Examining a staging model for anorexia nervosa: empirical exploration of a four stage model of severity.

BACKGROUND: An illness staging model for anorexia nervosa (AN) has received increasing attention, but assessing the merits of this concept is dependent on empirically examining a model in clinical samples. Building on preliminary findings regarding the reliability and validity of the Clinician Administered Staging Instrument for Anorexia Nervosa (CASIAN), the current study explores operationalising CASIAN severity scores into stages and assesses their relationship with other clinical features. METHOD: In women with DSM-IV-R AN and sub-threshold AN (all met AN criteria using DSM 5), receiver operating curve (ROC) analysis (n = 67) assessed the relationship between the sensitivity and specificity of each stage of the CASIAN. Thereafter chi-square and post-hoc adjusted residual analysis provided a preliminary assessment of the validity of the stages comparing the relationship between stage and treatment intensity and AN sub-types, and explored movement between stages after six months (Time 3) in a larger cohort (n = 171). RESULTS: The CASIAN significantly distinguished between milder stages of illness (Stage 1 and 2) versus more severe stages of illness (Stages 3 and 4), and approached statistical significance in distinguishing each of the four stages from one other. CASIAN Stages were significantly associated with treatment modality and primary diagnosis, and CASIAN Stage at Time 1 was significantly associated with Stage at 6 month follow-up. CONCLUSIONS: Provisional support is provided for a staging model in AN. Larger studies with longer follow-up of cases are now needed to replicate and extend these findings and evaluate the overall utility of staging as well as optimal staging models.

How well does Anorexia Nervosa fit with personal values? An exploratory study.

BACKGROUND: Despite an increasing clinical interest in the use of personal values as a motivational tool in psychological therapies for Anorexia Nervosa (AN), research is limited. This study explored personal values among individuals with AN, with a particular focus on the 'fit' between participants' values and their AN. METHODS: A qualitative research design was employed in this study. In-depth, semi-structured interviews were carried out among eight female outpatients and inpatients with a diagnosis of AN or Eating Disorder Not Otherwise Specified - AN type (EDNOS-AN type). Data was analysed using Interpretative Phenomenological Analysis (IPA; Smith, Jarman & Osborne, 1999). RESULTS: Three super-ordinate themes emerged from analysis: 'Balancing Values' (difficulty finding balance in relating to and acting on values), 'Congruence and Clashes between AN and Values' (experiences of AN representing a mixed-fit with values) and 'From Ambivalence to Motivation' (ambivalence toward both AN and recovery - in the context of its mixed-fit with values - and experiences of values as a motivational tool in recovery). CONCLUSIONS: Study findings support a role for psychological therapies in working with personal values as a means of promoting recovery in AN, through supporting individuals to explore AN's workability in the context of their values. Further research investigating the optimal stage of treatment to work with values as a motivational tool is warranted.

Predictors of therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa.

BACKGROUND: Therapeutic alliance (TA) has been found to be a significant predictor of outcome for patients with severe and enduring anorexia nervosa (SE-AN), accounting for more variance than treatment type. To better understand how to promote TA for this population, the aim of the current study was to investigate predictors of TA in adults with SE-AN. METHODS: Participants were 63 adult females with SE-AN presenting to an outpatient, multi-site randomized controlled trial conducted at two clinical sites. Participants' perception of the quality of their therapeutic relationship, demographic information, and eating disorder symptomatology were assessed via interview and questionnaire measures. RESULTS: Baseline ratings of how successful participants believed treatment would be for them was the only variable to significantly predict early (p = .01), mid (p = .009), and late treatment alliance (p = .03). No other variables investigated predicted the quality of patient rated TA at any point in treatment (ps > .57). CONCLUSIONS: Results suggest instilling hope in treatment outcome may enhance TA, and in turn, outcomes for patients with SE-AN in outpatient therapy.

Eating disorder symptoms and quality of life: where should clinicians place their focus in severe and enduring anorexia nervosa?

OBJECTIVE: The aim of this study was to examine the relationship between quality of life (QoL), weight, and eating disorder symptoms across treatment in individuals with severe and enduring anorexia nervosa (SE-AN). METHOD: Participants were 63 adult females with SE-AN presenting to an outpatient, multisite randomized clinical trial. QoL was assessed using three well-validated QoL questionnaire measures, the EDQOL, SF-12, and WSAS. Participants' weight and severity of symptoms was assessed by Eating Disorder Examination (EDE) and weekly BMI change. RESULTS: Predictors of QoL were evaluated in the context of concurrent, prospective,1 and lagged mixed-effects models. Changes in both BMI and EDE were found to significantly affect current and future QoL ratings. DISCUSSION: Findings suggest that improvements in QoL may be dependent on symptom change and weight gain. Treatments seeking solely to improve QoL may be unlikely to produce lasting change and clinicians should maintain a focus on weight and behavioral symptoms as much as on improvements in QoL.

BodyWise: evaluating a pilot body image group for patients with anorexia nervosa.

Body image disturbance can be enduring and distressing to individuals with eating disorders and effective treatments remain limited. This pilot study evaluated a group-based treatment-BodyWise-developed for use in full and partial hospitalization with patients with anorexia nervosa at low weight. A partial crossover waitlist design was used. BodyWise (N = 50) versus treatment as usual (N = 40) were compared on standardized measures of body image disturbance. Results demonstrated significant improvement in the group compared to treatment as usual for the primary outcome measure (Eating Disorder Examination-Questionnaire Shape Concern subscale) and other manifestations of body image disturbance including body checking and body image quality of life. BodyWise appeared acceptable to participants, and was easy to deliver within the pragmatics of a busy eating disorder service. There is potential for its wider dissemination as a precursor to more active body image interventions.

Predictors and moderators of outcome for severe and enduring anorexia nervosa.

Few of the limited randomized controlled trials (RCTs) for adults with anorexia nervosa (AN) have explored predictors and moderators of outcome. This study aimed to identify predictors and moderators of outcome at end of treatment (EOT) and 6- and 12-month follow-up for adults with AN (N = 63). All participants met criteria for severe and enduring AN (duration of illness ≥ 7 years) and participated in an RCT of cognitive-behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM). General linear models were utilized and included all available outcome data at all time points. Outcome was assessed across three domains: eating disorder quality of life (EDQOL), mental health (MCS), and depressive symptoms (BDI). Predictors of better outcome included: lower age, shorter duration of illness, having AN-R, being employed, not taking psychotropic medication, and better social adjustment. Four moderators of treatment outcome emerged: eating disorder psychopathology (EDE Global), depression (BDI), age, and AN subtype. Participants with higher baseline scores on these measures, older age, or binge eating/purging subtype benefited more from CBT-AN than SSCM. Older patients with more severe eating-related psychopathology and depression have better outcomes in a behaviorally targeted treatment such as CBT-AN rather than a supportive treatment such as SSCM.

Body checking and avoidance in low weight and weight restored individuals with anorexia nervosa and non-clinical females.

Body dissatisfaction (BD) is central to the development, maintenance and relapse of anorexia nervosa (AN). BD has been conceptualized as a multi-dimensional construct incorporating behaviours, cognitions and affect, yet little is known about the impact of weight and disordered eating on these aspects. 56 'below DSM-IV weight criteria for AN' (BMI 17.5 kg/m(2)) individuals currently receiving treatment for an eating disorder, and 60 non-eating disordered females completed the Body Checking Scale, Body Image Avoidance Questionnaire and the Body Image Anxiety Questionnaire. As expected, females diagnosed with AN showed significantly more behavioural and affective body dissatisfaction than the control group. Patients at lower weights showed significantly more avoidance behaviours and less body image anxiety than those with anorexia at higher weights. No difference was seen in checking behaviours between these groups. Weight based differences in avoidance behaviours continued to exist even when the effects of anxiety were controlled for. Affective and behavioural aspects of BD should be considered in clinical practice at all stages of treatment.

Confirmatory factor analysis for two questionnaires of caregiving in eating disorders.

Objective: Caring for someone diagnosed with an eating disorder (ED) is associated with a high level of burden and psychological distress which can inadvertently contribute to the maintenance of the illness. The Eating Disorders Symptom Impact Scale (EDSIS) and Accommodation and Enabling Scale for Eating Disorders (AESED) are self-report scales to assess elements of caregiving theorised to contribute to the maintenance of an ED. Further validation and confirmation of the factor structures for these scales are necessary for rigorous evaluation of complex interventions which target these modifiable elements of caregiving. Method: EDSIS and AESED data from 268 carers of people with anorexia nervosa (AN), recruited from consecutive admissions to 15 UK inpatient or day patient hospital units, were subjected to confirmatory factor analysis to test model fit by applying the existing factor structures: (a) four-factor structure for the EDSIS and (b) five-factor structure for the AESED. Results: Confirmatory factor analytic results support the existing four-factor and five-factor structures for the EDSIS and the AESED, respectively. Discussion: The present findings provide further validation of the EDSIS and the AESED as tools to assess modifiable elements of caregiving for someone with an ED.

Therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa.

OBJECTIVE: The aim of this study was to investigate the strength and role of therapeutic alliance in a trial comparing Cognitive Behavioral Therapy for anorexia nervosa (CBT-AN) and Specialist Supportive Clinical Management for the treatment of severe and enduring AN (SE-AN). METHOD: Participants were 63 adult females with SE-AN presenting to an outpatient, multisite randomized controlled trial conducted at two clinical sites. Participants completed measures assessing their perception of the quality of the therapeutic relationship, eating disorder (ED) symptomatology, and depressive symptomatology. RESULTS: Beyond the effect of early treatment change and treatment assignment, early therapeutic alliance was a significant predictor of Restraint and Shape Concern at follow-up (ps < .02). Late therapeutic alliance was a significant predictor of weight change, depressive symptomatology, and ED symptomatology at end of treatment and follow-up (ps < .008), with the exception of Shape Concern at follow-up (p = .07). DISCUSSION: The results suggest that therapeutic alliance can be effectively established in the treatment of SE-AN and may be relevant for treatment response, particularly in late treatment, on some aspects of ED and depressive symptomatology.

Caregiving and coping in carers of people with anorexia nervosa admitted for intensive hospital care.

OBJECTIVE: The aim of the study was to examine how carers cope practically and emotionally with caring for individuals with anorexia nervosa who require intensive hospital care. METHOD: This study explores objective burden (time spent with caregiving and number of tasks), subjective burden (psychological distress), and social support in a sample of parents (n = 224) and partners (n = 28) from a consecutive series of patients (n = 178) admitted to inpatient units within the United Kingdom. RESULTS: Most time was spent providing emotional support and less with practical tasks. Time spent with caregiving was associated with carer distress and was fully mediated by carer burden. This was ameliorated by social support. Partners received minimal support from others, and we found similar levels of burden and distress for mothers and partners. DISCUSSION: The data indicate that professional and social support alleviates carer distress and may be of particular value for partners who are more isolated than parents. The data also suggest that time spent with practical support may be of more value than emotional support.

Cognitive behavioural therapy for individuals with longstanding anorexia nervosa: adaptations, clinician survival and system issues.

Despite recent advances in the treatment of anorexia nervosa, some individuals will progress to a severe and enduring illness, with associated physical, psychological and social consequences. Working with these patients, however, may leave clinicians feeling overwhelmed, risking difficulties in the therapeutic relationship including disengagement or despair. Cognitive behaviour therapy has shown some promise in the treatment of eating disorders, yet some features may not be appropriate for this group. In this paper, we outline the ways in which we have adapted cognitive behaviour therapy to best meet the complex and challenging needs of this group. We stress the importance of maintaining a reassuring, accepting and motivational approach in combination with clear goal setting and boundaries.

The St George's eating disorders service meal preparation group for inpatients and day patients pursuing full recovery: a pilot study.

This naturalistic cohort study evaluates a meal cookery group-based occupational therapy intervention for adult inpatients and day patients with severe eating disorders. It also evaluates the Eating and Meal Preparation Skills Assessment (EMPSA) as an outcome measure, allowing clients pursuing recovery to rate ability and motivation to perform tasks related to preparing and eating 'normal' meals. Twenty-seven participants completed EMPSAs at their first, 10th and final sessions, plus 1 year later. The Ability subscale of EMPSA indicated significant improvements (p < 0.001) by the 10th session, which was maintained 1 year later. The Motivation subscale of EMPSA indicated no significant changes at the 10th session but highly significant improvements (p < 0.001) between the 10th and final session, which was maintained 1 year later. Internal consistency for EMPSA was demonstrated by Cronbach's alpha of 0.71 for Ability subscale and 0.95 for Motivation subscale. We conclude that the meal preparation group is effective and durable.

Why are we waiting? The relationship between low admission weight and end of treatment weight outcomes.

Inpatient eating disorder units are increasingly being asked to admit patients at lower BMI's, often delaying hospital treatment until medically unavoidable. This paper aims to explore the impact of this trend on treatment outcome. Eighty-two adults with anorexia nervosa admitted to a national inpatient eating disorder ward were assessed for BMI at admission, length of hospitalisation, discharge BMI and re-admission within 1-year post-treatment. In the current study, admission BMI was unrelated to amount of weight gain during treatment or to length of hospital stay. As such patients admitted at lower BMI's had significantly lower BMI's on discharge from treatment. Low admission BMI's were related to significantly higher likelihoods of re-admission within 1 year. This study provides strong evidence for the benefit of early treatment episodes and with more successful treatment outcomes being related to higher weights at start of treatment.

Assessing quality of life in the eating disorders: the HeRQoLED-S.

EVALUATION OF: Las Hayas C, Quintana JM, Padierna JA, Bilbao A, Muñoz P. Use of Rasch methodology to develop a short version of the Health Related Quality of Life for Eating Disorders questionnaire: a prospective study. Health Qual. Life Outcomes 8, 29 (2010). Quality of life has become of increasing interest for health professionals since the 1980s and is now incorporated into assessment, treatment and evaluation of many health interventions. Within the arena of eating disorders, adequate consideration of quality of life within treatment and research has been slower, but is now coming into line with wider physical and mental health fields. A number of eating disorder-specific measures have been developed that aim to assess perceived quality of life while also minimizing response bias, which can be attributable to the ego-syntonicity of the eating disorders. While these measures are of great importance, further work is still required to assess the reliability and validity of these scales and to adapt the current available measures to increase their suitability for incorporation into clinical and research protocols. The current discussed paper by Las Hayas et al. aims to evaluate the Health Related Quality of Life for the Eating Disorders - version 2 (HeRQoLEDv2) for reliability and validity, to develop a short form of this questionnaire, the Health Related Quality of Life for the Eating disorders - Short form (HeRQoLED-S) using Rasch methodology and to further assess the HeRQoLED-S for reliability and validity. The authors confirm their hypothesized internal structure of the scales and present evidence for the reliability of the short scale. However, the short measure should be subject to more rigorous analysis of its reliability and construct validity in order to provide evidence as to its relationship to quality of life as perceived by eating disorder individuals.

Exploring quality of life in the eating disorders.

OBJECTIVE: The present study aimed to investigate the impact of Body Mass Index (BMI), duration of illness and severity of illness on quality of life within a sample of individuals in treatment for an eating disorder. In addition this study explored differences in specific areas of quality of life (Psychological, Physical/Cognitive, Work/School and Financial) according to specific eating disorder diagnoses. METHOD: Participants (N = 156) were adults currently receiving treatment for an eating disorder. Eating disorder symptomatology and quality of life were assessed using self-report questionnaires. BMI, duration of illness and eating disorder diagnosis was obtained during a clinical interview. RESULTS: Severity of the eating disorder and BMI were predictors of low quality of life. Duration of illness, contrary to clinical expectations was not a significant predictor of poor quality of life. In terms of differences across diagnostic groups, individuals with a diagnosis of anorexia nervosa in this sample were found to have lower psychological and physical/cognitive quality of life than those with an EDNOS or BN diagnoses.

Investigating the role of attachment in social comparison theories of eating disorders within a non-clinical female population.

OBJECTIVE: The present study aimed to integrate attachment theory and sociocultural theory as predictors of disordered eating, thereby combining two previously distinct literatures in order to provide a more comprehensive model of eating disorder development. It was specifically proposed that women's attachment style may influence their tendency to socially compare themselves to idealized others. METHOD: Participants (N = 213) were non-clinical female undergraduates. Sociocultural attitudes to appearance, social comparison, attachment and eating disorder symptomatology were assessed using self-report questionnaires. RESULTS: Consistent with the hypothesis, social comparison was found to mediate the relationship between attachment anxiety and disordered eating. In addition, attachment avoidance, was not significantly associated with either internalisation of cultural ideals or social comparison but was significantly related to eating psychopathology. CONCLUSION: The findings suggest that attachment anxiety and avoidance influence disordered eating via different pathways, with attachment anxiety specifically being implicated in sociocultural models of disordered eating.

Exploring quality of life for eating-disordered patients.

This qualitative study used a semi-structured interview to explore whether user perspective on quality of life changed following a 12 week day therapy programme for eating disorders. Thematic analysis was used to explore emergent themes. The most significant finding was the difference between the trajectories of the completers and the non-completers of the day programme. Whilst completers and non-completers were similar at the start of the programme, completers moved through aspiration to actual change in the quality of their lives, whereas non-completers were unable to take their aspiration through to action. One possible explanation for the findings is that motivation may be an important intermediate variable, with completers of the programme being more motivated to improve not only their symptoms but also the quality of their lives more generally.

How important are motivation and initial Body Mass Index for outcome in day therapy services for eating disorders?

This study was designed to investigate the impact of initial Body Mass Index (BMI) and motivation for recovery on a 12-week day therapy programme for Eating Disorders. Outcome was assessed by changes in eating disorder symptomology, mood and self-esteem. A battery of assessment questionnaires was given to 34 eating disorder clients on admission to and completion of the programme. This study found that BMI at admission did not affect treatment outcome directly. Only patient self-rated motivation directly affected treatment outcome with more highly motivated clients making more significant changes to their eating disorder symptomology across the programme. However, motivation, BMI and duration of illness influenced how likely a patient was to complete the 12 weeks and completion of the programme had a direct effect on eating disorder symptomology, mood and self-esteem. BMI and motivation can therefore be seen to indirectly effect the outcome of treatment via the ability to complete the programme.

Socially driven eating and restriction in the eating disorders.

The aims of this study were: to develop a measure to examine the relationship between socially driven eating and specific eating behaviours; to examine whether different social situations increase or decrease eating in different diagnostic groups; and to determine whether dimensional links exist between responses to social triggers and different aspects of eating pathology. A clinical group of 107 eating-disordered women and 143 nonclinical women completed a measure of socially driven eating and restriction (the Social Eating Scale, or SES) and the Eating Disorders Inventory. The SES had good psychometric properties. Patients with binge-eating disorder (BED) ate more in all social situations, while those with anorexia nervosa ate less. In contrast, bulimia nervosa (BN) patients ate more in general social situations but less in situations where the social trigger was related to food, shape, or weight. There were consistent dimensional links between responses to social triggers and different aspects of eating pathology. These findings support the recent literature on social triggers of eating behaviours but stress the relevance of the mixed pathology of women with BN. The role of social triggers for eating might help to explain the effectiveness of interpersonal psychotherapy when applied to the eating disorders.