Applying family-based treatment (FBT) to three clinical presentations of avoidant/restrictive food intake disorder: Similarities and differences from FBT for anorexia nervosa.

OBJECTIVE: This article uses three brief case reports to illustrate how family-based treatment (FBT) can be used to treat pre-adolescents with avoidant/restrictive food intake disorder (ARFID). METHOD: We present case material illustrating how FBT can be used in three different clinical presentations of ARFID: (1) low appetite and lack of interest; (2) sensory sensitive eaters; and (3) fear of aversive consequences eaters-all without shape or weight concerns. RESULTS: This case material illustrates that the main principles of FBT-agnosticism as to the cause of the illness, externalization, emphasizing the seriousness of ARFID, parental empowerment, behavioral consultation, and practical behavioral focus-are applicable for a range of ARFID clinical presentations. Common challenges in this patient group include (1) promoting urgency; (2) challenging long term behavioral accommodation; (3) lack of parental alignment, parental fatigue, (4) and co-morbid psychiatric problems in the patients. Strategies to address these problems are described. CONCLUSION: FBT can be adapted for children with ARFID using the main principles of the approach.

Affect-based profiles of bulimia nervosa: The utility and validity of indicators assessed in the natural environment.

Theoretical conceptualizations of bulimia nervosa (BN) emphasize the role of emotion dysregulation in the development and maintenance of symptoms, which has been supported by ecological momentary assessment studies. Given the importance of affective disturbances in BN, this study aimed to classify a sample of adult women with BN (N = 130) based on primarily momentary affective indicators, including negative and positive affect, negative and positive affective lability, and depression. Participants completed baseline assessments followed by a two-week ecological momentary assessment protocol. Latent profile analysis revealed four groups: (1) a "stable normal" group characterized by low affective lability and intensity; (2) a "stable depressed" group characterized by low affective lability and higher affect intensity; (3) an "unstable normal" group characterized by higher affective lability but lower affect intensity; and (4) an "unstable depressed" group characterized by higher affective lability and intensity. The stable depressed group evidenced the highest levels of eating psychopathology, borderline personality traits, and childhood trauma history, while the stable normal group generally evidenced the lowest levels of psychopathology. The findings demonstrate significant heterogeneity in the topography of affect experienced by individuals with BN, and suggest that chronic, intense negative affect may be particularly important to address in treatment.

Adolescent Loss-of-Control Eating and Weight Loss Maintenance After Bariatric Surgery.

BACKGROUND: Loss-of-control (LOC) eating is common in adults undergoing bariatric surgery and is associated with poorer weight outcomes. Its long-term course in adolescent bariatric surgery patients and associations with weight outcomes are unclear. METHODS: Adolescents (n = 234; age range = 13-19 years) undergoing bariatric surgery across 5 US sites were assessed for postsurgery follow-up at 6 months and 1, 2, 3, and 4 years. Descriptive statistics and generalized linear mixed models were used to describe the prevalence of LOC eating episodes involving objectively large amounts of food and continuous eating, respectively. Generalized linear mixed models investigated the association of any LOC eating with short- and long-term BMI changes. RESULTS: At baseline, objectively large LOC eating was reported by 15.4% of adolescents, and continuous LOC eating by 27.8% of adolescents. Both forms of LOC eating were significantly lower at all postsurgical time points relative to presurgery (range = 0.5%-14.5%; Ps < .05). However, both behaviors gradually increased from 6-month to 4-year follow-up (Ps < .05). Presurgical LOC eating was not related to percent BMI change over follow-up (P = .79). However, LOC eating at 1-, 2-, and 3-year follow-up was associated with lower percent BMI change from baseline at the next consecutive assessment (Ps < .05). CONCLUSIONS: Although presurgical LOC eating was not related to relative weight loss after surgery, postoperative LOC eating may adversely affect long-term weight outcomes. Rates of LOC eating decreased from presurgery to 6-months postsurgery but increased thereafter. Therefore, this behavior may warrant additional empirical and clinical attention.

Subtypes of Adaptive and Maladaptive Perfectionism in Anorexia Nervosa: Associations with Eating Disorder and Affective Symptoms.

Perfectionism is hypothesized to contribute to the etiology of anorexia nervosa (AN). However, there is little research regarding whether individuals with AN can be classified according to maladaptive (e.g., evaluative concerns) and adaptive (e.g., high personal standards) facets of perfectionism that predict distinct outcomes and might warrant different intervention approaches. In this study, a latent profile analysis was conducted using data from adults with AN (n = 118). Frost Multidimensional Perfectionism Scale (Frost et al. Cognitive Therapy and Research, 14(5), 449-46, 1990) subscales were used to identify subgroups differing according to endorsed perfectionism features (e.g., adaptive and maladaptive perfectionism). Generalized linear models were used to compare subgroups on eating disorder and affective symptoms measured through questionnaire and ecological momentary assessment. Four subgroups were identified: (a) Low Perfectionism; (b) High Adaptive and Maladaptive Perfectionism; (c) Moderate Maladaptive Perfectionism; and (d) High Maladaptive Perfectionism. Subgroups differed on overall eating disorder symptoms (p < .001), purging (p = .005), restrictive eating (p < .001), and body checking (p < .001) frequency, depressive (p < .001) and anxiety (p < .001) symptoms, and negative (p = .001) and positive (p < .001) affect. The Low Perfectionism group displayed the most adaptive scores and the Moderate and High Maladaptive Perfectionism groups demonstrated the most elevated clinical symptoms. The High Adaptive and Maladaptive Perfectionism group demonstrated low affective disturbances, but elevated eating disorder symptoms. Results support the clinical significance of subtyping according to perfectionism dimensions in AN. Research is needed to determine if perfectionism subtyping can enhance individualized treatment targeting in AN.

Contextual factors associated with eating in the absence of hunger among adults with obesity.

Eating in the absence of hunger (EAH) is under-explored in adults with obesity. In this study, 50 adults with obesity recorded eating episodes and theoretically-relevant environmental, perceptual, and emotional correlates in the natural environment for 2weeks via ecological momentary assessment (EMA). Generalized linear models and mixed models were used to characterize correlates and consequences of EAH vs. non-EAH episodes/tendencies (within-subjects and between-subjects effects, respectively), time of day, and time of day×EAH interactions. Approximately 21% of EMA-recorded eating episodes involved EAH, and 70% of participants reported at least 1 EAH episode. At the within-person level, participants' EAH episodes were associated with greater self-labeled overeating than their non-EAH episodes. At the between-person level, participants who tended to engage in more EAH reported less self-labeled overeating than those who engaged in less EAH. Across EAH and non-EAH episodes, eating in the evening was associated with overeating, expecting eating to be more rewarding, greater alcoholic beverage consumption, eating alone, eating because others are eating, and eating while watching television. Significant EAH×time of day interactions were also observed but the pattern of findings was not consistent. Findings suggest that EAH may be a relevant target for reducing food intake in individuals with obesity given its high prevalence and association with perceptions of overeating, although results should be extended using objective measures of food intake. Associations between evening eating episodes and perceptual and environmental factors should be further explored.

Empirically derived personality subtyping for predicting clinical symptoms and treatment response in bulimia nervosa.

OBJECTIVE: Evidence suggests that eating disorder subtypes reflecting under-controlled, over-controlled, and low psychopathology personality traits constitute reliable phenotypes that differentiate treatment response. This study is the first to use statistical analyses to identify these subtypes within treatment-seeking individuals with bulimia nervosa (BN) and to use these statistically derived clusters to predict clinical outcomes. METHODS: Using variables from the Dimensional Assessment of Personality Pathology-Basic Questionnaire, K-means cluster analyses identified under-controlled, over-controlled, and low psychopathology subtypes within BN patients (n = 80) enrolled in a treatment trial. Generalized linear models examined the impact of personality subtypes on Eating Disorder Examination global score, binge eating frequency, and purging frequency cross-sectionally at baseline and longitudinally at end of treatment (EOT) and follow-up. In the longitudinal models, secondary analyses were conducted to examine personality subtype as a potential moderator of response to Cognitive Behavioral Therapy-Enhanced (CBT-E) or Integrative Cognitive-Affective Therapy for BN (ICAT-BN). RESULTS: There were no baseline clinical differences between groups. In the longitudinal models, personality subtype predicted binge eating (p = 0.03) and purging (p = 0.01) frequency at EOT and binge eating frequency at follow-up (p = 0.045). The over-controlled group demonstrated the best outcomes on these variables. In secondary analyses, there was a treatment by subtype interaction for purging at follow-up (p = 0.04), which indicated a superiority of CBT-E over ICAT-BN for reducing purging among the over-controlled group. DISCUSSION: Empirically derived personality subtyping appears to be a valid classification system with potential to guide eating disorder treatment decisions. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:506-514).

Trajectories of higher- and lower-order dimensions of negative and positive affect relative to restrictive eating in anorexia nervosa.

Despite robust support for the role of affect in the maintenance of binge eating and purging, the relationship between affect and restrictive eating remains poorly understood. To investigate the relationship between restrictive eating and affect, ecological momentary assessment data from 118 women with anorexia nervosa (AN) were used to examine trajectories of higher-order dimensions of negative affect (NA) and positive affect (PA), as well as lower-order dimensions of NA (Fear, Guilt) and PA (Joviality, Self-Assurance) relative to restrictive eating. Affect trajectories were modeled before and after restrictive eating episodes and AN subtype was examined as a moderator of these trajectories. Across the sample, Guilt significantly increased before and decreased after restrictive eating episodes. Global NA, Global PA, Fear, Joviality, and Self-Assurance did not vary relative to restrictive eating episodes across the sample. However, significant subtype by trajectory interactions were detected for PA indices. Among individuals with AN restricting subtype, Global PA, Joviality, and Self-Assurance decreased prior to and Self-Assurance increased following restrictive eating episodes. In contrast, Global PA and Self-Assurance increased prior to, but did not change following, restrictive eating episodes among individuals with AN binge eating/purging subtype. Results suggest that dietary restriction may function to mitigate guilt across AN subtypes and to enhance self-assurance among individuals with AN restricting subtype. (PsycINFO Database Record

Incorporating Social Support in the Treatment of Anorexia Nervosa: Special Considerations for Older Adolescents and Young Adults.

Currently, research support is strongest for family-based treatment (FBT) for the treatment of anorexia nervosa (AN) in adolescents. However, a strong evidence base for treatments for older adolescents and young adults with AN is lacking. Emphasizing social support in the treatment of AN may be beneficial for older adolescents and young adults with AN. This paper provides a brief review of the literature on FBT for adolescent AN and provides a case example of adolescent AN treated with FBT. We then discuss novel treatments that have incorporated social support for older adolescents and young adults with AN, such as modified FBT and couples-based interventions. We provide case studies of each of these novel treatment approaches as well. Additionally, this paper highlights and discusses developmental considerations and challenges in working with older adolescents and young adults with AN.

Examining affect and perfectionism in relation to eating disorder symptoms among women with anorexia nervosa.

This study examined personality and affective variables in relation to eating disorder symptoms in anorexia nervosa (AN). Women (N=118) with DSM-IV AN completed baseline questionnaires (Beck Depression Inventory, Frost Multidimensional Perfectionism Scale) and interviews (Eating Disorder Examination, Yale-Brown-Cornell Eating Disorder Scale), followed by two weeks of ecological momentary assessment (EMA) involving multiple daily reports of affective states and eating disorder behaviors. Hierarchical regression analyses were conducted using eating disorder symptoms as dependent variables (i.e., EMA binge eating, EMA self-induced vomiting, eating disorder rituals, eating disorder preoccupations, dietary restraint). Predictor variables were maladaptive perfectionism (baseline), depressive symptoms (baseline), and affect lability (EMA). Results revealed that affect lability was independently associated with binge eating, whereas depressive symptoms were independently associated with self-induced vomiting. Depressive symptoms were independently associated with eating disorder rituals, whereas both depressive symptoms and maladaptive perfectionism were independently associated with eating disorder preoccupations. Finally, maladaptive perfectionism and affect lability were both independently associated with dietary restraint. This pattern of findings suggests the importance of affective and personality constructs in relation to eating disorder symptoms in AN and may highlight the importance of targeting these variables in the context of treatment.

Loss of control eating and eating disorders in adolescents before bariatric surgery.

OBJECTIVE: This study assessed loss of control (LOC) eating and eating disorders (EDs) in adolescents undergoing bariatric surgery for severe obesity. METHOD: Preoperative baseline data from the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) multisite observational study (n = 242; median BMI = 51 kg/m2 ; mean age= 17; 76% female adolescents; 72% Caucasian) included anthropometric and self-report questionnaires, including the Questionnaire of Eating and Weight Patterns-Revised (QEWP-R), the Night Eating Questionnaire (NEQ), the Beck Depression Inventory (BDI-II), and the Impact of Weight on Quality of Life-Kids (IWQOL-Kids) RESULTS: LOC eating (27%) was common and ED diagnoses included binge-eating disorder (7%), night eating syndrome (5%), and bulimia nervosa (1%). Compared to those without LOC eating, those with LOC eating reported greater depressive symptomatology and greater impairment in weight-related quality of life. DISCUSSION: Before undergoing bariatric surgery, adolescents with severe obesity present with problematic disordered eating behaviors and meet diagnostic criteria for EDs. LOC eating, in particular, was associated with several negative psychosocial factors. Findings highlight targets for assessment and intervention in adolescents before bariatric surgery. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:947-952).

A latent profile analysis of childhood trauma in women with bulimia nervosa: Associations with borderline personality disorder psychopathology.

OBJECTIVE: The aim of this study was to empirically examine naturally occurring groups of individuals with bulimia nervosa (BN) based on their childhood trauma (CT) histories and to compare these groups on a clinically relevant external validator, borderline personality disorder (BPD) psychopathology. METHOD: This study examined the relationship between CT and BPD psychopathology among 133 women with BN using latent profile analysis (LPA) to classify participants based on histories of CT. Participants completed the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P), the Diagnostic Interview for Borderlines-Revised (DIB-R), and the Childhood Trauma Questionnaire (CTQ). RESULTS: The LPA revealed four trauma profiles: low/no trauma, emotional trauma, sexual trauma, and polytrauma. Results indicated that the sexual and polytrauma profiles displayed significantly elevated scores on the DIB-R and that the low/no and emotional trauma profiles did not differ significantly on the DIB-R. Secondary analyses revealed elevated levels of a composite CT score among those with both BN and BPD psychopathology compared to those with BN only. DISCUSSION: These findings suggest that both childhood sexual abuse and the additive effects of childhood polytrauma may be linked to BPD psychopathology in BN. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:689-694).

A naturalistic examination of the temporal patterns of affect and eating disorder behaviors in anorexia nervosa.

OBJECTIVE: Evidence supports the presence of significant variability in the timing of affective experiences and eating disorder (ED) behaviors across ED populations. This study examined the naturalistic timing of affective states and ED behaviors in anorexia nervosa (AN). METHODS: Women (N = 118) with full or subthreshold DSM-IV AN completed 2 weeks of ecological momentary assessment (EMA) involving self-reports of affect and ED behaviors. Patterns of positive affect, negative affect, and tension/anxiety across hours of the day and days of the week were examined using linear mixed models. Variation in ED behavior occurrence (i.e., binge eating, vomiting, exercise, meal skipping, and self-weighing) across hours of the day and days of the week was examined using general estimating equations. RESULTS: Results revealed significant variation in tension/anxiety across hours of the day; there were no significant associations between time of day and negative or positive affect. All affective variables significantly varied across days of the week, with both negative affect and tension/anxiety highest in the middle of the week and lowest on the weekends. The ED behaviors all significantly varied across hours of the day, with binge eating and vomiting most common in later hours, exercise and self-weighing most common in earlier hours, and meal skipping most common at times corresponding to breakfast and lunch. ED behaviors did not significantly vary across days of the week. CONCLUSION: The significant patterns of variation in the timing of affective experiences and ED behaviors may have utility in informing theories and interventions for AN.

Reciprocal associations between negative affect, binge eating, and purging in the natural environment in women with bulimia nervosa.

Although negative affect (NA) has been identified as a common trigger for bulimic behaviors, findings regarding NA following such behaviors have been mixed. This study examined reciprocal associations between NA and bulimic behaviors using real-time, naturalistic data. Participants were 133 women with bulimia nervosa (BN) according to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders who completed a 2-week ecological momentary assessment protocol in which they recorded bulimic behaviors and provided multiple daily ratings of NA. A multilevel autoregressive cross-lagged analysis was conducted to examine concurrent, first-order autoregressive, and prospective associations between NA, binge eating, and purging across the day. Results revealed positive concurrent associations between all variables across all time points, as well as numerous autoregressive associations. For prospective associations, higher NA predicted subsequent bulimic symptoms at multiple time points; conversely, binge eating predicted lower NA at multiple time points, and purging predicted higher NA at 1 time point. Several autoregressive and prospective associations were also found between binge eating and purging. This study used a novel approach to examine NA in relation to bulimic symptoms, contributing to the existing literature by directly examining the magnitude of the associations, examining differences in the associations across the day, and controlling for other associations in testing each effect in the model. These findings may have relevance for understanding the etiology and/or maintenance of bulimic symptoms, as well as potentially informing psychological interventions for BN.

Eating Disorders and Problematic Eating Behaviours Before and After Bariatric Surgery: Characterization, Assessment and Association with Treatment Outcomes.

Accumulating evidence suggests that bariatric surgery candidates are likely to present with eating disorders (EDs) and/or problematic eating behaviours (EBs), and research suggests that these problems may persist or develop after bariatric surgery. While there is growing evidence indicating that EDs and EBs may impact bariatric surgery outcomes, the definitions and assessment methods used lack consensus, and findings have been mixed. The aims of this paper were (1) to summarize the existing literature on pre-operative and post-operative EDs and problematic EBs; (2) to discuss the terms, definitions and assessment measures used across studies; and (3) to consider the extent to which the presence of these problems impact surgery outcomes. We highlight the importance of investigators utilizing consistent definitions and assessment methodologies across studies.

Clinical utility of subtyping binge eating disorder by history of anorexia or bulimia nervosa in a treatment sample.

OBJECTIVE: This study examined whether having a history of anorexia nervosa (AN) or bulimia nervosa (BN) is associated with response to treatment in adults with binge eating disorder (BED). METHOD: Data from 189 adults diagnosed with BED who were randomly assigned to one of three group cognitive-behavioral (CBT) treatments were analyzed to compare those with and without a history of AN/BN. RESULTS: A total of 16% of the sample had a history of AN/BN. The BED subgroup with a history of AN/BN presented with higher rates of mood disorders and greater eating-related symptom severity at baseline. Participants with a history of AN/BN also had higher global eating disorder (ED) symptoms at end of treatment (EOT), and more frequent objective binge-eating episodes at EOT and 12-month follow-up. DISCUSSION: These findings suggest that in adults with BED, a history of AN/BN is predictive of greater eating-related symptom severity following group-based CBT and poorer short- and long-term binge-eating outcomes. These findings suggest that considering ED history in the treatment of adults with BED may be clinically useful.

All better? How former anorexia nervosa patients define recovery and engaged in treatment.

The purpose of this study was to explore how individuals with anorexia nervosa (AN) engage in treatment and define recovery. A mixed methods design was used to triangulate the experience of 20 women with a history of AN. Interview data were analysed thematically to explore frequency of emergent themes and current eating disorder psychopathology was assessed using standardized self-report measures. Participants' mean age was 29.35 (SD = 12.11). Participants' scores were indicative of persistent psychopathology. Those with more involvement in treatment choice had better motivation to change and normalized eating. Participants' definition of recovery mapped on well to current research conceptualizations, though a substantial proportion of the group expressed some ambivalence around the concept. Results are interpreted in the context of self-determination theory of motivation and suggest that patients should be involved collaboratively in the formulation of shared goals and concepts of recovery in treatment settings.

A controlled trial of the methylphenidate transdermal system on before-school functioning in children with attention-deficit/hyperactivity disorder.

OBJECTIVE: Children with attention-deficit/hyperactivity disorder (ADHD) frequently manifest behavioral difficulties in the morning prior to school. Our aim was to examine the effects of the methylphenidate transdermal system (MTS) on before-school ADHD symptoms and functioning in children with ADHD. METHOD: In this randomized crossover study, conducted from May 2007 until December 2008, 6- to 12-year-old subjects with DSM-IV-defined ADHD received either MTS or a placebo transdermal system (PTS) at 10 mg for 1 week and then 20 mg for 1 week. Subjects were then crossed over directly to the other treatment for the remaining 2 weeks. The primary efficacy measure was the ADHD Rating Scale. All analyses were intent to treat, with the last observation carried forward. RESULTS: Thirty subjects completed at least 1 week of treatment, and 26 subjects completed the entire protocol. The sample was primarily male, with a mean +/- SD age of 9.17 +/- 1.84 years. Compared to PTS, there were significant reductions with MTS in the ADHD Rating Scale score (P < .001). Adverse effects of MTS during the active (versus PTS) phase were similar to those seen in other controlled trials of MTS. CONCLUSIONS: These results show that MTS is effective not only for morning ADHD symptoms, but also in improving associated activities and functioning that occur before school in children with ADHD. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00586157.

An open study of adjunct OROS-methylphenidate in children and adolescents who are atomoxetine partial responders: I. Effectiveness.

OBJECTIVE: This study evaluated the effectiveness of adding OROS methylphenidate (MPH) to children who are partial responders to atomoxetine (ATMX) in the treatment of attention-deficit/hyperactivity disorder (ADHD). METHODS: This is a two-phase, 7-week, open study in children aged 6-17 years. Phase I initiated ATMX for a minimum of 4 weeks. Phase II entered partial responders to ATMX and added up to 54 mg of OROS MPH to their regimen. Subjects were assessed on multiple outcomes, including ADHD, executive functioning, and adverse effects. All analyses were intent to treat, with last observation carried forward. RESULTS: Fifty subjects who were partial responders to ATMX were treated with the combination therapy, with 41 subjects completing the entire protocol. There was a 40% reduction in their ADHD Rating Scale from the start of phase II through the end of study (from 21.14 +/- 9.9 to 12.8 +/- 9.7, t = 6.5, p < 0.0001). In addition, there was a clinically significant reduction in the Clinical Global Index of ADHD severity from moderate to mild ADHD (start of phase II, 3.7; end of phase II, 2.7, 27%, t = 6.5, p < 0.0001), as well as improvements in executive functioning. CONCLUSION: These results suggest that OROS MPH added to the regimen of partial responders to ATMX improves ADHD and executive functioning, necessitating further controlled trials.

An open study of adjunct OROS-methylphenidate in children who are atomoxetine partial responders: II. Tolerability and pharmacokinetics.

OBJECTIVE: The aim of this study was to evaluate the tolerability of adding OROS methylphenidate (MPH) to children who are partial responders to atomoxetine (ATMX) in the treatment of attention-deficit/hyperactivity disorder (ADHD). METHODS: This was a two-phase, 7-week, open study in children aged 6-17 years. Phase 1 initiated ATMX for a minimum of 4 weeks. Phase 2 entered partial responders to ATMX and added OROS MPH to their regimen. Safety was assessed using blood pressure and heart rate measurements, electrocardiogram readings, AEs, laboratories, and ATMX levels. RESULTS: Fifty subjects who were partial responders to ATMX received the combination therapy, with 41 subjects completing the entire protocol. As reported elsewhere (Wilens et al., 2009 ), OROS MPH added to partial responders of ATMX was accompanied by a 40% reduction in the ADHD rating scale score and improvements in executive functioning. However, the combination of ATMX plus OROS MPH was associated with greater rates of insomnia, irritability, and loss of appetite compared to ATMX alone. A small significant increase in diastolic blood pressure was observed during adjunctive OROS MPH, with no clinically meaningful changes in electrocardiogram (ECG) parameters during the study. ATMX levels and liver function tests did not significantly change during the combination treatment. CONCLUSION: Adjunct OROS MPH in ATMX partial responders yielded an additive adverse effect burden in this short-term study. Further controlled research with larger samples of children is warranted.