinical trial for impulsivity management

OBJECTIVE

The aim of the present study was to test the usefulness of an add-on serious video game approach (i.e., Playmancer) to treatment as usual (TAU) on reducing impulsive behaviours and psychopathology in individuals diagnosed with an eating disorder (ED).

METHOD

Thirty-seven patients diagnosed with an ED according to the DSM-5 were included in the present randomized clinical trial (RCT; study record 35,405 in ClinicalTrials.gov) and were randomly assigned to either the TAU or TAU + Playmancer group. All participants completed a clinical interview. Impulsivity (UPPS-P self reported questionnaire and Stroop task) and general psychopathology (SCL-90-R) measures were assessed at: baseline, 4 weeks into treatment, at the end of TAU (after 16 weeks), and follow-up (2 years). In addition, patients in the experimental group underwent a total of nine sessions with Playmancer over the span of 3 weeks.

RESULTS

Patients in both treatment groups (TAU + Playmancer or TAU) improved on Stroop task performance and psychological distress. Additionally, patients in TAU-Playmancer improved on the impulsive trait domain of lack of perseverance. No statistical differences were found regarding treatment outcomes (i.e., treatment adherence and remission of eating symptomatology) when comparing the two treatment groups.

CONCLUSION

Our results suggest that the impulsivity associated with EDs should be addressed and could be modified, as some facets of trait impulsivity improved after Playmancer add-on treatment. Yet, there were no significant differences in treatment outcomes when comparing the two groups and further research needs to be conducted.

Development of a transdiagnostic digital interactive application for eating disorders: psychometric properties, satisfaction, and perceptions on implementation in clinical practice

BACKGROUND

Given limited availability of informed treatments for people affected by eating disorders (EDs), there has been increasing interest in developing self-administered, technology-based ED interventions. However, many available interventions are limited to a specific ED diagnosis or assume that participants are ready to change. We developed a digital self-help application (called ASTrA) that was explicitly designed to be transdiagnostic and to help increase motivation for change. The aim of the present study was to describe the development and examine the psychometric properties, user satisfaction and rated potentials for practical use of our application.

METHODS

The content of our application was based on concepts derived from self-determination theory, the transtheoretical model of change, and cognitive theory. The application was developed by a multidisciplinary team of clinicians, researchers, staff members and individuals with lived ED experience, each being involved in all steps of the application's development. We tested validity, reliability, satisfaction and perceived feasibility for clinical implementation in an independent sample of 15 patients with an ED and 13 clinicians specialized in ED treatment. Psychometric properties were evaluated using descriptive statistics, correlations, content validity indices and intraclass coefficients. Differences in satisfaction ratings and perceived potential for clinical implementation of the application between clinicians and patients were examined using Mann-Whitney U tests.

RESULTS

The digital application showed excellent validity (mean i-CVI: .93, range: .86-.96) and internal reliability (all Cronbach alpha's > .88). Patients and clinicians both considered the application acceptable, appropriate, and feasible for use in clinical practice.

CONCLUSIONS

Findings suggest that our transdiagnostic interactive application has excellent psychometric properties. Furthermore, patients and clinicians alike were positive about the possible use of the application in clinical practice. The next step will be to investigate the application's effectiveness as an intervention to promote autonomous motivation and to facilitate remission in people on the waitlist for specialized ED treatment.

At the Crossroads between Eating Disorders and Body Dysmorphic Disorders-The Case of Bigorexia Nervosa

Bigorexia nervosa (BN) is a controversial nosological entity, considered either a feeding/eating disorder (FED) or a subtype of body dysmorphic disorder (BDD). This rapid review aims to explore the characteristic features of BN and identify evidence-based therapeutic interventions for this condition. Three electronic databases (PubMed, Cochrane, and Google Scholar) were searched for relevant information about BN, and 26 reports were reviewed in detail. The results showed that bodybuilders, weightlifters, and other populations involved in athletic activities are the most vulnerable to the onset of this disorder. Patients with BN should also be screened for physical and psychiatric comorbidities and complications, such as anabolic steroid use disorder, physical exercise addiction, and depressive or anxiety disorders. The main differential diagnoses for BN are schizophrenia spectrum disorders, depressive disorders, anxiety disorders, bodily distress disorder, and obsessive-compulsive disorders. Using validated screening instruments is considered very important from a clinical perspective, with the aim of providing early identification of this disorder. Therapeutic interventions for patients with BN are still in the early phases of development, and no specific pharmacological treatment has yet been identified. Since it is similar to the obsessive-compulsive spectrum, cognitive behavioral therapy has been suggested as a useful intervention; however, it has not yet been validated in large-scale clinical trials. In conclusion, based on the reviewed data, clarifying the concept of BN is of practical importance for constructing adequate prevention strategies and validating proper therapeutic interventions.

Cognitive Flexibility in Hospitalized Patients with Severe or Extreme Anorexia Nervosa: A Case-Control Study

OBJECTIVE

To investigate whether cognitive inflexibility could be identified using the Wisconsin Card Sorting Test (WCST) in patients with severe and extreme anorexia nervosa (AN) compared to healthy control participants (HCs).

METHOD

We used the WCST to assess 34 patients with AN (mean age: 25.9 years, mean body mass index (BMI): 13.2 kg/m²) 3-7 days after admission to a specialized nutrition unit and 34 HCs. The Beck Depression Inventory II and the Eating Disorder Inventory 3 were distributed.

RESULTS

The patients displayed more perseveration than HCs controlled for age and years of education, with moderate effect sizes (perseverative responses (%): adjusted difference = -7.74, 95% CI: -14.29-(-1.20), p-value: 0.021; perseverative errors (%): adjusted difference = -6.01, 95% CI: -11.06-(-0.96), p-value: 0.020). There were no significant relationships between perseveration and depression, eating disorder symptoms, illness duration, or BMI.

DISCUSSION

Patients with severe and extreme AN demonstrated lower cognitive flexibility compared to HCs. Performance was not related to psychopathology or BMI. Patients with severe and extreme anorexia nervosa may not differ from less severe patients in cognitive flexibility performance. As this study exclusively focused on patients suffering from severe and extreme AN, potential correlations might be masked by a floor effect.

Hooked on weight control: An economic theory of anorexia nervosa and its impact on health and longevity

In this paper, I integrate a theory of body image, weight control, and addiction in a life cycle model with health deficit accumulation in order to explain the phenomenon of anorexia nervosa and its impact on health and longevity. Individuals consume normal goods and foods and can work off excess calories with physical exercise. There exists a healthy body mass index and deviations from it increasingly cause health deficits due to obesity or underweight. There exists also a subjective target weight and being heavier than target weight causes a loss of utility from body image. Anorexia is initiated in individuals who are particularly successful in weight control and prone to addiction. Addiction to weight control motivates anorexic individuals to perpetually adjust their target weight downwards and to eat less and exercise more. With declining weight, health deficits accumulate faster and mortality risk rises. I calibrate the model to an average American woman with bmi 28. Due to weight loss addiction, the bmi declines to a level of 15 and causes an expected loss of 15 years of life. I also discuss potential therapies and recovery from the disease.

Bridging cognitive, phenomenological and psychodynamic approaches to eating disorders

Cognitive, psychodynamic, and phenomenological scholars converged their attention on abnormal bodily phenomena as the core psychopathological feature of eating disorders (EDs). While cognitive approaches focus their attention on a need for "objective" (i.e., observable, measurable) variables (including behaviours and distorted cognitions), the phenomenological exploration typically targets descriptions of persons' lived experience. According to a new emerging phenomenological perspective, the classic behavioural and cognitive symptoms of EDs should be considered as epiphenomena of a deeper core represented by a disorder of the embodiment. The cognitive-behavioural model is the most studied and, up till now, clinically efficacious treatment for EDs. However, as any coherent and scientifically grounded model, it presents some limitations in its application. Numerous patients report a chronic course, do not respond to treatment and develop a personality structure based on pathological eating behaviours, since "being anorexic" becomes a new identity for the person. Furthermore, the etiopathogenetic trajectory of EDs influences the treatment response: for example, patients reporting childhood abuse or maltreatment respond differently to cognitive-behavioural therapy. To obtain a deeper comprehension of these disorders, it seems important to shift attention from abnormal eating behaviours to more complex and subtle psycho(patho)logical features, especially experiential ones. This characterisation represents the unavoidable premise for the identification of new therapeutic targets and consequently for an improvement of the outcome of these severe disorders. Thus, the present review aims to provide an integrated view of cognitive, psychodynamic, and phenomenological perspectives on EDs, suggesting new therapeutic targets and intervention strategies based on this integrated model. Level of Evidence: Level V.Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Growth factors in anorexia nervosa: a systematic review and meta-analysis of cross-sectional and longitudinal data

OBJECTIVES

Growth factors are signalling molecules that play roles in the survival, proliferation, migration, and differentiation of cells. Studies have found alterations in specific growth factors in anorexia nervosa (AN).

METHODS

This systematic review and meta-analysis examined articles from three databases, measuring growth factors in AN cross-sectionally and longitudinally, and in recovered AN (rec-AN) cross-sectionally. Random-effects meta-analyses were conducted for brain-derived neurotrophic factor (BDNF) and insulin growth factor-I (IGF-1) for cross-sectional and longitudinal studies.

RESULTS

A total of 82 studies were included: 56 cross-sectional (BDNF: n = 15; IGF-1: n = 41) and 24 longitudinal (BDNF: n = 5; IGF-1: n = 19) were meta-analysed and 20 studies were narratively synthesised. In cross-sectional analyses, BDNF and IGF-1 were lower in AN compared to controls, and BDNF was marginally greater in rec-AN compared to controls. In longitudinal meta-analyses, BDNF and IGF-1 increased from baseline to follow-up. Cross-sectional subgroup analyses revealed no differences in BDNF between controls and AN binge-eating/purging subtypes.

CONCLUSIONS

It is likely that the low BDNF and IGF-1 levels found in AN are consequences of starvation, which are reversible with weight restoration. The increase in BDNF and IGF-1 during therapeutic weight restoration might improve neuroplasticity, which is the basis of learning, and thus psychotherapeutic success.

Paper 2: a systematic review of narrative therapy treatment outcomes for eating disorders-bridging the divide between practice-based evidence and evidence-based practice

BACKGROUND

Narrative therapy has been proposed to have practice-based evidence however little is known about its research evidence-base in the treatment of eating disorders. The aim of this study was to conduct a systematic review of the outcome literature of narrative therapy for eating disorders.

METHOD

Treatment outcome data were extracted from 33 eligible included studies following systematic search of five data bases. The study is reported according to Preferred Reporting items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Of the identified 33 studies, 3 reported positive outcomes using psychometric instruments, albeit some were outdated. Otherwise, reported outcomes were based on therapy transcript material and therapist reports. The most commonly reported treatment outcome was in relation to shifts in identity narratives and improved personal agency with a trend towards under-reporting shifts in ED symptoms. Some improvements were reported in interpersonal and occupational engagement, reduced ED symptoms, and improved quality of life, however, there was an absence of standardized measures to support these reports.

CONCLUSIONS

This systematic review found limited support for narrative therapy in the treatment of eating disorders through practice-based evidence in clinician reports and transcripts of therapy sessions. Less is known about systematic treatment outcomes of narrative therapy. There is a need to fill this gap to understand the effectiveness of narrative therapy in the treatment of EDs through systematic (1) Deliveries of this intervention; and (2) Reporting of outcomes. In doing so, the research arm of narrative therapy evidence base will become more comprehensively known.

Cognitive Behavioral and Cognitive Remediation Strategies for Managing Co-Occurring Anorexia Nervosa and Elevated Autism Spectrum Traits

Anorexia nervosa (AN) is a potentially severe eating disorder whose core characteristics include energy intake restriction leading to low body weight. Autism spectrum disorder (ASD) is a developmental disorder characterized by deficits in social interaction and communication as well as repetitive, stereotyped behavior and interests. Both high ASD traits and diagnosed ASD are overrepresented among individuals with AN, and AN and ASD appear to share certain neurocognitive features. These features are associated with the severity of eating disorder symptoms and prolongation of AN. Thus, individuals with AN and high ASD traits or ASD may benefit less from traditional treatment when compared to those with low ASD traits. No previous reviews have summarized what is known about treatment adaptations for individuals with AN and high ASD traits or ASD. The purpose of this narrative review was to investigate the feasibility of cognitive remediation therapy (CRT), cognitive remediation and emotional skill training (CREST), and cognitive behavioral therapy (CBT), and give an overview of treatment modifications for individuals with AN and co-occurring ASD or high ASD traits. We found nine studies that fulfilled our inclusion criteria. The combined results suggest that individuals with AN and high ASD traits or ASD benefit less from CRT, CREST, and CBT than those with AN and low ASD traits. However, CRT and CREST administered in individual format may be associated with improved cognitive flexibility, motivation for change, and decreased alexithymia among adults with AN and high ASD traits or ASD. Individuals with comorbid AN and ASD themselves highlight the importance of treatment adaptations that take the characteristics of ASD into account. In the future, controlled studies of the treatment strategies for individuals with AN and ASD/high ASD traits are needed in order to improve the outcome of individuals with this challenging comorbidity.

Feasibility of guided internet-based cognitive behavioral therapy for patients with anorexia nervosa

OBJECTIVE

The objective of the present study was to investigate the feasibility of guided internet cognitive behavioral therapy (ICBT) for anorexia nervosa.

METHODS

We conducted a prospective single-arm study between January 2020 and March 2021. The intervention was built using videos, web programs, and chat tools. The intervention program was largely based on metacognitive training. Participants performed the self-help program once a week for 12 consecutive weeks. The primary outcome was the global Eating Disorder Examination Questionnaire (EDE-Q) score. Secondary outcomes included clinical symptoms of eating disorders, metacognitive function, body mass index, depression, and generalized anxiety. The main statistical analysis examined whether the EDE-Q score and other outcomes at the end of the intervention differed from the baseline.

RESULTS

Fourteen participants underwent the trial treatment, and 13 completed the intervention. There was a significant reduction in the global EDE-Q score from 3.48 (SD = 1.4) to 2.54 (SD = 1.5, p = 0.02, Cohen's d = 0.75) from baseline to post-intervention. Some EDE-Q subscales and body checking questionnaire scale demonstrated statistically significant improvements, with moderate to large effect sizes. Although there was no significant improvement in body mass index, metacognitive function, or depressive symptoms, there was a significant improvement in the severity of generalized anxiety (M = -4.0, p = 0.01, Cohen's d = 0.95). No adverse events were observed.

DISCUSSION

Our findings suggest that guided ICBT for anorexia nervosa is well accepted by female patients and practical as a telemedicine approach that improves symptoms. In the future, tightly controlled randomized controlled trials should be conducted for efficacy verification.

Cognitive and hormonal regulation of appetite for food presented in the olfactory and visual modalities

The ability to regulate appetite is essential to avoid food over-consumption. The desire for a particular food can be triggered by its odor before it is even seen. Using fMRI, we identify the neural systems modulated by cognitive regulation when experiencing appetizing food stimuli presented in both olfactory and visual modalities, while being hungry. Regulatory instruction modulated bids for food items and inhalation patterns. Distinct brain regions were observed for up and down appetite-regulation, respectively the dorsomedial prefrontal cortex (dmPFC) and dorsolateral PFC. Food valuation engaged the ventromedial PFC and bilateral striatum. Furthermore, we identified a neurobiological marker for successful appetite upregulation. Individuals with higher blood levels of ghrelin were better at exercising up-regulation, and engaged the dmPFC more. These findings characterize the neural circuitry regulating food consumption within the healthy population and highlight how cognitive regulation modulates olfactomotor measures of olfaction.

Reduced Environmental Stimulation in Anorexia Nervosa: An Early-Phase Clinical Trial

Reduced Environmental Stimulation Therapy (REST) alters the balance of sensory input to the nervous system by systematically attenuating sensory signals from visual, auditory, thermal, tactile, vestibular, and proprioceptive channels. Previous research from our group has shown that REST via floatation acutely reduces anxiety and blood pressure (BP) while simultaneously heightening interoceptive awareness in clinically anxious populations. Anorexia nervosa (AN) is an eating disorder characterized by elevated anxiety, distorted body representation, and abnormal interoception, raising the question of whether REST might positively impact these symptoms. However, this approach has never been studied in eating disorders, and it is unknown whether exposure to floatation REST might worsen AN symptoms. To examine these possibilities, we conducted an open-label study to investigate the safety and tolerability of REST in AN. We also explored the acute impact of REST on BP, affective symptoms, body image disturbance, and interoception. Twenty-one partially weight-restored AN outpatients completed a protocol involving four sequential sessions of REST: reclining in a zero-gravity chair, floating in an open pool, and two sessions of floating in an enclosed pool. All sessions were 90 min, approximately 1 week apart. We measured orthostatic BP before and immediately after each session (primary outcome), in addition to collecting BP readings every 10 min during the session using a wireless waterproof system as a secondary outcome measure. Each participant's affective state, awareness of interoceptive sensations, and body image were assessed before and after every session (exploratory outcomes). There was no evidence of orthostatic hypotension following floating, and no adverse events (primary outcome). Secondary analyses revealed that REST induced statistically significant reductions in BP (p < 0.001; Cohen's d, 0.2-0.5), anxiety (p < 0.001; Cohen's d, >1) and negative affect (p < 0.01; Cohen's d, >0.5), heightened awareness of cardiorespiratory (p < 0.01; Cohen's d, 0.2-0.5) but not gastrointestinal sensations, and reduced body image dissatisfaction (p < 0.001; Cohen's d, >0.5). The findings from this initial trial suggest that individuals with AN can safely tolerate the physical effects of REST via floatation. Future randomized controlled trials will need to investigate whether these initial observations of improved anxiety, interoception, and body image disturbance occur in acutely ill AN populations.

Clinical Trial Registration

ClinicalTrials.gov; Identifier: NCT02801084 (April 01, 2016).

Looking at the Figures: Visual Adaptation as a Mechanism for Body-Size and -Shape Misperception

Many individuals experience body-size and -shape misperception (BSSM). Body-size overestimation is associated with body dissatisfaction, anxiety, depression, and the development of eating disorders in individuals who desire to be thinner. Similar symptoms have been noted for those who underestimate their muscularity. Conversely, individuals with high body mass indices (BMI) who underestimate their adiposity may not recognize the risks of or seek help for obesity-related medical issues. Although social scientists have examined whether media representations of idealized bodies contribute to the overestimation of fat or underestimation of muscle, other scientists suggest that increases in the prevalence of obesity could explain body-fat underestimation as a form of renormalization. However, these disparate approaches have not advanced our understanding of the perceptual underpinnings of BSSM. Recently, a new unifying account of BSSM has emerged that is based on the long-established phenomenon of visual adaptation, employing psychophysical measurements of perceived size and shape following exposure to "extreme" body stimuli. By inducing BSSM in the laboratory as an aftereffect, this technique is rapidly advancing our understanding of the underlying mental representation of human bodies. This nascent approach provides insight into real-world BSSM and may inform the development of therapeutic and public-health interventions designed to address such perceptual errors.

Cognitive Behavior Therapy for the Eating Disorders

Cognitive behavioral therapy (CBT) is an evidence-based treatment for bulimia nervosa and binge-eating disorder and is regarded as the first-line treatment for both eating disorders. An enhanced version of the treatment (CBT-E) appears more effective in treating patients with severe comorbidity. There is less evidence that CBT is effective for the treatment of anorexia nervosa. Evidence suggests that CBT-E is no more effective than specialist care involving regular medical follow-up and supportive psychotherapy in the persistent adult form of anorexia nervosa (AN). Early studies suggest that CBT-E may be useful in treating the adolescent form of AN.

Introduction: Novel perspectives on the psychology and psychotherapy of eating disorders

The aim of this introduction to this issue is to review and summarize significant new psychological perspectives and psychotherapeutic interventions in the treatment of eating disorder (EDs). In this issue, five novel therapeutic strategies for the treatment of EDs are presented. These include a combination of psychodynamic psychotherapy and neuropsychology, two recent modifications of cognitive behavioral therapy (the MANTRA, and the conceptualization of change in patients with ED in terms of sense of agency), a specific group movement therapy, and an innovative rehabilitation treatment. In addition, one article offers an historic review of the development of psychotherapy of EDs, and two articles highlight specific considerations related to the treatment of EDs: compulsory treatment, and culturally sensitive treatment.

Visual attention mediates the relationship between body satisfaction and susceptibility to the body size adaptation effect

Body size misperception–the belief that one is larger or smaller than reality–affects a large and growing segment of the population. Recently, studies have shown that exposure to extreme body stimuli results in a shift in the point of subjective normality, suggesting that visual adaptation may be a mechanism by which body size misperception occurs. Yet, despite being exposed to a similar set of bodies, some individuals within a given geographical area will develop body size misperception and others will not. The reason for these individual difference is currently unknown. One possible explanation stems from the observation that women with lower levels of body satisfaction have been found to pay more attention to images of thin bodies. However, while attention has been shown to enhance visual adaptation effects in low (e.g. rotational and linear motion) and high level stimuli (e.g., facial gender), it is not known whether this effect exists in visual adaptation to body size. Here, we test the hypothesis that there is an indirect effect of body satisfaction on the direction and magnitude of the body fat adaptation effect, mediated via visual attention (i.e., selectively attending to images of thin over fat bodies or vice versa). Significant mediation effects were found in both men and women, suggesting that observers’ level of body satisfaction may influence selective visual attention to thin or fat bodies, which in turn influences the magnitude and direction of visual adaptation to body size. This may provide a potential mechanism by which some individuals develop body size misperception–a risk factor for eating disorders, compulsive exercise behaviour and steroid abuse–while others do not.

How certainty appraisal might improve both body dissatisfaction and body overestimation in anorexia nervosa: a case report

BACKGROUND

Patients with anorexia nervosa often report a conscious alteration of body image representation, with both body overestimation and body dissatisfaction. Cognitive and behavioural therapy is effective for treating many psychiatric disorders but often fails to treat anorexia nervosa and body image distortions. Although patients are aware of their weight loss, they continue to feel overweight - as if there were a conflict between a previous (maybe already false) body representation and the new one. These distortions are linked to negative emotions focused on the body but which can extend to the self (e.g. disgust and sadness).

CASE PRESENTATION

The present case report is the first in which the Appraisal Tendency Framework has been applied to decrease body image distortions in a patient with anorexia nervosa. The Appraisal Tendency Framework is usually used to understand how emotions influence decision making. Here, we report on a 24-year-old woman who suffered from anorexia nervosa and body image distortions, and was treated as an inpatient with conventional cognitive and behavioural therapy for an eating disorder. Body image distortions were assessed before and after the patient completed an adaptation of the Iowa Gambling Task, coupled with the induction of a heuristic processing emotion. We hypothesized that allowing the patient to focus on the emotional cues in the modified Iowa Gambling Task would improve her decisions about her true body shape.

CONCLUSION

All body image measures were improved after the protocol. Consequently, we suggest that the Appraisal Tendency Framework might be a valuable means of investigating body image issues in eating disorders and anorexia nervosa. Further studies are required to expand and detail these findings.

Exploring the perceived usefulness of practical food groups in day treatment for individuals with eating disorders

BACKGROUND/AIM

Recovery from eating disorders is a challenging process. Emerging literature suggests that occupational therapists may provide a useful contribution in delivering purposeful eating-related interventions as a potential treatment to support sustained cognitive and behavioural changes for individuals with eating disorders. This study aimed to evaluate participants' perceptions of the contribution of occupational therapy practical food groups (food based outings and cooking groups) in supporting their functional recovery.

METHODS

Individuals attended practical food groups as part of standard treatment at an outpatient eating disorders day program. Ninety-nine participants completed questionnaires at discharge and up to three follow-up points (6, 12 and 24 months). Questions related to practical food groups were analysed, exploring participants' experiences and perceived usefulness of groups using rating-scale and open-ended questions. Open-ended responses were analysed using thematic analysis. Descriptive statistics were calculated for responses to rating-scale questions.

RESULTS

At discharge, participants rated the importance and usefulness of practical food groups as high (4.73 and 4.43 on 5-point scales, respectively), but tended to rate their enjoyment of the groups lower (3.50 on a 5-point scale). Some skill transfer was typically reported by participants at discharge (3.92 on a 5-point scale). One core theme, 'success through participation', emerged from qualitative comments. Six subthemes were also identified: helpful components of practical food groups; perceived benefit of exposure; impact of applying cognitive and behavioural skills; challenges affecting participation; facilitating adaptation; and influence of eating disorders on challenging feared foods.

CONCLUSION

This study highlights that participation in practical food groups was perceived as useful in assisting individuals to improve eating behaviours and, in some circumstances, transfer these skills into their lives outside of day program. Results suggest that occupational therapists may have an important contribution in delivering these interventions to support recovery and facilitate application of adaptive coping strategies.

Body size and shape misperception and visual adaptation: An overview of an emerging research paradigm

Although body size and shape misperception (BSSM) is a common feature of anorexia nervosa, bulimia nervosa and muscle dysmorphia, little is known about its underlying neural mechanisms. Recently, a new approach has emerged, based on the long-established non-invasive technique of perceptual adaptation, which allows for inferences about the structure of the neural apparatus responsible for alterations in visual appearance. Here, we describe several recent experimental examples of BSSM, wherein exposure to “extreme” body stimuli causes visual aftereffects of biased perception. The implications of these studies for our understanding of the neural and cognitive representation of human bodies, along with their implications for clinical practice are discussed.

Treating Eating Disorders at Higher Levels of Care: Overview and Challenges

Higher levels of care (HLC)-including inpatient hospitalization, residential treatment, partial hospitalization, and intensive outpatient treatment-are frequently utilized within routine care for eating disorders. Despite widespread use, there is limited research evaluating the efficacy of HLC, as well as clinical issues related to care in these settings. This review describes the different levels of care for eating disorders and briefly reviews the most up-to-date guidelines and research regarding how to choose a level of care. In addition, as HLC approaches for ED continue to be developed and refined, pragmatic and conceptual challenges have emerged that provide barriers to clinical efficacy and the execution of high-quality treatment research. This review includes a discussion of various issues specific to HLC, as well as a summary of recent literature addressing them.

Identification des pratiques prometteuses dans le traitement de l’anorexie mentale

L’anorexie mentale inquiète, d’une part, car elle est associée à de nombreuses complications médicales et, d’autre part, car elle est liée à un mauvais pronostic. Face à ces constats, il est impératif que les traitements les plus efficaces soient offerts aux personnes présentant une anorexie mentale. Cet article vise à présenter une revue systématique de la littérature portant sur les modalités thérapeutiques prometteuses dans le domaine de l’anorexie mentale. Parmi celles-ci, notons le traitement ambulatoire, l’importance d’une équipe multidisciplinaire ainsi que différentes approches psychothérapeutiques, dont l’approche familiale.

Cognitive behavior therapy for eating disorders versus normalization of eating behavior

We examine the science and evidence supporting cognitive behavior therapy (CBT) for the treatment of bulimia nervosa and other eating disorders. Recent trials focusing on the abnormal cognitive and emotional aspects of bulimia have reported a remission rate of about 45%, and a relapse rate of about 30% within one year. However, an early CBT trial that emphasized the normalization of eating behavior had a better outcome than treatment that focused on cognitive intervention. In support of this finding, another treatment, that restores a normal eating behavior using mealtime feedback, has an estimated remission rate of about 75% and a relapse rate of about 10% over five years. Moreover, when eating behavior was normalized, cognitive and emotional abnormalities were resolved at remission without cognitive therapy. The critical aspect of the CBT treatment of bulimia nervosa therefore may actually have been the normalization of eating behavior.

Applying neurobiology to the treatment of adults with anorexia nervosa

BACKGROUND

Anorexia nervosa is a severe, biologically based brain disorder with significant medical complications. It is critical that new, effective treatments are developed to interrupt the persistent course of the illness due to the medical and psychological sequelae. Several psychosocial, behavioral and pharmacologic interventions have been investigated in adult anorexia nervosa; however, evidence shows that their impact is weak and treatment effects are generally small.

METHOD

This paper describes a new neurobiological anorexia nervosa model that shifts focus from solely external influences, such as social and family, to include internal influences that integrate genetic and neurobiological contributions, across the age span. The model serves as a theoretical structure for a new, five-day treatment, outlined in this paper, targeting anorexia nervosa temperament, which integrates neurobiological dimensions into evidence-based treatment interventions. The treatment is in two phases. Phase I is a five day, 40 hour treatment for anorexia nervosa adults. Phase II is the follow-up and is currently being developed.

RESULTS

Preliminary qualitative acceptability data on 37 adults with anorexia nervosa and 60 supports (e.g., spouses, parents, aunts, friends, partners, children of anorexia nervosa adults) are promising from Phase I. Clients with anorexia nervosa and their supports report that learning neurobiological facts improved their understanding of the illness and helped equip them with better tools to manage anorexia nervosa traits and symptoms. In addition, nutritional knowledge changed significantly.

CONCLUSIONS

This is the first neurobiologically based, five-day treatment for adults with anorexia nervosa and their supports. It is a new model that outlines underlying genetic and neurobiological contributions to anorexia nervosa that serves as a foundation to treat both traits and symptoms. Preliminary qualitative findings are promising, with both clients and supports reporting that the neurobiological treatment approach helped them better understand the illness, while better conceptualizing how to respond to their traits and manage their symptoms. Data in Phase I shows promise as a neurobiologically based intervention for anorexia nervosa, and it serves as a foundation for the development of Phase II. Evidence of ongoing program efficacy will be described as data are reported on Phase II.

TRIAL REGISTRATION

NCT NCT02852538 Registered 1 August 2016.

Psychological interventions for eating disorders

Eating disorders, including anorexia nervosa, bulimia nervosa and binge eating disorder, are common conditions, characterised by disturbances of eating behaviours and a core psychopathology centred on food, eating and body image concerns.^1,2 Eating disorders are associated with medical and psychological comorbidities; a significantly impaired health-related quality of life; a high rate of inpatient, outpatient and emergency care; significant healthcare costs; and increased mortality.^3-10 Here, we focus on the evidence for non-drug interventions for eating disorders.

Cultural Adaptation of Dialectical Behavior Therapy for a Chinese International Student With Eating Disorder and Depression

Limited information exists on the application of evidence-based treatments for eating disorders among diverse populations. An increasing number of international and immigrant clients provides a pressing need for culturally responsive treatments. This case study highlights an eating disorder treatment that incorporates dialectical behavior therapy and cultural adaptation guidelines. This study explicates a culturally adapted dialectical behavior therapy (DBT) treatment of a 24-year-old female Chinese international student suffering from an eating disorder, depression, and cultural adjustment issues. In particular, this case addresses Chinese cultural values, including conformity, interdependence, and filial piety, and how these values intersect with the client’s presenting issues and treatment. Cultural modifications made to the case conceptualization and dialectical behavior therapy are discussed. The client reported a significant decrease in distress, an increase in the quality of social relationships, and an increase in satisfaction with social roles. These results provide support for the effectiveness and importance of integrating cultural adaptation and evidence-based treatment. Clinical implications and recommendations for clinicians and students are provided.

Eating disorders need more experimental psychopathology

Eating disorders are severe and disabling mental disorders. The scientific study of eating disorders has expanded dramatically over the past few decades, and provided significant understanding of eating disorders and their treatments. Those significant advances notwithstanding, there is scant knowledge about key processes that are crucial to clinical improvement. The lack of understanding mechanisms that cause, maintain and change eating disorders, currently is the biggest problem facing the science of eating disorders. It hampers the development of really effective interventions that could be fine-tuned to target the mechanisms of change and, therefore, the development of more effective treatments. It is argued here that the science of eating disorders and eating disorder treatment could benefit tremendously from pure experimental studies into its mechanisms of change, that is, experimental psychopathology (EPP). To illustrate why eating disorders need more EPP research, some key symptoms - restriction of intake, binge eating and body overvaluation - will be discussed. EPP studies challenge some generally accepted views and offer a fresh new look at key symptoms. This will, consequently, better inform eating disorder treatments.

Neurobiologically informed treatment for adults with anorexia nervosa: a novel approach to a chronic disorder

Anorexia nervosa (AN) is a severe and debilitating disorder with significant medical and psychological sequelae. To date, there are no effective treatments for adults, resulting in high rates of chronicity, morbidity, and mortality. Recent advances in brain imaging research have led to an improved understanding of etiology and specific neurobiological mechanisms underlying symptoms. Despite this, there are no treatments focused on targeting symptoms using this empirically supported mechanistic understanding of the illness. Updated treatment approaches focused on targeting neurobiological mechanisms underlying core AN symptomatology are necessary to improve treatment out-comes for this population. Neurobiologically Enhanced With Family Eating Disorder Trait Response Treatment (NEW FED TR) is a neurobiologically informed treatment targeting key temperament constructs associated with the illness through the delivery of psychoeducation and skills training to patients and nominated carers.

The three-legged stool of evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives

BACKGROUND

Evidence-based practice in eating disorders incorporates three essential components: research evidence, clinical expertise, and patient values, preferences, and characteristics. Conceptualized as a 'three-legged stool' by Sackett et al. in 1996 (BMJ), all of these components of evidence-based practice are considered essential for providing optimal care in the treatment of eating disorders. However, the extent to which these individual aspects of evidence-based practice are valued among clinicians and researchers is variable, with each of these stool 'legs' being neglected at times. As a result, empirical support and patient preferences for treatment are not consistently considered in the selection and implementation of eating disorder treatment. In addition, clinicians may not have access to training to provide treatments supported by research and preferred by patients. Despite these challenges, integrating these three components of evidence-based practice is critical for the effective treatment of eating disorders.

DISCUSSION

Current research supports the use of several types of psychotherapies, including cognitive-behavioral, interpersonal, and family-based therapies, as well as certain types of medications for the treatment of eating disorders. However, limitations in current research, including sample heterogeneity, inconsistent efficacy, a paucity of data, the need for tailored approaches, and the use of staging models highlight the need for clinical expertise. Although preliminary data also support the importance of patient preferences, values, and perspectives for optimizing treatment, enhancing treatment outcome, and minimizing attrition among patients with eating disorders, the extent to which patient preference is consistently predictive of outcome is less clear and requires further investigation. All three components of evidence-based practice are integral for the optimal treatment of eating disorders. Integrating clinical expertise and patient perspective may also facilitate the dissemination of empirically-supported and emerging treatments as well as prevention programs. Further research is imperative to identify ways in which this three-legged approach to eating disorder treatment could be most effectively implemented.

Why study positive emotions in the context of eating disorders?

Experimental research, supported by systematic reviews, establishes that people with eating disorders have emotional difficulties in terms of recognising, regulating and expressing their emotions. These emotional difficulties contribute to poor social functioning and problems with relationships. The existing literature includes a broad range of studies, many of which have utilised self-report measures, but experimental studies of emotions in eating disorders are still limited. The primary aim of this paper is to highlight gaps in the clinical research on emotions in eating disorders, focusing on experimental investigations from our lab and highlighting potentially useful future directions for further basic research and its translation into new developments in treatment and prevention. Recent findings using experimental paradigms to study the expression of emotions along with neuroimaging research exploring differences in facial emotion processing are discussed, and clinical implications are presented.