Lifetime course of eating disorders: design and validity testing of a new strategy to define the eating disorders phenotype

Prospective associations between cognitive flexibility and eating disorder symptoms in anorexia nervosa and bulimia nervosa

This study investigated concurrent and prospective associations between measures of reversal learning and attentional set-shifting and eating disorder symptoms at baseline, 3 months, and 6 months among individuals with anorexia nervosa restricting subtype (AN-R, n = 26), AN binge eating/purging subtype (AN-BP, n = 22), bulimia nervosa (BN, n = 35), and healthy controls (n = 27), and explored whether these associations differed by diagnosis. At baseline, participants completed diagnostic interviews, height/weight measurements, and measures of set-shifting (the Intradimensional/Extradimensional shift task) and reversal learning (a probabilistic reversal learning task). At 3- and 6-month follow-up, participants with eating disorders completed assessments of weight and eating disorder symptoms. A one-way analysis of variance found no evidence that baseline reversal learning and attentional set-shifting differed across diagnostic groups. Multilevel modeling analyses indicated that perseverative errors (an index of reversal learning) predicted an increase in purging over time for individuals with AN-BP and BN. Set-shifting errors differentially predicted frequency of loss of control eating for individuals with AN-BP and BN; however, set-shifting was not related to loss of control eating when examined separately in AN-BP and BN. These findings suggest that disentangling facets of cognitive flexibility may help understand change in eating disorder symptoms.

Pediatric feeding disorders among children with parental history of feeding disorders: a distinct group of patients with unique characteristics

To investigate factors associated with pediatric feeding disorders (PFD) among children of parents that reported to have had feeding disorders during their own childhood compared to children with PFD with no history of parental PFD. We retrospectively reviewed the medical records of children diagnosed with PFD according to the recent WHO-based definition. The demographic and clinical characteristics of children with PFD with a parental history of PFD were compared to those of children with a PFD with no history of parental PFD. Included were 231 children with PFD (median [interquartile range] age 10 months [5.5-29] at diagnosis, 58% boys) of whom 133 children had parents without PFD and 98 children had parents with PFD. Unexpectedly, children of parents without PFD had a higher rate of low birth weight (28% vs. 19%, respectively, p = 0.007), more delivery complications (10% vs. 2%, p = 0.006), more hospitalizations (33% vs. 17%, p = 0.004), more prescription medications (27% vs. 18%, p = 0.05), and a higher percent of gastrostomy tube use (6% vs. 0, p = 0.02). Moreover, more parents with PFD had academic background compared with parents without PFD (72% vs. 59%, p = 0.05). There were no significant group differences in sex, history of breastfeeding, parental marital status, or type of the child's feeding disorder.  Conclusion: PFD among children with a parental history of PFD comprise a distinct group of patients with unique characteristics and outcomes. Since parental feeding history may explain their child's PFD in highly differing ways, such information may help in devising a specific family-based and multidisciplinary treatment plan for those children. What is Known: • Pediatric feeding disorder (PFD) is relatively common and its prevalence is increasing. • Information on an association between parental PFD and their child's feeding disorder is limited. What is New: • PFD among children with a parental history of PFD comprise a distinct group of patients with various characteristics and outcomes. • The parents' feeding history during childhood may provide important clues to their child's PFD.

Differences and similarities in personality functioning across different types of eating disorders

Objective

The classification of anorexia nervosa (AN) into subtypes is relevant due to their different symptomatology. However, subtypes (restricting type: AN-R; purging type: AN-P) differ also in terms of their personality functioning. Knowledge about these differences would allow for better treatment stratification. A pilot study indicated differences in structural abilities that can be assessed by the operationalized psychodynamic diagnosis (OPD) system. The aim of this study was therefore to systematically explore differences in personality functioning and personality between the two AN subtypes and bulimia nervosa (BN) using three personality (functioning) constructs.

Methods

A total of N = 110 inpatients with AN-R (n = 28), AN-P (n = 40), or BN (n = 42) were recruited in three clinics for psychosomatic medicine. Assignment to the three groups was performed using a comprehensive questionnaire validated for diagnostic purposes (Munich-ED-Quest). Personality functioning was examined using OPD Structure Questionnaire (OPD-SQ), personality by using the Personality Inventory for DSM-5-Brief Form and Big Five Inventory-10. (M)ANOVAs were used to examine differences across eating disorder groups. In addition, correlation and regression analyses were conducted.

Results

We observed differences on several sub- and main scales of the OPD-SQ. Whereas patients with BN showed the lowest levels, AN-R patients displayed the highest levels of personality functioning. On some sub- and main scales, such as "affect tolerance," the subtypes of AN differed from BN, whereas on the scale "affect differentiation," AN-R, differed from the other two groups. The total eating disorder pathology score of the Munich-ED-Quest best predicted overall personality structure [stand. β = 0.650; t(104) = 6.666; p < 0.001] and self-regulation [stand. β = 0.449; t(104) = 3.628; p < 0.001].

Discussion

Our findings confirm most of the results of the pilot study. These findings can facilitate the development of stratified treatment approaches for eating disorders.

One size does not fit all: Exploring how the five-factor model facets predict disordered eating behaviours among adolescent and young adult males and females

There is a wealth of research that has highlighted the relationship between personality and eating disorders. It has been suggested that understanding how subclinical disordered eating behaviours are uniquely associated with personality can help to improve the conceptualization of individuals with eating disorders. This study aimed to explore how the facets of the Five-Factor Model (FFM) predicted restrictive eating, binge eating, purging, chewing and spitting, excessive exercising and muscle building among males and females. An online survey assessing disordered eating behaviours, FFM and general psychopathology was completed by 394 females and 167 males aged between 16 and 30 years. Simultaneous equations path models were systematically generated for each disordered eating behaviour to identify how the FFM facets, body dissatisfaction and age predicted behaviour. The results indicated that each of the six disordered behaviours were predicted by a unique pattern of thinking, feeling and behaving. Considerable differences between males and females were found for each path model, suggesting differences between males and females in the personality traits that drive disordered eating behaviours. It was concluded that it is important to take personality into account when treating males and females who engage in disordered eating behaviours.

The impact of personality disorders and personality traits on psychotherapy treatment outcome of eating disorders: A systematic review

A significant proportion of those with eating disorders (EDs) do not respond to first-line treatments. This systematic review was conducted to identify whether personality disorders (PDs)/traits predict or moderate ED treatment outcomes and whether these outcomes were differentially influenced by ED or PD diagnostic subtypes, or treatment approach. A comprehensive systematic literature search was conducted using the PRISMA guidelines. A total of seven randomised controlled trials (RCTs) plus four follow-up studies were reviewed investigating the impact of PD and PD traits on treatment outcomes for EDs. The majority indicated that PD had some impact on treatment outcomes. Outcome measures and time-point measurements varied across studies. Included studies suggested that bulimia nervosa treatment outcomes were not hindered by co-morbidity of borderline PD; however, psychiatric impairment remained high at post-treatment and follow-up. Cluster C PDs were found to negatively impact treatment outcomes for binge ED and attrition rates for anorexia nervosa. Included studies suggested that interventions that addressed aspects of personality pathology showed greater main effects for ED treatment outcomes. There is an urgent need for future RCTs on ED treatments to include routine measures of core personality features to allow their impacts to be more thoroughly examined and for psychotherapies to be tailored accordingly.

The transition from restrictive anorexia nervosa to binging and purging: a systematic review and meta-analysis

Numerous studies addressed the topic of behavioral and symptomatic changes in eating disorders. Rates of transition vary widely across studies, ranging from 0 to 70.8%, depending on the diagnoses taken into account and the study design. Evidence shows that the specific transition from restrictive-type anorexia nervosa (AN-R) to disorders involving binging and purging behaviors (BPB) is related to a worsening of the clinical picture and worse long-term outcomes. The aim of this systematic review and meta-analysis is to focus on this specific transition, review existing literature, and summarize related risk factors. Medline and PsycINFO databases were searched, including prospective and retrospective studies on individuals with AN-R. The primary outcome considered was the rate of onset of BPB. Twelve studies (N = 725 patients) were included in the qualitative and quantitative analysis. A total of 41.84% (95% CI 33.58-50.11) of patients with AN-R manifested BPB at some point during follow-up. Risk factors for the onset of BPB included potentially treatable and untreatable factors such as the family environment, unipolar depression and higher premorbid BMI. These findings highlight that patients with AN-R frequently transition to BPB over time, with a worsening of the clinical picture. Existing studies in this field are still insufficient and heterogeneous, and further research is needed. Mental health professionals should be aware of the frequent onset of BPB in AN-R and its risk factors and take this information into account in the treatment of AN-R. LEVEL OF EVIDENCE: Evidence obtained from a systematic review and meta-analysis, Level I.

The relationship between disordered eating behaviour and the five factor model personality dimensions: A systematic review

The relationship between personality and eating disorders has received significant research attention. This review aimed to synthesize research regarding the Five Factor Model (FFM) and disordered eating behaviors, to gain an improved understanding of the relationship between normal-range personality and subclinical eating disorders. Electronic Databases were used to identify studies published in English that utilized self-report measures of disordered eating and the FFM. A qualitative synthesis of 45 papers was then conducted. High scores on Neuroticism were associated with increased disordered eating behavior. Different disordered eating behaviors were found to have unique relationships with personality dimensions. Facets within domains varied in direction of correlation with disordered eating behaviors, particularly in the Agreeableness, Contentiousness, and Openness domains. The results indicate that, further research is needed before generalizing treatment approaches for eating disorders for females, males, and gender diverse populations.

Comorbid obsessive-compulsive disorder in individuals with eating disorders: An epidemiological meta-analysis

The present study aimed to provide a precise, meta-analytic estimate of the prevalence of obsessive-compulsive disorder (OCD) amongst those with a current primary eating disorder (ED) diagnosis, and to isolate its predictors. An online search of PubMed and PsycINFO was conducted with a Boolean search phrase incorporating keywords related to OCD, EDs, comorbidity, prevalence, and epidemiology, complemented by references coded from related review articles and contact with experts in the field. Articles were included if they (a) reported an observational study examining current ED diagnoses, (b) used a semi-structured or structured diagnostic interview for OCD and ED diagnosis, (c) applied DSM or ICD criteria, (d) included adolescent or adult samples (age > 12), (e) included patient or community samples, and (f) reported lifetime or current OCD comorbidity. From the 846 articles identified, 35 lifetime and 42 current estimates were calculated. OCD prevalence was extracted from each study for each ED diagnostic category, along with eleven additional potential moderators. Analyses revealed an aggregate lifetime OCD prevalence of 13.9% CI_95% [10.4 to 18.1] and current OCD prevalence of 8.7% CI_95% [5.8 to 11.8] across EDs. Moderator analyses revealed the prevalence of and risk for OCD in EDs to be greatest in anorexia nervosa binge-eating purging type (ANBP). Further, OCD is most prevalent amongst patient samples than samples recruited from the community.

Association among Autistic Traits, Treatment Intensity and Outcomes in Adolescents with Anorexia Nervosa: Preliminary Results

The present study investigates the impact of Autism Spectrum Disorder (ASD) traits on the treatment intensity and outcomes (psychopathology and weight) of 22 adolescent inpatients with Anorexia Nervosa (AN), who were selected on the basis of suspected ASD traits. ASD traits were measured at admission (T0) using the Autism Diagnostic Observation Schedule-Second Edition (ADOS-2) and the Autism-Spectrum Quotient (AQ). Psychopathology was measured with Eating Disorder Inventory-3 (EDI-3) and Self-Administered Psychiatric Scales for Children and Adolescents (SAFA) at admission and discharge (T0, T1). Percentage BMI was assessed at admission, discharge, first follow-up (T2, 7–22 days) and second follow-up (T3, 22–45 days). Results were controlled for age and EDI-3 global psychological maladjustment. When compared with other patients with AN, AN individuals with ADOS-2 and AQ diagnostic scores for ASD showed overlapping types of treatments, as well as psychopathological and weight outcomes. ASD total scores were not correlated with treatment intensity or treatment outcomes. Preliminary results show that ASD traits do not impact treatment intensity and outcomes in adolescents with AN and suspected ASD traits.

Rates of comorbid obsessive-compulsive disorder in eating disorders: A meta-analysis of the literature

BACKGROUND

The high comorbidity between Eating Disorders (EDs) and Obsessive-Compulsive disorder (OCD) is well known, as well as its implications in terms of worse outcome and need to adapt treatment. Estimates of OCD comorbidities in EDs are variable in different studies and poorly informative for clinical purposes. In this study, we sought to derive more consistent estimates, taking into account potential methodological and sampling confounding factors.

METHODS

We searched published studies reporting lifetime and current rates of comorbid OCD in ED samples based on recent diagnostic criteria. Comorbidity rates were meta-analyzed using a binary random effects model. Heterogeneity among the studies and publication bias were systematically checked. Potential confounding factors were tested by meta-regression analysis and adjusted by sensitivity analysis.

RESULTS

Globally, respectively 18% and 15% of all patients with an ED had a lifetime and current comorbidity with OCD. Rates were slightly higher in anorexia (19% and 14%) than in bulimia nervosa (13% and 9%), although only the current comorbid OCD was significantly higher in anorexia than in bulimia. Prospective follow-up studies provided considerably higher lifetime estimates (EDs 38%, anorexia 44%, bulimia 19%).

LIMITATIONS

Temporal/causal relationship between ED and OCD could not be defined.

CONCLUSIONS

OCD comorbidity in EDs is a relevant phenomenon, affecting almost one fifth of the patients in cross-sectional observations and up to nearly 40% in prospective follow-up studies. These data indicate the need for focused attention to non-food or body-shape related OCD symptoms, for better diagnostic and prognostic accuracy, and targeted treatment.

Association of Genetic and Phenotypic Assessments With Onset of Disordered Eating Behaviors and Comorbid Mental Health Problems Among Adolescents

IMPORTANCE

Eating disorders are serious mental disorders with increasing prevalence. Without early identification and treatment, eating disorders may run a long-term course.

OBJECTIVE

To characterize any associations among disordered eating behaviors (DEBs) and other mental health disorders and to identify early associations with the development of symptoms over time.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, population-based, longitudinal cohort study used data from baseline (collected in 2010), follow-up 1 (collected in 2012), and follow-up 2 (collected in 2015) of the IMAGEN Study, which included adolescents recruited from 8 European sites. The present study assessed data from 1623 healthy adolescents, aged 14 years at baseline, recruited from high schools. Data analyses were performed from January 2018 to September 2019.

MAIN OUTCOMES AND MEASURES

Body mass index (BMI), mental health symptoms, substance use behaviors, and personality variables were investigated as time-varying associations of DEBs (dieting, binge eating, and purging) or change in BMI over time. Polygenic risk scores were calculated to investigate genetic contributions associated with BMI, attention-deficit/hyperactivity disorder (ADHD) and neuroticism to DEBs.

RESULTS

In this cohort study of 1623 adolescents (829 girls [51.1%]) recruited at a mean (SD) age of 14.5 (0.4) years and followed up at ages 16 and 19 years, 278 adolescents (17.1%) reported binge eating, 334 adolescents (20.6%) reported purging, and 356 adolescents (21.9%) reported dieting at 14, 16, or 19 years. Among the precursors of DEBs, high BMI was associated with future dieting (OR, 3.44; 95% CI, 2.09-5.65). High levels of neuroticism (OR, 1.04; 95% CI, 1.01-1.06), conduct problems (OR, 1.41; 95% CI, 1.17-1.69), and deliberate self-harm (OR, 2.18; 95% CI, 1.37-3.45) were associated with future binge eating. Low agreeableness (OR, 0.95; 95% CI, 0.92-0.97), deliberate self-harm (OR, 2.59; 95% CI, 1.69-3.95), conduct problems (OR, 1.42; 95% CI, 1.20-1.68), alcohol misuse (OR, 1.31; 95% CI, 1.10-1.54), and drug abuse (OR, 2.91; 95% CI, 1.78-4.74) were associated with future purging. Polygenetic risk scores for BMI were associated with dieting (at 14 years: OR, 1.27; lower bound 95% CI, 1.08; at 16 years: OR, 1.38; lower bound 95% CI, 1.17); ADHD, with purging (at 16 years: OR, 1.25; lower bound 95% CI, 1.08; at 19 years, OR, 1.23; lower bound 95% CI, 1.06); and neuroticism, with binge eating (at 14 years: OR, 1.32; lower bound 95% CI, 1.11; at 16 years: OR, 1.24; lower bound 95% CI, 1.06), highlighting distinct etiologic overlaps between these traits. The DEBs predated other mental health problems, with dieting at 14 years associated with future symptoms of depression (OR, 2.53; 95% CI, 1.56-4.10), generalized anxiety (OR, 2.27; 95% CI, 1.14-4.51), deliberate self-harm (OR, 2.10; 95% CI, 1.51-4.24), emotional problems (OR, 1.24; 95% CI, 1.08-1.43), and smoking (OR, 2.16; 95% CI, 1.36-3.48). Purging at 14 years was also associated with future depression (OR, 2.87; 95% CI, 1.69-5.01) and anxiety (OR, 2.48; 95% CI, 1.49-4.12) symptoms.

CONCLUSIONS AND RELEVANCE

The findings of this study delineate temporal associations and shared etiologies among DEBs and other mental health disorders and emphasize the potential of genetic and phenotypical assessments of obesity, behavioral disorders, and neuroticism to improve early and differential diagnosis of eating disorders.

Exploring the Eating Disorder Examination Questionnaire, Clinical Impairment Assessment, and Autism Quotient to Identify Eating Disorder Vulnerability: A Cluster Analysis

Eating disorders are very complicated and many factors play a role in their manifestation. Furthermore, due to the variability in diagnosis and symptoms, treatment for an eating disorder is unique to the individual. As a result, there are numerous assessment tools available, which range from brief survey questionnaires to in-depth interviews conducted by a professional. One of the many benefits to using machine learning is that it offers new insight into datasets that researchers may not previously have, particularly when compared to traditional statistical methods. The aim of this paper was to employ k-means clustering to explore the Eating Disorder Examination Questionnaire, Clinical Impairment Assessment, and Autism Quotient scores. The goal is to identify prevalent cluster topologies in the data, using the truth data as a means to validate identified groupings. Our results show that a model with k = 2 performs the best and clustered the dataset in the most appropriate way. This matches our truth data group labels, and we calculated our model’s accuracy at 78.125%, so we know that our model is working well. We see that the Eating Disorder Examination Questionnaire (EDE-Q) and Clinical Impairment Assessment (CIA) scores are, in fact, important discriminators of eating disorder behavior.

Alexithymia may explain the relationship between autistic traits and eating disorder psychopathology

BACKGROUND

Autistic people are disproportionately vulnerable to anorexia nervosa and other eating disorders (ED), and within the general population, autistic traits correlate with ED psychopathology. A putative mechanism which may underpin this heightened risk is alexithymia, a difficulty identifying and describing emotional states which is observed in both autism and ED. In two experiments with independent non-clinical samples, we explored whether alexithymia might mediate the heightened risk of eating psychopathology in individuals high in autistic traits.

METHODS

Our first experiment used the PROCESS macro for SPSS to examine relationships between alexithymia (measured by the Toronto Alexithymia Scale (TAS-20)), autistic traits (autism quotient (AQ)), and eating psychopathology (Eating Attitudes Test (EAT-26)) in 121 participants. Our second experiment (n = 300) replicated and furthered this analysis by examining moderating effects of sex and controlling for anxiety and depression as covariates. We also included an additional performance-based measure of alexithymia, the Levels of Emotional Awareness Scale (LEAS).

RESULTS

Study 1 suggested that TAS-20 scores mediated the relationship between heightened autistic traits and eating psychopathology. Replication and further scrutiny of this finding, in study 2, revealed that this mediation effect was partial and specific to the female participants in this sample. The mediation effect appeared to be carried by the difficulty identifying feelings subscale of the TAS-20, even when depression and anxiety were controlled for. LEAS scores, however, were not significantly related to autistic traits or eating psychopathology.

LIMITATIONS

Cross-sectional data prevents any conclusions around the direction and causality of relationships between alexithymia, autistic traits, and eating psychopathology (alongside depression and anxiety), necessitating longitudinal research. Our non-clinical sample was predominantly Caucasian undergraduate students, so it remains to be seen if these results would extrapolate to clinical and/or autistic samples. Divergence between the TAS-20 and LEAS raises crucial questions regarding the construct validity of these measures.

CONCLUSIONS

Our findings with respect to autistic traits suggest that alexithymia could partially explain the prevalence of ED in autistic people and may as such be an important consideration in the pathogenesis and treatment of ED in autistic and non-autistic people alike. Further research with clinical samples is critical to explore these ideas. Differences between men and women, furthermore, emphasize the importance of looking for sex-specific as well as generic risk factors in autistic and non-autistic men and women.

Self-criticism longitudinally predicts nonsuicidal self-injury in eating disorders

Dialectical Behavior Therapy (DBT) has long been successfully applied to such behaviors such as nonsuicidal self-injury (NSSI) and more recently, bulimic behaviors. However, it is less clear how patients experiencing these comorbid symptoms may benefit from this treatment modality. Self-criticism, defined as a highly negative attitude towards the self, has been implicated in both EDs and NSSI and is amenable to DBT; thus, further examination of this construct may be beneficial in informing DBT treatment approaches. However, research has only examined these relationships cross-sectionally and no published research has examined self-criticism as a longitudinal predictor of NSSI and ED symptoms. Thus, this study examined self-criticism as a potential driving factor of NSSI in EDs in order to inform treatments, particularly DBT. Data were collected from 92 treatment-seeking adults at ED treatment facilities in the United States. Participants self-reported ED pathology, NSSI engagement, and self-criticism at baseline and a two-month follow-up. A path analysis revealed that self-criticism at baseline was associated with NSSI frequency at follow-up over and above baseline NSSI and ED symptomology. Self-criticism at baseline was not associated with ED pathology at follow-up. Self-criticism longitudinally predicted NSSI, but not ED pathology, in an ED sample. As such, it may be important for clinicians to assess for self-criticism and consider treatments that target both self-criticism and self-injury, like DBT, for this population.

Extreme Risk-Taking Behaviors in Patients With Eating Disorders

BACKGROUND

Patients with eating disorders (EDs) engage in different self-inflicted at-risk behaviors, including suicide, attempted suicide and non-suicidal self-injury. Our aim was to describe the occurrence and underlying motivations of non-suicidal extreme risk-taking behaviors in patients with EDs.

METHODS

Four cases from different treatment centers in Israel were analyzed.

RESULTS

All patients were females hospitalized in inpatient settings because of long lasting anorexia nervosa (AN) with either binge/purge or purging episodes (AN-B/P/AN-P), including in most cases both self-induced voting and laxative abuse. Case [1] was an adolescent also diagnosed with type 1 diabetes mellitus. She abused insulin, both omission and overdose, was highly suicidal, and suffered from comorbid oppositional behavior, depression and anxiety. Case [2] was a 24-years old woman, transitioning from restricting to AN with vomiting and laxative use during inpatient treatment. She was also diagnosed with attention deficit hyperactivity disorder, depression, anxiety, and suicidal thoughts. In hospital, she developed excessive water consumption, leading to very low urine concentrations and sodium levels, and one episode of loss of consciousness. Case [3] was in her late thirties, demonstrating particularly massive laxative abuse. She also suffered from alcohol addiction, sexual trauma, and one attempted suicide. During hospitalization she developed laxative-abuse-related rectal prolapse that was successfully operated. Nonetheless, after operation she resumed laxative abuse. Case [4] was a 23-year old pregnant women with highly active AN-B/P during pregnancy. She was hospitalized at 23 weeks of gestation following abdominal pressure. She only partly complied with inpatient treatment, discharged herself against medical advice after 5 weeks, and gave birth at week 34.

DISCUSSION

All cases were females with long-standing B/P type AN, often with multiple purging behaviors, other impulsive and non-impulsive comorbidities, and many environmental vulnerabilities. Different motivations were found for these extreme behaviors in addition to ED-related factors, mostly not related to suicide. The severity of the medical and psychological condition required multimodal medical and psychological inpatient interventions. The patients mostly did not comply with their treatment, showing considerable indifference to their grave medical condition.

Facilitators and barriers in anorexia nervosa treatment initiation (FABIANA): study protocol for a mixed-methods and multicentre study

BACKGROUND

Anorexia nervosa is a serious disorder, which often takes a chronic course. Early treatment leads to a significantly better prognosis and prevents chronicity. However, existing evidence on facilitators and barriers in anorexia nervosa treatment initiation is scarce.

AIMS

Against this background, the FABIANA study (ClinicalTrials.gov Identifier: NCT03713541) aims to (a) identify potentially modifiable facilitators and barriers from the perspectives of adolescent and adult patients with anorexia nervosa, carers and physicians, (b) develop and test an instrument for the combined assessment of multiple key facilitators and barriers, and (c) quantify the effect of potentially modifiable versus non-modifiable key facilitators and barriers on the duration of untreated illness (DUI) in patients with anorexia nervosa.

METHOD

FABIANA is an observational, mixed-method-study divided into three consecutive substudies each corresponding to one of the study aims. All three substudies will include female patients with anorexia nervosa aged 14 years and older at the beginning of their first psychotherapeutic anorexia nervosa treatment. The qualitative substudy I and the quantitative substudy III will additionally include carers and involved physicians. The recruitment will take place at 20 cooperating study centres throughout Germany, which provide in-patient or out-patient anorexia nervosa specialist care. The DUI will be calculated based on the month of illness onset as determined in validated interviews on lifetime anorexia nervosa symptoms and the therapist-reported date of treatment initiation.

CONCLUSIONS

Strengths and limitations of the retrospective assessment of the DUI will be discussed. The findings of the FABIANA study will contribute to the development of evidence-based early-intervention approaches and the prevention of a chronic course of illness.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03713541.

DECLARATION OF INTEREST

None.

Mentalizing Self and Other and Affect Regulation Patterns in Anorexia and Depression

The study aimed to examine two constructs: general mentalizing processes and the specific component of affective mentalizing regarding self and others alongside the construct of affect regulation patterns in female adolescent and young adult inpatients with anorexia nervosa (AN; n = 41), depression (n = 20) and controls (n = 53). We further examined the predictive ability of affect regulation to eating-disorder (ED) symptoms beyond that of the mentalizing variables, and their potential role in mediating between mentalizing, depression and ED symptoms. We used tools assessing reflective functioning (RF), complex emotion recognition and theory of mind (ToM), alexithymia, affect regulation, depression, and ED symptoms. The AN and depression groups exhibited lower general mentalizing and higher alexithymia, emotional reactivity, and emotional cutoff patterns than controls, but showed no greater disturbance in ToM. The two clinical groups did not differ on any of these variables. Elevated mentalizing and adequate affect regulation patterns separately predicted lower severity of ED symptoms. Nonetheless, affect regulation did not add to the predictive value of mentalizing variables. Specifically, elevated alexithymia, and depressive symptomatology, but not RF, predicted greater ED symptomatology. Moreover, alexithymia directly accounted for elevated ED symptoms and also indirectly connected with ED symptoms via emotional hyperactivation and elevated depressive symptoms. These findings suggest that deficiencies in mentalization and affect regulation are not unique to AN, but may rather associated with psychopathology in general. Nonetheless, alexithymia and depression may increase ED-related symptomatology. Affect regulation deficiencies are mainly related with depressive symptoms and emotional hyperactivation is indirectly related with AN via the depressive symptoms.

Personality Variables and Eating Pathology

Personality variables have long been implicated in the onset and maintenance of eating disorders, as well as in symptom divergence between anorexia nervosa and bulimia nervosa. Clinical observations are broadly supported by the data, with restricting anorexia nervosa associated with higher levels of constraint and Persistence, and binge-purge behaviors linked to the tendency to take impulsive action when emotionally distressed. Considerable heterogeneity is found within diagnostic categories, however, suggesting that different personality structures may predispose individuals to develop disordered eating through alternative pathways.

Impact of eating disorders on obstetric outcomes in a large clinical sample: A comparison with the HUNT study

OBJECTIVE

Current evidence from clinical studies suggests that having an active eating disorder (ED) during pregnancy is associated with unfavorable obstetric outcomes. However, the role of a lifetime diagnosis of ED is not fully understood. Variations in findings suggest a need for additional studies of maternal ED. This study aims to identify associations between a lifetime ED and obstetric outcomes.

METHOD

Data from a hospital patient register and a population-based study (The HUNT Study) were linked to the Medical Birth Registry in Norway. Register based information of obstetric complications (preeclampsia, preterm birth, perinatal deaths, small for gestational age (SGA), large for gestational age (LGA), Caesarean sections, and 5-min Apgar score) were acquired for 532 births of women with ED and 43,657 births of non-ED women. Multivariable regression in generalized estimating equations was used to account for clusters within women as they contributed multiple births to the dataset.

RESULTS

After adjusting for parity, maternal age, marital status, and year of delivery, lifetime history of anorexia nervosa was associated with increased odds of having offspring who were SGA (Odds ratio (OR) 2.7, 95% Confidence Interval (CI) 1.4-5.2). Women with a lifetime history of bulimia nervosa had higher odds of having a Caesarian section (OR 1.7 95% CI 1.1-2.5). Women with EDNOS/sub-threshold ED had a higher likelihood of having a low Apgar score at 5 min (OR 3.1, 95% CI 1.1-8.8).

CONCLUSION

Our study corroborates available evidence on the associations between maternal ED and adverse obstetric outcomes.

Altered Reward Reactivity as a Behavioural Endophenotype in Eating Disorders: A Pilot Investigation in Twins

Altered reward reactivity is a potential risk endophenotype for eating disorders (EDs). The aim of this study was to examine reward reactivity in female twins with EDs and compare it with a twin control group. A sample of 112 twins [n = 51 met lifetime DSM-IV ED criteria (anorexia nervosa n = 26; bulimic disorders n = 24), n = 19 unaffected cotwins and n = 42 control twins] was administered measures assessing reward reactivity, including the Game of Dice Task, the Behavioural Inhibition/Activation (BIS/BAS) Scales and the Appetitive Motivation Scale (AMS). Within pair, correlations for monozygotic and dizygotic twins were calculated and generalised estimating equations compared probands with non-ED cotwins and controls. The BAS and the AMS were reduced in EDs and negatively associated with restrictive symptoms. In addition, monozygotic twins pairs demonstrated significant within pair similarity for the BAS and AMS. Conversely, there was less evidence to support the BIS or risky decision-making as measured by the Game of Dice Task as an endophenotype in EDs. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Investigation of Autism Spectrum Disorder and Autistic Traits in an Adolescent Sample with Anorexia Nervosa

This study aimed to examine the presence of Autism Spectrum Disorder (ASD) in a sample of female adolescents with Anorexia Nervosa (AN) during the acute phase of illness. We also compare the level of autistic traits, social perception skills and obsessive-compulsive symptoms in four groups: AN, ASD, and two gender- and age-matched control groups. Of the 30 AN participants, only three scored above the conventional ADOS-2 threshold for ASD. The AN participants were similar to their controls on autistic trait measures, and to the ASD group on obsessive-compulsive measures, and on theory of mind ability and affect recognition measures. Further longitudinal studies are needed in order to determine the association between these conditions.

Lifetime and 12-month prevalence of eating disorders amongst women in mid-life: a population-based study of diagnoses and risk factors

BACKGROUND

Eating disorders (EDs) are common amongst women; however, no research has specifically investigated the lifetime/12-month prevalence of eating disorders amongst women in mid-life (i.e., fourth and fifth decade of life) and the relevant longitudinal risk factors. We aimed to investigate the lifetime and 12-month prevalence of EDs and lifetime health service use and to identify childhood, parenting, and personality risk factors.

METHODS

This is a two-phase prevalence study, nested within an existing longitudinal community-based sample of women in mid-life. A total of 5658 women from the UK Avon Longitudinal Study of Parents and Children (ALSPAC; enrolled 20 years earlier) participated. ED diagnoses were obtained using validated structured interviews. Weighted analyses were carried out accounting for the two-phase methodology to obtain prevalence figures and to carry out risk factor regression analyses.

RESULTS

By mid-life, 15.3% (95% confidence intervals, 13.5-17.4%) of women had met criteria for a lifetime ED. The 12-month prevalence of EDs was 3.6%. Childhood sexual abuse was prospectively associated with all binge/purge type disorders and an external locus of control was associated with binge-eating disorder. Better maternal care was protective for bulimia nervosa. Childhood life events and interpersonal sensitivity were associated with all EDs.

CONCLUSIONS

By mid-life a significant proportion of women will experience an ED, and few women accessed healthcare. Active EDs are common in mid-life, both due to new onset and chronic disorders. Increased awareness of the full spectrum of EDs in this stage of life and adequate service provision is important. This is the first study to investigate childhood and personality risk factors for full threshold and sub-threshold EDs and to identify common predictors for full and sub-threshold EDs. Further research should clarify the role of preventable risk factors on both full and sub-threshold EDs.

Association Between Oxytocin Receptor Genotype, Maternal Care, and Eating Disorder Behaviours in a Community Sample of Women

This study aimed to investigate associations between oxytocin receptor gene (OXT-R) polymorphisms (rs53576 and rs2254298), their interaction with maternal care (GxE), and ED behaviours in a community sample. We studied 3698 women from the Avon Longitudinal Study of Parents and Children (ALSPAC) who participated in a two-phase prevalence study of lifetime ED and had genotype data. The GG rs53576 genotype was associated with binge eating and purging, and the rs2254298 AG/AA genotype with restrictive eating lifetime. In addition, the rs2254298 AG/AA genotype interacted with poor maternal care to increase the odds of binge eating and purging (odds ratio = 4.40 (95% confidence intervals: 1.11-17.4)). This study replicates previous findings of an association between OXT-R polymorphisms and ED, and it is the first to show an interaction between OXT-R genotype and poor maternal care. As such, these findings highlight the important role of oxytocin in understanding the pathophysiology of ED. © 2016 The Authors European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd.

A systematic review and secondary data analysis of the interactions between the serotonin transporter 5-HTTLPR polymorphism and environmental and psychological factors in eating disorders

OBJECTIVES

To summarize and synthesize the growing gene x environment (GxE) research investigating the promoter region of the serotonin transporter gene (5-HTTLPR) in the eating disorders (ED) field, and overcome the common limitation of low sample size, by undertaking a systematic review followed by a secondary data meta-analysis of studies identified by the review.

METHOD

A systematic review of articles using PsycINFO, PubMed, and EMBASE was undertaken to identify studies investigating the interaction between 5-HTTLPR and an environmental or psychological factor, with an ED-related outcome variable. Seven studies were identified by the systematic review, with complete data sets of five community (n = 1750, 64.5% female) and two clinical (n = 426, 100% female) samples combined to perform four secondary-data analyses: 5-HTTLPR x Traumatic Life Events to predict ED status (n = 909), 5-HTTLPR x Sexual and Physical Abuse to predict bulimic symptoms (n = 1097), 5-HTTLPR x Depression to predict bulimic symptoms (n = 1256), and 5-HTTLPR x Impulsiveness to predict disordered eating (n = 1149).

RESULTS

Under a multiplicative model, the low function (s) allele of 5-HTTLPR interacted with traumatic life events and experiencing both sexual and physical abuse (but not only one) to predict increased likelihood of an ED and bulimic symptoms, respectively. However, under an additive model there was also an interaction between sexual and physical abuse considered independently and 5-HTTLPR, and no interaction with traumatic life events. No other GxE interactions were significant.

CONCLUSION

Early promising results should be followed-up with continued cross-institutional collaboration in order to achieve the large sample sizes necessary for genetic research.

Suicidality in adolescents and adults with binge-eating disorder: Results from the national comorbidity survey replication and adolescent supplement

OBJECTIVE

The relation between binge-eating disorder (BED) and suicidality (i.e., suicide ideation, plan, and/or attempt) has not been studied extensively, and it is unknown whether BED is uniquely associated with suicidality when adjusting for comorbid psychopathology. Moreover, the course of suicidality in BED has not been determined and it is unknown whether BED precedes suicidality or vice versa.

METHOD

A total of 10,123 adolescents and 2,980 adults from two nationally representative surveys were administered diagnostic interviews assessing psychopathology and suicidality, as well the retrospectively reported ages of onset.

RESULTS

Among adults and adolescents, BED was associated with elevated odds of suicide ideation, plan, and attempt at a univariate level, but BED was not associated with elevated odds of suicidality when adjusting for comorbid psychopathology. Kaplan-Meier estimates of temporal patterns displayed that most adolescents experienced suicidality onset following BED onset, whereas most adults experienced suicidality onset prior to BED onset.

DISCUSSION

BED, comorbid disorders, and suicidality share common factors and interrelations, and individuals with BED and comorbid disorders may be at particularly high risk for suicidal outcomes. The presence of BED in adolescence may serve as a marker for more severe symptomatology that precedes the occurrence of suicidality. Research is needed to understand how eating disorder symptoms, comorbid symptoms, and suicidality affect one another over time. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2017; 50:40-49).

Central Coherence in Eating Disorders: A Synthesis of Studies Using the Rey Osterrieth Complex Figure Test

Background

Large variability in tests and differences in scoring systems used to study central coherence in eating disorders may lead to different interpretations, inconsistent findings and between study discrepancies. This study aimed to address inconsistencies by collating data from several studies from the same research group that used the Rey Osterrieth Complex Figure Test (Rey Figure) in order to produce norms to provide benchmark data for future studies.

Method

Data was collated from 984 participants in total. Anorexia Nervosa, Bulimia Nervosa, recovered Anorexia Nervosa, unaffected family members and healthy controls were compared using the Rey Figure.

Results

Poor global processing was observed across all current eating disorder sub-groups and in unaffected relatives. There was no difference in performance between recovered AN and HC groups.

Conclusions

This is the largest dataset reported in the literature and supports previous studies implicating poor global processing across eating disorders using the Rey Figure. It provides robust normative data useful for future studies.

Addictive-Like Eating, Body Mass Index, and Psychological Correlates in a Community Sample of Preadolescents

INTRODUCTION

The two main objectives were to identify addictive-like eating in youth and determine the relationship between addictive-like eating, hedonic hunger, and psychological variables.

METHOD

A cross-sectional design was used. Each subject's objective heights and weights were measured. Subjects completed questionnaires about anxiety, depression, appetitive responsiveness, addictive-like eating, other forms of disordered eating, and exercise patterns.

RESULTS

Sixty-five children, ages 9 to 14 years, participated in the study. The mean body mass index percentile for age and gender was 69%. Thirty-eight percent of the children were either overweight or obese. Sixteen percent reported three or more addictive-like eating behaviors, and 4% met the criteria for "food addiction." Addictive-like eating was significantly correlated with appetitive responsiveness but not body mass index, anxiety, depression, or other measures of disordered eating.

DISCUSSION

Addictive-like eating occurs in children as young as 9 years and appears to be a different type of disordered eating. The hedonic value and proximity of food is a contributor to addictive-like eating behaviors.

Attention deficit hyperactivity disorder and disordered eating behaviors: links, risks, and challenges faced

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that often persists in adulthood. It is defined by inattention and/or hyperactivity-impulsivity. ADHD is associated with many comorbidities, including eating disorders (EDs). In the last decade, studies have reported that ADHD is linked with binge EDs, bulimia nervosa, and anorexia nervosa. Many postulates have been proposed to explain the association: 1) impulsive behavior in ADHD patients leads to disordered eating behavior; 2) other psychologic comorbidities present in ADHD patients account for eating behavior; 3) poor eating habits and resulting nutritional deficiencies contribute to ADHD symptoms; and 4) other risk factors common to both ADHD and EDs contribute to the coincidence of both diseases. Additionally, sex differences become a significant issue in the discussion of EDs and ADHD because of the higher incidence of bulimia nervosa and anorexia nervosa in females and the ability of females to mask the symptoms of ADHD. Interestingly, both EDs and ADHD rely on a common neural substrate, namely, dopaminergic signaling. Dopaminergic signaling is critical for motor activity and emotion, the latter enabling the former into a combined motivated movement like eating. This linkage aids in explaining the many comorbidities associated with ADHD. The interconnection of ADHD and EDs is discussed from both a historical perspective and the one based on the revealing nature of its comorbidities.

Are There Differences in Central Coherence and Set Shifting Across the Subtypes of Anorexia Nervosa?: A Systematic Review

Anorexia nervosa (AN) has been associated with weaknesses in central coherence and set shifting. In this line, it has been proposed to directly address these neuropsychological features in treatment (e.g., cognitive remediation therapy). It is not clear, however, whether the 2 subtypes of AN, the restricting (AN-R) and bingeing/purging (AN-BP) type, have the same amount of problems in these domains. A systematic search of the literature was conducted, using the databases Web of Science and PubMed, looking for studies on the comparison of AN-R and AN-BP in performing central coherence/set-shifting tasks. Notably, very few authors describe the results of a direct comparison of the performance of patients with AN-R and AN-BP. In summary, the available indications for possible group differences are not strong enough to draw definitive conclusions.

Social cognition in children at familial high-risk of developing an eating disorder

Objective: Diagnosis of an eating disorder (ED) has been associated with differences in social cognition. To date research investigating social cognition and ED has mainly employed patient and recovered samples. It is therefore unclear whether differences in social cognition are present prior to onset of ED, potentially contributing to development, or whether differences observed are a consequence of the disorder. We aimed to further explore whether individuals at high-risk for ED present social cognition characteristics previously found in ED groups.

Methods: Our sample was drawn from a population-based cohort, the Avon Longitudinal Study of Parents and Children (ALSPAC). Data on maternal ED behaviors over the lifetime were collected through in-depth clinical interviews (n = 1128) conducted using the Structured Clinical Interview for DSM disorders (SCID), and were used to categorize mothers according to ED behaviors over the lifetime: Restricting and Excessive Exercising (n = 58), Purging (n = 70), Binge-eating (n = 72), Binging and Purging (n = 66), no ED (n = 862). High-risk status of children was determined using these maternal lifetime behavioral phenotypes. Children at high-risk (maternal ED exposure) were compared to children at low-risk (born to mothers with no ED) on three measures of social cognition: the Social Communication Disorders Checklist (SCDC) (n = 922), the faces subtest of the Diagnostic Analysis of Non-Verbal Accuracy (DANVA) (n = 722), and the Emotional Triangles Task (n = 750).

Results: Children at high-risk for ED showed poorer performance on measures of social cognition compared to children at low-risk. Maternal lifetime binge-eating, and maternal lifetime binging and purging were associated with poorer social communication in children (OR: 2.4, 95% CI: 1.0, 5.7, p = 0.05; and OR: 2.7, 95% CI: 1.1, 6.5, p = 0.03 respectively). Maternal binging and purging was also found to be associated with differential facial emotion processing and poorer recognition of fear from social motion cues (B: −0.7, 95% CI: −1.1, −0.2, p = 0.004).

Discussion: Children at high-risk for ED showed slight differences in some areas of social cognition when compared to children at low-risk. Characteristic patterns in social cognition are present in children at high-risk for ED, particularly among children whose mothers have binge-eating and purging behaviors over the lifetime. Our findings support the hypothesis that these differences may be part of an intermediate phenotype for ED: perhaps contributing to development, or perhaps indexing a shared liability with psychiatric disorders characterized by abnormal social cognition.

Refractory depression: mechanisms and evaluation of radically open dialectical behaviour therapy (RO-DBT) [REFRAMED]: protocol for randomised trial

INTRODUCTION

Only 30-40% of depressed patients treated with medication achieve full remission. Studies that change medication or augment it by psychotherapy achieve only limited benefits, in part because current treatments are not designed for chronic and complex patients. Previous trials have excluded high-risk patients and those with comorbid personality disorder. Radically Open Dialectical Behaviour Therapy (RO-DBT) is a novel, transdiagnostic treatment for disorders of emotional over-control. The REFRAMED trial aims to evaluate the effectiveness and cost-effectiveness of RO-DBT for patients with treatment-resistant depression.

METHODS AND ANALYSIS

REFRAMED is a multicentre randomised controlled trial, comparing 7 months of individual and group RO-DBT treatment with treatment as usual (TAU). Our primary outcome measure is depressive symptoms 12 months after randomisation. We shall estimate the cost-effectiveness of RO-DBT by cost per quality-adjusted life year. Causal analyses will explore the mechanisms by which RO-DBT is effective.

ETHICS AND DISSEMINATION

The National Research Ethics Service (NRES) Committee South Central - Southampton A first granted ethical approval on 20 June 2011, reference number 11/SC/0146.

TRIAL REGISTRATION NUMBER

ISRCTN85784627.

Has the time come for a staging model to map the course of eating disorders from high risk to severe enduring illness? An examination of the evidence

AIM

To examine the evidence to support using a staging heuristic for eating disorders, suggesting that the diagnosis of an eating disorder follows a trajectory across the life course. Specifically, to examine whether high-risk markers and prodromal features presenting in childhood and adolescence can later transition to the full manifestation of the illness in early adulthood, and whether over time, the illness can be described as becoming severe and enduring, often resistant to treatment.

METHODS

We conducted a comprehensive literature search on the MEDLINE, PubMed, PsycINFO, EMBASE and Cochrane databases from using the following terms: staging, duration of illness, early intervention, developmental epidemiology, neurobiological marker, phenotype, partial syndrome, severe enduring, chronic, prospective, longitudinal, cohort, epidemiology, adolescent, adult with anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder. The evidence was organized according to the staging heuristic defined by McGorry.

RESULTS

Evidence from epidemiological studies, neuropsychological findings, treatment responsivity and prognosis, support a specific staging trajectory for anorexia nervosa in that there is a longitudinal trajectory with evidence of neurobiological progression and evidence that interventions matched to stage of illness may optimize the benefit. There is less data at the moment to support such a model for bulimia nervosa and binge eating disorder.

CONCLUSION

The staging heuristic is a useful model for anorexia nervosa in terms of providing prognostic information and stage matched interventions. Although the evidence is encouraging, further research is needed before a similar model could be applied for bulimia nervosa and binge eating disorder.

Do women with eating disorders who have social and flexibility difficulties really have autism? A case series

Background

Many women with eating disorders (EDs) have social impairments and difficulties with flexibility. It is unclear to what extent these are manifestations of an underlying autism spectrum disorder (ASD); or whether they are instead the consequence of starvation, anxiety, low mood or obsessive compulsive disorder, all of which are highly prevalent in EDs. The resolution of this clinically and theoretically important uncertainty will require the use of gold-standard ASD assessment measures. To date these have not been employed in ED research. This case series is the first report of a well-validated, direct-observational measure of ASD, the Autism Diagnostic Observation Schedule (ADOS), being administered to women with EDs. We aimed to learn about the feasibility of the ADOS in this population, and to contribute to debates about whether a sub-group with EDs really have ASD.

Methods

Ten women (mean age = 26.4 years, range = 19 to 38 years) who had a suspected ASD due to social and flexibility difficulties and were receiving treatment for ED (seven anorexia, two ED not otherwise specified, one bulimia) at a specialist service (four inpatient, six outpatient) received an ADOS Module 4 assessment.

Results

All 10 participants completed all activities of the ADOS Module 4. Five scored in the ASD range on the ADOS diagnostic algorithm. An additional two were judged likely to have ASD, even though they scored below the ADOS’s diagnostic threshold. This was on the basis of clinical observation, participant self-report and parent report. The seven women who we estimated to have ASD all reported autistic difficulties prior to the onset of their ED. They commonly described longstanding non-autistic neurodevelopmental problems, including dyslexia, dyspraxia and epilepsy. Only one had a childhood diagnosis of ASD.

Conclusions

A substantial proportion of women with EDs who present with social and flexibility difficulties may have an unrecognised ASD, indicated by a constellation of autistic difficulties that appears to predate the onset of their eating problems. The ADOS is a useful component of an ASD assessment for adult women with ED.

Emotion generation and regulation in anorexia nervosa: a systematic review and meta-analysis of self-report data

This systematic review sought to examine the generation and regulation of emotion in people with Anorexia Nervosa (AN). Key databases (Medline, Embase, PsychINFO and Web of Science) were searched for peer-reviewed articles published by March 2015 yielding 131 studies relevant to emotion generation and emotion regulation (ER) processes as defined by Gross (1998). Meta-analyses determined pooled group differences between AN and healthy control (HC) groups. More maladaptive schemata were reported by people with AN than HCs, with largest pooled effects for defectiveness/shame (d=2.81), subjugation (d=1.59) and social isolation (d=1.66). Poorer awareness of and clarity over emotion generated and some elevated emotionality (disgust and shame) were reported. A greater use of 'maladaptive' ER strategies was reported by people with AN than HCs, alongside less use of 'adaptive' strategies. Pooled differences of particularly large effect were observed for: experiential avoidance (d=1.00), negative problem-solving style (d=1.06), external/social comparison (d=1.25), submissiveness (d=1.16), attention concentration (worry/rumination; d=1.44) and emotion suppression (d=1.15), particularly to avoid conflict (d=1.54). These data support the notion that emotion regulation difficulties are a factor in AN and support use of associated cognitive-affective models. The implications of these findings for further understanding AN, and developing models and related psychological interventions are discussed.

The effectiveness of cognitive remediation therapy in patients with a severe or enduring eating disorder: a randomized controlled trial

BACKGROUND

Individuals with eating disorders show deficits in neuropsychological functioning which might preexist and underlie the etiology of the eating disorders and influence relapse. Deficits in cognitive flexibility, i.e., set-shifting and central coherence, might perpetuate the symptoms. Cognitive remediation therapy (CRT) was developed to improve cognitive flexibility, thereby increasing the likelihood of improved outcome. The focus of CRT is on how patients think, rather than on what patients think. The present study investigated the effectiveness of CRT for patients with a severe or enduring eating disorder by means of a randomized controlled trial comparing intensive treatment as usual (TAU) to CRT plus TAU.

METHODS

Eighty-two patients were randomly assigned to CRT plus TAU (n = 41) or TAU alone (n = 41). Outcome measures were set-shifting, central coherence, eating disorder and general psychopathology, motivation, quality of life and self-esteem. Assessments were performed at baseline (n = 82) and after 6 weeks (T1; n = 75) and 6 months (T2; n = 67). Data were analyzed by means of linear mixed model analyses.

RESULTS

Patients who received CRT in addition to TAU improved significantly more with regard to eating disorder-related quality of life at the end of treatment (T1) and eating disorder psychopathology at follow-up (T2), compared to those who received TAU only. Moreover, moderator analyses revealed that patients with poor baseline set-shifting abilities benefited more from CRT than patients with no deficits in set-shifting abilities at baseline; the quality of life of the former group was higher than that of the latter at follow-up.

CONCLUSIONS

CRT seems to be promising in enhancing the effectiveness of concurrent treatment.

Characteristics and stability of empirically derived anorexia nervosa subtypes: towards the identification of homogeneous low-weight eating disorder phenotypes

Anorexia nervosa (AN) is characterized by within-group heterogeneity in symptom presentation, which poses problems for research on etiology and treatment. This study sought to identify homogeneous subtypes of AN, and examine their short-term stability, using empirical methods. A treatment-seeking sample with AN (n = 194) was assessed at baseline and 6- and 12-month follow-ups. Latent class analysis was used to identify homogeneous AN subgroups, and latent transition analysis was used to examine the stability of latent classes. Three low-weight eating disorder classes were identified: 1) fat-phobic restricting (AN-R-FP); 2) fat-phobic binge-eating/purging (AN-BP-FP); and 3) non-fat-phobic restricting (AN-R-NFP). Subtype membership was stable over follow-up, with .68 to .88 probabilities of remaining in the same class from baseline to 6 months, and .87 to 1.00 from 6 months to 12 months. The most common transition pattern was between AN-R-FP and AN-R-NFP (56.8% of transitions); the majority of these participants transitioned from AN-R-FP to AN-R-NFP (n = 20/21). Predictors of latent class membership included lifetime mood and substance use disorder comorbidities, negative temperament, illness duration, and body mass index at treatment presentation. Disinhibition (vs. constraint), history of overweight or obesity, and illness duration decreased the probability of latent transition. Findings support the presence of 3 low-weight eating disorder phenotypes that are highly stable over short-term follow-up. Identification of a stable non-fat-phobic AN phenotype is intriguing and highlights the importance of studying mechanisms that differentiate fat-phobic and non-fat-phobic eating disorders.

Compulsivity in anorexia nervosa: a transdiagnostic concept

The compulsive nature of weight loss behaviors central to anorexia nervosa (AN), such as relentless self-starvation and over-exercise, has led to the suggestion of parallels between AN and other compulsive disorders such as obsessive-compulsive disorder (OCD) and addictions. There is a huge unmet need for effective treatments in AN, which has high rates of morbidity and the highest mortality rate of any psychiatric disorder, yet a grave paucity of effective treatments. Viewing compulsivity as a transdiagnostic concept, seen in various manifestations across disorders, may help delineate the mechanisms responsible for the persistence of AN, and aid treatment development. We explore models of compulsivity that suggest dysfunction in cortico-striatal circuitry underpins compulsive behavior, and consider evidence of aberrancies in this circuitry across disorders. Excessive habit formation is considered as a mechanism by which initially rewarding weight loss behavior in AN may become compulsive over time, and the complex balance between positive and negative reinforcement in this process is considered. The physiological effects of starvation in promoting compulsivity, positive reinforcement, and habit formation are also discussed. Further research in AN may benefit from a focus on processes potentially underlying the development of compulsivity, such as aberrant reward processing and habit formation. We discuss the implications of a transdiagnostic perspective on compulsivity, and how it may contribute to the development of novel treatments for AN.

Childhood obsessive-compulsive traits in anorexia nervosa patients, their unaffected sisters and healthy controls: a retrospective study

Although there is evidence that childhood perfectionistic traits predate the onset of eating disorders, few studies to date have examined the prevalence and clinical correlates of these traits in patients with anorexia nervosa (AN) and their unaffected sisters. The aim of this work was to study the prevalence of childhood obsessive-compulsive traits in patients with lifetime AN, their unaffected sisters and healthy women. A total of 116 AN patients, 32 healthy sisters and 119 controls were assessed by the EATATE Interview to assess traits such as perfectionism, inflexibility, rule-bound traits, drive for order and symmetry, and excessive doubt and cautiousness. Both self-report and maternal reports were collected. AN patients reported more childhood obsessive-compulsive traits than their healthy sisters and controls. In contrast, no differences between healthy controls and unaffected sisters emerged. In patients with AN, a dose-response relationship was found between the number of childhood obsessive-compulsive traits and psychopathology, including body image distortion, thus indicating that these traits are an important feature to be considered in assessing and treating eating disorders.

Axis-I comorbidity is linked to prospective instability of diagnoses within eating disorders

BACKGROUND

Eating disorders (ED) are classified into Anorexia Nervosa, Bulimia Nervosa, and eating disorder not otherwise specified. Prospectively, the diagnostic instability within ED is high, but it is not clear which factors may account for this instability. So far, there is no evidence of whether psychiatric comorbidity may play a role in ED diagnostic crossover. We sought to determine possible influences of comorbidities of axis I and II on diagnostic crossover within ED.

METHODS

Longitudinal data of 192 female patients were collected. All patients had a diagnosis of a current ED at study entry (baseline, T0). Diagnoses were re-established both 12 months (T1) and 30 months (T2) after T0. Comorbid psychiatric diagnoses were grouped into axis I and axis II according to DSM-IV.

RESULTS

Patients with instable ED diagnoses had lifetime axis-I comorbidity more frequently than patients with stable ED diagnoses (χ2 = 4.74, df = 1, p < 0.05). Post-hoc exploratory tests suggested that the effect was mainly driven by affective disorders like major depression. There was no difference for axis-II comorbidity between stable and instable diagnostic profiles.

CONCLUSIONS

Following previous reports of diagnostic crossover in ED, the present investigation points to an influence of a life-time psychiatric comorbidity, in particular of axis I, on follow-up diagnoses of ED. Comorbid affective disorders like major depression might facilitate a switching between clinical phenotypes. The understanding of mechanisms and causes of the symptoms fluctuation will be subject of future studies.

A review of cognitive neuropsychiatry in the taxonomy of eating disorders: state, trait, or genetic?

A greater understanding of neuropsychological traits in eating disorders may help to construct a more biologically based taxonomy. The aim of this paper is to review the current evidence base of neuropsychological traits in people with eating disorders. Evidence of difficulties in set shifting, weak central coherence, emotional processing difficulties, and altered reward sensitivity is presented for people both in the acute and recovered phase of the illness. These traits are also seen in first degree relatives. At present there is limited research linking these neuropsychological traits with genetic and neuroanatomical measures. In addition to improving the taxonomy of eating disorders, neuropsychological traits may be of value in producing targeted treatments.

Set shifting and central coherence as neurocognitive endophenotypes in eating disorders: a preliminary investigation in twins

OBJECTIVES

Weak central coherence and poor set shifting are risk markers for eating disorders that are present post recovery and in first degree relatives. The aim of this study was to examine these traits in twins with eating disorders.

METHODS

Neuropsychological tests were administered to 114 female twins (n = 53 met lifetime DSM-IV eating disorder criteria, n = 19 non-eating disorder cotwins and n = 42 controls). Within pair correlations for monozygotic (MZ) and dizygotic (DZ) twins were calculated and generalised estimating equations (GEE) compared probands, with non-eating disorder cotwins and controls.

RESULTS

The genetic basis was highest for the central coherence tasks (Rey-Osterrieth Complex Figure Task: MZ twins r = 0.44 [CI: 0.07-0.70, P = 0.01] and Group Embedded Figures Test: MZ twins r = 0.58 [CI: 0.26-0.79, P = 0.00]). Poor set shifting was related to obsessive compulsive symptoms in both individuals with eating disorders and their non-eating disorder cotwins (r = 0.2-0.5).

CONCLUSION

Set shifting abilities and central coherence appear to be endophenotypes associated with eating disorders.

Eating problems and overlap with ADHD and autism spectrum disorders in a nationwide twin study of 9- and 12-year-old children

Aim. To establish the prevalence of restrictive eating problems, the overlap and association with attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorders (ASD) and to estimate the heritability of eating problems in a general population sample of twins aged 9 and 12. Methods. Parents of all Swedish 9- and 12-year-old twin pairs born between 1993 and 1998 (n = 12,366) were interviewed regarding symptoms of ADHD, ASD, and eating problems (EAT-P). Intraclass correlations and structural equation modelling were used for evaluating the influence of genetic and environmental factors. Cross-twin, cross-trait correlations were used to indicate a possible overlap between conditions. Results. The prevalence of eating problems was 0.6% in the study population and was significantly higher in children with ADHD and/or ASD. Among children with eating problems, 40% were screened positive for ADHD and/or ASD. Social interaction problems were strongly associated with EAT-P in girls, and impulsivity and activity problems with EAT-P in boys. The cross-twin, cross-trait correlations suggested low correlations between EAT-P and ADHD or EAT-P and ASD. Genetic effects accounted for 44% of the variation in liability for eating problems. Conclusions. In the group with eating problems, there was a clear overrepresentation of individuals with ADHD and/or ASD symptoms.

The severity of ADHD and eating disorder symptoms: a correlational study

BACKGROUND

Attention deficit/hyperactivity disorders (ADHD) and eating disorders (ED) share several clinical features. Research on the association between ADHD and ED is still quite sparse and findings are ambiguous.

METHODS

Correlations between the severity of ADHD key features (Barratt Impulsiveness Scale, and Attention Deficit/Hyperactivity Disorder-Self-Rating questionnaire) and the severity of specific ED symptoms (Structured Interview for Anorexia and Bulimia Nervosa) were examined in 32 female patients diagnosed with ED.

RESULTS

Most correlations between the severity of ADHD features and the severity of ED symptoms were low (r<0.30) and did not reach statistical significance. The only exception was a statistically significant, but counterintuitive association between impulsivity and the avoidance of fattening food.

CONCLUSIONS

The findings in this small sample suggest a weak link between the severity of ADHD key features and the severity of single ED symptoms in female patients with ED. The role of ADHD features for the development, maintenance, and treatment of EDs seems to be intricate and requires further study.