Treatment outcomes for anorexia nervosa: a systematic review and meta-analysis of randomized-controlled trials - CORRIGENDUM

Treatment Targets and Strategies for Eating Disorders Recovery: A Delphi Consensus With Lived Experience, Carers, Researchers, and Clinicians

OBJECTIVE

Long-term recovery rates following eating disorders (EDs) treatment remain low. This might be partly due to a lack of agreement between key stakeholder groups, including people with lived experience, carers, clinicians, and researchers, regarding optimal therapeutic targets and strategies. We aimed to reach a consensus across these diverse groups on the most valued treatment targets and strategies for fostering ED recovery.

METHOD

We used the Delphi method with two phases: (i) Survey development and (ii) Expert rating. The survey development phase included the design of an initial set of items through scoping review and feedback from a committee of 14 experts. During the survey rating, we engaged a larger panel of 185 experts who comprised the stakeholder groups: Individuals with lived ED experience (n = 49), carers (n = 44), researchers (n = 46), and clinicians (n = 46).

RESULTS

Thirty-one targets and 29 strategies reached consensus (> 70% agreement over three rounds). Psychological-emotional-social targets including quality of life, sense of purpose, and emotion regulation, along with ED behaviors, reached the highest agreement (> 90%). Strategies reflecting an individualized approach to treatment (i.e., considering diversity, assessing comorbidities, and enhancing rapport) achieved the highest agreement (> 90%). Responses across groups were similar, except researchers leaning more towards consideration of weight- and eating-related targets.

DISCUSSION

Holistic targets and individualized therapeutic strategies have consistent support from the different stakeholder groups involved in ED treatment. The agreed set of targets/strategies may be used, in triangulation with other sources of evidence, to design and evaluate coproduced and personalized interventions.

Factors influencing the duration of untreated illness among patients with anorexia nervosa: A multicenter and multi-informant study

INTRODUCTION

The duration of untreated illness (DUI), that is, the interval between the onset of anorexia nervosa (AN) symptoms and start of specialized treatments, has a strong influence on the prognosis.

OBJECTIVE

To quantify modifiable predictors of the DUI and to derive recommendations for secondary prevention strategies.

METHODS

Within a multicenter, multi-informant study, DUI was assessed in interviews with patients undergoing first specialized AN treatment. Modifiable factors were assessed perspectives of AN-patients, their relatives, and primary care practitioners [PCPs]) with the FABIANA-checklist (Facilitators and barriers in anorexia nervosa treatment initiation). The effect of FABIANA-items on the DUI for each perspective was calculated using Cox Regression (control variables: age, eating disorder pathology, health care status, migration background, body mass index [BMI]).

RESULTS

We included data from N = 125 female patients with AN (72 adults, 53 adolescents, Mage  = 19.2 years, SD = 4.2, MBMI  = 15.7 kg/m2 , SD = 1.9), N = 89 relatives (81.8% female, 18.2% male, Mage  = 46.0 years, SD = 11.0) and N = 40 PCPs (Mage  = 49.7 years, SD = 9.0). Average DUI was 12.0 months. Watching or reading articles about the successful treatment of other individuals with AN (patients' perspective) and regular appointments with a PCP (PCPs' perspective) were related to a shorter DUI (HR = 0.145, p = .046/ HR = 0.395, p = .018). Patients whose relatives rated that PCPs trivialized patients' difficulties had a longer DUI (HR = -0.147, p = .037). PCPs and relatives rated PCPs' competence higher than patients did.

DISCUSSION

It is recommended (a) to incorporate treatment success stories in prevention strategies, (b) to inform PCPs about potential benefits of regular appointments during the transition to specialized care, and (c) to train PCPs in dealing with patients' complaints.

PUBLIC SIGNIFICANCE

Many individuals with AN seek treatment very late. Our study shows that a promising approach to facilitate earlier AN treatment is to inform patients about successful treatments of affected peers, to foster regular appointments with a PCP and, to motivate these PCPs to take individuals' with AN difficulties seriously. Thus, our study provides important suggestions for interventions that aim to improve early treatment in AN.

Perfectionism in anorexia nervosa: Associations with clinical picture and personality traits

Although many researchers addressed the topics, no consistent data are currently available regarding the relationship between perfectionism and personality traits in anorexia nervosa (AN). The present study aimed to assess differences between high- and low-perfectionism groups of patients with AN and to identify which variables show the strongest association with perfectionism. A group of inpatients with AN (n = 193) was recruited and completed a battery of self-report questionnaires regarding eating-related and general psychopathology, perfectionism, and personality. On the basis of perfectionism scores, patients were divided into high- and low-perfectionism groups. High-perfectionist patients displayed higher eating-related and general psychopathology; higher depressive, cyclothymic, irritable and anxious temperament, and lower self-directedness, cooperativeness and self-esteem. Perfectionism was associated with the drive for thinness, cooperativeness, self-esteem and anxious temperament. On the basis of the two personality traits most strongly correlated with perfectionism (i.e., cooperativeness and anxious temperament), patients could be correctly assigned to the high- or low-perfectionism group by an algorithm. The study suggests that perfectionism in AN is related to eating psychopathology, especially of restrictive type, and personality features such as cooperativeness and anxious temperament. These findings confirm the important role of perfectionism in AN, not only concerning eating behaviour but personality as well.

Modification of Body-Related Attentional Bias through Virtual Reality and Eye-Tracking in Healthy Participants: Implications for Anorexia Nervosa Treatments

Cognitive biases have a significant impact on the etiology and treatment of eating disorders (EDs). These biases, including selective attentional bias (AB) to disliked body parts, may reinforce concerns about body shape, fear of gaining weight and body image disturbances and may contribute to dietary restriction and restraint. Decreasing AB could reduce core symptoms in anorexia nervosa (AN). This study represents a preliminary exploration aiming to assess whether AB towards weight-related (WR) and non-weight-related (NW) body parts could be reduced through an AB modification task in a virtual reality (VR) environment in healthy participants. A total of 54 female participants, aged 22.98 ± 1.89, were recruited. The task consisted of directing the participants' attention towards all body parts equally in a VR setting. Eye-tracking (ET) measurements (complete fixation time [CFT] and number of fixations [NF]) were made before and after the task. The results showed a significant reduction of the AB in the two groups with an initial AB towards WR body parts or towards NW body parts. Participants showed a tendency to more balanced (non-biased) attention after the intervention. This study provides evidence of the usefulness of AB modification tasks in a non-clinical sample.

Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa

PURPOSE

Patients with eating disorders (ED) pose a high-risk group regarding relapse. The understanding of factors contributing to a better outcome is much-needed. Therapeutic alliance (TA) is one important, pantheoretical variable in the treatment process, which has shown to be connected with outcome. This review looks into a possible predictive effect of TA on outcome as well as related variables.

METHODS

A systematic review with pre-determined inclusion criteria following the PRISMA guidelines was conducted for studies published since 2014. Three previous reviews including studies up until 2014 were analyzed for studies matching our inclusion criteria. A total of 26 studies were included.

RESULTS

The results were heterogeneous between different patient groups. Regarding the predictive effect of TA, in adolescent samples, the TA of either the patients or their parents seems to impact outcome as well as completion. For adults, results are mixed, with a tendency to a greater impact of TA for anorexia nervosa (AN) patients, while some samples of adult bulimia nervosa (BN) patients did not find any relation between TA and outcome.

CONCLUSION

The effect of TA on clinical outcome depends on the patient group. TA has a greater impact on adolescents, irrespective of diagnosis, and on adults with AN. The examined studies have different limitations which include small sample sizes and questionable study design. The examination of motivation as a potential influencing factor is recommended.

LEVEL OF EVIDENCE

Level I, systematic review.

Expressive suppression a mediating variable between stress and procrastination in eating behavior disorder

Eating disorders (EDs) are psychiatric illnesses in which emotions play an important role in their development and maintenance. These disorders are associated with expressive suppression, stress, and procrastination. The purpose of this work was to explain eating disorders from stress and procrastination, with expressive suppression as a mediating variable. It was attended by 918 students from three universities in Ecuador. The information was collected through four instruments: inventory of eating disorders, perceived stress scale, Tuckman procrastination scale and emotional regulation questionnaire. The data was analyzed through a mediational analysis in the Jasp program, version 15. The independent variables were: procrastination and stress, the dependent variable was risk of experiencing bulimia (REB) and the mediating variable was expressive suppression. Procrastination and stress, mediated by expressive suppression, were found to have no statistically significant effect on EBR. Procrastination has a direct effect on REB, although stress does not, and the model between expressive suppression and REB explains a good percentage of the variance.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Rehospitalization and "Revolving Door" in Anorexia Nervosa: Are There Any Predictors of Time to Readmission?

Objective: Anorexia nervosa (AN) is a severe psychiatric illness with multifactorial etiology and unsatisfactory treatment outcomes. Hospitalization is required for a substantial number of patients, and readmission (RA) commonly occurs. Some individuals need multiple hospitalizations sometimes over a short amount of time, thus, delineating the "revolving door" (RD) phenomenon. However, very little is known about readmissions and their frequency in AN. Therefore, we aimed to longitudinally investigate readmissions in AN in order to: (a) characterize patients with AN who need readmission (i.e., RA-AN), sometimes rapidly (RD-AN); (b) ascertain differences between RA-AN and non-RA-AN groups during baseline hospitalization; (c) investigate as to whether clinical or psychometric parameters worsened on RA; and (d) analyze predictors of time-to-readmission in AN. Methods: A total of 170 inpatients with AN were enrolled at their baseline hospitalization; all their subsequent rehospitalizations were recorded with a longitudinal design by which each patient has been observed for 3 years. Patients were classified as RD-AN if requiring a readmission <12 months since last discharge. Clinical characteristics were measured upon admission and discharge for each hospitalization, and at all time points, patients completed questionnaires assessing eating and general psychopathology, and body shape concerns. Results: Sixty-seven patients (39.4%) needed at least one readmission and 62 (92.5% of RA-AN) reported RD. Compared with non-RA-AN, those with RA-AN were younger, reported a shorter duration of illness, and were more frequently diagnosed with AN-BP. Also, greater severity of anxious and depressive symptoms and body shape concerns emerged in the RA-AN group. The outcome of baseline hospitalization did not differ between groups, and only depressive symptoms worsened at readmission. Shorter duration of AN and low weight gain during baseline hospitalization predicted early readmission but did not survive statistical control. In contrast, high scores on drive for thinness upon baseline hospital entry robustly predicted a shorter time to readmission even after statistical control. Discussion: Individuals with AN who require readmission do so over a short period notwithstanding a positive treatment outcome during their baseline hospitalization. Shorter time-to-readmission can be predicted mostly in case of marked drive for thinness and poor weight gain at baseline hospital admission.

Comorbid depression as a negative predictor of weight gain during treatment of anorexia nervosa: A systematic scoping review

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness with high rates of relapse and mortality. Psychiatric comorbidities are common but their impact on the prognosis is largely unknown.

OBJECTIVE

The aim was to investigate the influence of psychiatric comorbidity on weight gain during treatment of AN.

METHODS

A systematic search was performed in PubMed/MEDLINE, EMBASE and PsycINFO. Studies evaluating psychiatric comorbidity as a predictor for treatment outcome (weight gain) were included, however, comorbid alcohol/drug addiction was excluded from this review.

RESULTS

Four thousand five hundred and twenty six publications were identified from which 15 were included. The majority of the included studies had a prospective open naturalistic study design, a short-term follow-up period, and were based on small populations of primarily adolescent and adult women. Four studies indicate depression, and two obsessiveness as negative prognostic factors, whilst one study indicated moderate depression and yet another, neuroticism, as positive predictors for weight gain.

DISCUSSION

The systematic scoping review found a large number of publications whereof only a few directly described the influence of psychiatric comorbidity on weight gain in AN. Overall, studies were heterogeneous in design, purpose and outcome making comparisons difficult. Findings were divergent but depression had a negative influence on weight gain in four studies.

Stigma: the representation of anorexia nervosa in UK newspaper Twitter feeds

BACKGROUND

There is evidence that the representation of mental health in newspapers has an influence on readers' attitudes, however, relatively little is known about how the industry presents accounts of anorexia nervosa. Further, the industry increasingly uses Twitter as a medium for reaching readers and this remains an under-examined area of research.

AIMS

To explore the representation of anorexia nervosa in the UK national press' Twitter feeds.

METHOD

Frame analysis was used to examine the manner in which anorexia nervosa was represented in the Twitter feeds of all national UK newspapers between 2009 and 2019 (n = 332). This qualitative approach used Braun and Clarke's stages of thematic analysis, while drawing on Van Gorp's use of a frame matrix to support the definition of the news frames.

RESULTS

The analysis identified four news frames: social model, illness model, stress-recovery model and clickbait model.

CONCLUSIONS

The newspapers drew on a range of perspectives in their representation of anorexia nervosa, which typically were not stigmatising in their accounts. However, there was a pattern of using sensationalistic images in some of the tweets, which may encourage readers to view people with anorexia nervosa as Other, and as a consequence contribute to stigmatisation.

Examining intra-individual variability in food-related inhibitory control and negative affect as predictors of binge eating using ecological momentary assessment

Binge eating presents in the context of several eating disorders (EDs) and has been shown to be associated with negative affectivity and inhibitory control deficits. While considerable ecological momentary assessment (EMA) work in EDs has demonstrated the importance of intra-individual variability in affect in predicting binge episodes, no research has considered how fluctuations in inhibitory control and negative affect together influence binge eating, or the extent to which these relationships may differ across ED diagnoses. Therefore, the present EMA study assessed the extent to which daily inhibitory control moderated momentary associations between negative affect and binge eating, and whether the presence of regular compensatory behaviors influenced these associations. Participants were 40 women reporting regular binge eating (anorexia nervosa binge-purge type [AN-BP], bulimia nervosa [BN], binge-eating disorder [BED]/subthreshold BED) who completed a 10-day EMA protocol that included measures of affect, eating, and a daily ambulatory Go/No-go task that included palatable food and neutral stimuli. Results of generalized estimating equations indicated greater between-person food-related inhibitory control deficits were associated with greater binge likelihood, and there was a three-way interaction between momentary negative affect, daily food-related inhibitory control, and compensatory behavior group. For individuals with BN or AN-BP, the relationship between momentary negative affect and subsequent binge eating was stronger on days characterized by reduced inhibitory control, whereas no main or interactive effects of negative affect or inhibitory control were observed for those with BED/subthreshold BED. Together these results demonstrate the importance of intra-individual variability in executive functioning and affective processes that underlie binge eating, as well as meaningful individual differences in these momentary associations.

IS BODY FAT PERCENTAGE A GOOD PREDICTOR OF MENSTRUAL RECOVERY IN FEMALES WITH ANOREXIA NERVOSA AFTER WEIGHT RESTORATION? A SYSTEMATIC REVIEW AND EXPLORATORY AND SELECTIVE META-ANALYSIS

The resumption of menses (ROM) is an important outcome in anorexia nervosa treatment and is considered as a sign of recovery. Identification of relevant factors in its prediction is important in clinical practice. Therefore we aimed to conduct a systematic review and exploratory meta-analysis of the association between total body fat percentage (%BF) and ROM after weight restoration in adolescents and young adults with anorexia nervosa. The study was conducted by adhering to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data were collated using meta-analysis and a narrative approach. Of the 604 articles retrieved, only seven studies comprising a total of 366 adolescent and young adult females with anorexia nervosa met the inclusion criteria and were reviewed, and preliminary results revealed three main findings. Firstly, patients who resumed their menstrual cycle had a significantly higher mean %BF when compared to those who did not, an overall effect confirmed by the meta-analysis (SMD: 3.74, 95% CI: 2.26-5.22). Secondly, %BF was found to be an independent predictor of the ROM in this population and an increase of only one unit of %BF can increase the odds of menstruation by ≈15-20%. Thirdly, despite the paucity of data, a cut-off point of %BF≈21was suggested as the minimum needed for ROM. In conclusion, a higher %BF seems to be associated with the ROM in weight-restored adolescent and young adult females with anorexia nervosa. Its assessment is important in a clinical setting, especially after complete weight restoration. The PROSPERO Registry - A systematic review and meta-analysis of the factors associated with the resumption of the menstrual cycle in females with anorexia nervosa after weight restoration (CRD42019111841).

Family-based Treatment of Eating Disorders: A Narrative Review

Eating disorders (EDs) are serious psychiatric illnesses that typically develop during adolescence or young adulthood, indicating that individuals with EDs may benefit from early intervention. Family-based treatment is the leading treatment of youth with anorexia nervosa, with increasing evidence of its efficacy for youth with bulimia nervosa. This review describes the role of family engagement within family-based treatment of EDs, followed by a summary of current empirically supported, family-based ED interventions. It concludes with discussion of the ways in which family interventions are expanding and adapting to improve the breadth and scope of ED treatment in adolescence and young adulthood.