Rate, timing and predictors of relapse in patients with anorexia nervosa following a relapse prevention program: a cohort study

Myo-inositol Levels in the Dorsal Anterior Cingulate Cortex Predicts Anxiety-to-Eat in Anorexia Nervosa

Background

Anorexia nervosa (AN) is a mental and behavioral health condition characterized by an intense fear of weight or fat gain, severe restriction of food intake resulting in low body weight, and distorted self-perception of body shape or weight. While substantial research has focused on general anxiety in AN, less is known about eating-related anxiety and its underlying neural mechanisms. Therefore, we sought to characterize anxiety-to-eat in AN and examine the neurometabolic profile within the dorsal anterior cingulate cortex (dACC), a brain region putatively involved in magnifying the threat response.

Methods

Women seeking inpatient treatment for AN and women of healthy weight without a lifetime history of an eating disorder (healthy controls; HC) completed a computer-based behavioral task assessing anxiety-to-eat in response to images of higher (HED) and lower (LED) energy density foods. Participants also underwent magnetic resonance spectroscopy of the dACC in a 3 Tesla scanner.

Results

The AN group reported greater anxiety to eat HED and LED foods relative to the HC group. Both groups reported greater anxiety to eat HED foods relative to LED foods. The neurometabolite myo-inositol (mI) was lower in the dACC in AN relative to HC, and mI levels negatively predicted anxiety to eat HED but not LED foods in the AN group only. mI levels in the dACC were independent of body weight, body mass, and general anxiety.

Conclusions

These findings provide critical new insight into the clinically challenging feature and underlying neural mechanisms of eating-related anxiety and indicate mI levels in the dACC could serve as a novel biomarker of illness severity that is independent of body weight to identify individuals vulnerable to disordered eating or eating pathology as well as a potential therapeutic target.

Staging models in eating disorders: A systematic scoping review of the literature

Eating Disorders (ED) are characterized by low remission rates, treatment drop-out, and residual symptoms. To improve assessment and treatment of ED, the staging approach has been proposed. This systematic scoping review is aimed at mapping the existing staging models that explicitly propose stages of the progression of ED. A systematic search of PubMed, PsycINFO, Scopus was conducted with the terms staging, anorexia nervosa, bulimia nervosa, binge-eating disorders, eating disorders. Eleven studies met inclusion criteria presenting nine ED staging models, mostly for anorexia nervosa. Three were empirically tested, one of which was through an objective measure specifically developed to differentiate between stages. Most staging models featured early stages in which the exacerbation of EDs unfolds and acute phases are followed by chronic stages. Intermediate stages were not limited to acute stages, but also residual phases, remission, relapse, and recovery. The criteria for stage differentiation encompassed behavioral, psychological, cognitive, and physical features including body mass index and illness duration. One study recommended stage-oriented interventions. The current review underscores the need to empirically test the available staging models and to develop and test new proposals of staging models for other ED populations. The inclusion of criteria based on medical features and biomarkers is recommended. Staging models can potentially guide assessment and interventions in daily clinical settings.

Transition support for patients admitted to intensive treatment for anorexia nervosa: qualitative study of patient and carer experiences of a hybrid online guided self-help intervention (ECHOMANTRA)

BACKGROUND

Adults with anorexia nervosa experience high levels of relapse following in-patient treatment. ECHOMANTRA is a novel online aftercare intervention for patients and carers, which provides psychoeducation and support to augment usual care.

AIMS

To explore patient and carer experiences of receiving the ECHOMANTRA intervention.

METHOD

This is part of the process evaluation of the ECHOMANTRA intervention as delivered in the TRIANGLE trial (ISRCTN: 14644379). Semi-structured interviews were conducted with 20 participants randomised to the ECHOMANTRA (ten patients and ten carers). Thematic analysis was used to analyse the interview transcripts.

RESULTS

Five major themes were identified: (1) Mixed experience of the intervention; (2) tailoring the intervention to the stage of recovery; (3) involvement of carers; (4) acceptability of remote support; and (5) impact of self-monitoring and accountability.

CONCLUSIONS

Participants were mostly positive about the support offered. The challenges of using remote and group support were counterbalanced with ease of access to information when needed. Components of the ECHOMANTRA intervention have the potential to improve care for people with eating disorders.

Development and usability testing of a cognitive-behavioral therapy-guided self-help mobile app and social media group for the post-acute treatment of anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is often treated in the acute setting, but relapse after treatment is common. Cognitive-behavioral therapy (CBT) is useful in the post-acute period, but access to trained providers is limited. Social support is also critical during this period. This study utilized a user-centered design approach to develop and evaluate the usability of a CBT-based mobile app and social networking component for post-acute AN support.

METHOD

Participants (N = 19) were recently discharged from acute treatment for AN. Usability testing of the intervention was conducted over three cycles; assessments included the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), the Mobile Application Rating Scale (MARS), a social media questionnaire, and a semi-structured interview.

RESULTS

Interview feedback detailed aspects of the app that participants enjoyed and those needing improvement. Feedback converged on three themes: Logistical App Feedback, boosting recovery, and Real-World App/Social Media Use. USE and MARS scores were above average and SUS scores were "good" to "excellent" across cycles.

CONCLUSION

This study provides evidence of feasibility and acceptability of an app and social networking feature for post-acute care of AN. The intervention has potential for offering scalable support for individuals with AN in the high-risk period following discharge from acute care.

Reduced dorsal fronto-striatal connectivity at rest in anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a serious psychiatric illness that remains difficult to treat. Elucidating the neural mechanisms of AN is necessary to identify novel treatment targets and improve outcomes. A growing body of literature points to a role for dorsal fronto-striatal circuitry in the pathophysiology of AN, with increasing evidence of abnormal task-based fMRI activation within this network among patients with AN. Whether these abnormalities are present at rest and reflect fundamental differences in brain organization is unclear.

METHODS

The current study combined resting-state fMRI data from patients with AN (n = 89) and healthy controls (HC; n = 92) across four studies, removing site effects using ComBat harmonization. First, the a priori hypothesis that dorsal fronto-striatal connectivity strength - specifically between the anterior caudate and dlPFC - differed between patients and HC was tested using seed-based functional connectivity analysis with small-volume correction. To assess specificity of effects, exploratory analyses examined anterior caudate whole-brain connectivity, amplitude of low-frequency fluctuations (ALFF), and node centrality.

RESULTS

Compared to HC, patients showed significantly reduced right, but not left, anterior caudate-dlPFC connectivity (p = 0.002) in small-volume corrected analyses. Whole-brain analyses also identified reduced connectivity between the right anterior caudate and left superior frontal and middle frontal gyri (p = 0.028) and increased connectivity between the right anterior caudate and right occipital cortex (p = 0.038). No group differences were found in analyses of anterior caudate ALFF and node centrality.

CONCLUSIONS

Decreased coupling of dorsal fronto-striatal regions indicates that circuit-based abnormalities persist at rest and suggests this network may be a potential treatment target.

Anorexia nervosa: Enhancing motivation to change with self-determination theory

Motivational deficits (little or no motivation to change) are often reported in patients with eating disorders, particularly anorexia nervosa. The motivational approaches frequently used by French clinicians rely solely on a dichotomous view of motivation (intrinsic vs. extrinsic). In self-determination theory, certain forms of extrinsic motivation can strengthen an individual's commitment to an activity, providing they are self-determined. This theory therefore extends and enriches the dual motivational approach by highlighting potentially useful forms of extrinsic motivation and by emphasizing the importance of behavioral regulation. Empirical work is now needed to assess how clinicians can use self-determination theory to enhance motivation to change among patients with anorexia nervosa and encourage their adherence to care management plans.

An overview and investigation of relapse predictors in anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

An extensive number of predictors has been examined across the literature to improve knowledge of relapse in anorexia nervosa (AN). These studies provide various recovery and relapse definitions, follow-up durations and relapse rates. The current study summarizes these values and predictors of relapse in AN in a review and meta-analysis.

METHOD

The study was executed according to PRISMA guidelines. Different databases were searched and studies in which participants did not receive an official clinical diagnosis were excluded. A quality analysis was performed using the National Institute of Health's Study Quality Assessment Tool. Random-effects meta-analyses were conducted to summarize data.

RESULTS

Definitions of relapse and recovery were diverse. During an average follow-up period of 31 months an average relapse rate of 37% was found. Predictive variables from 28 studies were grouped in six categories: age and sex, symptoms and behaviors, AN subtype and duration, weight or weight change, comorbidity, and personality. The studies were characterized by non-significant and contradictory results. Meta-analyses were performed for the predictors age, AN duration, pre-treatment BMI, post-treatment BMI and depression. These yielded significant effects for post-treatment BMI and depression: higher pre-treatment depression (SMD = .40 CI [.21-.59] and lower post-treatment BMI (SMD = -.35 CI [-.63 to -.07]) increased relapse chances in AN.

DISCUSSION

Our results emphasized a lack of sufficiently powered studies, consistent results, and robust findings. Solely post-treatment BMI and pre-treatment depression predicted relapse. Future research should use uniform definitions, larger samples and better designs, to improve our understanding of relapse in AN.

PUBLIC SIGNIFICANCE

Knowledge about predictors is important to understand high relapse rates. Our study performed a review and meta-analysis of relapse predictors in AN. Related to the heterogeneity in studies examining predictors, an overview of relapse and recovery definitions, follow-up durations and relapse rates for AN was provided. Significant effects were found for post-treatment BMI and pre-treatment depression. More studies with uniform definitions are needed to improve clinical implications.

Testing anxiety and reward processing in anorexia nervosa as predictors of longitudinal clinical outcomes

Anorexia nervosa (AN) is a psychiatric disorder with a tenuous longitudinal course marked by a high risk of relapse. Previous studies suggest that aberrant threat perception and reward processing operate in many with AN, and may produce obstacles to treatment engagement; therefore, these could potentially represent predictors for longitudinal clinical outcomes. In this study, anxiety and reward symptoms, behaviors, and neural circuit connectivity were measured in intensively treated AN-restrictive subtype patients (n = 33) and healthy controls (n = 31). Participants underwent an fMRI experiment using a monetary reward task in combination with either overlapping individually tailored anxiety-provoking words or neutral words. Behavioral/psychometric measures consisted of reaction times on the monetary reward task and self-ratings on anxiety symptoms at study entry. We tested multimodal, multivariate models based on neural, behavioral, and psychometric measures of reward and anxiety to predict physiological (Body Mass Index; BMI) and psychological (eating disorder symptom severity) longitudinal outcomes in AN over six months. Our results indicated that higher anxiety symptom psychometric scores significantly predicted BMI reductions at follow-up. Untreated anxiety after intensive treatment could put individuals with AN at heightened risk for weight loss. This represents a potentially modifiable risk factor that could be targeted more aggressively to help reduce the chance of future clinical worsening.

Identification of adipose tissue transcriptomic memory of anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a complex debilitating disease characterized by intense fear of weight gain and excessive exercise. It is the deadliest of any psychiatric disorder with a high rate of recidivism, yet its pathophysiology is unclear. The Activity-Based Anorexia (ABA) paradigm is a widely accepted mouse model of AN that recapitulates hypophagia and hyperactivity despite reduced body weight, however, not the chronicity.

METHODS

Here, we modified the prototypical ABA paradigm to increase the time to lose 25% of baseline body weight from less than 7 days to more than 2 weeks. We used this paradigm to identify persistently altered genes after weight restoration that represent a transcriptomic memory of under-nutrition and may contribute to AN relapse using RNA sequencing. We focused on adipose tissue as it was identified as a major location of transcriptomic memory of over-nutririon.

RESULTS

We identified 300 dysregulated genes that were refractory to weight restroration after ABA, including Calm2 and Vps13d, which could be potential global regulators of transcriptomic memory in both chronic over- and under-nutrition.

CONCLUSION

We demonstrated the presence of peristent changes in the adipose tissue transcriptome in the ABA mice after weight restoration. Despite being on the opposite spectrum of weight perturbations, majority of the transcriptomic memory genes of under- and over-nutrition did not overlap, suggestive of the different mechanisms involved in these extreme nutritional statuses.

Eating disorder outcomes: findings from a rapid review of over a decade of research

BACKGROUND

Eating disorders (ED), especially Anorexia Nervosa (AN), are internationally reported to have amongst the highest mortality and suicide rates in mental health. With limited evidence for current pharmacological and/or psychological treatments, there is a grave responsibility within health research to better understand outcomes for people with a lived experience of ED, factors and interventions that may reduce the detrimental impact of illness and to optimise recovery. This paper aims to synthesise the literature on outcomes for people with ED, including rates of remission, recovery and relapse, diagnostic crossover, and mortality.

METHODS

This paper forms part of a Rapid Review series scoping the evidence for the field of ED, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/MEDLINE were searched for studies published between 2009 and 2022 in English. High-level evidence such as meta-analyses, large population studies and Randomised Controlled Trials were prioritised through purposive sampling. Data from selected studies relating to outcomes for people with ED were synthesised and are disseminated in the current review.

RESULTS

Of the over 1320 studies included in the Rapid Review, the proportion of articles focused on outcomes in ED was relatively small, under 9%. Most evidence was focused on the diagnostic categories of AN, Bulimia Nervosa and Binge Eating Disorder, with limited outcome studies in other ED diagnostic groups. Factors such as age at presentation, gender, quality of life, the presence of co-occurring psychiatric and/or medical conditions, engagement in treatment and access to relapse prevention programs were associated with outcomes across diagnoses, including mortality rates.

CONCLUSION

Results are difficult to interpret due to inconsistent study definitions of remission, recovery and relapse, lack of longer-term follow-up and the potential for diagnostic crossover. Overall, there is evidence of low rates of remission and high risk of mortality, despite evidence-based treatments, especially for AN. It is strongly recommended that research in long-term outcomes, and the factors that influence better outcomes, using more consistent variables and methodologies, is prioritised for people with ED.

Adapting a mobile app to support patients with anorexia nervosa following post-acute care: perspectives from eating disorder treatment center stakeholders

Introduction

Anorexia nervosa (AN) is a harmful, life-threatening illness. Patients with severe AN often receive acute treatment but, upon discharge, experience high relapse rates. Evidence-based, outpatient treatment following acute care is critical to preventing relapse; however, numerous barriers (e.g., location, financial limitations, low availability of providers) preclude individuals from accessing treatment. mHealth technologies may help to address these barriers, but research on such digital approaches for those with AN is limited. Further, such technologies should be developed with all relevant stakeholder input considered from the outset. As such, the present study aimed to garner feedback from eating disorder (ED) treatment center providers on (1) the process of discharging patients to outpatient services, (2) their experiences with technology as a treatment tool, and (3) how future mHealth technologies may be harnessed to offer the most benefit to patients in the post-acute period.

Methods

Participants (N = 11, from 7 ED treatment centers across the United States) were interviewed. To analyze the data for this study, each interview was manually transcribed and analyzed using components of Braun and Clarke's six-phase thematic analysis framework (Braun & Clarke, 2006).

Results

Participants indicated proactively securing outpatient care for their patients, but mentioned several barriers their patients face in accessing evidence-based ED treatment. All participants had some experience using various technologies for treatment (e.g., teletherapy, self-monitoring apps), and mentioned a high level of interest in the development of a new app to be used by patients recently discharged from acute treatment for AN. Participants also offered suggestions of effective and relevant content for a potential app and adjunctive social networking component for post-acute care of AN.

Discussion

Overall, participants expressed positive attitudes toward the integration of an app into the care flow, suggesting the high potential benefit of harnessing technology to support individuals recovering from AN.

A pilot randomized controlled trial of a cognitive-behavioral therapy guided self-help mobile app for the post-acute treatment of anorexia nervosa: A registered report

INTRODUCTION

Relapse following acute treatment for anorexia nervosa (AN) is common. Evidence suggests cognitive-behavioral therapy (CBT) may be useful in the post-acute period, but few patients have access to trained providers. mHealth technologies have potential to increase access to high-quality care for AN, including in the post-acute period. The aim of this study is to estimate the preliminary feasibility and effectiveness of a CBT-based mobile intervention plus treatment as usual (TAU), offered with and without an accompanying social networking feature.

METHOD

In the current pilot randomized controlled trial, women with AN who have been discharged from acute treatment in the past 2 months (N = 90) will be randomly assigned to a CBT-based mobile intervention plus treatment as usual (TAU), a CBT-based mobile intervention including social networking plus TAU, or TAU alone. We will examine feasibility, acceptability, and preliminary effectiveness of the three conditions in terms of reducing eating disorder psychopathology, reducing frequency of eating disorder behaviors, achieving weight maintenance, reducing depression and suicidal ideation, and reducing clinical impairment. We will examine rehospitalization and full recovery rates in an exploratory fashion. We will also examine whether the mobile intervention and social networking feature change the proposed targets and whether changes in targets are associated with benefit, as well as conduct exploratory analyses to identify within-mobile intervention predictors and moderators of outcome.

DISCUSSION

Ultimately, this research may lead to increased access to evidence-based treatment for individuals with AN and prevention of the extreme negative consequences that can result from this serious disorder.

PUBLIC SIGNIFICANCE

Relapse after acute treatment for anorexia nervosa is common, and few patients have access to trained providers to support them following acute care. This study will pilot a coached mobile app, including a social networking component, for this population. If ultimately successful, our approach could greatly increase access to evidence-based treatment for individuals with anorexia nervosa and ultimately prevent the extreme negative consequences that can result from this serious disorder.

Predictors of relapse in eating disorders: A meta-analysis

INTRODUCTION

Eating disorders (EDs) have high rates of relapse. However, it is still not clear which factors are the strongest predictors of ED relapse, and the extent to which predictors of relapse may vary due to study and individual differences.

OBJECTIVE

We conducted a meta-analysis to quantify and compare which factors predict relapse in EDs and evaluate various potential moderators of these relations (e.g., ED subtype, sample age, length of follow-up, timing of predictor assessment, relapse operationalization).

METHODS

A total of 35 papers (effects = 315) were included. We used a multilevel random-effects model to estimate summary study-level effect sizes, and multilevel mixed-effects models to examine moderator effects.

RESULTS

Higher level of care, having psychiatric comorbidity, and higher severity of ED psychopathology were associated with higher odds of relapse. Higher leptin, higher meal energy density/variety, higher motivation for change, higher body mass index/weight/body fat, better response to treatment, anorexia nervosa-restricting (vs. anorexia nervosa-binge purge) subtype diagnosis, and older age of ED onset were associated with lower odds of relapse. Several moderators were identified.

DISCUSSION

A variety of variables can predict ED relapse. Furthermore, predictors of ED relapse vary among ED subtypes, sample ages, lengths of follow-up, timing of predictor assessments, and relapse operationalization. Future research should identify the mechanisms by which these variables may contribute to relapse.

The Role of Brain-Derived Neurotrophic Factor (BDNF) in Diagnosis and Treatment of Epilepsy, Depression, Schizophrenia, Anorexia Nervosa and Alzheimer's Disease as Highly Drug-Resistant Diseases: A Narrative Review

Brain-derived neurotrophic factor (BDNF) belongs to the family of neurotrophins, which are growth factors with trophic effects on neurons. BDNF is the most widely distributed neurotrophin in the central nervous system (CNS) and is highly expressed in the prefrontal cortex (PFC) and hippocampus. Its distribution outside the CNS has also been demonstrated, but most studies have focused on its effects in neuropsychiatric disorders. Despite the advances in medicine in recent decades, neurological and psychiatric diseases are still characterized by high drug resistance. This review focuses on the use of BDNF in the developmental assessment, treatment monitoring, and pharmacotherapy of selected diseases, with a particular emphasis on epilepsy, depression, anorexia, obesity, schizophrenia, and Alzheimer's disease. The limitations of using a molecule with such a wide distribution range and inconsistent method of determination are also highlighted.

Transition of young adults with metabolic bone diseases to adult care

As more accurate diagnostic tools and targeted therapies become increasingly available for pediatric metabolic bone diseases, affected children have a better prognosis and significantly longer lifespan. With this potential for fulfilling lives as adults comes the need for dedicated transition and intentional care of these patients as adults. Much work has gone into improving the transitions of medically fragile children into adulthood, encompassing endocrinologic conditions like type 1 diabetes mellitus and congenital adrenal hyperplasia. However, there are gaps in the literature regarding similar guidance concerning metabolic bone conditions. This article intends to provide a brief review of research and guidelines for transitions of care more generally, followed by a more detailed treatment of bone disorders specifically. Considerations for such transitions include final adult height, fertility, fetal risk, heritability, and access to appropriately identified specialists. A nutrient-dense diet, optimal mobility, and adequate vitamin D stores are protective factors for these conditions. Primary bone disorders include hypophosphatasia, X-linked hypophosphatemic rickets, and osteogenesis imperfecta. Metabolic bone disease can also develop secondarily as a sequela of such diverse exposures as hypogonadism, a history of eating disorder, and cancer treatment. This article synthesizes research by experts of these specific disorders to describe what is known in this field of transition medicine for metabolic bone diseases as well as unanswered questions. The long-term objective is to develop and implement strategies for successful transitions for all patients affected by these various conditions.

The Follow-Up of Eating Disorders from Adolescence to Early Adulthood: A Systematic Review

Eating disorders (EDs) are common among children and adolescents and are characterized by excessive concerns for physical appearance, distorted body image, and fear of gaining weight. The purpose of this review is to evaluate the follow-up of EDs from adolescence to adulthood, analyzing persistence, relapses, and associated comorbidities. We searched scientific articles in PubMed, PsycInfo, Scopus, and Embase through two research strings, one for quantitative outcomes (recovery/persistence, relapse, and remission) and one for the other outcomes (psychiatric and medical comorbidities, substance use, and social-relational complications). From a total of 8043 retrieved articles, we selected 503 papers after exclusion of duplicates and title/abstract screening. After a full-text evaluation, we included 16 studies eligible for this review. We performed a meta-analysis describing the quantitative results, and we created a narrative synthesis for the qualitative outcomes. Results: Our results confirm that EDs can persist in early adulthood in 40.7% of cases with a relapse percentage of 24.5%. Individuals with an ED more frequently present with an empathy deficit and comorbid anxiety and depressive disorders. EDs are chronic and complex disorders, more frequent in females. In most cases, EDs reduce the autonomy of individuals who present many difficulties in affirming their independence from parental family.

Lived experience perspectives on a definition of eating disorder recovery in a sample of predominantly white women: a mixed method study

BACKGROUND

There has recently been a push for recovery-focused research in the eating disorder (ED) field, starting with a consensus definition of recovery. One definition, in particular, proposed by Bardone-Cone et al. [21] has received considerable attention given its transdiagnostic nature and validation studies. However, no studies to date have elicited lived experience views of this definition. The goal of the current study was to examine perspectives on this definition of recovery from individuals with a past or present ED and to determine whether participant agreement with the model differed based on diagnostic history or current symptom severity.

METHODS

Sixty-two individuals (95.2% women; 91.9% White/European) participated in a 1-2 h interview aimed at capturing their perspectives on ED recovery. Transcripts were analyzed using qualitative content analysis and codebook thematic analysis to examine agreement with and thoughts on Bardone-Cone's definition of recovery, respectively. Chi-squared tests of independence and binary logistic regression were computed to determine whether agreement with the definition differed across diagnostic history and self-reported symptoms.

RESULTS

Although some participants indicated acceptance of the definition, the majority expressed concerns related to its categorical nature, proposed criteria, feasibility, language, and applications. There were no differences in acceptance based on diagnostic history or current symptom severity.

CONCLUSION

A single definition of recovery does not seem to fit individuals' lived ED experience. Future research may benefit from distinguishing between recovery as an individually-defined phenomenon and related constructs such as remission (i.e., loss of diagnosis or absence of clinical symptoms). A more comprehensive multi-faceted, and person-centered model of recovery may have merit in clinical settings.

Design and testing of a health economic Markov model for treatment of anorexia nervosa

OBJECTIVES

Anorexia Nervosa (AN) is a severe psychiatric disorder and knowledge about the cost-effectiveness of potential interventions is limited. The aim of this paper is to introduce the Trimbos Institute health economic cost-effectiveness model for Anorexia Nervosa (AnoMod-TI), a flexible modelling tool for assessing the long-term cost-effectiveness of interventions for AN in late adolescent and adult patients, which could support clinical decision making.

METHODS

AnoMod-TI is a state-transition cohort simulation (Markov) model developed from a Dutch societal perspective, which consists of four health states - namely full remission (FR), partial remission (PR), AN and death. Results are expressed as total healthcare costs, QALYs and incremental cost-effectiveness ratio.

RESULTS

For the purpose of demonstrating AnoMod-TI and how it could be used to estimate cost-effectiveness over a 20-year time horizon, it was applied to a hypothetical treatment scenario. Results illustrate how a relatively costly intervention with only modest effects can still be cost-effective in the long term.

CONCLUSIONS

AnoMod -TI can be used to examine long-term cost-effectiveness of various interventions aimed at either treating AN or preventing relapse from a state of partial or full remission. AnoMod-TI is freely available upon request to the authors.

Cortical reorganization of the glutamate synapse in the activity-based anorexia rat model: impact on cognition

Patients suffering from anorexia nervosa (AN) display altered neural activity, morphological, and functional connectivity in the fronto‐striatal circuit. In addition, hypoglutamatergic transmission and aberrant excitability of the medial prefrontal cortex (mPFC) observed in AN patients might underpin cognitive deficits that fuel the vicious cycle of dieting behavior. To provide a molecular mechanism, we employed the activity‐based anorexia (ABA) rat model, which combines the two hallmarks of AN (i.e., caloric restriction and intense physical exercise), to evaluate structural remodeling together with alterations in the glutamatergic signaling in the mPFC and their impact on temporal memory, as measured by the temporal order object recognition (TOOR) test. Our data indicate that the combination of caloric restriction and intense physical exercise altered the homeostasis of the glutamate synapse and reduced spine density in the mPFC. These events, paralleled by an impairment in recency discrimination in the TOOR test, are associated with the ABA endophenotype. Of note, after a 7‐day recovery period, body weight was recovered and the mPFC structure normalized but ABA rats still exhibited reduced post‐synaptic stability of AMPA and NMDA glutamate receptors associated with cognitive dysfunction. Taken together, these data suggest that the combination of reduced food intake and hyperactivity affects the homeostasis of the excitatory synapse in the mPFC contributing to maintain the aberrant behaviors observed in AN patients. Our findings, by identifying novel potential targets of AN, may contribute to more effectively direct the therapeutic interventions to ameliorate, at least, the cognitive effects of this psychopathology.

Genetics of anorexia nervosa: an overview of genome-wide association studies and emerging biological links

Anorexia nervosa (AN) is a complex disorder with a strong genetic component. Comorbidities are frequent and there is substantial overlap with other disorders. The lack of understanding of the molecular and neuroanatomical causes has made it difficult to develop effective treatments and it is often difficult to treat in clinical practice. Recent advances in genetics have changed our understanding of polygenic diseases, increasing the possibility of understanding better how molecular pathways are intertwined. This review synthetizes the current state of genetic research providing an overview of genome-wide association studies (GWAS) findings in AN as well as overlap with other disorders, traits, pathways, and imaging results. This paper also discusses the different putative global pathways that are contributing to the disease including the evidence for metabolic and psychiatric origin of the disease.

The association between leptin and weight maintenance outcome in anorexia nervosa

OBJECTIVE

Relapse after weight restoration in anorexia nervosa (AN) is a critical problem. Higher body fat percentage after weight gain has been shown to predict better weight maintenance outcome. Leptin, a fat-derived hormone, has been associated with progress during weight gain, but its association with weight maintenance is unknown. This study aims to determine whether leptin levels after weight restoration in AN are associated with weight maintenance.

METHOD

Participants were 41 women with AN hospitalized for inpatient treatment. Participants were evaluated 2-4 weeks after weight restoration to body mass index (BMI) ≥ 19.5 kg/m² for plasma leptin and body composition. Weight maintenance outcome was defined by whether a participant maintained a BMI of at least 18.5 kg/m² at the end of 1 year following hospital discharge.

RESULTS

Twenty (48.8%) out of 41 patients maintained their weight at 1 year. Percent body fat and leptin were significantly higher in the group who maintained weight (body fat, p = .004, Hedges' g = 0.944; log-leptin, p = .010, Hedges' g = 0.821), but there were no differences in predischarge BMI, duration of illness, and duration of amenorrhea. Using regression modeling, only higher log-leptin (p_Wald = .021) and percent body fat (p_Wald = .010), as well as fat-adjusted leptin (p_Wald = .029), independently predicted weight maintenance at 1 year.

DISCUSSIONS

Our findings suggest that for acutely-weight restored women with AN, higher predischarge leptin measurements are associated with better outcome in the year following treatment. Prospective studies examining leptin as well as other parameters of metabolic health could offer insights into biomarkers that may improve clinical outcomes.

Metacognition in individuals recovered from anorexia nervosa: a voxel-based morphometry study

Recent evidence shows that individuals with Anorexia Nervosa (AN) can be characterized by dysfunctional metacognition as well as reductions of gray matter volumes (GMV) in prefrontal brain regions involved in cognitive processes. However, whether these differences are reversible or stable markers has yet to be understood. Thus, we aimed at characterizing metacognition and brain morphometry in individuals recovered from AN (rec-AN). A combined psychometric-brain morphometry investigation on metacognitive functioning in rec-AN individuals was conducted. Fifteen healthy controls (HC) and fifteen rec-AN women underwent a psychometric assessment for metacognitive functioning and a high-resolution T1-weighted Magnetic Resonance Imaging measurement to assess global and regional brain volumes, using Voxel-Based Morphometry. The two groups did not differ for metacognitive functioning and GMV, while regional GMV reductions were observed in rec-AN compared to HC in the left Inferior Frontal Gyrus (IFG). While changes in metacognitive abilities may not represent a stable trait of AN, regional GMV reductions in brain regions devoted to specific cognitive functions, such as inhibitory/top-down control processes, can act as a neurobiological fingerprint for such condition. These findings can represent a promising hint for future investigations on the maintaining factors of AN.

Functional connectivity underlying hedonic response to food in female adolescents with atypical AN: the role of somatosensory and salience networks

Atypical anorexia nervosa (AN) usually occurs during adolescence. Patients are often in the normal-weight range at diagnosis; however, they often present with signs of medical complications and severe restraint over eating, body dissatisfaction, and low self-esteem. We investigated functional circuitry underlying the hedonic response in 28 female adolescent patients diagnosed with atypical AN and 33 healthy controls. Participants were shown images of food with high (HC) or low (LC) caloric content in alternating blocks during functional MRI. The HC > LC contrast was calculated. Based on the previous literature on full-threshold AN, we hypothesized that patients would exhibit increased connectivity in areas involved in sensory processing and bottom-up responses, coupled to increased connectivity from areas related to top-down inhibitory control, compared with controls. Patients showed increased connectivity in pathways related to multimodal somatosensory processing and memory retrieval. The connectivity was on the other hand decreased in patients in salience and attentional networks, and in a wide cerebello-occipital network. Our study was the first investigation of food-related neural response in atypical AN. Our findings support higher somatosensory processing in patients in response to HC food images compared with controls, however HC food was less efficient than LC food in engaging patients' bottom-up salient responses, and was not associated with connectivity increases in inhibitory control regions. These findings suggest that the psychopathological mechanisms underlying food restriction in atypical AN differ from full-threshold AN. Elucidating the mechanisms underlying the development and maintenance of eating behavior in atypical AN might help designing specific treatment strategies.

Food-Intake Normalization of Dysregulated Fatty Acids in Women with Anorexia Nervosa

Anorexia nervosa (AN) is a psychiatric disorder affected by psychological, environmental, and biological factors. Individuals with AN avoid high-fat, high-calorie diets and have shown abnormal metabolism of fatty acids (FAs), which are essential for brain and cognitive/neuropsychiatric health. To clarify the relationship between FAs and AN, fasting and postprandial plasma FAs in AN patients and age-matched control women were analyzed via mass-spectrometry. Clinical phenotypes were assessed using Becker Anxiety Inventory and Becker Depression Inventory. AN patients and controls exhibited different FA signatures at both fasting and postprandial timepoints. Lauric acid, eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), and alpha-linoleic acid (ALA) were higher in AN than in controls (lauric acid: 15,081.6 ± 14,970.2 vs. 8257.4 ± 4740.2 pmol/mL; ALA at fasting: 2217.7 ± 1587.6 vs. 1087.9 ± 821.2 pmol/mL; ALA at postprandial: 1830.9 ± 1115.6 vs. 1159.4 ± 664.7 pmol/mL. EPA: 33,788.3 ± 17,487.5 vs. 22,860.6 ± 12,642.4 pmol/mL; DPA: 32,664.8 ± 16,215.0 vs. 20,969.0 ± 12,350.0 pmol/mL. FDR-adjusted p-values < 0.05). Food intake and AN status modified the correlations of FAs with body mass index (BMI), depression, and anxiety. Desaturases SCD-18 and D6D showed lower activities in AN compared to controls. Altered FA signature, specifically correlations between elevated n-3 FAs and worsened symptoms, illustrate metabolic underpinnings in AN. Future studies should investigate the mechanisms by which FA dysregulation, specifically elevated n-3 FAs, affects AN risk and outcome.

Brain and Cognitive Development in Adolescents with Anorexia Nervosa: A Systematic Review of fMRI Studies

Anorexia nervosa (AN) is an eating disorder often occurring in adolescence. AN has one of the highest mortality rates amongst psychiatric illnesses and is associated with medical complications and high risk for psychiatric comorbidities, persisting after treatment. Remission rates range from 23% to 33%. Moreover, weight recovery does not necessarily reflect cognitive recovery. This issue is of particular interest in adolescence, characterized by progressive changes in brain structure and functional circuitries, and fast cognitive development. We reviewed existing literature on fMRI studies in adolescents diagnosed with AN, following PRISMA guidelines. Eligible studies had to: (1) be written in English; (2) include only adolescent participants; and (3) use block-design fMRI. We propose a pathogenic model based on normal and AN-related neural and cognitive maturation during adolescence. We propose that underweight and delayed puberty-caused by genetic, environmental, and neurobehavioral factors-can affect brain and cognitive development and lead to impaired cognitive flexibility, which in turn sustains the perpetuation of aberrant behaviors in a vicious cycle. Moreover, greater punishment sensitivity causes a shift toward punishment-based learning, leading to greater anxiety and ultimately to excessive reappraisal over emotions. Treatments combining physiological and neurobehavioral rationales must be adopted to improve outcomes and prevent relapses.

Activity Based Anorexia as an Animal Model for Anorexia Nervosa-A Systematic Review

Anorexia nervosa (AN) is a severe eating disorder affecting around 1 per 100 persons. However, the knowledge about its underlying pathophysiology is limited. To address the need for a better understanding of AN, an animal model was established early on in the late 1960's: the activity-based anorexia (ABA) model in which rats have access to a running wheel combined with restricted food access leading to self-starving/body weight loss and hyperactivity. Both symptoms, separately or combined, can also be found in patients with AN. The aim of this systematic review was to compile the current knowledge about this animal model as well as to address gaps in knowledge. Using the data bases of PubMed, Embase and Web of science 102 publications were identified meeting the search criteria. Here, we show that the ABA model mimics core features of human AN and has been characterized with regards to brain alterations, hormonal changes as well as adaptations of the immune system. Moreover, pharmacological interventions in ABA animals and new developments, such as a chronic adaptation of the ABA model, will be highlighted. The chronic model might be well suited to display AN characteristics but should be further characterized. Lastly, limitations of the model will be discussed.

Relapse in anorexia nervosa: a systematic review and meta-analysis

PURPOSE OF REVIEW

Relapse is common in patients with anorexia nervosa. The aim of this study is to systematically review the existing literature on relapse in anorexia nervosa.

RECENT FINDINGS

A systematic literature search was conducted in PubMed, PsychInfo and CINAHL published up to April 2018. Of the 1527 studies screened, 16 studies were included in the present review.

SUMMARY

This analysis shows that, of the patients included in this review, 31% relapsed after treatment. The highest risk of relapse is during the first year after discharge and this risk continues for up to 2 years. An overview was made of all factors significantly associated with a higher risk of relapse, resulting in the following four clusters: eating disorder variables, comorbidity symptoms, process treatment variables and demographic variables. Future research on relapse prevention is necessary to further unravel the mechanisms that might lead to relapse.

Relapse prevention in anorexia nervosa: Experiences of patients and parents

One of the main aims of treatment after successful recovery from anorexia nervosa (AN) is to prevent a relapse. The Guideline Relapse Prevention (GRP) Anorexia Nervosa offers a structured approach to relapse prevention. This study explores how patients and their parents experience working with the guideline. It also describes the factors that support or hinder successful application of the guideline. A descriptive qualitative research design was chosen involving in-depth interviews with seventeen patients with anorexia nervosa and six sets of parents. Patients and family members were generally satisfied with the support provided by the GRP. It contributed significantly to a better understanding of the personal process of relapse. Patients and families valued being able to keep in touch with their professional during the aftercare programme. The GRP supports the patient's use of self-management strategies for relapse prevention.

A Novel In-Home Relapse Prevention Treatment for Anorexia Nervosa

Anorexia nervosa (AN) is a difficult-to-treat mental illness associated with dangerous behavioral symptomatology. Interventions that augment the outcomes of existing inpatient and outpatient protocols for AN are critically needed. In-home treatments that address environmental change as a means to further promote behavior change have been applied for the care of multiple behaviorally based psychiatric illnesses, but not for eating disorders. The present study outlines the pilot application of a posthospitalization, four-session in-home relapse prevention treatment for a woman with a long history of AN. Over a 1-, 3-, and 6-month follow-up period, the patient exhibited substantial improvements in eating disorder symptomatology, sustained a healthy body mass index, and maintained positive environmental changes made by the end of treatment. The treatment was feasible and readily accepted by the patient. These positive findings suggest that more formalized research to further evaluate this novel adjunctive treatment for AN is warranted.

Role of antidepressants in the treatment of adults with anorexia nervosa

Introduction:

Anorexia nervosa (AN) is a severe psychiatric disorder that is difficult to treat and is associated with frequent relapses and high mortality rates. Psychiatric symptomatology (eg, depression, anxiety, obsessive-compulsive disorder/behaviors) are common comorbidities. This review provides current information about safety and efficacy of antidepressant therapy for management of AN in adults.

Methods:

A literature review of randomized controlled trials, open-label studies, and case reports with adults or adults/adolescents was conducted. PubMed and Medline were searched using anorexia management and treatment, antidepressants, selective serotonin reuptake inhibitors (SSRIs), fluoxetine, sertraline, citalopram, and mirtazapine in AN, relapse prevention in AN, and psychotropic medications in AN.

Results:

The role and utility of antidepressants in AN were published in double-blind, placebo-controlled studies; open-label trials; and a retrospective study. Antidepressants should not be used as sole therapy for AN although their use for confounding symptomatology makes discerning efficacy difficult as they are given together with other therapies. Neurobiological changes due to starvation and AN itself complicate results interpretation. For safety, tricyclic antidepressants and monoamine oxidase inhibitors are not recommended, and bupropion is contraindicated. Use of SSRIs during acute treatment lacks efficacy. Use of SSRIs—primarily fluoxetine and to some extent citalopram, sertraline, or mirtazapine—may aid in relapse prevention and improvement of psychiatric symptomatology in weight-restored anorexic patients.

Discussion:

Health care professionals should use clinical judgment regarding fluoxetine or possibly citalopram, sertraline or mirtazapine as adjunctive treatment to psychotherapy for relapse prevention, improvement of depressive and anxiety symptoms, and/or obsessive-compulsive behaviors unresolved with nutritional rehabilitation and psychotherapy.

Establishment of a chronic activity-based anorexia rat model

BACKGROUND

Anorexia nervosa (AN) is often a chronic eating disorder characterised by body image disturbance and low body weight often associated with starvation-induced amenorrhoea and excessive exercise. Activity-based anorexia (ABA) is an animal model representing many somatic aspects of this psychiatric illness. We systematically manipulated the extent and length of starvation and animal age to find the optimal parameters to study chronic starvation.

NEW METHODS

Wistar rats had 24h/day running wheel access and received 40% of their baseline food intake until a 20% or 25% weight reduction was reached (acute starvation). This body weight was then maintained for two weeks (chronic starvation). The rats of different ages of 4 or 8 weeks were used to represent early and late adolescent animals, respectively. The complete absence of a menstrual cycle was defined as the primary outcome parameter.

RESULTS

Acute starvation caused a disruption of the oestrous cycle in 58% of the animals. During chronic starvation, a complete loss of the oestrous cycle could be found. Furthermore, 4-week-old rats exhibited higher levels of hyperactivity and amenorrhoea than 8-week-old animals. A 20% starvation level led to 90% loss of cycle, while a 25% starvation level triggered complete loss.

COMPARISON WITH EXISTING METHODS

Most current ABA models focus on acute starvation, while most patients are chronically ill.

CONCLUSIONS

The optimal parameters to achieve complete amenorrhoea included early adolescence, chronic starvation and 25% weight loss. The new ABA model allows studying the effects of chronic AN on underlying behavioural, hormonal and brain pathobiology.

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

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