“It exists”: An exploratory study of treatment experiences in men with eating disorders

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.

Characterising use of recovery record among a large, transdiagnostic sample of adults with eating disorders across higher levels of care

OBJECTIVE

Smartphone applications (i.e., apps) designed to target mental health symptoms have received increasing public and empirical attention, including in eating disorder|eating disorders (EDs) treatment. While some data have begun to characterise app users in non-controlled settings, there is limited information on use of apps in higher levels of care (e.g., partial hospitalisation or residential treatment programs) for EDs.

METHOD

This study aimed to explore metrics of use while in treatment for a commonly used ED-focused mobile app (Recovery Record) among individuals enroled in intensive outpatient, partial hospitalisation, residential, or inpatient treatments (N = 2042).

RESULTS

Results indicated that older individuals and participants with binge eating disorder demonstrated more frequent app engagement compared to younger participants and other ED diagnoses, respectively. Individuals entering at intensive outpatient and partial hospitalisation levels of care, as well as those with routine discharges engaged more frequently with RR compared to individuals entering in inpatient or residential treatment, and those with non-routine discharges.

CONCLUSIONS

Our data provide initial descriptions of how RR may be used within higher levels of care for adults with EDs. Further work is needed to establish the benefit of these apps in clinical settings for EDs over and above standard treatment, better characterise for whom these apps provide benefit, and identify how best to tailor the experience to promote engagement across the full spectrum of ED patients.

Barriers and facilitators affecting treatment uptake behaviours for patients with eating disorders: A systematic review synthesising patient, caregiver and clinician perspectives

OBJECTIVE

A significant treatment gap exists between persons affected by eating disorders (ED), and those engaging with treatment services. This systematic review aims to provide a thorough understanding of the barriers and facilitators affecting eating disorder treatment engagement, including a synthesis of the perspectives of patients, caregivers and healthcare professionals.

METHOD

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were retrieved from three databases (PubMed, PsycInfo, Web of Science) and were screened and assessed independently by two raters. A thematic analysis was completed to determine the key barriers and facilitators reported by the included studies.

RESULTS

A total of 73 studies were included. From these studies, 12 barriers and 13 facilitators were identified. Patients reported stigma, shame and guilt as the most prominent barrier affecting their engagement with treatment services. Meanwhile, caregivers and healthcare professionals reported a lack of eating disorder knowledge of clinicians as the most important barrier. Positive social support was cited as the most prominent facilitator to promote help-seeking.

DISCUSSION

Patients, caregivers and healthcare professionals experience a variety of barriers and facilitators to treatment uptake for ED. Interventions addressing barriers and facilitators could increase treatment engagement, including anti-stigma campaigns and positive peer-support interventions.

Experiences of inpatient eating disorder admissions: A systematic review and meta-synthesis

OBJECTIVE

There has been a significant increase in the number of inpatient admissions for individuals with eating disorders and, with the most critical cases requiring inpatient treatment, it is essential that we continue to improve associated outcomes. The aim of the study was to synthesise the available qualitative literature on the experiences of inpatient admissions for eating disorders to understand individuals' experiences and identify areas that may require further research and/or service development.

METHOD

Searches were performed on the following online databases: PsycINFO, PsycArticles, PsycTherapy MEDLINE, Embase, CINAHL, ASSIA, Scopus and Proquest Open Access Theses. Only papers with qualitative data regarding individuals' experiences of inpatient eating disorder treatment were considered. The CASP qualitative checklist was used to assess studies and relevant data items were extracted. Thematic synthesis was used to integrate the findings in the identified studies. GRADE-CERQual was used to rate the confidence in the findings.

RESULTS

Twenty-eight studies were identified which the CASP assessment considered to be adequate. The synthesis produced 5 main themes; 'Care and control', 'Inpatient bubble', 'Being supported and understood', 'Challenges of living with others' eating disorders' and finally 'Relationship to eating disorder'. The GRADE CERQual framework rated findings with high or moderate confidence.

CONCLUSIONS

Findings reaffirmed the importance of patient-centred care and the significant impact of being separated from normal life with others also experiencing an eating disorder.

Investigating service users' perspectives of eating disorder services: A meta-synthesis

OBJECTIVE

Despite a number of qualitative studies published from the perspective of eating disorder (ED) service users, there has been no attempt to exclusively synthesize their views to gain a fuller understanding of their ED service experiences. It is important to understand this perspective, since previous research highlights the difficulties ED healthcare professionals report when working with this client group.

METHOD

A systematic search of the literature was conducted to identify qualitative studies focusing on experiences of ED services from the perspective of service users. Twenty-two studies met the inclusion criteria and underwent a quality appraisal check using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. These were then synthesized using a meta-synthesis approach.

RESULTS

Four overarching themes were generated: "Treatment: Focus on physical vs. psychological symptoms"; "Service Environment: The role of control within services"; "Staff: Experiences with staff and the value of rapport"; and "Peer Influence: Camaraderie vs. comparison." Service users expressed a desire for more psychological input to tackle underlying difficulties relating to their ED. A complex relationship with feelings of control was described, with some feeling over-controlled by service providers, while others retrospectively recognized the need for control to be taken away. Staff values, knowledge and trust played a significant role in treatment and recovery. Peers with an ED were described to be a valuable source of understanding and empathy, but some found peer influence to perpetuate comparison and competitiveness.

DISCUSSION

The results portray some of the conflicts and complexities that service users encounter in ED services. A running thread throughout is the perceived importance of adopting an individualized approach within these services.

Gender Differences in Treatment Outcomes for Eating Disorders: A Case-Matched, Retrospective Pre–Post Comparison

Eating disorders (EDs) are increasingly emerging as a health risk in men, yet men remain underrepresented in ED research, including interventional trials. This underrepresentation of men may have facilitated the development of women-centered ED treatments that result in suboptimal outcomes for men. The present study retrospectively compared pre- vs. post-treatment outcomes between age-, diagnosis-, and length-of-treatment-matched samples of n = 200 men and n = 200 women with Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), or Eating Disorder Not Otherwise Specified (EDNOS), treated in the same setting during the same period, and using the same measurements. Compared to women, men with AN showed marked improvements in weight gains during treatment as well as in ED-specific cognitions and general psychopathology. Likewise, men with BED showed marked weight loss during treatment compared to women with BED; ED-specific cognitions and general psychopathology outcomes were comparable in this case. For BN and EDNOS, weight, ED-specific cognitions, and general psychopathology outcomes remained largely comparable between men and women. Implications for treatments are discussed.

Psychometric properties of the 26-item eating attitudes test (EAT-26): an application of rasch analysis

BACKGROUND

The 26-item Eating Attitudes Test (EAT-26) is a commonly used tool to assess eating disorder risk. The purpose of this study was to examine the psychometric properties of the EAT-26 with a combined sample: (1) of adults with overweight and obesity enrolled in a behavioral weight loss program and (2) general adult sample (n = 469; age = 36.17 ± 17.83 years; female = 72.5%; white = 66.3%; obese BMI category = 58%).

METHODS

Rasch modeling was used to assess model-data fit, create an item-person map to evaluate relative distribution items and persons, item difficulty, and person's eating disorder (ED) risk level of the EAT-26. Differential item functioning (DIF) and rating scale functioning of the EAT-26 were also evaluated using Rasch analysis.

RESULTS

A total of 7 misfit items were removed from the final analysis due to unacceptable Infit and Outfit mean square residual values. The item-person map showed that the items were biased toward participants with moderate to high levels of ED risk and did not cover those who had low risk for having an ED (< - 1 logits). The DIF analyses results showed that none of the items functioned differently across sex, but 5 items were flagged based on obesity status. The six-category Likert-type rating scale did not function well indicating a different response format may be needed.

CONCLUSION

Several concerns were identified with the psychometric evaluation of the EAT-26 that may question its utility in assessing ED risk in individuals at low risk for ED, within samples of people who have overweight and obesity seeking weight loss treatment. The 26-item Eating Attitudes Test is a self-rated measure of eating attitudes that measures symptoms and concerns of eating disorders (ED). Very little is known about how this instrument performs differently based on individual factors like body mass index (BMI) and sex (male/female). We used an advanced measurement theory (i.e., Rasch analysis) to determine if the EAT-26 is an adequate measure to detect disordered eating in men and women of different BMIs. Results indicated that the EAT-26 was biased toward participants with moderate to high levels of disordered eating risk and did not adequately detect individuals at low risk for disordered eating. The EAT-26 did not function differently based on sex (male/female). However, five questions did function differently based on obesity status (those without obesity/ those with obesity). Finally, we observed the six-category rating scale did not function appropriately and that a new response format may be warranted. In sum, there were several issues (e.g., poor rating scale and different item functioning) with the EAT-26 and future work should develop screening tools that detect low risk of disordered eating as well as function well in adults with overweight and obesity.

Perspectives on barriers to treatment engagement of people with eating disorder symptoms who have not undergone treatment: a qualitative study

BACKGROUND

Many people with an eating disorder (ED) never engage with an evidence-based ED treatment. Of the few studies that have qualitatively explored barriers to receiving treatment, some do so in relation to mental health conditions in general, and others focus on participants who have already undergone treatment. This study aims to address this gap in the literature by exploring the barriers to ED treatment engagement from the perspectives of individuals in the community with an ED (either self-identified or professionally diagnosed) and had not received ED treatment/s.

METHOD

Fifty-six of 772 participants in an online Eating Disorders Treatment Experience survey had self-identified as having symptoms consistent with an ED, or had received a diagnosis of an ED and indicated that they had never undergone treatment for an ED. They were asked to share the reasons for which they did not receive treatment with an open-ended question. Qualitative analysis of survey responses was completed using the Framework Method to generate overarching themes that encapsulated the diverse participant accounts.

RESULTS

The thematic analysis generated two main themes, each with two subthemes. The first theme was the negotiation of the need for treatment within oneself (intrapersonal factors; theme 1). The second theme explored interpersonal contexts that shaped the participant's decision not to seek treatment (interpersonal/external factors; theme 2). Two cross-cutting subthemes of fear and health literacy were also generated that demonstrated a high degree of overlap with the aforementioned main themes.

CONCLUSIONS

The process by which individuals decide whether or not to engage with ED treatment services is complex and involves intra- and interpersonal negotiations intertwined with health literacy and fear. A factor not prominent in previous research was negative self-perceptions and the belief of being undeserving of treatment. These factors have implications for ongoing community and clinical interventions to further address barriers to ED treatment engagement.

Help-seeking attitudes and behaviours among youth with eating disorders: a scoping review

BACKGROUND

Although early intervention is crucial in interrupting the development of eating disorders, little is currently known about help-seeking behaviours among individuals experiencing eating disorder symptoms. Given that eating disorders typically begin early in life, it is necessary to investigate the processes employed by children, adolescents, and emerging adults when seeking services for troubling symptoms. This is a growing concern as the COVID-19 pandemic has resulted in an increase in the number of individuals engaging in disordered eating behaviours. This scoping review explores the current state of the literature for evidence on how youth with eating disorder symptoms seek help, with the aim of better understanding how to identify and treat more individuals earlier.

METHODS

Using scoping review methodology, we searched seven databases for studies published from January 2000 to April 2021 that reported on help-seeking attitudes, behaviours, and healthcare utilization patterns for children and adolescents (< 18 years), emerging adults (18-25 years), and a mixture of these groups (< 25 years). Seven thousand, two hundred, and eighteen articles were identified for review. After duplicates were removed, three reviewers independently screened titles and abstracts and reviewed full-text articles. Findings related to help-seeking activity were extracted from the 62 articles that were ultimately included in this scoping review.

RESULTS

Study findings were summarized into help-seeking patterns (i.e., rates, types) as well as factors ranging from the individual level to society that influenced help-seeking behaviour. Many youth meeting eating disorder criteria were not seeking help. Notable barriers to help-seeking included poor mental health literacy, experiences with healthcare providers who failed to detect and lacked knowledge about eating disorders, minimal support from family and friends, and stigma surrounding eating disorders and help-seeking for mental health concerns.

CONCLUSIONS

The results of this scoping review can be used to inform early intervention and health promotion program development. Future research should focus on the help-seeking attitudes and activities among underrepresented groups with eating disorders (e.g., men, ethnic and gender minorities), the perspectives of family and other supporters in the help-seeking process for youth, and retrospective accounts from adults with lived experience of an eating disorder. Plain English summary Addressing and interrupting eating disorder-related thoughts and behaviours as soon as possible, with the help of a mental health professional, leads to better outcomes for youth struggling with an eating disorder. However, little is known about what prompts youth to talk about their weight, body, or eating concerns with someone-like their parent, friend, teacher, guidance counsellor, or primary care practitioner. This review explores the available published research on help-seeking patterns and preferences among youth with eating disorder concerns. Our team followed a standardized process to find 62 relevant articles for this paper. Of note, many young people who reported eating disorder concerns were not seeking help for themselves. Feeling supported by family and their primary care provider, understanding the signs of an eating disorder, and not feeling shame for reaching out for help reportedly led youth to speak up about their concerns. The findings have clinical implications for learning effective ways to help youth feel safe to speak freely about their eating disorder-related concerns, which enhances the chances of intervening early and catching symptoms before they worsen.

A Plea for Diversity in Eating Disorders Research

Eating disorders (EDs) are often stereotyped as affecting the SWAG, that is, as affecting mostly skinny, White, affluent girls. Over the last decade, however, significant progress has been made toward increasing diversity in ED research. There is consensus that EDs affect individuals of all genders, ages, sexual orientations, ethnic, and socio-economic backgrounds, with recent studies exploring social determinants of ED etiology, ED presentation, and developing diversity-affirming ED assessments. This article provides a brief summary of current developments related to diversity as a research theme, and proposes different perspectives toward further improving diversity in ED research. Specifically, we argue for exploring the role of diversity in ED treatment settings and outcomes, for pursuing diversity-oriented research pro-actively rather than as a reaction to issues of under-representation, and for integrating diversity across different areas of medical education and trainings in psychotherapy. Limitations with respect to the paucity of research, and the link between diversity as a research theme and ED-related workforce diversity are discussed.

The minority or the misunderstood? A young man's journey with anorexia nervosa

INTRODUCTION

Despite findings that 1 in 4 eating disorder sufferers are male (Beat, 2017), they continue to be known as "female" disorders, an association which delays diagnosis in males and prevents them from seeking the help that they need to recover.

AIM

The current paper aimed to challenge this misconception by enabling and supporting Ben, a young male diagnosed with Anorexia Nervosa aged 16, to share his experience of seeking and receiving treatment for the disorder.

METHOD

It achieved this by exploring how his disorder developed, his experience of a child and adolescent inpatient service and the events leading up to this, and his life post-discharge, all in collaboration with Ben himself and using his own words.

DISCUSSION

The paper concludes with some implications for future practice, including that eating disorders should not be skewed towards any gender, treatment programmes need to ensure full inclusivity of males, and more gender sensitive information is required to raise awareness of this population and thus reduce the stigma and isolation they experience at present. It is hoped that these, along with the rest of the paper, will be accessible to and utilized by both professionals and non-professionals alike.

ACCESSIBLE SUMMARY

● Around one quarter of people diagnosed with an eating disorder are male, yet they continue to be known as "female" disorders. Because of this, young males are often missed by the system and as a result, receive treatment later than they should. They are currently underrepresented in services. ● This paper challenges the association above by supporting a young man who suffered with a type of eating disorder known as Anorexia Nervosa to share his journey from his personal perspective. It provides great insight into what it is like to be a male with an eating disorder, including how it felt to be the only male in an inpatient facility surrounded by females with the same disorder. ● The paper also provides important information for professionals working in the area. For example, eating disorders, including Anorexia Nervosa, should not be associated with one specific gender, and treatment programmes for young people with eating disorders should ensure they are appropriate for both females and males. As a society, we need to challenge the stigma which exists for males in admitting when they are struggling and asking for help, and we need to do everything we can to ensure that young men are picked up earlier in the system, in order to give them the best chance of recovery. ● It is hoped that Ben's story and the recommendations from it can go on to help other males who might be struggling.

Men's experiences of eating disorder treatment: A qualitative systematic review of men-only studies

WHAT IS KNOWN ON THE SUBJECT?: There is a widespread perception that eating disorders are predominantly women´s illnesses. Most studies in the field of eating disorders include predominantly women. Current eating disorder programmes are tailored to meet women´s needs. At the same time, studies show that the rate of eating disorders among men is rising. Men tend to seek help for their eating disorder late in the course of their illness; even when they do seek treatment, they run risk of being undiagnosed by health professionals. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We assessed the current knowledge on how men think and feel about their eating disorders and explored how this may affect their help-seeking behaviours and how they go about managing their eating disorders. Men experience unique symptoms and issues that may translate into unique treatment needs. There is a call to re-evaluate the current status quo for men with eating disorders regarding access to and receiving treatment for their eating disorders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is becoming an increasing priority to effectively treat men with eating disorders. Men need to be recognized as stakeholders in eating disorder-associated health care delivery. Healthcare professionals should receive training about the nature of eating disorders in men. Eating disorder-specific treatments will require adaptations to mirror the needs of individuals rather than particular gender/sex entities. ABSTRACT: Objective Despite the widespread perception that eating disorders (EDs) are predominantly experienced by women and girls, the incidence rate among men has risen substantially in recent years. Men may face unique challenges accessing treatment, which can negatively affect prognosis. The present paper aimed to review men's thoughts and feelings about their ED, and their experiences of ED treatment. Method We conducted a systematic search for qualitative articles focusing on the treatment experiences of men with EDs. Results Nine studies met inclusion criteria. Key themes that emerged across the studies were as follows: (a) recognition of the ED, (b) help-seeking, (c) treatment characteristics and (d) patient characteristics. Given that EDs are widely regarded to exclusively affect women and girls, men were reluctant to recognize their EDs, faced minimization of their symptoms by health professionals and had difficulty finding treatments that were tailored to their unique needs and preferences as men. Conclusions The present findings may serve as reference points to design future ED-specific interventions that are more inclusive of men. Further studies are needed to explore the differential experiences of men across diagnostic categories and treatment types, as well as elucidate the potential role of men-only services.