Understanding community provider practices in diagnosing and treating atypical anorexia nervosa: A mixed methods study.

OBJECTIVE: There is a lack of consensus in defining "significant weight loss" when diagnosing atypical anorexia nervosa (atypical AN) and no guidelines exist for setting target weight (TW). The current study aimed to identify community providers' practices related to the diagnosis of atypical AN and the determination of TW. A secondary aim was to evaluate whether professional discipline impacted "significant weight loss" definitions. METHOD: A variety of providers (N = 141; 96.4% female) completed an online survey pertaining to diagnostic and treatment practices with atypical AN. Descriptive statistics were computed to characterize provider-based practices and Fisher's exact tests were used to test for differences in diagnostic practices by professional discipline. Thematic analysis was used to examine open-ended questions. RESULTS: Most (63.97%) providers diagnosed atypical AN in the absence of any weight loss if other AN criteria were met, but doctoral-level psychologists and medical professionals were less likely to do so compared to nutritional or other mental health professionals. Most providers found weight gain was only sometimes necessary for atypical AN recovery. Qualitative responses revealed providers found atypical AN to be a stigmatizing label that was not taken seriously. Providers preferred to use an individualized approach focused on behaviors, rather than weight when diagnosing and treating atypical AN. DISCUSSION: Lack of diagnostic clarity and concrete treatment guidelines for atypical AN may result in substantial deviations from the DSM-5-TR criteria in real-world practice. Clinically useful diagnostic definitions for restrictive eating disorders and evidence-based treatment guidelines for TW and/or other relevant recovery metrics are needed. PUBLIC SIGNIFICANCE: The current study found variability in how community providers diagnose and determine target recovery weight for atypical anorexia nervosa (atypical AN). Many providers viewed the diagnosis of atypical AN as stigmatizing and preferred to focus on behaviors, rather than weight. This study underscores the importance of creating a clinically useful diagnostic definition and guidelines for recovery for atypical AN backed by empirical evidence that providers may implement in practice.

The Building Healthy Eating and Self-Esteem Together for University Students Mobile App to Treat Eating Disorders: User-Centered Research Design and Feasibility Study.

BACKGROUND: University students are an at-risk group for the development of eating disorders (EDs); however, many college campuses lack sufficient resources to provide ED specialty care. Students report unique reasons for not seeking ED treatment, including the desire to solve the problem on their own (eg, seeking help from friends, self-medicating, or waiting to see if their problems improve), inability to afford treatment, lack of time to participate in the treatment, fear of seeing their primary care physician, and lack of recognition of their issues as an ED. Mobile health (mHealth) apps may be a cost-effective, helpful adjunctive tool to overcome personal and systemic barriers and encourage help seeking. OBJECTIVE: This paper describes the development, usability, and acceptability of the Building Healthy Eating and Self-Esteem Together for University Students (BEST-U) mHealth smartphone app, which is designed to fill critical gaps in access to ED treatment on college campuses. METHODS: We undertook a 4-phase iterative development process that focused on user-centered design. The 4 phases included needs assessment based on literature reviews, prototype development and initial evaluation in a pilot trial, redesign, and further pilot-testing to assess the usability and acceptability of the final version of the mHealth app. Acceptability and user satisfaction were assessed using an ad hoc survey that ranged from 1 (strongly disagree) to 7 (strongly agree). RESULTS: Our needs assessment identified a lack of accessible and affordable treatments for university students. To help meet this need, the BEST-U prototype was designed as an 11-week program that provided interactive, weekly modules that focused on second- and third-wave cognitive behavioral skills. The modules focused on topics such as psychoeducation, reducing thought distortions and body checking, improving body image, interpersonal effectiveness, and behavior chain analysis. The content included interactive quizzes, short answer questions, daily and weekly logs, and surveys completed in the app. BEST-U was paired with brief 25-30 minutes of weekly telehealth coaching sessions provided by a licensed provider or supervised trainee. Pilot-testing revealed minor issues with one module of the app content, which some participants viewed as having low relevance to their experience and therapist concerns about the organization of the app content. These issues were addressed through the removal, addition, and reorganization of BEST-U modules, with the help of therapists-in-training across 2 workshops. The revised version of the BEST-U app had a grand mean acceptability rating of 5.73 out of 7. The participants completed 90.1% (694/770) of the BEST-U modules, indicating high compliance. CONCLUSIONS: BEST-U is a new, acceptable, and user-friendly mHealth app to help therapists deliver brief, evidence-based cognitive behavioral interventions. Owing to its acceptability and user-friendly nature, BEST-U has high user compliance and holds promise for future implementation and dissemination in university mental health settings.

A pilot multiple-baseline study of a mobile cognitive behavioral therapy for the treatment of eating disorders in university students.

OBJECTIVE: Eating disorders (EDs) are serious psychiatric disorders associated with substantial morbidity and mortality that are prevalent among university students. Because many students do not receive treatment due to lack of access on university campuses, mobile-health (mHealth) adaptations of evidence-based treatments represent an opportunity to increase treatment accessibility and engagement. The purpose of this study was to test the initial efficacy of Building Healthy Eating and Self-Esteem Together for University Students (BEST-U), which is a 10-week mHealth self-guided cognitive-behavioral therapy (CBT-gsh) app that is paired with a brief 25-30-min weekly telehealth coaching, for reducing ED psychopathology in university students. METHOD: A non-concurrent multiple-baseline design (N = 8) was used to test the efficacy of BEST-U for reducing total ED psychopathology (primary outcome), ED-related behaviors and cognitions (secondary outcomes), and ED-related clinical impairment (secondary outcome). Data were examined using visual analysis and Tau-BC effect-size calculations. RESULTS: BEST-U significantly reduced total ED psychopathology and binge eating, excessive exercise, and restriction (effect sizes ranged from -0.39 to -0.92). Although body dissatisfaction decreased, it was not significant. There were insufficient numbers of participants engaging in purging to evaluate purging outcomes. Clinical impairment significantly reduced from pre-to-post-treatment. DISCUSSION: The current study provided initial evidence that BEST-U is a potentially efficacious treatment for reducing ED symptoms and ED-related clinical impairment. Although larger-scale randomized controlled trials are needed, BEST-U may represent an innovative, scalable tool that could reach greater numbers of underserved university students than traditional intervention-delivery models. PUBLIC SIGNIFICANCE: Using a single-case experimental design, we found evidence for the initial efficacy of a mobile guided-self-help cognitive-behavioral therapy program for university students with non-low weight binge-spectrum eating disorders. Participants reported significant reductions in ED symptoms and impairment after completion of the 10-week program. Guided self-help programs show promise for filling an important need for treatment among university students with an ED.

Screening for eating disorders across genders in college students: Initial validation of the brief assessment of stress and eating.

Given that eating disorders (EDs) are relatively common in college populations, it is important to have reliable and valid tools to identify students so that they can be referred to evidence-based care. Although research supports the psychometric properties of existing ED screens for identifying cases of EDs, most studies have been conducted in samples of young white-majority women or have not reported the psychometric properties of the screening tool in men. OBJECTIVE: The purpose of the current study was to validate a brief, 10-item screening tool for the identification of EDs-the brief assessment of stress and eating (BASE). METHOD: Participants were college students (N = 596; 68.2% cisgender women) from a large Midwestern university who completed the BASE and SCOFF. The Eating Disorders Diagnostic Survey was used to generate DSM-5 ED diagnoses. We evaluated area under the curve (AUC) for both receiver operating curves (ROC) and precision-recall curves (PRC). RESULTS: Both the BASE and SCOFF performed significantly better than chance at identifying probable EDs in cisgender women (BASE AUC: ROC = .787, PRC = .633, sensitivity = .733, specificity = .697; SCOFF AUC: ROC = .810, PRC = .684, sensitivity = .793, specificity = .701). However, the BASE (AUC: ROC = .821, PRC = .605, sensitivity = .966, specificity = .495) significantly outperformed the SCOFF (AUC: ROC = .710, PRC = .354, sensitivity = .828, specificity = .514) for identifying probable EDs in cisgender college men. DISCUSSION: The BASE is appropriate for student healthcare and college research settings. Because the BASE outperforms the SCOFF in college men, results from the current study are expected to contribute to improved identification of EDs on college campuses. PUBLIC SIGNIFICANCE: The BASE is a new screening tool to identify eating disorders. The BASE performed as well as, if not better than, the SCOFF (particularly in men). Given the need for brief, psychometrically strong, and unbiased ED screening tools in college students, the current study helps address an unmet student healthcare need that we expect will contribute to improved identification of EDs on college campuses.

HiTOP Assessment of the Somatoform Spectrum and Eating Disorders.

We report on Phase 1 efforts of the Hierarchical Taxonomy of Psychopathology (HiTOP) measurement subgroup tasked with developing provisional scales for the somatoform spectrum and eating disorders. In Study 1, items were written to assess five somatoform spectrum constructs (bodily distress symptoms, conversion symptoms, health anxiety, disease conviction, and somatic preoccupation). Scale development analyses were conducted on 550 university students. The conversion symptom items were too infrequently endorsed and were set aside for Phase 2. Analyses of the other items yielded four scales corresponding closely to their hypothesized structure. In Study 2, we delineated 15 specific feeding and eating disorder constructs. A sample of 400 university students were administered candidate items and several eating disorder questionnaires for criterion validity. Analyses yielded six scales capturing previously described constructs, tapping content related to body image and weight concerns, restricting and purging, cognitive restraint, binging, excessive exercise, and muscle building. Two scales representing additional constructs deemed to be of high clinical import-negative attitude towards obesity and avoidant/restrictive food intake disorder-were retained for Phase 2, for a total of eight scales. Overall, we concluded that Phase 1 had been successful at generating a comprehensive set of provisional scales for inclusion in Phase 2.

Measurement invariance of the Eating Pathology Symptoms Inventory (EPSI) in adolescents and adults.

Adolescence is a common period for eating disorder (ED) onset. The availability of psychometrically sound measures of ED psychopathology enables clinicians to accurately assess symptoms and monitor treatment outcomes continuously from adolescence and adulthood. The purpose of this study was to assess if the Eating Pathology Symptoms Inventory (EPSI) is invariant across adolescents and adults. Participants (N = 29,821) were adolescent (n = 5250) and adult (n = 24,571) users of the Recovery Record (RR) mobile phone application who provided EPSI responses through the application. Measurement invariance testing was conducted to assess invariance of the EPSI Body Dissatisfaction, Restricting, Excessive Exercise, Purging, Cognitive Restraint, and Binge Eating scales across adolescents (age 13 through 17) and adults (age 18 and older). Findings indicated that all EPSI factors administered in the RR app replicated in both adolescent and adult users. The EPSI factor structure was largely equivalent in adolescents and adults, demonstrating evidence for configural and metric invariance, as well as some evidence for scalar invariance. Our results indicated that EPSI scales measured the same constructs across development. Clinicians and researchers may benefit from utilizing the EPSI to measure ED psychopathology in adolescents and for continued progress monitoring into adulthood.

Do differences between individuals who are healthy weight or overweight on self-report measures of disinhibited eating and restrained eating reflect reality or item "bias"?

In light of increasing rates of overweight and obesity worldwide, there is a critical need for accurate self-report measures of disinhibited and restrained eating behaviors across the weight spectrum. Item response theory was used to determine whether differences in disinhibited and restrained eating between healthy weight and overweight or obese individuals were due to item bias (i.e., differential item functioning). Study 1 participants were healthy weight (n = 510) or overweight or obese (n = 304) adults recruited from the community. Study 2 participants were healthy weight (n = 778) or overweight or obese (n = 320) college students. Study 1 participants completed the Eating Disorder Examination-Questionnaire (EDE-Q), Eating Disorder Inventory-3, Dutch Eating Behaviors Questionnaire, Restraint Scale, and Three-Factor Eating Questionnaire. Study 2 participants completed the Eating Pathology Symptoms Inventory (EPSI). Items on the Restraint Scale demonstrated the most evidence for bias (60% of items), whereas the majority of other scales demonstrated low to moderate levels of item bias (17-38% of items). However, EDE-Q Restraint and EPSI Binge Eating, Cognitive Restraint, Excessive Exercise, Muscle Building, and Negative Attitudes Toward Obesity scales did not show any evidence of differential item functioning among weight groups. Participants with the same level of disordered eating responded differently to certain eating disorder self-report items due to weight-bias, rather than true between-groups differences. Nevertheless, EDE-Q Restraint, EPSI Cognitive Restraint, and EPSI Binge Eating did not exhibit any evidence of bias and are ideal for assessing restrained and disinhibited eating across the weight spectrum in both research and clinical settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A new approach to eating-disorder classification: Using empirical methods to delineate diagnostic dimensions and inform care.

OBJECTIVE: Despite changes to the diagnostic criteria for eating disorders (EDs) in the DSM-5, the current diagnostic system for EDs has limited ability to inform treatment planning and predict outcomes. Our objective was to test the clinical utility of a novel dimensional approach to understanding the structure of ED psychopathology. METHOD: Participants (N = 243; 82.2% women) were community-recruited adults with a DSM-5 ED assessed at baseline, 6-month, and 1-year follow-up. Hierarchical factor analysis was used to identify a joint hierarchical-dimensional structure of eating, mood, and anxiety symptoms. Exploratory structural equation modeling was used to test the ability of the dimensional model to predict outcomes. RESULTS: At the top of the hierarchy, we identified a broad Internalizing factor that reflected diffuse symptoms of eating, mood, and anxiety disorders. Internalizing branched into three subfactors: distress, fear-avoidance (fears of certain stimuli and behaviors to neutralize fears, including ED behaviors designed to reduce fear of weight gain), and body dissatisfaction, which was nested within distress. The lowest level of the hierarchy was characterized by 15 factors. The hierarchical model predicted 60.1% of the variance in outcomes at 6-month follow-up, whereas all DSM eating, mood, and anxiety disorders combined predicted 35.8% of the variance in outcomes. DISCUSSION: A dimensional approach to understanding and diagnosing EDs improved the ability to prospectively predict clinical course above-and-beyond the traditional categorical (DSM-based) approach. Our findings have implications for endeavors to improve the prediction of ED prognosis and course, and to develop more effective trans-diagnostic treatments.

New Horizons in Measurement: a Review of Novel and Innovative Approaches to Eating-Disorder Assessment.

PURPOSE OF REVIEW: Eating disorders are serious mental-health concerns that will affect over 30 million individuals in the USA at some point in their lives. Eating disorders occur across the lifespan, in a variety of ethnicities and races, in both men and women, and across the socioeconomic spectrum. Given the prevalence and severity of eating disorders, it is important that clinicians and researchers have access to appropriate assessment tools to aid in the early identification and treatment referral, differential diagnosis, treatment planning, and progress monitoring, and to ensure valid research findings. In this review, we describe novel and innovative assessment tools that were developed within the past 5 years for utilization in research and/or clinical practice with individuals with eating disorders. RECENT FINDINGS: We identified six multidimensional assessments for eating disorders, all of which can be administered online (with some also offering paper-and-pencil versions). Strengths of the measures included good internal consistency, test-retest reliability, and convergent validity. However, in part, due to problematic scale construction methods, certain scales had poor discriminant validity and most were developed and validated in mostly female samples. There are promising new eating disorder measures from which to choose; however, many measures continue to be limited by poor discriminant validity and need additional validation prior to incorporation into routine research and clinical practice.

Understanding eating disorders within internalizing psychopathology: A novel transdiagnostic, hierarchical-dimensional model.

BACKGROUND: Several problems with the classification and diagnosis of eating disorders (EDs) have been identified, including proliferation of 'other specified' diagnoses, within-disorder heterogeneity, and frequent diagnostic migration over time. Beyond problems within EDs, past research suggested that EDs fit better in a spectrum of internalizing psychopathology (characterized by mood and anxiety disorders) than in a separate diagnostic class. PURPOSE: To develop a transdiagnostic, hierarchical-dimensional model relevant to ED psychopathology that: 1) reduces diagnostic heterogeneity, 2) includes important dimensions of internalizing psychopathology that are often excluded from ED diagnostic models, and 3) predicts clinical impairment. PROCEDURES: Goldberg's (2006) method and exploratory structural equation modeling were used to identify a hierarchical model of internalizing in community-recruited adults with EDs (N=207). FINDINGS: The lowest level of the hierarchy was characterized by 15 factors that defined specific aspects of eating, mood, and anxiety disorders. At the two-factor level, Internalizing bifurcated into Distress (low well-being, body dissatisfaction, suicidality, dysphoria, ill temper, traumatic intrusions) and Fear-Avoidance (claustrophobia, social avoidance, panic symptoms, dietary restricting, excessive exercise, and compulsions). Results showed that the lowest level of the hierarchy predicted 67.7% of the variance in clinical impairment. In contrast, DSM eating, mood, and anxiety disorders combined predicted 10.6% of the variance in impairment secondary to an ED. CONCLUSIONS: The current classification model represents an improvement over traditional nosologies for predicting clinically relevant outcomes for EDs.

Do state mental health plans address the New Freedom Commission's goals for children's mental health?

The latest initiative to address mental health needs of the nation, including those of children and youth, is the President's New Freedom Commission on Mental Health (NFC). The NFC formulated a benchmark of six goals and related recommendations toward which the U.S. should strive, including the recommendation that each state develop a comprehensive mental health plan. It is not clear, however, whether the states' developed plans address the goals established by the NFC and to what degree. This project provides a summary of 50 state mental health plans regarding children and youth in the U.S. by examining components that address each of the six NFC goals and is a test of federal leadership on a state issue. Results indicate that state mental health plans addressed the NFC goals to differing degrees with specific attention to children and youth mental health services. Overall, the NFC goal of eliminating disparities in mental health services was addressed most completely, while the NFC goal of understanding that mental health and physical health are associated was addressed least often. The information provided by this analysis represents a first step in gaining a comprehensive picture about public policies for the mental health of children, adolescents, and their families.