Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa

Genetic and functional analyses of CTBP2 in anorexia nervosa and body weight regulation

The C-terminal binding protein 2 (CTBP2) gene (translational isoforms: CTBP2-L/S, RIBEYE) had been identified by a cross-trait analysis of genome-wide association studies for anorexia nervosa (AN) and body mass index (BMI). Here, we did a mutation analysis in CTBP2 by performing polymerase chain reactions with subsequent Sanger-sequencing to identify variants relevant for AN and body weight regulation and ensued functional studies. Analysis of the coding regions of CTBP2 in 462 female patients with AN (acute or recovered), 490 children and adolescents with severe obesity, 445 healthy-lean adult individuals and 168 healthy adult individuals with normal body weight detected 24 variants located in the specific exon of RIBEYE. In the initial analysis, three of these were rare non-synonymous variants (NSVs) detected heterozygously in patients with AN (p.Arg72Trp - rs146900874; p.Val289Met -rs375685611 and p.Gly362Arg - rs202010294). Four NSVs and one heterozygous frameshift variant were exclusively detected in children and adolescents with severe obesity (p.Pro53Ser - rs150867595; p.Gln175ArgfsTer45 - rs141864737; p.Leu310Val - rs769811964; p.Pro397Ala - rs76134089 and p.Pro402Ser - rs113477585). Ribeye mRNA was detected in mouse hypothalamus. No effect of fasting or overfeeding on murine hypothalamic Ribeye expression was determined. Yet, increased Ribeye expression was detected in hypothalami of leptin-treated Lepob/ob mice. This increase was not related to reduced food intake and leptin-induced weight loss. We detected rare and frequent variants in the RIBEYE specific exon in both patients with AN and in children and adolescents with severe obesity. Our data suggest RIBEYE as a relevant gene for weight regulation.

Chronic starvation induces microglial cell depletion in an activity-based anorexia model

Anorexia nervosa (AN) is a severe psychiatric disease with a largely unknown pathophysiology. AN leads to reduced brain volume and a disbalance of the gut microbiome suggesting the involvement of the gut-brain-axis. Also, in the activity-based anorexia (ABA) animal model mimicking AN brain volume loss is observed. This study investigated the impact of chronic starvation on brain cell populations and evaluated the potential protective effects of omega-3 fatty acids (FA) and probiotics in rats. We used a chronic ABA model and provided daily oral supplementation of omega-3 FA and probiotics. Immunohistochemistry and qPCR were used to analyze GFAP-positive astrocytes, IBA1-positive microglia, OLIG1/2-positive oligodendrocytes, MAP2-positive neurons and Ki-67-positive proliferating cells in the cerebral cortex and corpus callosum. We found a significant reduction of astrocytes and microglia in all ABA groups, likely due to reduced proliferating cells. Reduced running wheel activity and reduced amount of food needed to sustain body weight were observed in animals with supplementation with omega-3 FA and probiotics but we did not observe alterations in brain cells that could be attributed to these supplementations. Our results indicate that glial cell depletion potentially underlies the diminished brain volume found in ABA rats. Omega-3 FA and probiotics show potential for reducing AN-related symptoms and merit further study as a therapeutic approach.

[Anorexia nervosa-An update. German version]

Anorexia nervosa (AN) is a severe psychiatric disorder with the highest mortality rate among eating disorders. It predominantly affects adolescents and young adults, with a significant increase in prevalence among adolescents observed since the coronavirus disease 2019 (COVID-19) pandemic. It is frequently associated with other psychiatric disorders, such as depression, anxiety and obsessive-compulsive disorders as well as numerous physical complications. An early diagnosis and treatment are associated with better outcomes. The treatment of choice for AN includes cognitive behavioral therapy and family-based therapy for children and adolescents. Innovative treatment approaches, such as home treatment and technology-based interventions, have shown promising preliminary results. With the exception of moderate evidence supporting the use of olanzapine regarding weight gain, there is currently no evidence for the efficacy of psychopharmacotherapy in AN. Future research should focus on prevention, early detection and intervention, relapse prevention, personalized treatment approaches, management of comorbid disorders, long-term studies and the influence of psychosocial factors.

Do previous pediatric inpatient interventions predict better outcomes for psychiatric inpatient treatment of anorexia nervosa?

OBJECTIVES

To explore the benefits and drawbacks of pediatric hospitalization of adolescents with anorexia nervosa prior to psychiatric hospitalization.

METHODS

Epidemiologic data, anthropometric measures, and vital signs, as well as hospitalization characteristics and outcomes, were collected retrospectively and analyzed for 104 patients aged 12-18 years old.

RESULTS

Pediatric hospitalization prior to psychiatric admission did not result in significant advantages in treatment outcomes. Furthermore, no significant advantages were attributed to long pediatric hospitalization as compared to short hospitalization.

CONCLUSIONS

This study suggests that for treating adolescent anorexia nervosa, pediatric hospitalization should be recommended only for immediate correction of urgent and life-threatening physical conditions, with short stays preferred over long pediatric hospitalization.

Treatment outcomes for adolescent bulimia nervosa: a systematic scoping review of quantitative findings

BACKGROUND

This study aimed to systematically scope the available quantitative evidence for adolescent Bulimia Nervosa (BN) interventions. Specifically, the study aimed to review psychological and behavioural symptoms outcomes, as well as changes in comorbid psychiatric and caregiver factors.

METHOD

Five main and three grey literature databases were searched on 4th September 2024. Eligible peer-reviewed journal articles, dissertations and book chapters were included. Studies included children and adolescents with primary diagnoses of Bulimia Nervosa, Eating Disorder Not Otherwise Specified (EDNOS-BN) and Other Specified Feeding and Eating Disorder (OSFED-BN).

RESULTS

Findings from 18 studies (seven randomised controlled trials, three secondary analyses, eight single-arm studies) encompassing 710 participants were synthesised. All studies were conducted in the USA (10/18, 55.6%), UK (4/18, 22.2%), and mainland Europe (4/18, 22.2%). Most were conducted in an outpatient setting (14/18, 77.8%), with the remainder conducted in a day hospital (2/18, 11.1%), mixed outpatient/day hospital (1/18, 5.6%), or residential (1/18, 5.6%) setting. Family-focused therapies (10/18, 55.6%) and cognitive behavioural therapies (10/18, 55.6%) were most represented. Both were associated with improvements in BN psychopathology, comorbid difficulties and parent/caregiver factors. Weak evidence in favour of adjunctive therapies and Fluoxetine were reported.

DISCUSSION

There is a striking paucity in adolescent bulimia nervosa intervention research. Whilst family-focused and cognitive behavioural therapies show promise, the evidence base is relatively small. Most studies had small sample sizes and were conducted with predominately White, female participants. Very little data are available regarding parent/caregiver outcomes. Future research focusing on theory-driven mechanisms that target the broader presentation of BN are needed.

Neurofibromatosis associated with anorexia nervosa and attention-deficit hyperactivity disorder

We report a female patient with neurofibromatosis type 1 (NF1) who developed anorexia nervosa (AN) in her early 30s. This required several admissions for weight restoration. The patient's body image concerns and experience of stigma related to the dermatological manifestations of NF1 and her misconceptions regarding the relationship between weight and NF1 appeared to be aetiological factors for AN development. This view influenced the psychotherapeutic approach she received for AN, which was successful (current body mass index =20.5 kg/m2). After being diagnosed with AN, she was diagnosed with attention-deficit hyperactivity disorder (ADHD) and successfully treated with stimulant medication (dexamphetamine) without compromising her body weight. In summary, the case illustrates that NF1 may be a risk factor for AN development and that recovery from AN is possible while treating comorbid ADHD with stimulant medications.

Computational Perspectives on Cognition in Anorexia Nervosa: A Systematic Review

Anorexia nervosa (AN) is a severe eating disorder, marked by persistent changes in behaviour, cognition and neural activity that result in insufficient body weight. Recently, there has been a growing interest in using computational approaches to understand the cognitive mechanisms that underlie AN symptoms, such as persistent weight loss behaviours, rigid rules around food and preoccupation with body size. Our aim was to systematically review progress in this emerging field. Based on articles selected using systematic and reproducible criteria, we identified five current themes in the computational study of AN: 1) reinforcement learning; 2) value-based decision-making; 3) goal-directed and habitual control over behaviour; 4) cognitive flexibility; and 5) theory-based accounts. In addition to describing and appraising the insights from each of these areas, we highlight methodological considerations for the field and outline promising future directions to establish the clinical relevance of (neuro)computational changes in AN.

Investigating the impact of causal attributions on anorexia nervosa stigma

BACKGROUND

Stigmatisation of eating disorders can have debilitating consequences for individuals experiencing such conditions, such as reduced help-seeking and physical and mental deterioration. Dispositional attribution of blame appears to be central to this stigmatisation. Currently, it remains unclear as to whether precise aspects of blame, such as control over and responsibility for the disorder, specifically contribute to these negative dispositional attributions. So, the current study sought to explore causal attribution patterns towards individuals with AN among an adult population.

METHODS

One-hundred and forty-six participants (M = 36.52 years; SD = 14.45; 118 female) completed an online survey where they were initially randomly assigned to read either a blameworthy (n = 61) or unblameworthy (n = 85) vignette describing a fictional character with AN. Following this, participants completed two self-report inventories (Causal Attribution Scale and Eating Disorder Stigma Scale) measuring their causal attributions and stigma levels regarding the character. Mann-Whitney U tests were completed to evaluate attitudinal differences across groups.

RESULTS

Participants in the blameworthy condition significantly attributed more control over the illness to the AN character and held greater mean levels of stigma than participants in the unblameworthy condition. No significant differences were found between conditions for attributions of responsibility and blame. Finally, total causal attribution scores significantly predicted total stigma scores.

CONCLUSION

The findings indicate that stigma towards those with AN may result in part from negative attitudes where individuals experiencing AN are viewed as being in control of their condition. Erroneous attribution of dispositional control can influence interpretations of the cause of AN and trigger inappropriate behavioural responses such as stigmatisation, which can have serious consequences for help-seeking in those with AN. Responsibility-based attributions demonstrated less influence on stigma levels.

Changes in Circadian Rhythm in Chronically-Starved Mice Are Associated With Glial Cell Density Reduction in the Suprachiasmatic Nucleus

OBJECTIVE

Anorexia nervosa (AN) is an eating disorder characterized by severe weight loss and associated with hyperactivity and circadian rhythm disruption. However, the cellular basis of circadian rhythm disruption is poorly understood. Glial cells in the suprachiasmatic nucleus (SCN), the principal circadian pacemaker, are involved in regulating circadian rhythms. We hypothesize that the circadian rhythm disruption in AN patients is associated with glial cell changes in the SCN.

METHOD

In the starvation-induced hyperactivity mouse model, mice had free access to a running wheel and received a restricted amount of food once a day, until a 25% body weight loss was reached and maintained their weight loss for two weeks. This was followed by a refeeding phase. Different daily periods of running wheel activity were defined, such as food anticipatory activity up to 4 h before feeding. Circadian rhythmicity was analyzed using the cosinor method. Gene expression was evaluated using real-time polymerase chain reaction. Immunohistochemistry was used to quantify astrocytes, microglia, and oligodendrocytes.

RESULTS

Starvation induced changes in circadian rhythm, as indicated by changes in cosinor-based characteristics. Refeeding reversed these effects. Additionally, there was an increase in cryptochrome circadian regulator 1 expression and a decrease in the density of astrocytes and oligodendrocytes in the SCN after chronic starvation.

DISCUSSION

Starvation-induced alterations in circadian rhythms are associated with molecular, and cellular changes in the hypothalamus. Reduced astrocytes and oligodendrocytes in the SCN in a mouse model of AN suggest that glial pathophysiology may play a role in circadian rhythm disruption.

Comprehensive insights into emerging advances in the Neurobiology of anorexia

BACKGROUND

Anorexia is a complex eating disorder influenced by genetic, environmental, psychological, and socio-cultural factors. Research into its molecular mechanisms and neural circuits has deepened our understanding of its pathogenesis. Recent advances in neuroscience, molecular biology, and genetics have revealed key molecular and neural circuit mechanisms underlying anorexia.

AIM OF REVIEW

Clarify the peripheral and central molecular mechanisms regulating various types of anorexia, identify key cytokines and neural circuits, and propose new strategies for its treatment. Key scientific concepts of review: Anorexia animal models, including activity-induced, genetic mutation, and inflammation-induced types, are explored for their relevance to studying the disorder. Anorexic behavior is regulated by cytokines, hormones (like GDF15, GLP-1, and leptin), and neural circuits such as AgRP, serotonergic, dopaminergic, and glutamatergic pathways. Disruptions in these pathways, including GABAergic signaling in AgRP neurons and 5-HT2C and D2 receptors, contribute to anorexia. Potential therapies target neurotransmitter receptors, ghrelin receptors, and the GDF15-GFRAL pathway, offering insights for treating anorexia, immune responses, and obesity.

Genetic and Genomic Literacy of Healthcare Providers Treating Anorexia Nervosa in the United States: A Mixed Methods, Cross-Sectional Study

BACKGROUND

Genetic testing has the potential to transform the prevention, treatment, and management of anorexia nervosa (AN) as it has for other conditions. However, healthcare providers require the knowledge and openness to implement genetic testing effectively.

OBJECTIVES

This study had two main objectives, first, to determine the genomic literacy of those treating AN in the United States and second to assess the viewpoints of these healthcare providers on genetic testing and research, and the influence of genetics on AN.

METHODS

A mixed methods approach combining the GKnowM, a validated genomic literacy tool, Likert-like statements and thematic analysis of free-text responses was used. Participant consent, dissemination of the survey, and response collection were performed through Qualtrics.

RESULTS

Participant's average GKnowM score was 19.6 (SD = 2.8) on a scale of 0-26 (75% correct). Positive correlations were identified between GKnowM score and responses to questions about the influence of genetics on AN and the importance of genetics research, and negative correlations were found between age and years in practice and views on the current value of genetic testing. In addition, participants communicated a need for more genetics learning opportunities, and the challenge of accessing and paying for quality AN treatment in the United States.

DISCUSSION

The results of this study indicate a need for targeted genetics and genomics learning opportunities for healthcare providers. Improving genomic literacy has the potential to positively influence attitudes toward genetic research and testing and empower healthcare providers to engage in productive and scientifically sound discussions with their patients and society as a whole.

A feasibility study of an add-on psychomotor body-image protocol during CBT-E in female patients with an eating disorder

BACKGROUND AND OBJECTIVES

Disturbed body image is a potential precursor and maintaining factor when it comes to eating disorders. One of the dominant treatment approaches for eating disorders, enhanced cognitive-behaviour therapy (CBT-E), includes the cognitive-affective body image dimension as a core treatment target. Adding a component that focuses on the lived body dimension, could improve body image. In the current study, the feasibility of a psychomotor body image treatment as an add-on to CBT-E was examined.

METHODS

In this pilot study, 115 primarily female patients with different eating disorders in outpatient CBT-E treatment participated. They were asked to complete questionnaires examining body image before and after the psychomotor body image treatment.

RESULTS

Results showed good satisfaction with the treatment, and a significant improvement in body attitude and body satisfaction after the psychomotor body image treatment, with large effect sizes and clinical relevance. Results also showed that, overall, pre-treatment levels and changes over the course of treatment in body attitude and body satisfaction did not differ between patients within anorexia nervosa, bulimia nervosa or binge eating disorder diagnostic subgroups.

LIMITATIONS

Limitations were lack of a control group, and the fact that the body image treatment was complementary to CBT-E. This means that it is unclear whether other factors contributed to the change in body image as shown in the current study.

CONCLUSIONS

These results indicate that an experiential psychomotor approach in addition to a more cognitive-behavioral approach is feasible, and warrants future research.

Exploring the Relationship Between Eating Disorders and Reproductive Health, with a Focus on Fertility, Obstetric, and Fetal Outcomes: A Narrative Review

PURPOSE OF REVIEW

Eating disorders can profoundly impact reproductive health in females, spanning from the onset of puberty through menopause. The impact is due to a variety of factors, including nutritional status, body fat percentage, and hormone regulation. Notably, fertility and pregnancy are particularly vulnerable to undernutrition and disordered eating. This narrative review provides a comprehensive summary and discussion of available literature from the past 5 years exploring the impact of eating disorders on fertility, obstetric outcomes, and fetal outcomes.

RECENT FINDINGS

Current literature demonstrates that EDs can have a negative impact on fertility, obstetric outcomes, and fetal outcomes. Primary research and systematic reviews support associations including increased use of assisted reproductive treatment for infertility, anemia and hyperemesis during pregnancy, and preterm delivery. Associated fetal outcomes include infant low birth weight, small for gestational age, and microcephaly. EDs, when unrecognized and left untreated, can negatively impact fertility, obstetric outcomes, and fetal outcomes. It is important for providers to be aware of these associations and implement screening to identify at-risk patients, as appropriate treatment can improve reproductive outcomes.

Increased Serum Neurofilament Light Chain Concentration Associated With Microglial Morphology Changes in Chronically-Starved Mice

OBJECTIVE

Anorexia nervosa (AN) is associated with hyperactivity, amenorrhea, and brain atrophy. Weight rehabilitation reversed these symptoms, although the underlying pathophysiological mechanisms are mostly unknown. Serum neurofilament light chain (NfL) levels are widely used as a biomarker of neurodegeneration. Based on neuroimaging studies and increased serum NfL levels, we assume that neurodegeneration is a core neuropathological feature in AN patients.

METHOD

Female mice were given a limited amount of food once a day and had unlimited access to a running wheel until they reached a 25% weight reduction, which was maintained for 2 weeks to mimic chronic starvation. This was followed by 3 weeks of refeeding. Running activity was measured by wheel sensors, while amenorrhea was determined by analyzing vaginal smears. Brain sections were used to investigate brain volumes. NfL levels were determined using a NF-light assay. Behavioral tests such as forced swim and elevated plus maze assessed behavioral changes. Immunohistochemistry was used to quantify the density of microglia, while their morphological analysis was performed using Neurolucida 360.

RESULTS

Chronic starvation led to AN-related symptoms of hyperactivity and amenorrhea. The decreased cerebral cortex, hippocampal, and corpus callosum volumes were paralleled by increased NfL levels after chronic starvation. A behavioral association was reduced anxiety-like behavior after chronic starvation. Starvation induced decreased microglial density, increased soma area, and prolonged microglial processes.

DISCUSSION

Chronic starvation led to an increase in NfL levels and changed microglial morphology in a mouse model of AN, suggesting that neuronal pathophysiology may contribute to the disease.

Revealing the effects of various immune cells in anorexia nervosa: Evidence from Mendelian randomization

The aim of this study was to assess the causal relationship between immune cells and anorexia nervosa (AN) by Mendelian randomization (MR). Data on immune cell phenotypes and AN were obtained from genome-wide association studies. Next, single nucleotide polymorphisms included in the MR analysis were screened according the basic assumptions. Furthermore, inverse variance weighted was used as the main method for MR analysis to evaluate the causal effect of immune cell phenotypes on AN. Finally, MR-Egger intercept, Cochran Q, and leave-one-out sensitivity analyses were used to assess horizontal pleiotropy, heterogeneity, and robustness, respectively. The MR analysis showed that NKT %lymphocyte (OR 1.201, 95% CI = 1.021-1.411, P = .027), NKT %T cell (OR 1.258, 95%CI 1.043-1.519, P = .017), double negative (DN) (CD4-CD8-) NKT %lymphocyte (OR 1.235, 95%CI 1.074-1.420, P = .003), DN (CD4-CD8-) NKT %T cell (OR 1.222, 95%CI 1.060-1.410, P = .006), CD8dim NKT absolute count (OR 1.225, 95%CI 1.045-1.436, P = .012), CD8dim NKT %lymphocyte (OR 1.214, 95%CI 1.043-1.414, P = .012), CD8dim NKT %T cell (OR 1.215, 95%CI 1.035-1.425, P = .017), CD16-CD56 on NKT (OR 1.193, 95%CI 1.014-1.402, P = .033), CD28 + CD45RA + CD8br %T cell (OR 1.020, 95%CI 1.002-1.037, P = .025) were associated with increased genetic susceptibility to AN. MR-Egger showed no horizontal pleiotropy (P ≥ .05). Cochran Q and sensitivity analysis showed that the results were not heterogeneous and were robust. This MR analysis revealed 9 immune cell phenotypes related to increased genetic susceptibility to AN, emphasizing the importance of NKT and CD8 in AN. This finding provides new insights for understanding the pathogenesis of AN and developing immune-targeted drugs.

Sexual Dysfunction in Women With Eating Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Eating disorders (EDs) are common mental health conditions that impact people globally. Sexual health problems are also widely researched across various contexts. This paper explores the connection between these two areas by conducting a meta-analysis to assess sexual dysfunction (SD) in women with EDs compared to healthy individuals.

METHODS

Multiple electronic databases were searched. Studies reporting mean scores of SD scales in women with EDs compared to women without these conditions, were included. The combined analyses used standardized mean deviations (SMDs), with relevant 95% confidence intervals (CIs). Each study was weighted using inverse variance models with random effects. The risk of publication bias was estimated.

RESULTS

From an initial pool of 2665 studies, 7 studies met inclusion criteria for the systematic review, involving 908 individuals. Out of these, five studies focussing on women with AN or BN were eligible for meta-analysis. No study involving the BED female group met the inclusion criteria to be included in the meta-analysis. The association between SD and AN showed a random-effects pooled SMD of -0.95 (95% CI = -1.40 to -0.50) with high heterogeneity (I2 = 78.32%, p = 0.01). For BN, this was of -0.51 (95% CI = -0.88 to -0.13) with no heterogeneity (I2 = 0.00%, p = 0.76). Sensitivity analyses showed that the overall effect is sensitive to the type of questionnaire used to measure the SD.

CONCLUSION

The results indicate that SD is more pronounced in women with AN than in those with BN. More studies with robust methodological designs are necessary to further investigate SD. The female BED group should be included in future studies focussing on SD. The findings suggest that sexual health interventions should target women with EDs, as these conditions have a significant impact on relationships and sexual satisfaction.

Intervention research in anorexia nervosa - a plea for single case experimental designs

Anorexia nervosa (AN) is a severe eating disorder and among the mental disorders with the highest mortality rate. To date, not much is known about its development and maintenance, and treatment outcomes are improvable. At the same time, research on psychological interventions for AN is a complicated endeavor, often characterized by small sample sizes and methodological heterogeneity, which impedes the comparison and evaluation of treatment outcomes. In this paper, several population-related, therapist-related and methodological challenges that may be encountered during research on psychological interventions for AN are discussed. The use of single case experimental designs (SCEDs), which could account for several of these challenges, is suggested as a complementary approach to current methods of assessing treatment efficacy. The use of SCEDs could be beneficial to the field, by contributing to the knowledge about AN and to the development and evaluation of better treatments, which are sorely needed.

Screening of the Risk of Eating Disorders Among Medical Students in the MENA region and Its Associated Factors: A Multinational Cross-Sectional Study

BACKGROUND

Eating disorders (EDs) are a group of mental diseases marked by disrupted eating behaviors, and are associated with several factors. Medical students are highly exposed to this mental disorder with a prevalence of 17.35% in 2022.

OBJECTIVE

To evaluate the risk of EDs and its associated factors among medical students in the Middle East and North Africa (MENA) region.

METHODS

A web-based cross-sectional study was conducted among medical students in the MENA region during the months of June and July 2024. The primary data collection instrument was a comprehensive questionnaire that contained the Eating Attitudes Test (EAT-26) and sociodemographic and clinical features and designed using Google Forms and distributed via social media platforms.

RESULTS

The total number of participants was 5061. The mean age in our population was 22.58 ± 3.27. Our population's average EAT-26 score was 13.87 ± 10.7, with ranges varying from 0 to 72. Based on their EAT-26 scores being 20 or above, 1254 people (24.8%) were deemed to be at risk of EDs. Among the participants, 8% were underweight. The multivariable logistic regression model revealed several eating disorder risk factors such as T1DM, schizophrenia, autism, female gender, IBD, and daily exposure to thin body ideal. Regular sports practice and weight satisfaction were protective factors.

CONCLUSION

There exists a higher prevalence of individuals at risk for the development of EDs in the MENA region especially females, students with comorbidities, and those having conflictual relationships with their parents. Regular sports practice and weight satisfaction are protective factors.

Patterns of Medical Diagnoses Before and After a Diagnosis of Anorexia Nervosa: A Danish Nationwide Cohort Study

OBJECTIVE

This study investigates the overall pattern and timing of medical diagnoses up to 10 years before an anorexia nervosa (AN) diagnosis and explores differences before and after AN diagnosis aiming to improve early detection.

METHOD

In this nationwide population-based cohort study, we included all patients diagnosed with incident AN from 1987 to 2018 (n = 13,345) and a 1:10 age- and sex-matched general population comparison cohort, using Danish health registries. Using conditional logistic regression, we calculated odds ratios (ORs) of medical diagnoses up to 10 years before AN diagnosis. Additionally, we calculated crude and adjusted hazard ratios (aHRs) for risk of medical diagnoses after AN diagnosis using Cox proportional hazards model.

RESULTS

AN was associated with increased odds of any medical diagnosis up to 10 years before AN diagnosis: OR 1.3 [95% CI 1.2-1.3] and the odds increased during the 12 months preceding AN diagnosis: OR 1.6 [95% CI 1.5-1.7]. The medical diagnoses associated with the highest odds up to 10 years prior AN were malnutrition: OR 5.0 [95% CI 4.0-6.3] anemia: OR 2.9 [95% CI 2.3-3.6], amenorrhea: OR 2.7 [95% CI 2.3-3.2], and irritable bowel syndrome: OR 2.1 [95% CI 1.9-2.4]. The pre-diagnosis pattern mirrored the post-diagnosis pattern.

CONCLUSION

The similarity in diagnosis patterns before and after AN diagnosis suggests that many patients receive medical diagnoses for conditions potentially linked to AN-related restricted eating, malnutrition and progressive weight loss even years prior to a formal AN diagnosis. Identifying these early conditions may enable earlier AN diagnosis and improve treatment outcomes.

Impairments in personality functioning in adolescents with anorexia nervosa

OBJECTIVE

Impairments in personality functioning (PF) according to the Alternative Model of Personality Disorders (AMPD) may affect anorexia nervosa (AN) and its treatment. However, PF impairments in adolescents with AN have not been studied. This case-control study analysed PF impairments in adolescent inpatients suffering from AN compared to a clinical control group (CC) and investigated the relationship of PF with AN severity.

METHOD

Adolescent patients with AN (n = 43) and CC (n = 127) were matched by age, sex, and global functioning. Validated interviews were applied to assess impairments in PF (Semi-Structured Interview for Personality Functioning, STiP-5.1) and severity of AN (Eating Disorder Examination, EDE), as well as weight measures. Group comparisons of PF impairment and the relationship between PF impairment and AN severity were analysed using multiple linear regression.

RESULTS

AN patients showed greater impairment in the facet 'self-esteem' (p = 0.033, Cohen's f2 = 0.036) than CC. In AN patients, impairments in the domain 'self-functioning' (p = 0.003, Cohen's f2 = 0.254) and its underlying element 'identity' (p = 0.016, Cohen's f2 = 0.172) were associated with AN severity (EDE). Additionally, higher impairments in two facets of 'empathy' (p = 0.019, Cohen's f2 = 0.223) and 'intimacy' (p = 0.026, Cohen's f2 = 0.199) were associated with higher AN severity (lower BMI percentiles).

CONCLUSIONS

These results support theoretical frameworks of AN and highlight the importance of PF impairments in understanding and treating AN. Future research should investigate how impairments in PF affect AN development and treatment response through longitudinal studies.

Purging frequency and number of purging methods as indicators of severity in bulimia nervosa: Interactive effects with binge eating episodes

OBJECTIVE

In the Diagnostic and Statistical Manual of Mental Disorders-5, severity of bulimia nervosa (BN) is defined by the frequency of purging behaviour. Previous research suggests the number of purging methods as an alternative rating. The current analysis investigated characteristics (sociodemographic and treatment-related variables, body mass index [BMI], eating disorder-specific and general psychopathology) of persons with BN as a function of purging frequency and number of purging methods in order to examine which approach might be better suited for indicating severity of BN.

METHOD

Two-hundred and sixty-one persons (98.5% female; mean age 25.2 years, SD = 9.41; mean BMI 22.0 kg/m2, SD = 3.79) with BN completed self-report questionnaires on eating disorder-specific and general psychopathology at admission to inpatient (n = 214) or daypatient (n = 47) treatment.

RESULTS

Higher severity based on either purging frequency or number of purging methods tended to relate to lower BMI and higher eating disorder-specific and general psychopathology. In addition, binge-eating frequency differentially related to eating disorder-specific and general psychopathology as a function of severity groups.

CONCLUSIONS

This study partially supports the utility of both purging frequency and the number of purging methods as indicators of severity in persons with BN. However, focussing only on purging behaviours may be short-sighted as it appears necessary to consider the number of binge-eating episodes as well when evaluating severity of BN.

Eating Disorders, Co-Morbid Disorders and Early Risk Factors Amongst Post-9/11 Veteran Men and Women

OBJECTIVE

To assess, by interview, the rates of eating disorders in a nationally representative sample of recent veterans, describe their DSM-5 eating disorder diagnoses and the occurrence of comorbid psychiatric disorders. To conduct an exploratory case-control analysis of previously documented and additional specific military risk factors before eating disorder onset to inform studies of prospective risk.

METHOD

Using a two-stage design, probable cases and controls were identified by screening questionnaires from a sample of 1494 veterans who completed a survey study and interviewed to establish case status and confirm probable co-morbid psychiatric diagnoses. Previously documented risk factors and military risk factors occurring before disorder onset were investigated.

RESULTS

Ninety-one cases and 51 controls were confirmed. Weighted prevalence for any eating disorder was 5.2%, with estimates for anorexia nervosa, bulimia nervosa, binge eating disorder and other specified eating disorder being 0.01%, 0.6%, 1.4%, and 1.6%, respectively. Seventy-nine (86.8%) confirmed cases had a diagnosis of one or more co-morbid psychiatric disorders. Previously documented risk factors were associated with subsequent case status, while in this sample, military risk factors were not.

DISCUSSION

Rates of eating disorder and co-occurring psychiatric disorders in recent veterans were comparable to those reported for non-veterans, with levels of posttraumatic stress disorder likely higher. As co-occurring psychiatric disorders, particularly posttraumatic stress disorder, may complicate achieving good outcomes with existing evidence-based treatments, there is an urgent need to adapt them where necessary to improve outcomes. Military risk factors may maintain or exacerbate pre-existing problems and need to be investigated alongside other maintaining factors in longitudinal studies.

PUBLIC SIGNIFICANCE

Rates of eating disorder and co-occurring psychiatric disorders in recent veterans were comparable to those reported for non-veterans, highlighting a need to detect eating problems and address unmet treatment need. Co-occurring psychiatric disorders may complicate achieving good outcomes with existing treatments, emphasising a need to adapt them to improve outcomes. Investigating maintaining factors, including military factors in longitudinal studies will likely aid treatment development.

Application of Genetic Testing for Anorexia Nervosa: An Ethical Analysis

OBJECTIVE

Anorexia Nervosa (AN) is a severe, debilitating disorder with a high mortality rate. Research indicates that genetics plays a significant role in AN manifestation and persistence. Genetic testing has the potential to transform how AN is treated, however, in clinical practice, care must be taken to consider the ethical complexities involved. Our objective was to perform an ethical analysis of genetic testing in AN.

METHODS

We applied the principlist approach, taking into consideration the stakeholders involved and the core ethical principles of autonomy, beneficence, non-maleficence, and justice to (1) evaluate the possible ethical implications of the use of genetic testing in the treatment of patients with AN, and (2) assess whether such testing is justified and if so, under what conditions.

RESULTS

Potential benefits of genetic testing identified include reduction of misdiagnosis and identification of treatable concurrent genetic conditions. The identified potential risks of genetic testing for possible AN-associated risk variants outside of a research setting, especially without more effective treatment options, include a false sense of reassurance for those testing negative and a reduced emphasis on the importance of behavioral-based therapies that may be of benefit.

DISCUSSION

Genetic testing for complex disorders, including AN, has tremendous potential, but is still primarily research-based. Currently, for those presenting with atypical AN, and severe and enduring AN who, by definition, have not benefited from traditional treatment, genetic testing to rule out or identify other genetic conditions could be of benefit.

Neuropsychological profile in young girls at high risk of developing anorexia nervosa

OBJECTIVE

Previous research has shown anorexia nervosa (AN) to be associated with a specific neuropsychological profile, including set-shifting and central coherence deviances. A similar profile has been shown in adult unaffected relatives. The aim of this study was to examine whether poor set-shifting and central coherence abilities could be detected in children at high risk of developing AN.

METHOD

Twenty-eight biological healthy daughters of women with previous or current AN and 42 biological daughters of healthy women, all between six and 12 years of age, participated in the study. A neuropsychological test battery (Wechsler Intelligence Scale for Children, Wisconsin Card Sorting Test, Trail Making Test and Rey Complex Figure Test) was used to assess set-shifting and central coherence abilities.

RESULTS

No differences in set-shifting or central coherence performance were detected between the high-risk group and the comparison group. Adjustments for age and intelligence quotient (IQ) did not affect the results.

CONCLUSIONS

Our results did not support the notion of preexisting neuropsychological deficits in AN-related cognitive domains among high-risk girls.

A Systematic Review to Explore a Neuropsychological Profile that Predates Anorexia Nervosa

OBJECTIVE

Research demonstrates reduced cognitive flexibility and weak central coherence during acute illness and following recovery from anorexia nervosa (AN). This systematic review investigated if these impairments are present in first-degree relatives of individuals with AN, representing a possible neuropsychological risk profile.

METHODS

A systematic review of electronic databases was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search ended on July 14, 2023. Established search terms and inclusion criteria identified relevant research. Risk of bias was assessed using the Critical Appraisal Skills Program. The review was registered with Prospero international prospective register of systematic reviews (No. CRD42023401268). Study selection, descriptive data, critical appraisal, and risk of bias are presented in tables and figures.

RESULTS

The search yielded 10 studies. The included studies conducted neuropsychological assessments of discordant AN relatives and lifetime longitudinal study participants. Most studies found cognitive flexibility and central coherence to be significantly reduced in participants with AN and their relatives compared with controls. One study found decision making to be significantly impaired in AN participants and relatives. Effect sizes were moderate to large.

DISCUSSION

Reduced cognitive flexibility and weak central coherence appear to be endophenotypes of AN. Further research is required with relatives concordant for AN to establish whether these biomarkers co-segregate with AN within families. These findings suggest a possibility of developing screeners to identify individuals at risk of AN allowing for early intervention.

Willing to wait: Anorexia nervosa symptomatology is associated with higher future orientation and reduced intertemporal discounting

Anorexia nervosa is a severe eating disorder characterized by food restriction in service of a future goal: thinness and weight loss. Prior work suggests altered intertemporal decision-making in this disorder, with more farsighted decisions-i.e. reduced delay discounting-in patients with acute anorexia nervosa. Future-oriented cognition, such as frequent prospective future thinking in daily life, promotes farsighted decision making. However, whether temporal orientation is altered in anorexia nervosa, potentially contributing to reduced delay discounting in this population, remains unclear. We measured delay discounting behavior, anorexia nervosa symptomatology, and temporal orientation in a large sample of never-diagnosed individuals. We found that higher anorexia nervosa symptomatology was associated with reduced delay discounting. Anorexia nervosa symptoms were also correlated with increased future-oriented cognition. Moreover, future-oriented cognition mediated the difference in delay-discounting behavior between high and low anorexia nervosa symptom groups. These results were unrelated to subjective time perception and independent of mood and anxiety symptomatology. Collectively, these findings suggest that future-oriented cognition may be a cognitive mechanism underlying altered intertemporal decision making in anorexia nervosa.

Zinc levels in severe eating disorders

PURPOSE

Severe eating and feeding disorders including Anorexia Nervosa of both restricting (AN-R) and binge-purge (AN-BP) subtypes and Avoidant Restrictive Food Intake Disorder (ARFID) lead to multiple macronutrient and micronutrient deficiencies, including zinc, in the setting of inadequate dietary intake. We investigated whether zinc levels correlated with severe malnutrition, with particular subtypes of eating disorders (EDs), and the effect of the refeeding process.

METHODS

This prospective study included 92 adult patients with severe AN or ARFID hospitalized in a medical stabilization unit. Denver Health staff were recruited as controls. Blood samples were drawn within four days of admission and 72 h of discharge. All inferential analyses were performed using general linear models.

RESULTS

Admission zinc levels were statistically significantly lower in cases compared to controls. Admission zinc levels were significantly higher for patients with AN-R than patients with AN-BP. Zinc levels decreased significantly during treatment in cases, compared to controls. ED diagnoses and percent ideal body weight (%IBW) did not appear to predict changes in zinc levels during admission.

CONCLUSIONS

Given zinc's pervasive roles in metabolism throughout the body as well as common symptoms of deficiency including impaired taste and smell, decreased appetite, and depression, zinc levels could be relevant to the high relapse rate in severe ED. The observed decrease in zinc, which was larger in cases than controls, during refeeding suggests the possibility of a "refeeding hypozincemia" which may present a new therapeutic target. These characteristics make zinc an intriguing focus of future study that could impact the recidivism rate in severe ED.

LEVEL OF EVIDENCE III

Evidence obtained from well-designed cohort or case-control analytic studies.

Healthy or skinny? The negotiation between fear appeal and danmu in anorexia awareness videos

BACKGROUND

This study seeks to investigate the impact of anorexia awareness videos on the perception of anorexic figures and pro-anorexia attitude among young females, considering the employed fear appeals and the presence of pro-anorexia content in danmu, an online commenting system prevalent in China.

METHODS

An experiment was conducted employing a 3 (Fear level of video: low, medium, high) × 4 (Danmu type: no danmu, pro-anorexia, anti-anorexia, mixed pro- and anti-anorexia) between-participants design. A total of 633 female participants were randomly assigned to view one of the twelve videos and subsequently evaluated on fear arousal, pro-anorexia attitude and perception of the anorexic figure scales.

RESULTS

A moderated moderated mediation model demonstrates that heightened fear levels of anorexia awareness videos were linked to a more adverse perception of individuals with anorexia, subsequently reducing pro-anorexia attitude. Furthermore, the fear level of an anorexia awareness video, aroused fear, and the type of danmu interacted in a three-way manner regarding the perception of anorexic individuals. The presence of pro-anorexia content in danmu counteracted the observed positive impact.

CONCLUSIONS

These results imply that anorexia awareness videos should strive to evoke appropriate levels of fear while also addressing the potential adverse effects of pro-anorexia danmu, which may glorify anorexic bodies and undermine the intended protective outcomes.

Examining the associations between laxative use, substance use, depressive symptoms, and obsessions and compulsions in adults with an eating disorder

This study examined laxative and substance use in adults with an eating disorder, and the association with depression, compulsions, and obsessions. A retrospective chart review of 182 women who had a formal diagnosis of an eating disorder and were receiving specialized outpatient treatment was conducted. The chart review included questionnaires completed at intake assessment, including a demographic survey with questions asking about laxative use, substance use, and the types of substances used. Adults also reported their levels of depression, obsessions and compulsions on psychometric questionnaires. Overall, 31.3% of adults with an eating disorder endorsed engagement in laxative use. Substance use was reported by 34.6% of adults with alcohol (36%) and over the counter medications (39%) being the most endorsed substances. Engagement in laxative use and substance use did not differ across the eating disorder diagnoses of anorexia nervosa (AN), bulimia nervosa (BN) or other specified feeding or eating disorder (OSFED). Engagement in substance use was not associated with adults' symptoms of depression, obsessions, or compulsions. Compulsions were found to be a significant predictor of engagement in laxative use. Variables associated with engagement in laxative use may help to inform the development of novel approaches for addressing these behaviors in adults with an eating disorder. More work is needed to better understand the complex interplay of these behaviors.

Comorbidity of anorexia nervosa and schizophrenia: A systematic review

Research on the intersection between eating disorders and schizophrenia (SCZ) has mainly focused on binge eating, since increased appetite and metabolic side effects are common during antipsychotic use. However, the prevalence of restrictive eating and anorexia nervosa may be higher in people with SCZ than in the general population, and evidence suggests shared genetic liability for SCZ and anorexia nervosa (AN). The aim of this systematic review was to examine the prevalence, psychological and biological mechanisms, and theoretical underpinnings underlying the co-occurrence of AN and SCZ. We identified 40 articles that met inclusion criteria. Evidence suggested that the prevalence of AN in patients with SCZ is higher than would be expected in the general population; conversely, evidence regarding the prevalence of SCZ in AN was mixed. Psychological mechanisms underlying AN in people with SCZ fell into three categories: positive symptoms, negative symptoms, and atypical pathways. A limited literature generally supports the hypothesis of higher prevalence of AN in patients with SCZ, but there are few studies in this area. Studies of the prevalence of SCZ in AN yield more mixed findings, although these studies are also relatively small and few. Further, studies of both types tend to include only clinically ascertained samples, which limits the generalizability of findings beyond patients. Larger, better-designed studies may improve identification and treatment of people with co-occurring SCZ and AN.

Eyes on the body: Assessing attentional bias toward body-related stimuli in Anorexia Nervosa

OBJECTIVE

The aim of the present study was to assess whether patients with Anorexia Nervosa (AN) presented an attentional bias toward pictures of other women's bodies, as this bias could implicitly promote self-other comparisons thus increasing body/weight concerns.

METHODS

The sample included 48 healthy controls (HC) and 54 patients with AN. All participants performed a dot-probe task with pictures of bodies or body parts of underweight (UWB), normal weight (NWB) and overweight (OWB) women, while their gaze was recorded with an eye-tracking system. Two indices of attentional bias, a gaze direction bias and a gaze duration bias were extracted.

RESULTS

The models conducted on both direction bias and duration bias showed a significant main effect of group, revealing a stronger attentional bias toward bodies in patients as compared to controls. One sample t-tests conducted on the direction bias of patients with AN revealed that they presented a significant positive bias at 500 ms toward all the bodies. At 1500 ms, instead, they presented a positive bias toward UWB and an avoidance bias of OWB. HC instead presented an initial avoidance of all body stimuli, and an avoidance of NWB and OWB at 1500 ms.

DISCUSSION

Our results revealed a stronger attentional bias toward other women's bodies in patients than in HC. Moreover, patients presented a tendency to focalize their attention on UWB while they avoided maintaining their attention on OWB. This pattern might promote upward social comparisons, which are usually associated with negative self-evaluation and increased levels of body dissatisfaction.

Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis

INTRODUCTION

Low energy availability (LEA) occurs when energy expenditure from athletic training and bodily functions exceeds caloric intake. This imbalance results in declines in athletic performance and increases the risk of injury. Relative energy deficiency in sport (REDs) is a condition that occurs when the energy deficit is severe enough to cause alterations to metabolic rate, menstrual function, immune function, bone health, protein synthesis, and cardiovascular function. Many athletes, particularly those competing in endurance, aesthetic, or weight-class sports, are adversely impacted by this condition.

OBJECTIVES

This study aims to determine the prevalence of LEA and REDs among athletes and present the first secondary analysis of the impacts of these phenomena on sports performance and risk of injury.

METHODS

This systematic review was registered on PROSPERO (CRD42023469253). Literature searches were performed following PRISMA guidelines using PubMed, Embase, and Cochrane online databases. Inclusion criteria were articles discussing the prevalence of LEA or REDs, the impact of LEA or REDs on athletic performance, or the impact of LEA or REDs EA on injury.

RESULTS

A total of 59 studies met the inclusion criteria for this meta-analysis, and 2737 of 6118 athletes (44.7%) in 46 different studies were determined to have LEA, including 44.2% of female athletes and 49.4% of male athletes. In addition, 460 of 730 athletes (63.0%) in eight different studies were determined to be at risk of REDs. Athletes with LEA were found to have decreased run performance, training response, endurance performance, coordination, concentration, judgment, explosive power, and agility relative to athletes with normal energy availability, as well as an increased likelihood of absence from training due to illness. Studies had mixed results as to whether LEA increased the risk of injury in general. However, most studies concluded that athletes with LEA have impaired bone health and a higher risk of bone stress injuries.

DISCUSSION

To our knowledge, this is the first systematic review analyzing the impacts of LEA and REDs on athletic performance and risk of injury. Due to the high estimated prevalence of LEA among athletes, coaches may want to consider employing surveys such as the low energy availability in females questionnaire (LEAF-Q) to identify athletes at risk for LEA, as early identification and correction of LEA can prevent the development of symptoms of REDs, reduce the risk of impaired bone health and bone stress injuries, and help athletes optimize the performance benefits from their training.

A Case of Hypoglycemia Associated With Anorexia Nervosa Revealing Isolated Adrenocorticotropic Hormone (ACTH) Deficiency

Anorexia nervosa (AN) typically affects young women and leads to severe emaciation, while isolated adrenocorticotropic hormone (ACTH) deficiency (IAD) usually occurs in middle-aged and older adults, causing secondary adrenal insufficiency, appetite loss, and weight loss. Although differentiating between these conditions can be challenging, their coexistence is rare. We encountered a patient with AN hospitalized for impaired consciousness due to hypoglycemia, who was later diagnosed with IAD. It is important to consider IAD as a differential diagnosis when hypoglycemia occurs in patients with AN.

Exploring the role of beta-endorphin in activity-based anorexia in mice

Anorexia nervosa (AN) remains one of the most lethal mental health disorders and is poorly understood from a neurobiological perspective. The most widely used animal model of AN is activity-based anorexia (ABA) where scheduled food presentation leads to a spontaneous maladaptive increase in running-wheel activity and rapid weight loss in rodents, recapitulating specific aspects of AN. Research using the ABA paradigm to probe the role of hedonic and homeostatic circuits has indicated that the hypothalamic proopiomelanocortin (POMC) system may play a role in both the increased activity and reduced food intake observed. Previous work has shown that Pomc mRNA and its peptide product beta-endorphin (β-end) are increased during the onset of ABA. β-end is reinforcing and increases locomotor activity, and mice lacking the mu opioid receptor (MOR), the primary target of β-end, display blunted food-anticipatory activity in the ABA paradigm. Thus, the current work was designed to determine if aspects of ABA would be diminished in mice lacking β-end. We did not find any significant differences in wheel-running, food intake, or body weight loss in β-end knockout mice of either sex during ABA compared to wild-type littermates. Therefore, we conclude that the development of ABA does not require β-end.

The current clinical approach to feeding and eating disorders aimed to increase personalization of management

Feeding and eating disorders (FEDs) are a heterogeneous grouping of disorders at the mind-body interface, with typical onset from childhood into emerging adulthood. They occur along a spectrum of disordered eating and compensatory weight management behaviors, and from low to high body weight. Psychiatric comorbidities are the norm. In contrast to other major psychiatric disorders, first-line treatments for FEDs are mainly psychological and/or nutrition-focused, with medications playing a minor adjunctive role. Patients, carers and clinicians all have identified personalization of treatment as a priority. Yet, for all FEDs, the evidence base supporting this personalization is limited. Importantly, disordered eating and related behaviors can have serious physical consequences and may put the patient's life at risk. In these cases, immediate safety and risk management considerations may at least for a period need to be prioritized over other efforts at personalization of care. This paper systematically reviews several key domains that may be relevant to the characterization of the individual patient with a FED aimed at personalization of management. These domains include symptom profile, clinical subtypes, severity, clinical staging, physical complications and consequences, antecedent and concomitant psychiatric conditions, social functioning and quality of life, neurocognition, social cognition and emotion, dysfunctional cognitive schemata, personality traits, family history, early environmental exposures, recent environmental exposures, stigma, and protective factors. Where possible, validated assessment measures for use in clinical practice are identified. The limitations of the current evidence are pointed out, and possible directions for future research are highlighted. These also include novel and emerging approaches aimed at providing more fine-grained and sophisticated ways to personalize treatment of FEDs, such as those that utilize neurobiological markers. We additionally outline remote measurement technologies designed to delineate patients' illness and recovery trajectories and facilitate development of novel intervention approaches.

Reducing the urge to be physically active in patients with anorexia nervosa through virtual reality: protocol for a randomised-controlled feasibility trial

INTRODUCTION

Weight restoration is a primary goal in anorexia nervosa (AN) treatment. Recent studies suggest that addressing physical activity urges in patients with AN is a promising target to facilitate weight restoration. This trial will evaluate the feasibility of a virtual reality (VR)-based intervention as an add-on treatment to psychotherapy to improve activity urges and, consequently, initial treatment responses on core outcomes as targeted per AN treatment guidelines.

METHODS AND ANALYSIS

This single-centre feasibility trial adopts the single-blind, two-arm design and outcome measures of an intended full-scale randomised controlled trial (RCT) in order to establish that all necessary trial components work together as intended. It will evaluate feasibility as the primary endpoint and compare changes in ratings of the urge to be active between patients with AN randomly assigned to receiving VR intervention sessions and patients with AN in a control procedure. The feasibility of the full-scale RCT will depend on whether patients (1) will evaluate the experience as acceptable, (2) tolerate VR side effects and (3) will adhere to the intended intervention schedule. We define a set of three-tiered, formal progression criteria and employ a 'traffic light system' demarcating go (green), amend (amber) and stop (red) signals for advancing to the full-scale RCT.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of the Ruhr University Bochum's Medical Faculty at Campus East-Westphalia (AZ 2024-1296, 9 December 2024). Patients have to provide written consent before taking part in the study. The findings will be published with open access.

TRIAL REGISTRATION NUMBER

DRKS00035681, German Clinical Trials Register.

Brain network alterations in anorexia Nervosa: A Multi-Center structural connectivity study

Anorexia nervosa (AN) is a severe eating disorder characterized by intense fear of weight gain, distorted body image, and extreme food restriction. This research employed advanced diffusion MRI techniques including single-shell 3-tissue constrained spherical deconvolution, anatomically constrained tractography, and spherical deconvolution informed filtering of tractograms to analyze brain network alterations in AN. Diffusion MRI data from 81 AN patients and 98 healthy controls were obtained. The structural brain connectome was constructed based on nodes set in 84 brain regions, and graph theory analysis was conducted. Results showed that AN patients exhibited significantly higher clustering coefficient and local efficiency in several brain regions, including the left fusiform gyrus, bilateral orbitofrontal cortex, right entorhinal cortex, right lateral occipital gyrus, right superior temporal gyrus, and right insula. A trend towards higher global efficiency and small-worldness was also observed in AN patients, although not statistically significant. These findings suggest increased local connectivity and efficiency within regions associated with behavioral rigidity, emotional regulation, and disturbed body image among AN patients. This study contributes to the understanding of the neurological basis of AN by highlighting structural connectivity alterations in specific brain regions.

Resting-state functional brain connectivity in female adolescents with first-onset anorexia nervosa

OBJECTIVE

Women with anorexia nervosa (AN) have been shown to demonstrate differences in functional connectivity in brain regions associated with cognitive control, somatosensory processing, and emotion regulation. However, previous studies have been conducted on small samples and have inconsistent findings. Therefore, this study aimed to identify aberrant brain networks related to the core clinical symptoms of AN and to explore the longitudinal association with clinical outcome in a large population of adolescents experiencing their first episode of AN.

METHODS

Functional MRI (fMRI) of brain resting-state functional connectivity (RS-FC) of female adolescents with first-onset AN (n = 56) were compared to age- and education-matched typically developing (TD) adolescents (n = 64). To account for the severity of underweight, separate analyses were performed to investigate differences in RS-FC between underweight AN participants and TD adolescents, as well as between underweight (n = 30) and weight-restored AN (n = 26) participants. Clinical outcomes, i.e. body mass index and eating disorder (ED) symptoms, were assessed at baseline and one-year follow-up. Independent component analyses (ICA) were used to extract the brain networks of interest: the default mode (DMN), left and right frontoparietal (FPN), and the insular (IN) networks. Linear regression analyses were conducted to assess differences in RS-FC between AN and TD participants, as well as to assess whether RS-FC was associated with clinical symptoms at baseline and at one-year of follow-up. Two statistical models were used: model 1 adjusted for age and socioeconomic status (SES), and model 2 additionally adjusted for baseline anxiety and depressive symptoms.

RESULTS

Underweight AN participants had lower RS-FC between the DMN-IN, as well as between the FPN-IN compared to the TD adolescents. After correction for multiple testing, no significant differences in RS-FC were found between underweight AN participants and weight-restored AN participants, as well as between the whole AN group and the TD group. RS-FC was not associated with the severity of clinical symptoms at baseline nor at one-year of follow-up.

CONCLUSION

AN is associated with changes in RS-FC between the FPN-IN and DMN-IN during the underweight state. These changes in RS-FC were no longer observed in weight-restored AN participants, emphasizing the impact of underweight on RS-FC in AN. Changes in these brain networks may partly explain the impaired cognitive control and difficulties with emotion and behavioral regulation in individuals with AN during the underweight state.

Eating disorders: clinical update

Variation exists in our attitude and behaviour towards food and exercise, resulting in different degrees of health and ill health. Cultural and economic factors contribute to this, alongside personal choices, leading to a spectrum from normative eating, through disordered eating to the extremes of eating disorders (EDs). Understanding the intricate interplay between biological, psychological, and sociocultural factors to eating, exercise and body image is paramount to understand the current state regarding EDs and to deliver/develop multifaceted and individualised treatments. Significant service developments have occurred following the launch of the Irish Health Service Executive Model of Care for EDs in 2018. However, incomplete roll out and surge in EDs referrals post Covid-19 require generic child and adolescent mental health services (CAMHS) to be competent in assessment of EDs, and to keep abreast of clinical updates in order to offer effective treatment.This review provides an evidenced based update on eating related difficulties, outlines a useful assessment framework, offers information on appropriate clinical management, and highlights exciting clinically relevant research developments.

Clinicians' Experiences of Eating Disorder Focused Family Therapy With Autistic Young People

OBJECTIVE

Eating disorder focused family therapy (FT-ED) is the leading outpatient intervention for adolescents with Anorexia Nervosa. Autistic people report poorer eating disorder treatment experiences and may be at increased risk of inpatient admissions. There is a need to consider adaptions to eating disorder treatment for this population. The aim of this study is to explore the experiences of clinicians in the delivery of FT-ED for Autistic young people with Anorexia Nervosa and any adaptations currently being implemented.

METHOD

FT-ED trained clinicians who had experience of delivering this modality with young Autistic people and their families, were invited to take part in interviews. Transcripts were analysed using Reflexive Thematic Analysis.

RESULTS

Eleven clinicians completed interviews and analysis generated four themes and eight subthemes: (1) Systemic context, (2) Raising potential autism, (3) Autism eating disorders crossover, (4) Manual versus adaptations.

CONCLUSIONS

This paper is the first exploration of clinician's experience delivering FT-ED to Autistic young people and their families and highlighted unique considerations with this population. It is an initial step to consider adaptations to the FT-ED model, with the aim of making eating disorder treatments more effective, accessible and acceptable for Autistic young people and their families.

Relationships of eating behaviors with psychopathology, brain maturation and genetic risk for obesity in an adolescent cohort study

Unhealthy eating, a risk factor for eating disorders (EDs) and obesity, often coexists with emotional and behavioral problems; however, the underlying neurobiological mechanisms are poorly understood. Analyzing data from the longitudinal IMAGEN adolescent cohort, we investigated associations between eating behaviors, genetic predispositions for high body mass index (BMI) using polygenic scores (PGSs), and trajectories (ages 14-23 years) of ED-related psychopathology and brain maturation. Clustering analyses at age 23 years (N = 996) identified 3 eating groups: restrictive, emotional/uncontrolled and healthy eaters. BMI PGS, trajectories of ED symptoms, internalizing and externalizing problems, and brain maturation distinguished these groups. Decreasing volumes and thickness in several brain regions were less pronounced in restrictive and emotional/uncontrolled eaters. Smaller cerebellar volume reductions uniquely mediated the effects of BMI PGS on restrictive eating, whereas smaller volumetric reductions across multiple brain regions mediated the relationship between elevated externalizing problems and emotional/uncontrolled eating, independently of BMI. These findings shed light on distinct contributions of genetic risk, protracted brain maturation and behaviors in ED symptomatology.

The Neural Correlates of Body Image Processing in Anorexia Nervosa and Bulimia Nervosa: An Activation Likelihood Estimation Meta-Analysis of fMRI Studies

Body image concerns are key prognostic and pathogenic factors of anorexia nervosa (AN) and bulimia nervosa (BN). This study aimed to investigate the neural mechanisms underlying body image perception across its two domains of estimation and satisfaction in anorexia and bulimia patients and healthy controls (HC). Systematic searches were conducted across eight databases, including PubMed; Cochrane Library; Ovid; Google Scholar; Sage Journals; Scopus; PsycInfo; and ScienceDirect, from database inception until the 23rd of April 2023. The sample pertained to 14 functional magnetic resonance imaging (fMRI) studies and 556 participants, with tasks primarily including image and silhouette-based body estimation and satisfaction paradigms. ALE meta-analysis was conducted to investigate significant clusters of activation foci across the different studies. Shared activations were observed between HC, AN, and BN patients in cortical regions related to object manipulation and recognition, visuospatial awareness, and memory and negative affect regulation. Differential activation in interoceptive and higher-order cognitive or affective control regions likely hold the key to pathological body distortion. This study outlined commonalities and differences in the correlates driving healthy body mapping and eating disorder pathology. Our findings provide pertinent implications for future research, current clinical interventions, and therapeutic outcomes.

Multimodal quantitative magnetic resonance imaging alterations of the basal ganglia circuit underlie the severity of bulimia nervosa

Background

Neuroimaging alterations in the basal ganglia circuit have been reported to correlate with the severity of various eating or addictive disorders, but their relationship to the severity of bulimia nervosa (BN) remains largely unknown. This study sought to investigate the basal ganglia circuit structural and functional imaging differences in BN patients with different severity.

Methods

Based on the MRI data acquired from 34 mild BN patients, 35 moderate-to-extreme BN patients and 35 healthy controls (HCs), differences in gray matter volume (GMV), fractional anisotropy, fractional amplitude of low-frequency fluctuation (fALFF), and seed-based functional connectivity (FC) of basal ganglia circuit (including the caudate, globus pallidus, nucleus accumbens and putamen) were compared across the three groups.

Results

Compared to HCs, the mild patients only exhibited decreased fALFF in the left ventromedial putamen and increased FC between the nucleus accumbens and orbitofrontal cortex, without any structural imaging alterations. Whereas, the moderate-to-extreme patients exhibited significant basal ganglia imaging alterations, characterized by widespread higher FC between basal ganglia regions and several frontal-parietotemporal regions, and disrupted white matter integrity. Based on receiver operating characteristic curves, we discovered that seed-based FC had acceptable discriminatory values in classifying BN patients into mild or moderate-to-extreme groups.

Conclusion

This study reveals that basal ganglia circuit imaging alterations in BN patients become more pronounced with increasing disease severity, suggesting a crucial role of basal ganglia circuit in the progression of BN. Functional network reorganization between basal ganglia and other regions may serve as a potential risk imaging marker for BN progression.

Efficacy of Eating Disorder Focused Family Therapy for Adolescents With Anorexia Nervosa: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review and evaluate the efficacy of eating disorder focused family therapy (FT-ED) in comparison to all other forms of psychotherapy for children and adolescents with anorexia nervosa. A secondary aim is to assess the relative efficacy of different variations of FT-ED (e.g., shorter vs. longer dose, parent-focused).

METHODS

A search with relevant terms was systematically conducted on four databases. Twenty-three publications across 18 randomized controlled trials met inclusion criteria. Outcomes of interest included variables related to weight, eating psychopathology, and remission status. Study quality was assessed, and data were extracted by two independent researchers.

RESULTS

Adolescents receiving FT-ED gained significantly more weight by the end of treatment in comparison to those receiving individual psychotherapy. FT-ED that was delivered just to parents or to parents and child separately offered preferable weight outcomes and rates of recovery at the end of treatment in comparison to conjoint FT-ED. No other outcomes tested in the meta-analysis were statistically significant at the end of treatment or follow-up.

DISCUSSION

Currently available data suggest the use of FT-ED in its conjoint or separated/parent focused format is the best outpatient treatment option for adolescents with anorexia nervosa when immediate weight gain is paramount. The variability of outcome measurement, including the tools used and timepoints chosen, limit comparison among no more than a handful of studies. The field would benefit from the standardization of measurement and reporting guidelines for future clinical trials.

TRIAL REGISTRATION

PROSPERO number: CRD42023396263.

Investigating the Presence of Autistic Traits and Prevalence of Autism Spectrum Disorder Symptoms in Anorexia Nervosa: A Systematic Review and Meta-Analysis

OBJECTIVE

The present meta-analysis aims to assess whether individuals with anorexia nervosa (AN) demonstrate elevated autistic traits, to explore potential associations between autistic traits and eating disorder symptoms; as well as to estimate the prevalence of a positive screen for autism spectrum disorder (ASD) assessed via Autism Diagnostic Observation Schedule (ADOS), in AN.

METHOD

A systematic literature search was conducted in PsycINFO, MEDLINE, and Web of Science in August 2023 and later updated in April 2024 to identify relevant studies. Twenty-two studies with 1172 AN patients and 2747 healthy controls (HCs) met the inclusion criteria.

RESULTS

There was a significant difference between AN and HC groups in autistic traits (g = 0.88, CI = 0.65-1.12), and a significant but modest correlation was found between autistic traits and severity of eating disorder symptoms (r = 0.28, CI = 0.11-0.44). Proportion meta-analysis indicated that 29% (CI = 0.19-0.38) of children and adults scored above the cut-off for ASD.

DISCUSSION

The current findings suggest that AN frequently overlaps with both autistic traits and autistic symptomatology. Therefore, it is essential to evaluate autism and autistic traits in individuals with AN to tailor individualized treatment plans.

Atypical presentation of anorexia nervosa pediatric patient: A multidisciplinary approach to diagnosis and management

This case report describes the complex presentation, diagnostic problems, and multidisciplinary therapy of a 13-year-old Syrian girl with an unusual form of anorexia nervosa (AN). The goal is to improve understanding of AN's varied clinical spectrum while emphasizing the significance of a complete diagnostic approach and multidisciplinary therapy in juvenile cases. The patient reported considerable weight loss, amenorrhea, and physical indications of starvation over the previous two months. Notably, she did not exhibit the typical psychological symptoms linked with AN. Extensive examinations, including gastrointestinal, endocrinology, rheumatology, psychology, psychiatry, and neurology, were carried out to determine the underlying reason and develop a personalized care plan. The diagnostic process found unexpected traits that challenged established AN criteria. A multidisciplinary approach aided incorrect diagnosis and guided a treatment strategy that included nutritional rehabilitation, psychosocial support, and medical measures. The patient's outcomes included weight gain, menstruation resumption, and hormonal and physical parameter normalization. This instance contributes to our growing understanding of AN as a group of illnesses with a variety of clinical manifestations. The patient's atypical traits highlight the necessity for flexible diagnostic criteria and personalized, multidisciplinary care. The favorable outcomes demonstrate the possibility for positive outcomes with a complete strategy, paving the door for further investigation of diagnostic frameworks and treatment techniques in pediatric AN cases.

Maladaptive Restrictive Food Choice Behavior in Adolescents With Anorexia Nervosa

OBJECTIVE

Individuals with anorexia nervosa persistently restrict their food intake while often severely underweight. This maladaptive food choice behavior and related decision-making processes have mainly been investigated in adults. It is unknown whether the same decision-making processes drive food choices in adolescents, given their more favorable treatment outcomes. This study investigated maladaptive food choice behavior in adolescents with AN and examined whether they display the same decision-making processes as adults.

METHOD

Adolescents with AN (n = 42) and age-matched controls (n = 42) completed a computer-based food choice task, rating food images for healthiness and tastiness before choosing between two food items.

RESULTS

Adolescents with AN chose high-fat foods less frequently than controls, with food choices more influenced by their perceived "healthiness" and less by their "tastiness" than they did among controls. Relative to controls, adolescents with AN also reported lower overall tastiness ratings and greater habit strength of restrictive eating, which was, however, not related to food choices.

DISCUSSION

Adolescents with AN display the same maladaptive food choice behavior as adults, namely the persistent restriction of high-fat food choices. Their choices were more strongly influenced by the perceived healthiness of a food item, compared to the choices of controls.

Celiac Disease, Gluten-Free Diet, and Eating Disorders: From Bench to Bedside

Celiac disease (CD) and eating disorders (EDs) are complex chronic conditions in adolescents, sharing symptoms such as weight change, malnutrition, and gastrointestinal symptoms. CD, an autoimmune disorder triggered by gluten ingestion, is managed through a strict gluten-free diet that can unintentionally foster disordered eating behaviors due to dietary restrictions. Conversely, EDs may mask and complicate CD symptoms, leading to diagnostic delays and treatment challenges. Evidence reveals an increased risk of EDs in CD individuals and vice versa, indicating a potential bidirectional relationship. This review explores the mechanisms and clinical implications of this interplay and proposes integrated screening and care strategies to improve the quality of life for individuals with both conditions.

Exploring the neurobiological correlates of psilocybin-assisted psychotherapy in eating disorders: a review of potential methodologies and implications for the psychedelic study design

Eating disorders (EDs) are a group of debilitating mental illnesses characterized by maladaptive eating behaviors and severe cognitive-emotional dysfunction, directly affecting 1-3% of the population. Standard treatments are not effective in approximately one third of ED cases, representing the need for scientific advancement. There is emerging evidence for the safety and efficacy of psilocybin-assisted psychotherapy (PAP) to improve treatment outcomes in individuals with EDs. However, the limited knowledge of the neurobiological mechanisms underlying the therapeutic effects of PAP restricts the ability to confirm its clinical utility. This narrative review presents an overview of methodologies used to elucidate the pathophysiological mechanisms of EDs or the effects of psilocybin that could be employed to probe the neurobiological correlates of PAP in EDs, including magnetic resonance imaging and molecular neuroimaging techniques, electrophysiological approaches, and neuroplasticity markers. Finally, the implications of these methodologies are described in relation to the unique features of the psychedelic study design, challenges, limitations, and future directions to advance the field. This paper represents a valuable resource for scientists during study conceptualization and design phases and stimulates advancement in the identification of effective therapeutic interventions for EDs.