Therapy outcome of day treatment for people with anorexia nervosa before and during the COVID-19 pandemic.

OBJECTIVE: The current research aimed to compare clinical outcome measures of two National Eating Disorder (ED) Day Services at the Maudsley Hospital from before the COVID-19 lockdown, when treatment was face to face, with after the lockdown when treatment moved online. METHOD: Clinical outcome measures collected as part of the admission and discharge process were compared from the beginning and end of treatment for patients treated either via face-to-face or online delivery. Twenty-nine patients' data were analyzed (89% of them female, 11% male, 89% from White ethnic backgrounds, 11% from BAME ethnic backgrounds and a mean age of 25.99 years). Additionally, the mean change in outcome measures was also compared between the two groups (pre-lockdown face to face and during lockdown online). RESULTS: Treatment delivered face to face led to significant improvements in body mass index (BMI) but not in Eating Disorder Examination Questionnaire (EDEQ) Global and Work and Social Adjustment Scale (WSAS) Total scores. In contrast, treatment delivered online led to significant improvements in EDEQ Global and WSAS Total scores but not in BMI. Neither one of the delivery modalities created significantly larger mean changes in any of the clinical outcome measures than the other. CONCLUSIONS: Both face-to-face and online delivery of eating disorder day treatment show some success. Suggested improvements for using online delivery of treatment include implementing additional support opportunities, adapting the online format to improve communication and commitment and using a hybrid model of specific face-to-face elements with some online treatment.

An evaluation of binge eating characteristics in individuals with eating disorders: A systematic review and meta-analysis.

The objective of this review is to provide an updated synthesis of studies in individuals with eating disorders that examined the following components of binge eating episodes (BEEs): caloric intake, episode duration, and also the association of BEE size with psychopathology. A systematic review and meta-analysis were performed following the PRISMA guidelines. Searches were conducted on PubMed, PsycINFO, Scopus, SciELO, ScienceDirect and ProQuest databases. Meta-analysis was performed using random effects models and meta-regression. Forty-three studies were included. There was a paucity of information regarding BEE in individuals with anorexia nervosa. The pooled caloric intake of participants with bulimia nervosa (BN) during BEE in laboratory studies was significantly greater in comparison to the caloric intake during BEE in clinical studies [(3070 (95%CI 2596, 3544) vs. 1789 (95%CI 1498, 2081)], respectively. In participants with binge eating disorder (BED), the pooled means were 2088 (95%CI 1819, 2358) kcal in laboratory studies and 1903 (95%CI 1622, 2184) kcal in clinical studies, with no statistically significant difference between groups. Overall, BEE had a mean duration of 37.3 min in participants with BN and 41.7 min in those with BED. We found a positive correlation between the average caloric intake and level of depression (ß = 55.5; p = 0.019). BEE in individuals with BN or BED were characterized by the consumption of extremely large quantities of calories. This was mainly found in laboratory studies of individuals with BN. BEE had a mean duration of less than 1 h in individuals with BN or BED. BEE size was positively associated with depression severity. Future research should explore the relevance of binge size as a core component of binge eating in clinical samples, in males, and in pediatric populations.

Effectiveness of Pharmacologic Interventions in the Management of Weight Gain in Patients With Severe Mental Illness: A Systematic Review and Meta-Analysis.

OBJECTIVE: To collate and analyze randomized controlled trials (RCTs) that evaluated pharmacologic interventions to reduce weight gain in patients with severe mental illness (SMI). DATA SOURCES: Searches were conducted in PubMed, Web of Science, and PsycINFO databases from inception through May 9, 2019, using the terms ("severe mental disease" OR "severe mental illness" OR "severe mental disorder" OR schizophre* OR bipolar OR antipsychotic*) AND (weight) AND (pharmacologic* OR treatment). There was no language restriction, and the electronic search was complemented by a manual search for additional articles in reference lists and previous reviews. STUDY SELECTION: Fifty-two studies investigating different pharmacologic weight loss interventions in SMI were retrieved. Only RCTs assessing pharmacologic interventions to manage weight gain in adult subjects with SMI and reporting change in body weight as a primary outcome were included. DATA EXTRACTION: Two reviewers independently extracted data about the name and dose of the pharmacologic agent used to manage weight gain, trial duration, agent used for index disease, psychiatric diagnostics, and the mean change in body weight over the course of the trial. A meta-analysis was performed using a random effects model to pool mean body weight change over the course of the trial. RESULTS: The most-studied agent was metformin (14 studies), followed by topiramate (6 studies), nizatidine (4 studies), and sibutramine (3 studies). Other agents were investigated in 1 or 2 isolated studies. A meta-analytical procedure showed a significant pooled mean difference of -3.27 kg (95% CI, -4.49 to -2.06) for metformin compared with placebo and -5.33 kg (95% CI, -7.20 to -3.46) favoring topiramate. CONCLUSIONS: Metformin and topiramate were the most-studied agents for weight control in SMI and were considered efficacious and safe in promoting weight reduction compared to placebo in this population. More studies are required with larger sample sizes and in line with the recommendations from research from the obesity and metabolic field to better define guidelines for use of pharmacologic interventions to reduce weight gain in patients with SMI.

Adult avoidant/restrictive food intake disorder: a case report / Transtorno alimentar evitativo/restritivo em uma adulta: um relato de caso

ABSTRACT The aim this report is to present an adult case of avoidant/restrictive food intake disorder (ARFID) in a patient with atypical development. To emphasize the diagnostic and behavioral characteristics of this new nosological category included in the Feeding and Eating Disorders (FED) section of DSM-5. A woman with Down Syndrome in early adulthood who developed restriction and avoidance symptoms of food until the total eating refusal with weight loss, malnutrition and dependence exclusively on enteral feeding by gastrostomy tube. This case exemplified how ARFID may remain a hidden diagnosis and even be misdiagnosed as other eating disorders, such as anorexia nervosa. The increase in diagnostic suspicion for this nosological entity with neurobiological/behavioral mechanisms involved in its clinical presentations in mind, might increase knowledge about this serious eating disorder, aiming the development of evidence-based interventions.

RESUMO O objetivo deste relato é apresentar um caso de transtorno alimentar evitativo/restritivo (TARE) em uma paciente adulta com desenvolvimento atípico e salientar as características diagnósticas e comportamentais dessa nova categoria nosológica incluída na seção de Transtornos Alimentares da DSM-5. Mulher com síndrome de Down que, no início da vida adulta, evoluiu com sintomas de restrição e evitação alimentar até a recusa total da alimentação, com perda de peso, desnutrição e dependência total de alimentação enteral por gastrostomia. Este caso elucida como o diagnóstico de TARE pode permanecer oculto e ser confundindo com outras condições patológicas alimentares, como a anorexia nervosa. O aumento da suspeição diagnóstica para essa entidade nosológica, tendo em mente os mecanismos neurobiológicos/comportamentais envolvidos em suas apresentações clínicas, possibilitará o aumento do conhecimento sobre esse grave transtorno alimentar, visando ao desenvolvimento de intervenções eficazes baseadas em evidências.

The influence of oxytocin on risk-taking in the balloon analogue risk task among women with bulimia nervosa and binge eating disorder.

Previous theoretical models of bulimia nervosa (BN) and binge eating disorder (BED) have implicated cross-domain risk-taking behaviour as a significant maintenance factor in both disorders. The present study aimed to test this hypothesis by administering the Balloon Analogue Risk Task (BART) to 25 women with BN or BED and 27 healthy comparison women without a history of an eating disorder. Furthermore, we tested the effect of a divided dose of 64 IU of oxytocin on risk-taking behaviour in the BART. Contrary to our hypothesis, women with BN or BED did not exhibit baseline differences in performance on the BART in the placebo condition (t = 1.42, df = 50, P = 0.161, d = 0.39). Oxytocin did not have a main effect on performance in the BART (F = 0.01, df = 1, P = .907, η2partial  < 0.001); however, there was an interaction, such that participants in the BN/BED participant group, compared to the healthy comparison group, demonstrated safer behaviour on the BART in the oxytocin condition, but not in the placebo condition (F = 4.29, df = 1, P = 0.044, η2partial  = 0.082). These findings cast doubt on the common assumption that individuals with BN and BED exhibit greater risk-taking behaviour in all domains and add to the evidence that oxytocin plays a functional role in modulating behaviours that entail trade-offs between reward approach and risk in humans. We recommend that future dose-response studies investigate the effect of oxytocin on reward approach behaviour further in women with recurrent binge eating behaviour, as well as the clinical significance of this effect.

How do we target the factors that maintain anorexia nervosa? A behaviour change taxonomical analysis.

All psychological treatments for anorexia nervosa appear to have equal (albeit modest) effects. This may be explained because they target similar processes. Although different psychological treatments have been developed for anorexia nervosa treatment, their taxonomical components have not been compared. This study undertook a taxonomical analysis of behaviour change techniques (BCTs), using the CALO-RE analysis tool, from the manuals of Enhanced Cognitive Behavioural Therapy (CBT-E), Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA), Family Based Therapy (FBT), Specialist Supportive Clinical Management (SSCM), and Focal Psychodynamic Psychotherapy (FPT). The highest number of BCTs were found in FPT (72,5%), and the lowest were in SSCM (30%). The other interventions had a similar range of BCTs which mainly focused on goal planning (FBT (50%), CBT-E (47.5%), MANTRA (42.5%)). Modelling, shaping, and training communication, self-monitoring, and fear arousal were the less commonly used BCTs across manuals. Manualized psychological interventions for people with anorexia nervosa share a substantial number of behaviour change techniques which might explain their similar levels of effectiveness. New strategies may be needed in order to improve outcomes.

Eating disorder symptoms in Brazilian university students: a systematic review and meta-analysis

Objective: To synthesize the risk of eating disorder (ED) symptoms in Brazilian university students through a systematic review and meta-analysis. Secondary goals were to analyze whether any specific majors were related to higher ED risk and whether any regions of Brazil had higher proportions of college students at risk of ED. Methods: The procedures followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, and a search was conducted in three electronic databases (MEDLINE, LILACS, and SciELO). Results: Thirty-three studies were included in the analysis, of which 14 were included in the meta-analysis. All included studies used self-report questionnaires, the most frequent of which was the Eating Attitudes Test (EAT-26). None of the studies used a structured interview to diagnose ED. A meta-analysis of studies with a cutoff ≥ 20 for the EAT-26 (n=5) found 14.9% (95%CI 12.8-17.2%) positive screenings, while those with a cutoff of t ≥ 21 (n=9) found 13.3% (95%CI 11.3-15.6%) positive screenings. There was a significantly higher proportion of positive screenings among nutrition majors than all other majors combined (26.5 and 20.5%, respectively). Conclusion: Nutrition students seem to be at higher risk of ED. Further research should investigate whether positive screenings translate to actual ED diagnoses.

Eating disorder symptoms in Brazilian university students: a systematic review and meta-analysis.

OBJECTIVE: To synthesize the risk of eating disorder (ED) symptoms in Brazilian university students through a systematic review and meta-analysis. Secondary goals were to analyze whether any specific majors were related to higher ED risk and whether any regions of Brazil had higher proportions of college students at risk of ED. METHODS: The procedures followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, and a search was conducted in three electronic databases (MEDLINE, LILACS, and SciELO). RESULTS: Thirty-three studies were included in the analysis, of which 14 were included in the meta-analysis. All included studies used self-report questionnaires, the most frequent of which was the Eating Attitudes Test (EAT-26). None of the studies used a structured interview to diagnose ED. A meta-analysis of studies with a cutoff ≥ 20 for the EAT-26 (n=5) found 14.9% (95%CI 12.8-17.2%) positive screenings, while those with a cutoff of t ≥ 21 (n=9) found 13.3% (95%CI 11.3-15.6%) positive screenings. There was a significantly higher proportion of positive screenings among nutrition majors than all other majors combined (26.5 and 20.5%, respectively). CONCLUSION: Nutrition students seem to be at higher risk of ED. Further research should investigate whether positive screenings translate to actual ED diagnoses.

By the book: ADHD prevalence in medical students varies with analogous methods of addressing DSM items

Objective: The marked increase in the prevalence of attention-deficit/hyperactivity disorder (ADHD) among university students gives rise to questions about how best to diagnose in this setting. The aim of the present study was to calculate ADHD prevalence in a large non-clinical sample of medical students using a stepwise design and to determine whether ADHD diagnosis varies if interviewees use additional probing procedures to obtain examples of positive DSM items. Methods: A total of 726 students were screened with the Adult Self-Report Scale (ASRS) and invited for an interview with the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) adapted for adults. Results: The ASRS was positive for 247 students (37%), although only 83 (7.9%) received an ADHD diagnosis. ASRS sensitivity and specificity rates were 0.97 and 0.40, respectively. Probing procedures were used with a subgroup of 226 students, which decreased the number of ADHD diagnoses to 12 (4.5%). Conclusion: Probing for an individual's real-life examples during the K-SADS interview almost halved ADHD prevalence rate based on the ASRS and K-SADS, which rendered the rate consistent with that typically reported for young adults. In reclassified cases, although examples of inattention did not match the corresponding DSM item, they often referred to another DSM inattention item.

Eating Disorders Impact on Vigilance and Decision Making of a Community Sample of Treatment Naive Attention-Deficit/Hyperactivity Disorder Young Adults.

Although impulsivity is suggested as a possible link to explain the association of Attention-Deficit/Hyperactivity Disorder (ADHD) with an Eating Disorder (ED), there is little research on how clinical and cognitive/neuropsychological functioning might change when this comorbidity occurs. ADHD individuals are at a higher of developing ED and also obesity. Some research has described the impact of ADHD in clinical treatment-seeking samples of ED patients. Consequently, we investigated how ED impacted on clinical and cognitive variables of a community sample of treatment-naive ADHD individuals. Ninety college students arranged in three groups (ADHD+ED, ADHD only and Controls) were analyzed using semi-structured interviews for ADHD (K-SADS), the Iowa Gambling Task, the Conner's Continuous Performance Test, Digit and Visual span, as well as rating scales for anxiety (STAI), depression (BDI) and impulsivity (BIS-11), and binge eating (BES). We found that ADHD+ED individuals significantly differed from both groups, presenting with a higher body mass index; more hyperactivity-impulsivity symptoms; higher binge eating scores; more omission errors on the Continuous Performance Test; disadvantageous choices on the Iowa Gambling Task. Also, we demonstrated through a moderation/mediation analysis that a greater level of binge eating mediated the increases in body mass index on our sample. There were no significant paths to explain binge-eating severity through changes on any of the neuropsychological tests used. The presence of an ED in normal weight in a community sample of ADHD individuals is associated with higher body mass index and a worse cognitive functioning.

Testing the addictive appetite model of binge eating: The importance of craving, coping, and reward enhancement.

In the current study, we examine components of the "addictive appetite" model of recurrent binge eating. Specifically, we tested the influence of addictive processes and the influence of emotional regulation processes on recurrent binge eating behaviour. We recruited 79 women in total for the current study: 22 with bulimia nervosa, 26 weight-matched lean comparison women, 15 women with binge eating disorder, and 16 weight-matched overweight/obese comparison women. Participants completed questionnaire assessments of food craving and motivations for eating. Compared with weight-matched comparison women, women with binge-type eating disorders endorse significantly greater levels of food craving, eating for purposes of coping, and eating for purposes of reward enhancement. A cluster analysis revealed that these three traits distinguish women with binge-type eating disorders from weight-matched comparison women. These findings provide support for the addictive appetite model of binge eating behaviour and highlight addictive and emotional regulation processes as potential targets for treatment.

By the book: ADHD prevalence in medical students varies with analogous methods of addressing DSM items.

OBJECTIVE: The marked increase in the prevalence of attention-deficit/hyperactivity disorder (ADHD) among university students gives rise to questions about how best to diagnose in this setting. The aim of the present study was to calculate ADHD prevalence in a large non-clinical sample of medical students using a stepwise design and to determine whether ADHD diagnosis varies if interviewees use additional probing procedures to obtain examples of positive DSM items. METHODS: A total of 726 students were screened with the Adult Self-Report Scale (ASRS) and invited for an interview with the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) adapted for adults. RESULTS: The ASRS was positive for 247 students (37%), although only 83 (7.9%) received an ADHD diagnosis. ASRS sensitivity and specificity rates were 0.97 and 0.40, respectively. Probing procedures were used with a subgroup of 226 students, which decreased the number of ADHD diagnoses to 12 (4.5%). CONCLUSION: Probing for an individual's real-life examples during the K-SADS interview almost halved ADHD prevalence rate based on the ASRS and K-SADS, which rendered the rate consistent with that typically reported for young adults. In reclassified cases, although examples of inattention did not match the corresponding DSM item, they often referred to another DSM inattention item.

An examination of the clinical outcomes of adolescents and young adults with broad autism spectrum traits and autism spectrum disorder and anorexia nervosa: A multi centre study.

OBJECTIVES: To compare the clinical outcomes of adolescents and young adults with anorexia nervosa (AN) comorbid with broad autism spectrum disorder (ASD) or ASD traits. METHOD: The developmental and well-being assessment and social aptitude scale were used to categorize adolescents and young adults with AN (N = 149) into those with ASD traits (N = 23), and those who also fulfilled diagnostic criteria for a possible/probable ASD (N = 6). We compared both eating disorders specific measures and broader outcome measures at intake and 12 months follow-up. RESULTS: Those with ASD traits had significantly more inpatient/day-patient service use (p = .015), as well as medication use (p < .001) at baseline. Both groups had high social difficulties and poorer global functioning (strengths and difficulties questionnaire) at baseline, which improved over time but remained higher at 12 months in the ASD traits group (p = .002). However, the improvement in eating disorder symptoms at 12 months was similar between groups with or without ASD traits. Treatment completion rates between AN only and ASD traits were similar (80.1 vs. 86.5%). DISCUSSION: Adolescents with AN and ASD traits show similar reductions in their eating disorder symptoms. Nevertheless, their social difficulties remain high suggesting that these are life-long difficulties rather than starvation effects.

To Go or Not to Go: A Proof of Concept Study Testing Food-Specific Inhibition Training for Women with Eating and Weight Disorders.

Inefficient food-specific inhibitory control is a potential mechanism that underlies binge eating in bulimia nervosa and binge eating disorder. Go/no-go training tools have been developed to increase inhibitory control over eating impulses. Using a within-subjects design, this study examined whether one session of food-specific go/no-go training, versus general inhibitory control training, modifies eating behaviour. The primary outcome measure was food consumption on a taste test following each training session. Women with bulimia nervosa and binge eating disorder had small non-significant reductions in high-calorie food consumption on the taste test following the food-specific compared with the general training. There were no effects on eating disorder symptomatic behaviour (i.e. binge eating/purging) in the 24 h post-training. The training task was found to be acceptable by the clinical groups. More research is needed with larger sample sizes to determine the effectiveness of this training approach for clinical populations. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

A Pilot, Multicentre Pragmatic Randomised Trial to Explore the Impact of Carer Skills Training on Carer and Patient Behaviours: Testing the Cognitive Interpersonal Model in Adolescent Anorexia Nervosa.

AIM: The aim of the study is to establish the acceptability, feasibility and approximate size of the effect of adding a carer intervention [Experienced Caregivers Helping Others (ECHO)] to treatment as usual (TAU) for adolescents with anorexia nervosa. METHODS: The study is a pilot randomised trial comparing TAU (n = 50) alone or TAU plus ECHO with (n = 50) or without (n = 49) telephone guidance. Effect sizes (ESs) were regression coefficients standardised by baseline standard deviations of measure. RESULTS: Although engagement with ECHO was poor (only 36% of carers in the ECHO group read over 50% of the book), there were markers of intervention fidelity, in that caregivers in the ECHO group showed a moderate increase in carer skills (ES = 0.4) at 12 months and a reduction in accommodating and enabling behaviour at 6 months (ES = 0.17). In terms of efficacy, in the ECHO group, carers spent less time care giving (ES = 0.40, p = 0.04) at 1 year, and patients had a minor advantage in body mass index (ES = 0.17), fewer admissions, decreased peer problems (ES = -0.36) and more pro-social behaviours (ES = 0.53). The addition of telephone guidance to ECHO produced little additional benefit. CONCLUSIONS: The provision of self-management materials for carers to standard treatment for adolescent anorexia nervosa shows benefits for both carers and patients. This could be integrated as a form of early intervention in primary care. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.