Open trial of family-based treatment for full and partial anorexia nervosa in adolescence: evidence of successful dissemination

Atypical anorexia nervosa: A scoping review to determine priorities in research and clinical practice

BACKGROUND

There is currently a limited understanding of the identification, nature, and treatment of Atypical Anorexia Nervosa (AAN). Recent systematic reviews have identified only small numbers of candidate papers, and some areas lack any meaningful review so far - particularly treatment outcomes. A key issue is the lack of clarity in the literature regarding the definition of weight loss criteria.

OBJECTIVES

This scoping review aimed to determine the nature and extent of our knowledge of AAN, in order to assist in the development of future systematic reviews and meta-analyses, as well as indicating what further research is needed.

METHOD

Following the identification of 6747 records, 317 records using the term AAN or a defined equivalent were identified from six databases, including the 'grey' literature.

RESULTS

Of the 317 studies, 111 provided participant characteristics, and only 10 provided discrete treatment outcomes. Each of these subsets of the data are tabulated and supported with supplementary material, so that future systematic reviewers can access this resource.

DISCUSSION

The pattern and content of the existing studies allows recommendations to be made regarding future reviews, research and clinical practice. There is a particular need for clear weight/weight loss criteria and adequate interventions.

Course and outcome in individuals with atypical anorexia nervosa: Findings from the Study of Refeeding to Optimize iNpatient Gains (StRONG)

OBJECTIVE

We previously reported that participants with atypical anorexia nervosa (atypical AN) had higher historical and admission weights, greater eating disorder psychopathology, but similar rates of amenorrhea and weight suppression at baseline as compared to anorexia nervosa (AN); here, we compare 1-year outcomes.

METHOD

Weight, % median body mass index (%mBMI), Eating Disorder Examination Questionnaire (EDE-Q) scores, resumption of menses, and rehospitalizations were examined at 3, 6, and 12 months post-discharge. Analyses (N = 111) compared changes in %mBMI, weight suppression, and EDE-Q scores over time between atypical AN and AN.

RESULTS

Among the participants (48 atypical AN, 63 AN), both groups gained weight but those with atypical AN had lower gains than those with AN in %mBMI (p = .02) and greater weight suppression (p = .002) over time. EDE-Q scores improved over time, independent of weight suppression, with no significant difference between atypical AN and AN. Groups did not differ by rates of resumption of menses (80% atypical AN, 76.9% AN) or rehospitalization (29.2% atypical AN, 37.9% AN). Greater weight suppression predicted longer time to restore menses and more days of rehospitalization.

DISCUSSION

Individuals with atypical AN regained a smaller proportion of body mass and were more weight suppressed over time. Change in eating disorder cognitions, resumption of menses, and rehospitalization rates at 1-year follow-up did not differ between groups. There was no significant difference in weight suppression between groups for those who were psychologically improved at 12 months. Findings highlight limitations in our understanding of weight recovery in atypical AN. New metrics for recovery are urgently needed.

PUBLIC SIGNIFICANCE

Little is known about outcome in atypical anorexia nervosa (atypical AN). We examined recovery metrics in young people with atypical AN and anorexia nervosa (AN) 1 year after medical hospitalization. Individuals with atypical AN showed slower weight gain and remained further from their pre-illness weight. There were no differences in the rates of psychological recovery, resumption of menses, or rehospitalization. New metrics are needed to assess recovery in atypical AN.

Cross-sectional assessment of body composition and detection of malnutrition risk in participants with low body mass index and eating disorders using 3D optical surface scans

BACKGROUND

New recommendations for the assessment of malnutrition and sarcopenia include body composition, specifically reduced muscle mass. Three-dimensional optical imaging (3DO) is a validated, accessible, and affordable alternative to dual X-ray absorptiometry (DXA).

OBJECTIVE

Identify strengths and weaknesses of 3DO for identification of malnutrition in participants with low body mass index (BMI) and eating disorders.

DESIGN

Participants were enrolled in the cross-sectional Shape Up! Adults and Kids studies of body shape, metabolic risk, and functional assessment and had BMI of <20 kg/m2 in adults or <85% of median BMI (mBMI) in children and adolescents. A subset was referred for eating disorders evaluation. Anthropometrics, scans, strength testing, and questionnaires were completed in clinical research centers. Lin's Concordance Correlation Coefficient (CCC) assessed agreement between 3DO and DXA; multivariate linear regression analysis examined associations between weight history and body composition.

RESULTS

Among 95 participants, mean ± SD BMI was 18.3 ± 1.4 kg/m2 in adult women (N = 56), 19.0 ± 0.6 in men (N = 14), and 84.2% ± 4.1% mBMI in children (N = 25). Concordance was excellent for fat-free mass (FFM, CCC = 0.97) and strong for appendicular lean mass (ALM, CCC = 0.86) and fat mass (FM, CCC = 0.87). By DXA, 80% of adults met the low FFM index criterion for malnutrition, and 44% met low ALM for sarcopenia; 52% of children and adolescents were <-2 z-score for FM. 3DO identified 95% of these cases. In the subset, greater weight loss predicted lower FFM, FM, and ALM by both methods; a greater percentage of weight regained predicted a higher percentage of body fat.

CONCLUSIONS

3DO can accurately estimate body composition in participants with low BMI and identify criteria for malnutrition and sarcopenia. In a subset, 3DO detected changes in body composition expected with weight loss and regain secondary to eating disorders. These findings support the utility of 3DO for body composition assessment in patients with low BMI, including those with eating disorders. This trial was registered at clinicaltrials.gov as NCT03637855.

Paediatric eating disorders: Exploring virtual family therapy during a global pandemic

AIM

Explore treatment response and effectiveness of virtual treatment for a paediatric eating disorder sample.

METHODS

Twenty patients and their families who received either virtual or in-person family therapy were included in the study. Family therapy was informed by family-based treatment (FBT) principles. Patients' weight restoration at 1, 3, and 6 months after starting treatment was examined. Independent sample t tests assessed group differences and a Fisher exact test was used to evaluate the association between treatment group and weight restoration.

RESULTS

Weight restoration did not significantly differ between treatment groups (virtual vs. in-person) at any time point and there was no association between group and remission weight at 6 months.

CONCLUSIONS

Study results are considered exploratory. Future research addressing study limitations is needed. Results suggest that paediatric eating disorder patients may benefit from family therapy delivered via a virtual platform.

The Treatment Experience of Anorexia Nervosa in Adolescents from Healthcare Professionals' Perspective: A Qualitative Study

Anorexia nervosa (AN) is a serious psychiatric illness with a high mortality rate and a poor outcome. AN in adolescents can be difficult to treat. The prognosis of patients with AN depends highly on how early specialized AN treatment starts. Therefore, the purpose of this study was to explore the experiences of healthcare professionals in treating adolescents with AN. A qualitative study approach was conducted. Through semi-structured interviews, 16 healthcare professionals, including 10 nurses, 3 dieticians and 3 physicians from the paediatric ward at a university-affiliated medical centre in central Taiwan, shared their experiences. Recorded interviews were transcribed and analyzed by content analysis. Five themes and ten subthemes were identified: 1. Building a trusting relationship first: (a) spending time to build trust with the client and (b) establishing a relationship with the client's parents; 2. The key to treatment success: (a) Clients' awareness of the illness and (b) parents' support for clients; 3. Consistency of team treatment goals: (a) maintaining stable vital signs and (b) achieving caloric intake; 4. Empowerment with knowledge about anorexia: (a) continuing education for healthcare professionals and (b) interdisciplinary collaborative care; and 5. Using different interaction strategies: (a) the hard approach and (b) the soft approach. In conclusion, the findings will provide important information for healthcare professionals to apply in monitoring the psychological and emotional states of adolescents with AN. The findings indicate that healthcare professionals should invite parents to participate in the treatment, support and guide them in their adolescent care, develop scales of family stress and support for AN in adolescents, develop interventions, and establish an early therapeutic alliance.

Weight restoration in adolescent anorexia: parents' goal-directed processes

BACKGROUND

Parent-led weight restoration is a key intervention of family-based treatment, an empirically supported treatment for adolescent anorexia. Successful outcomes in family-based treatment depend almost entirely on parental action, yet current understandings of this intervention are primarily informed by professional theory and expert perspectives. Comparatively little is known about parents' goals and actions while implementing the treatment, despite goal-directed action being an explicit framework of family-based treatment. This study seeks to investigate parents' involvement in weight restoration from the perspective of the goal-directed actions they construct and engage in themselves and with others. This study focuses on the phenomenon of parent-led weight restoration as a project and addresses the following research question: "How do parents participate in the weight restoration of their adolescent as the adolescent recovers from anorexia nervosa?".

METHOD

This multicase study used the action project method and conceptual framework of contextual action theory to examine four cases of five parents engaged in actions to help their adolescent regain weight and recover from anorexia. Data were collected using multi-part interviews and analyzed according to the action project method and the multicase approach.

RESULTS

Parents' weight restoration projects were identified and grouped based on three common a themes. The primary theme, progressing toward health and well-being, was supported by three key processes: maintaining a holistic focus, trusting, and monitoring progress. Two secondary themes captured actions that were integral to the parents' projects, but with less prominence. Secondary themes were creating capacity, which was supported by three processes (managing emotions to maintain a helpful focus, personal work, and resourcing time and finances), and coordinating and negotiating partnerships. The socio-cultural valuing of the thin ideal emerged as a unique process salient in one case. This study presents a goal-directed and contextual perspective on how parents translated the principles of family-based treatment into their daily lives. It joins a small but growing body of work concerned with generating new understandings and frameworks for practitioners and researchers to enhance the effectiveness of family-based treatment in community settings.

Phase 2 of family-based treatment: an exploratory assessment of clinician practices

PURPOSE

In manualized family-based treatment (FBT) for eating disorders, phase 1 of the 3-phase treatment-during which parents are put in control of eating-related issues-is perhaps the most critical phase, and is comprehensively addressed in the manual. Phase 2, during which control over eating is gradually returned to the patient, is more variable and the manual dedicates less space to this phase. The purpose of the current exploratory study was to assess Phase 2 practices of clinicians providing FBT and to compare these practices to the guidance offered in the manual.

METHODS

In the current study, a survey assessing Phase 2 practices was sent to clinicians. Twenty-seven providers responded. Two providers reported that they did not provide FBT in an outpatient setting. One reported not currently providing outpatient FBT but had in the past. The remaining providers were currently providing FBT in an outpatient setting.

RESULTS

No items addressing the core interventions of Phase 2, including encouraging age-appropriate independent eating, were endorsed by 100% of respondents as being addressed 100% of the time in Phase 2.

CONCLUSION

Responses reflected some adherence to the manual, along with examples of therapist drift and incorporation of therapeutic interventions that are not described in the FBT manual. Adherence to manualized treatments may improve outcome for some patients, while allowing for flexibility to address clinical situations that are not addressed in the manual.

LEVEL OF EVIDENCE

V. Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

A scoping review of non-specific predictors, moderators, and mediators of family-based treatment for adolescent anorexia and bulimia nervosa: a summary of the current research findings

PURPOSE

This scoping review presents an up-to-date synthesis of the current evidence base for non-specific predictors, moderators, and mediators of family-based treatment (FBT) for adolescent anorexia and bulimia nervosa.

METHODS

We identify ways in which end-of-treatment outcomes have been shown to differ based upon baseline clinical features and person-specific factors and explore psychological mechanisms that may explain differences in treatment response. We draw from this evidence base to outline recommendations for clinical practice, as well as directions for future clinical eating disorder research.

RESULTS

Noted findings from review include that early response in weight gain and parental criticism may be particularly influential in treatment for anorexia nervosa. Further, for adolescents with either anorexia or bulimia nervosa, eating-related obsessionality may be a key intervention target to improve outcomes.

CONCLUSION

In addition to highlighting a need for attention to specific patient- and caregiver-level factors that impact treatment response, recommendations for research and clinical practice include testing whether certain targeted treatments (e.g., exposure-based approaches) may be suitable within the context of FBT for eating disorders.

LEVEL OF EVIDENCE

Level I: Evidence obtained from: at least one properly designed randomized controlled trials; experimental studies.

The five tenets of family-based treatment for adolescent eating disorders

Family-based treatment (FBT) is the leading treatment for adolescent eating disorders and is based on five tenets, or fundamental assumptions: (1) the therapist holds an agnostic view of the cause of the illness; (2) the therapist takes a non-authoritarian stance in treatment; (3) parents are empowered to bring about the recovery of their child; (4) the eating disorder is separated from the patient and externalized; and (5) FBT utilizes a pragmatic approach to treatment. Learning these tenets is crucial to the correct practice and implementation of manualized FBT. The purpose of the current paper is to provide an in-depth overview of these five tenets and to illustrate how they are used in clinical practice. This overview will aid clinicians who are learning FBT.

Rescripting-A grounded theory study of the contribution that fathers make to Family-Based Treatment when a young person has anorexia nervosa

AIM

To present a grounded theory of the contribution that fathers make to family-based treatment when a young person has anorexia nervosa.

BACKGROUND

Research indicates a potential to improve outcomes by involving both parents in the treatment of anorexia nervosa. However, fathers are underrepresented both within treatment and research. Family-based treatment requiring the involvement of both parents presents an opportunity to better understand the role of the father in treatment.

DESIGN

Classic grounded theory.

METHODS

Individual interviews conducted with fifteen fathers involved in family-based treatment. The COREQ checklist was followed.

RESULTS

Fathers valued being involved in family-based treatment and felt they had an important contribution to make. The analysis captures the overall contribution that fathers make and the impact of their involvement. Four categories; Being on the Outside, Finding a Way In, Finding a Way to Be and Finding a Way to Let Go and one core category Repositioning were generated from the data. A substantive theory of Rescripting, generated from categories and the core category, describes the way that participating in family-based treatment changes fathers and their role.

CONCLUSIONS

Fathers make an important and significant contribution to family-based treatment when a young person has anorexia nervosa. The findings inform clinicians about the importance of including fathers in the treatment of young people with anorexia nervosa. They highlight the importance of incorporating support mechanisms into family-based treatment to harness and maximise the paternal contribution.

RELEVANCE TO CLINICAL PRACTICE

Paternal contribution to family-based treatment can be maximised to improve outcomes for young people with anorexia nervosa.

Implementation of family-based treatment for Asian adolescents with anorexia nervosa: A consecutive cohort examination of outcomes

OBJECTIVE

This study describes the implementation of family-based treatment (FBT) in an eating disorder program in Asia as well as clinical outcomes of Asian adolescents with anorexia nervosa (AN) treated with FBT.

METHOD

This retrospective consecutive cohort study of 147 Asian adolescents with AN was compared between those in FBT (n = 65) versus treatment as usual (TAU) (n = 82). Variables associated with weight restoration were analyzed between groups.

RESULTS

Participants' mean age was 14.2 (SD = 1.5) years and 93% were female. Mean presenting %mBMI was 74.0 (SD = 7.8) and average illness duration was 7.7 (SD = 6.1) months. The two groups' baseline characteristics were not significantly different. Weight restoration rates in the FBT group were significantly higher than the TAU group at 6-, 12-, and 24-month time points. A linear mixed model showed the mean %mBMI was significantly higher at 0, 6, 12, and 24 months in the FBT group. The median time to weight restoration for patients on FBT was shorter (FBT: 7.0 months, TAU: 19.0 months; 95% CI [14.5, 23.5] χ² = 15.84, p < .001). Within the FBT group, those that completed ≥9 FBT sessions had significantly higher rates of weight restoration at 12 months. Across all participants, those with a lower starting %mBMI were less likely to achieve weight restoration by 12 months.

CONCLUSION

FBT can be effectively implemented in a multidisciplinary eating disorder program managing Asian adolescents with AN with improved rates of weight restoration. Further research is needed to understand the predictors and moderators of remission using FBT in Asian adolescents with AN.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

Dialectical behavioral therapy skills group as an adjunct to family-based therapy in adolescents with restrictive eating disorders

Dialectical behavior therapy (DBT) is commonly used in the treatment of eating disorders (ED), yet few studies have examined the utility of DBT skills groups as an adjunct to evidence-based therapy for ED. Thus, we sought to examine the preliminary efficacy of a DBT skills group as an adjunct to Family-Based Treatment (FBT) for adolescent restrictive ED. Our preliminary pilot study included 18 adolescent girls ages 13-18 (M= 15.3, SD = 1.64) with restrictive ED, including Anorexia Nervosa (AN; N = 10), Atypical Anorexia Nervosa (AAN, N = 5), and Other Specific Feeding or Eating Disorder (OSFED; N = 3). All participants were enrolled in a 6-month, weekly DBT skills group and were concurrently receiving family-based treatment (FBT). Participants who completed the intervention experienced large effect sizes for increases in adaptive skills (Cohen's d = .71) and decreases in general dysfunctional coping strategies (Cohen's d = .85); and small to medium effect sizes for decreases in binge eating (Cohen's d = .40) and increases in percent expected body weight (% EBW; Cohen's d = .32). Finally, small effect sizes were evidenced in decreases in Global EDE-Q scores (Cohen's d = .26), EDE-Q restraint (Cohen's d = .29) and CDI scores (Cohen's d = .28). Our study presents promising preliminary data suggesting that adolescents with restrictive EDs receiving FBT could benefit from an adjunctive DBT skills group. Feasibility of and considerations for tailoring a DBT skills group to an outpatient ED treatment program are discussed.

Family therapy approaches for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa.

DATA COLLECTION AND ANALYSIS

Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures.

MAIN RESULTS

We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I² = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I² = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I² = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I² = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up.

AUTHORS' CONCLUSIONS

There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or other psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.

Family therapy approaches for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa.

DATA COLLECTION AND ANALYSIS

Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures.

MAIN RESULTS

We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I2 = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I2 = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up.

AUTHORS' CONCLUSIONS

There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.

Adaptation and implementation of family-based treatment enhanced with dialectical behavior therapy skills for anorexia nervosa in community-based specialist clinics

Although family-based therapy (FBT) is a well-established treatment for anorexia nervosa, its implementation and effectiveness in clinical settings has been neglected. A group of seven therapists at a community-based eating disorders clinic were trained in skills-enhanced FBT and provided treatment to 11 youth with anorexia nervosa. Family-based skills training, which borrowed heavily from dialectical behavior therapy, was introduced in four additional sessions and then integrated throughout the remainder of FBT. FBT was perceived as appropriate and acceptable by all participants. Therapists reported high treatment fidelity. There was a large improvement in weight and moderate improvement in caregiver-reported eating disorder psychopathology but no clinically significant change by youth report. This study provides preliminary data on the implementation and effectiveness of FBT in the community.

A case series of family-based treatment for adolescents with atypical anorexia nervosa

The aim of this case series was to examine engagement in and outcomes of family-based treatment (FBT) for adolescents with DSM-5 atypical AN, that is, adolescents who were not underweight at presentation. Consecutive referrals for FBT of adolescents with atypical AN to a specialist child and adolescent eating disorder program were examined. Engagement in treatment (i.e., dose of treatment, completion rate), and changes in psychological symptomatology (i.e., eating disorder symptoms, depressive symptoms, self-esteem, obsessive compulsiveness), weight, and menstrual function were examined. The need for additional interventions (i.e., hospitalization and medication), and estimated remission rates were also examined. The sample comprised 42 adolescents aged 12-18 years (88% female). Engagement in FBT was high, with 83% completing at least half the treatment dose. There were significant decreases in eating disorder and depressive symptoms during FBT (p < .05) but no improvement in self-esteem. There was no significant change in percent of median BMI for age and gender for the sample as a whole (105 vs. 106%, p = .128). However, adolescents who were not admitted to hospital prior to FBT gained some weight (M = 3.4 kg) while those who were admitted did not gain weight during FBT (M = 0.2 kg, p < .01). The overall remission rate ranged from 38 to 52% depending on the criteria applied. FBT appears to be an effective treatment for adolescents with atypical AN. However, more research is needed into systematic adaptations of FBT and other treatments that could improve overall remission rates.

Themes arising in clinical consultation for therapists implementing family-based treatment for adolescents with anorexia nervosa: a qualitative study

BACKGROUND

Our study aims to explore and describe themes arising in sessions of clinical consultation with therapists implementing Family-Based Treatment (FBT) for adolescents with Anorexia Nervosa (AN). There is currently no literature describing the content of clinical consultation for FBT. Thus, this knowledge will add to the evidence-base on what therapists need from consultants in ongoing clinical consultation.

METHODS

Eight therapists at four sites participated in this study, which spanned a two-year period. Following a two-day training workshop, each therapist treated at least one adolescent patient presenting with a restrictive eating disorder with FBT, focusing on adherence to the treatment manual. Clinical consultation sessions occurred monthly and were led by an external FBT expert. Thirty-five (average per site = 9) audio recorded group clinical consultation sessions were transcribed verbatim and coded for themes. Twenty percent of the transcripts were double-coded to ensure consistency. Fundamental qualitative description guided the sampling and data collection.

RESULTS

Thematic content analysis revealed ten common themes relating to the provision of clinical consultation to therapists implementing FBT in clinical practice: encouraging parental meal time supervision,discussing the role of mothers, how to align parents, ensuring parental buy-in, when to transition to Phase 2, weighing the patient and the patients' knowledge of their weight, the role of siblings in FBT sessions, how best to manage patient co-morbidities, the role of the father in FBT and how best to manage the family meal.

CONCLUSIONS

In conclusion, clinical consultation themes aligned with many of the central tenets of FBT, including how to help parents align their supportive approach during the refeeding process, and how to help parents assume control of eating disordered behaviours. This knowledge helps to guide consultants to anticipate common issues brought forward by therapists attempting to implement FBT.

The effectiveness of family-based treatment for full and partial adolescent anorexia nervosa in an independent private practice setting: Clinical outcomes

OBJECTIVE

Anorexia nervosa (AN) is a severe psychiatric illness with little evidence supporting treatment in adults. Among adolescents with AN, family-based treatment (FBT) is considered first-line outpatient approach, with a growing evidence base. However, research on FBT has stemmed from specialist services in research/public health settings. This study investigated the effectiveness of FBT in a case series of adolescent AN treated in a private practice setting.

METHOD

Thirty-four adolescents with full or partial AN, diagnosed according to DSM-IV criteria, participated, and were assessed at pretreatment and post-treatment. Assessments included change in % expected body weight, mood, and eating pathology.

RESULTS

Significant weight gain was observed from pretreatment to post-treatment. 45.9% of the sample demonstrated full weight restoration and a further 43.2% achieved partial weight-based remission. Missing data precluded an examination of change in mood and ED psychopathology.

DISCUSSION

Effective dissemination across different service types is important to the wider availability of evidence-based treatments. These weight restoration data lend preliminary support to the implementation of FBT in real world treatment settings. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1023-1026).

Family Therapy for Child and Adolescent Eating Disorders: A Critical Review

Eating disorder-focused family therapy has emerged as the strongest evidence-based treatment for adolescent anorexia nervosa, supported by evidence from nine RCTs, and there is increasing evidence of its efficacy in treating adolescent bulimia nervosa (three RCTs). There is also emerging evidence for the efficacy of multifamily therapy formats of this treatment, with a recent RCT demonstrating the benefits of this approach in the treatment of adolescent anorexia nervosa. In this article, we critically review the evidence for eating disorder-focused family therapy through the lens of a moderate common factors paradigm. From this perspective, this treatment is likely to be effective as it provides a supportive and nonblaming context that: one, creates a safe, predictable environment that helps to contain anxiety generated by the eating disorder; two, promotes specific change early on in treatment in eating disorder-related behaviors; and three, provides a vehicle for the mobilization of common factors such as hope and expectancy reinforced by the eating disorder expertise of the multidisciplinary team. In order to improve outcomes for young people, there is a need to develop an improved understanding of the moderators and mediators involved in this treatment approach. Such an understanding could lead to the refining of the therapy, and inform adaptations for those families who do not currently benefit from treatment.

An Update on Evidence-Based Psychosocial Treatments for Eating Disorders in Children and Adolescents

Eating disorders are relatively common and serious disorders in adolescents. However, there are few controlled psychosocial intervention studies with this younger population. This review updates a previous Journal of Clinical Child and Adolescent Psychology review published in 2008. The recommendations in this review were developed after searching the literature including PubMed/Medline and employing the relevant medical subject headings. In addition, the bibliographies of book chapters and treatment guideline articles were reviewed; last, colleagues were asked for suggested additional source materials. Psychosocial treatments examined include family therapy, individual therapy, cognitive behavioral therapy, interpersonal psychotherapy, cognitive training, and dialectical behavior therapy. Using the most recent Journal of Clinical Child and Adolescent Psychology methodological review criteria, family treatment-behavior (FT-B) is the only well-established treatment for adolescents with anorexia nervosa. Family treatment-systemic and insight oriented individual psychotherapy are probably efficacious treatments for adolescents with anorexia nervosa. There are no well-established treatments for adolescents with bulimia nervosa, binge eating disorder, or avoidant restrictive food intake disorder. Possibly efficacious psychosocial treatments for adolescent bulimia nervosa include FT-B and supportive individual therapy. Internet-delivered cognitive behavioral therapy is a possibly efficacious treatment for binge eating disorder. Experimental treatments for adolescent eating disorders include enhanced cognitive behavioral therapy, dialectical behavioral therapy, cognitive training, and interpersonal psychotherapy. FT-B is the only well-established treatment for adolescent eating disorders. Additional research examining treatment for eating disorders in youth is warranted.

Dissemination and Implementation of Manualized Family-Based Treatment: A Systematic Review

The objective of this article was to systematically review the literature pertaining to the dissemination and implementation of manualized family-based treatment (FBT). Several studies were found looking at the dissemination of FBT to sites beyond those of the primary research, mainly focusing on patient outcomes. Alternatively, articles were found which focused primarily on implementation outcomes, such as the barriers and facilitating factors for FBT uptake, a knowledge transfer model that could be applied to improve uptake, and team decision-making processes. It remains important to study the implementation of FBT in clinical practice due to the barriers identified in the literature.

Who's in the Room? A Parent-Focused Family Therapy for Adolescent Anorexia Nervosa

Family therapy is often assumed to involve the whole family; that is both parents and children attending the therapist's office together. In practice, however, which family members are included in family therapy, how often, and in what ways, is much more variable. In this article we provide an overview of the recent history of family therapy in regard to who is directly involved in therapy, and contrast changing practices in the eating disorders field with those in the family therapy field more widely. This overview leads into a discussion of current practices in family-based treatment for adolescent anorexia nervosa and the development of a new form of family therapy that is parent-focused.

From efficacy to effectiveness: comparing outcomes for youth with anorexia nervosa treated in research trials versus clinical care

This study examined outcomes for 84 youth with anorexia nervosa (AN) who received family-based treatment (FBT) in a research trial (randomized trial care [RTC]: n = 32) compared to fee-for-service care (specialty clinical care [SCC]: n = 52) at an outpatient eating disorder clinic. Weight was collected up to 12 months post-baseline. Survival curves were used to examine time to weight restoration as predicted by type of care, baseline demographic and clinical characteristics, and their interaction. There was not a significant main effect for type of care, but its interaction with initial %EBW was significant (p = .005), indicating that weight restoration was achieved faster in RTC compared to SCC for youth with a lower initial %EBW (i.e., ≤81), while rates of weight restoration were comparable for those with a higher initial %EBW (i.e., >81). These data suggest that FBT is as effective as it is efficacious, except for youth with lower initial body weights. Therefore, clinicians may need to be particularly active in encouraging early weight gain for this subset of patients. Nevertheless, this study suggests that FBT is appropriate as a first-line treatment for youth with AN who present for clinical care.

Implementation of family-based treatment for adolescents with anorexia nervosa

Although the implementation of new treatment models can be a challenging process for health care services, the outcomes can be greatly beneficial to patients and service providers. This article describes the process of change experienced within our multidisciplinary specialist eating disorder service when we implemented a new evidence-based model of care focusing on outpatient family-based treatment (FBT). Clinical outcomes were positive, including a 56% decrease in admissions, a 75% decrease in readmissions, and a 51% decrease in total bed days. Of families referred to FBT, 83% completed treatment and 97% of completers achieved >90% of their expected body weight. Despite these gains, many challenges were experienced, including misgivings about the suitability of FBT and difficulties in adhering to changes in professional roles. We describe these challenges, describe how they were overcome, and review factors perceived to be critical to the program's success, including integration of medical and mental health services, communication, and training.

The role of the pediatrician in family-based treatment for adolescent eating disorders: opportunities and challenges

Empiric research supports that family-based treatment (FBT) is an effective treatment for adolescents with eating disorders. This review outlines the role of the pediatrician in FBT for adolescent eating disorders, specifically focusing on how pediatric care changes during treatment, and discusses current challenges and misconceptions regarding FBT. Although FBT introduces unique challenges to pediatricians trained in earlier eating disorder treatment approaches, effective support of the approach by pediatricians is critical to its success.

Who am I? How do I look? Neural differences in self-identity in anorexia nervosa

Anorexia nervosa (AN) patients exhibit a disparity in their actual physical identity and their cognitive understanding of their physical identity. Functional magnetic resonance imaging (fMRI) tasks have contributed to understanding the neural circuitry involved in processing identity in healthy individuals. We hypothesized that women recovering from AN would show altered neural responses while thinking about their identity compared with healthy control women. We compared brain activation using fMRI in 18 women recovering from anorexia (RAN) and 18 healthy control women (CON) using two identity-appraisal tasks. These neuroimaging tasks were focused on separable components of identity: one consisted of adjectives related to social activities and the other consisted of physical descriptive phrases about one's appearance. Both tasks consisted of reading and responding to statements with three different perspectives: Self, Friend and Reflected. In the comparisons of the RAN and CON subjects, we observed differences in fMRI activation relating to self-knowledge ('I am', 'I look') and perspective-taking ('I believe', 'Friend believes') in the precuneus, two areas of the dorsal anterior cingulate, and the left middle frontal gyrus. These data suggest that further exploration of neural components related to identity may improve our understanding of the pathology of AN.

Clinical outcomes of a novel, family-centered partial hospitalization program for young patients with eating disorders

AIM

Eating disorders (ED) in children and younger adolescents are becoming more evident, but there is a small evidence base for their management in this population. We hypothesized that a new family-centered partial hospital program for young patients would be effective in promoting weight gain, as well as improvement in psychiatric symptoms.

METHODS

A retrospective chart review of 56 patients treated in the program between August 2008 and November 2009 was performed. Historical data, anthropometric variables and scores from psychological instruments [Children's Eating Attitudes Test (ChEAT), Children's Depression Inventory (CDI), and Revised Children's Manifest Anxiety Scale (RCMAS)] were collected on admission and at discharge. After exclusion, 30 patients were available for statistical analysis, using paired t-tests. The primary outcome variables were improvement in weight and change in total ChEAT score. Secondary outcomes included improvements in the CDI and RCMAS scores. Multivariate analysis included linear regression models that controlled for patient-specific fixed effects.

RESULTS

The cohort was 87% female with a mean age of 12.8±2 years; 60% were diagnosed with ED not otherwise specified. Two-thirds had a co-morbid depressive and/or anxiety disorder. Change in weight was significant (p<0.0001), as were improvements on total ChEAT (p<0.0001), CDI (p=0.0002), and RCMAS (p<0.0001) scores. No historical factors were correlated with improvement, nor was use of psychotropic medications. Length of stay in weeks significantly predicted greater weight gain (p=0.004, R2=0.26).

CONCLUSIONS

Patients treated in a family-centered partial hospital program had significant improvements in weight and psychological parameters. This approach holds significant promise for the management of young ED patients.

Classification of feeding and eating disorders: review of evidence and proposals for ICD-11

Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification of feeding and eating disorders in ICD-11 requires substantial changes to remediate the shortcomings. We review evidence on the developmental and cross-cultural differences and continuities, course and distinctive features of feeding and eating disorders. We make the following recommendations: a) feeding and eating disorders should be merged into a single grouping with categories applicable across age groups; b) the category of anorexia nervosa should be broadened through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations; c) a severity qualifier "with dangerously low body weight" should distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis; d) bulimia nervosa should be extended to include subjective binge eating; e) binge eating disorder should be included as a specific category defined by subjective or objective binge eating in the absence of regular compensatory behaviour; f) combined eating disorder should classify subjects who sequentially or concurrently fulfil criteria for both anorexia and bulimia nervosa; g) avoidant/restrictive food intake disorder should classify restricted food intake in children or adults that is not accompanied by body weight and shape related psychopathology; h) a uniform minimum duration criterion of four weeks should apply.

Family-based early intervention for anorexia nervosa

OBJECTIVE

This study explores whether potential risk factors for anorexia nervosa (AN) can be modified by a family-based Internet-facilitated intervention and examines the feasibility, acceptability, and short-term efficacy of the Parents Act Now programme in the USA and Germany.

METHOD

Forty-six girls aged 11-17 were studied during a 12-month period and evaluated at screening, baseline, and post-intervention. Parents participated in the six-week intervention.

RESULTS

Twenty-four per cent of girls (n = 791) screened met the risk criteria for AN. Parents accessed the majority of the online sessions and rated the programme favourably. At post-assessment, 16 of 19 participants evidenced reduced risk status. Participants remained stable or increased in ideal body weight and reported decreased eating disorder attitudes and behaviours.

DISCUSSION

Results suggest that an easily disseminated, brief, online programme with minimal therapist support is feasible, accepted favourably by parents, and may be beneficial for prevention of exacerbation of AN pathology.

Transdiagnostic Theory and Application of Family-Based Treatment for Youth with Eating Disorders

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.

Treating Anorexia Nervosa in the Couple Context

Anorexia nervosa is a serious mental illness that affects women and men of all ages. Despite the gravity of its chronic morbidity, risk of premature death, and societal burden, the evidence base for its treatment-especially in adults-is weak. Guided by the finding that family-based interventions confer benefit in the treatment of anorexia nervosa in adolescents, we developed a cognitive-behavioral couple-based intervention for adults with anorexia nervosa who are in committed relationships that engages both the patient and her/his partner in the treatment process. This article describes the theoretical rationale behind the development of Uniting Couples in the treatment of Anorexia nervosa (UCAN), practical considerations in delivering the intervention, and includes reflections from the developers on the challenges of working with couples in which one member suffers from anorexia nervosa. Finally, we discuss future applications of a couple-based approach to the treatment of adults with eating disorders.

A randomized controlled trial of adjunctive family therapy and treatment as usual following inpatient treatment for anorexia nervosa adolescents

Research on treatments in anorexia nervosa (AN) is scarce. Although most of the therapeutic programs used in ‘real world practice’ in AN treatment resort to multidisciplinary approaches, they have rarely been evaluated.

Objective

To compare two multidimensional post-hospitalization outpatients treatment programs for adolescents with severe AN: Treatment as Usual (TAU) versus this treatment plus family therapy (TAU+FT).

Method

Sixty female AN adolescents, aged 13 to 19 years, were included in a randomized parallel controlled trial conducted from 1999 to 2002 for the recruitment, and until 2004 for the 18 months follow-up. Allocation to one of the two treatment groups (30 in each arm) was randomised. The TAU program included sessions for the patient alone as well as sessions with a psychiatrist for the patient and her parents. The TAU+FT program was identical to the usual one but also included family therapy sessions targeting intra-familial dynamics, but not eating disorder symptoms. The main Outcome Measure was the Morgan and Russell outcome category (Good or Intermediate versus Poor outcome). Secondary outcome indicators included AN symptoms or their consequences (eating symptoms, body mass index, amenorrhea, number of hospitalizations in the course of follow-up, social adjustment). The evaluators, but not participants, were blind to randomization.

Results

At 18 months follow-up, we found a significant group effect for the Morgan and Russell outcome category in favor of the program with family therapy (Intention-to-treat: TAU+FT :12/30 (40%); TAU : 5/29 (17.2%) p = 0.05; Per Protocol analysis: respectively 12/26 (46.2%); 4/27 (14.8%), p = 0.01). Similar group effects were observed in terms of achievement of a healthy weight (i.e., BMI≥10^th percentile) and menstrual status.

Conclusions

Adding family therapy sessions, focusing on intra-familial dynamics rather than eating symptomatology, to a multidimensional program improves treatment effectiveness in girls with severe AN.

Trial Registration

Controlled-trials.com ISRCTN71142875

Family-based interventions for child and adolescent disorders

Emotional and behavioral symptoms and disorders are prevalent in children and adolescents. There has been a burgeoning literature supporting evidence-based treatments for these disorders. Increasingly, family-based interventions have been gaining prominence and demonstrating effectiveness for myriad childhood and adolescent disorders. This article presents the current evidence in support of family-based interventions for mood, anxiety, attention-deficit hyperactivity, disruptive behavior, pervasive developmental particularly autism spectrum, and eating disorders. This review details recent data from randomized controlled trials (RCTs) and promising interventions not yet examined using a randomized controlled methodology. It highlights the evidence base supporting various specific family-based interventions, some of which are disorder dependent. A practitioner perspective is then offered with regard to recommendations for future practice and training. The article closes with a summary and directions for future research.

Identity and eating disorders (IDEA): a questionnaire evaluating identity and embodiment in eating disorder patients

BACKGROUND

In this paper we tested the hypothesis that persons with eating disorders (EDs) are affected by disturbances of the way they experience their own body (embodiment) and shape their personal identity, assuming that the various kinds of anomalies of eating behavior are consequences thereof.

SAMPLING AND METHODS

We developed and validated a new self-reported questionnaire named IDEA (IDentity and EAting disorders), which was administered to 147 ED patients and 187 healthy controls. Test-retest reliability, internal consistency, psychopathological correlates, and concurrent validity were evaluated. A factor analysis was performed to verify the distribution of items into subscales.

RESULTS

The questionnaire showed good test-retest reliability, and internal consistency. IDEA scores were specifically associated with ED psychopathology, and they did not show any correlation with sociodemographic and general clinical variables. Four factors were extracted, which were related to the following phenomena: 'feeling oneself only through the gaze of the other and defining oneself only through the evaluation of the other', 'feeling oneself only through objective measures', 'feeling extraneous from one's own body', and 'feeling oneself through starvation'.

CONCLUSIONS

IDEA represents a multidimensional, brief, versatile, easy-to-perform instrument for clinical evaluation, assessing abnormalities in lived corporeality, and of personal identity, which appeared to be specifically associated with the core features of ED psychopathology. The main limitations of the study are the cross-sectional design. Also, it is impossible to ascertain whether the domains we assessed are specific traits of patients with EDs, or state-related features. To answer this question, a longitudinal study is needed.

Perception of Autonomy and Connectedness Prior to the Onset of Anorexia Nervosa and Bulimia Nervosa

Objective: This study examines retrospective correlates of nonshared family environment prior to onset of disease, by means of multiple familial informants, among anorexia and bulimia nervosa patients. Methods: A total of 332 participants was included (anorexia nervosa, restrictive type (AN-R): n = 41 plus families); bulimic patients (anorexia nervosa, binge-purging type; bulimia nervosa: n = 59 plus families). The EATAET Lifetime Diagnostic Interview was used to establish the diagnosis; the Subjective Family Image Test was used to derive emotional connectedness (EC) and individual autonomy (IA). Results: Bulimic and AN-R patients perceived significantly lower EC prior to onset of disease compared to their healthy sisters. Bulimic patients perceived significantly lower EC prior to onset of disease compared to AN-R patients and compared to their mothers and fathers. A low family sum – sister pairs sum comparison – of EC had a significant influence on the risk of developing bulimia nervosa. Contrary to expectations, AN-R patients did not perceive significantly lower levels of IA compared to their sisters, prior to onset of disease. Findings of low IA in currently ill AN-R patients may represent a disease consequence, not a risk factor. Conclusions: Developmental child psychiatrists should direct their attention to disturbances of EC, which may be present prior to the onset of the disease.

Eating disorders in youth: diagnostic variability and predictive validity

OBJECTIVE

The primary aim was to examine the utility of DSM-IV criteria in predicting treatment outcome in a sample of adolescents with eating disorders.

METHOD

We (a) descriptively compared the baseline rates of anorexia nervosa (AN) and bulimia nervosa (BN) across multiple reference points for diagnostic criteria, (b) using ROC curve analyses, assessed the sensitivity and specificity of each diagnostic criterion in predicting clinical outcome, and (c) with logistic regression analyses, examined the incremental predictive value of each criterion.

RESULTS

Results show a high degree of variability in the baseline diagnostic profiles as a function of the information used to inform each DSM-IV criterion. For AN, Criterion A yielded the best predictive validity, with Criteria B-D providing no significant incremental value. For BN, none of the measures had a significant AUC, and results from logistic regression analyses showed that none of the indicators were robust in predicting outcome.

DISCUSSION

For AN, the existing Criterion A is appropriate for children and adolescents, and is sufficient to predict outcome in the context of active refusal to maintain a normal weight as well as multiple informants and behavioral indicators of the psychological aspects of AN. For BN, predictive validity could not be established.

Adolescent-adult discrepancies on the eating disorder examination: a function of developmental stage or severity of illness?

OBJECTIVE

Across studies, adolescents score lower on measures of eating disorder pathology than adults, but it is unclear whether such findings reflect discrepancies inherent to site/study or true developmental differences. The aim of this study was to determine whether age predicts subscale and diagnostic scores of the Eating Disorder Examination (EDE) in adolescents and adults with anorexia nervosa (AN) admitted to a single research center within the same period of time.

METHOD

The sample consisted of 16 adolescent and 20 adult consecutive admissions to parallel, age-specific, research-based AN treatment programs. Participants completed a baseline evaluation at admission that included the EDE, depression measures, and global assessment of functioning scales.

RESULTS

Age significantly predicted EDE scores in univariate regression analyses. However, in multivariate models that included severity indices of general and specific psychopathology as covariates, age was no longer a significant predictor of severity of eating disorder symptoms.

DISCUSSION

This study adds to the growing body of data showing lower scores on the EDE for adolescents with AN relative to their adult counterparts, while eliminating potential site confounds. Results indicate that the higher adult scores may be carried in part by a more overall severe and chronic general clinical profile.

Evaluation of family treatment models for eating disorders

PURPOSE OF REVIEW

Interest in the effectiveness of family interventions for eating disorders has increased over the past 5 years. This review considers the theoretical justification and current evidence base for the use of family treatments for eating disorders in children and adolescents.

RECENT FINDINGS

Family-based treatment is the best studied treatment. It has the strongest evidence base for effectiveness for anorexia nervosa in adolescents. Family-based treatment can be delivered in several formats and doses, and preliminary data suggest it can be disseminated by training and manuals. There is a more limited evidence base demonstrating the usefulness of family interventions for bulimia nervosa in adolescents.

SUMMARY

The implications of the findings of this review are that family interventions are the current first-line treatment for adolescent anorexia nervosa and promising for adolescent bulimia nervosa. Pilot studies suggest that family interventions can be disseminated in diverse clinical settings.

Impact of broadening definitions of anorexia nervosa on sample characteristics

Practical limitations and sample size considerations often lead to broadening of diagnostic criteria for anorexia nervosa (AN) in research. The current study sought to elucidate the effects of this practice on resultant sample characteristics in terms of eating disorder behaviors, psychiatric comorbidities, temperament and personality characteristics, and heritability point estimates. Three definitions of AN were created: meeting all Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for AN (AN-DSM-IV), meeting all DSM-IV criteria except criterion D, amenorrhea, (AN-noD), and broadening DSM-IV AN criteria by allowing a higher body mass index value, eliminating criterion D, and allowing less stringent body weight concerns (AN-Broad). Using data from the Swedish Twin Registry, 473 women fit one of the three definitions of AN. Women with AN-DSM-IV reported significantly more eating disorder behaviors than women with AN-Broad. Women with AN-noD reported more comorbid psychiatric disorders than women with AN-DSM-IV and AN-Broad. Temperament and personality characteristics did not differ across the three groups. Heritability point estimates decreased as AN definition broadened. Broadening the diagnostic criteria for AN results in an increased number of individuals available for participation in research studies. However, broader criteria for AN yield a more heterogeneous sample with regard to eating disorder symptoms and psychiatric comorbidity than a sample defined by narrower criteria.

Anxiety in anorexia nervosa and its management using family-based treatment

Anorexia nervosa (AN) is characterized by its similarity to anxiety disorders, especially obsessive-compulsive disorder (OCD). Family-based treatment (FBT) has shown promising initial results for treatment of AN in adolescents, yet the precise mechanisms of action are unknown. We present a theoretical argument and model, suggesting that FBT may work via exposure (and habituation) to food and its consumption. First, we review the evidence for pathological anxiety in AN, and suggest a framework for identifying specific anxious triggers, emotions (fear and worry) and avoidance strategies. Second, we briefly review evidence indicating that cognitive-behavioural therapy (CBT) and specifically exposure in its various forms is most effective for treating anxiety disorders in youth. Third, we consider distinct approaches to exposure therapy based on the pattern of triggers, anxious emotions and avoidance. We conclude that the interventions utilized in FBT share clear similarities to exposure with response prevention, a type of exposure therapy commonly used with OCD, and may work via facilitating habituation to food and eating in one's natural environment. We also highlight how parents facilitate this process in between sessions by effectively coaching their children and facilitating naturalistic exposure to food and related triggers. Options for future research are considered.

Early response to family-based treatment for adolescent anorexia nervosa

OBJECTIVE

The purpose of this study was to determine if early weight gain predicted remission at the end of treatment in a clinic sample of adolescents with anorexia nervosa (AN).

METHOD

Sixty five adolescents with AN (mean age = 14.9 years, SD = 2.1), from two sites (Chicago n = 45; Columbia n = 20) received a course of manualized family-based treatment (FBT). Response to treatment was assessed using percent ideal body weight (IBW) with remission defined as having achieved ≥ 95% IBW at end of treatment (Session 20).

RESULTS

Receiver operating characteristic analyses showed that a gain of at least 2.88% in ideal body weight by Session 4 best predicted remission at end of treatment (AUC = 0.674; p = 0.024).

DISCUSSION

Results suggest that adolescents with AN, receiving FBT, who do not show early weight gain are unlikely to remit at end of treatment.

Adolescent eating disorders: treatment and response in a naturalistic study

This naturalistic study investigated the treatment and outcome of adolescents with eating disorders (EDs) in the community. Clinicians from a practice-research network provided data on ED symptoms, global functioning, comorbidity, treatment, and outcome for 120 adolescents with EDs. ED "not otherwise specified" was the most common ED diagnosed. After an average of 8 months of treatment, about one third of patients had recovered, with patients with anorexia nervosa showing the most improvement. Clinicians utilized a range of psychotherapy interventions and two thirds of the patients had received adjunct psychoactive medication. Although CBT showed the strongest association with outcome in a subsample characterized by poor relational/personality functioning, dynamic therapy was associated with better global outcome in the overall sample.