Validation and assessment of psychometric properties of the Greek Eating Behaviors Assessment for Obesity (GR-EBA-O).

INTRODUCTION: With increasing morbidity and risk of death, obesity has become a serious health problem largely attributable to difficulties in finding proper treatments for related diseases. Many studies show how detecting abnormal eating behaviors could be useful in developing effective clinical treatments. This study aims at validating the Greek version of the Eating Behaviors Assessment for Obesity (EBA-O). METHOD: After a double English/Greek forward/backward translation of the EBA-O, 294 participants completed the Greek version (GR-EBA-O), the Eating Disorder Examination Questionnaire, the Binge Eating Scale, and the Yale Food Addiction Scale. Confirmatory factor analysis (CFA) and construct validity were calculated, and Two-way MANOVA was computed with the factors of GR-EBA-O controlling for sex and BMI categories. RESULTS: CFA confirmed the second-order five factors (i.e., food addiction, night eating, binge eating, sweet eating, and prandial hyperphagia) structure of the original EBA-O with excellent fit indices. GR-EBA-O factors were highly correlated. The GR-EBA-O subscales were also significantly correlated with the remaining measures, demonstrating good concurrent validity. CONCLUSION: The Greek version of the EBA-O has demonstrated sound psychometric properties and appears a reliable and user-friendly tool to identify pathological eating behaviors in obesity. LEVEL OF EVIDENCE: V, descriptive research.

Effects of family functioning on eating pathology and psychosocial quality of life: The mediating role of self-esteem.

OBJECTIVE: Family dysfunction and self-esteem play an important role in the development of eating disorders (EDs), but this role has not been sufficiently examined regarding eating pathology and psychosocial quality of life (QoL), which often remains unchanged even after ED symptoms reduce. The purpose of this study was to therefore assess the mediating role of self-esteem between family dysfunction and both eating pathology and psychosocial QoL in ED patients and controls. METHOD: One hundred and fifty four female adult ED patients and 154 female healthy adult controls were recruited from Athens, Greece, and self-reported measures were used to assess family dysfunction, eating pathology, self-esteem, and psychosocial QoL. Structural equation modelling (SEM) was employed to test the mediation hypotheses. RESULTS: For both the ED and control groups, family dysfunction levels did impact eating pathology, but only through self-esteem. Family dysfunction, self-esteem, and eating pathology had a direct effect on both groups' psychosocial QoL. CONCLUSION: Self-esteem's important role in EDs was confirmed in both groups, along with its sensitivity to family dysfunction. We propose a parsimonious yet comprehensive theoretical model of the role of family dysfunction and self-esteem in EDs which future studies should further investigate longitudinally and in other population groups.

A 12-month study of dialectical behavioral therapy for bοrderline patients suffering from eating disorders.

PURPOSE: Individuals with eating disorders (ED) and comorbid borderline personality disorder (BPD) may benefit from therapies focusing on emotion regulation, such as dialectical behavioral therapy (DBT). The aim of the study was to evaluate the effectiveness of one-year standard DΒΤ enhanced with cognitive-behavioral therapy (CBT) strategies for patients suffering from ED and BPD. METHODS: Seventy-two BPD and ED (anorexia and bulimia nervosa) participants were recruited from the eating disorders unit of the 1st Psychiatric Department of National and Kapodistrian University of Athens. All participants completed one year of standard DBT. ED-related behaviors were added to the treatment plan according to the DBT targeting hierarchy. Individual therapy and skills training group sessions were adapted to incorporate CBT strategies for nutritional and weight restoration. BPD and ED symptomatology were measured at the beginning and at the end of one year of treatment. RESULTS: The major finding of the study was the significant improvement of patients in all the outcome measurements after one year of treatment. The study's second finding was that the severity of BPD symptomatology was significantly related to the severity of ED symptomatology. It was also shown that improvement of the patients coping skills was correlated with the reduction of ED and BPD symptomatology. CONCLUSIONS: These results support previous studies on the effectiveness of DBT for comorbid BPD and EDs. Despite the promising results, randomized controlled trials are needed to establish the efficacy of DBT for BPD and ED patients. LEVEL OF EVIDENCE: Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Olfactory capacity in anorexia nervosa: correlations with set-shifting ability.

PURPOSE: The purpose of this study is to examine olfactory capacity in adults with anorexia nervosa (AN), in terms of odor identification and odor threshold and search for possible correlations between odor identification and cognitive flexibility in this population. METHODS: Thirty-nine patients diagnosed with AN and 60 healthy participants, participated. Odor identification was assessed using the University Pennsylvania Smell Identification Test and a two alternative forced choice, ascending method with n-butanol was used to assess odor threshold. Cognitive flexibility was determined using the Intra/Extra-Dimensional Set-Shift test (IED), a subtest of the Cambridge Neuropsychological Test Automated Battery (CANTAB). RESULTS: Patients with AN presented a poorer performance in odor identification compared with controls (p = 0.001). No differences were found in odor threshold, between the two groups. Patients with AN exhibited poor cognitive flexibility compared with controls (p = 0.003). A significant correlation between odor identification and cognitive flexibility was documented in AN (p = 0.01), but not in controls. CONCLUSION: Our findings suggest that olfactory capacity is altered in AN: Qualitative characteristics of olfaction were affected in patients with AN (lower odor identification), while there was no difference in quantitative characteristics (odor threshold) compared with controls. Furthermore, odor identification in AN was correlated to cognitive flexibility. LEVEL OF EVIDENCE: Level III: case-control analytic study.

Exercise dependence and orthorexia nervosa in Crossfit: exploring the role of perfectionism.

Physical exercise and healthy diet have a positive effect on health. However, the pathological dimension of both behaviors, namely exercise dependence and orthorexia nervosa, can lead to negative results. So far, literature on these behaviors in the context of high-intensity sports is limited. The present study aims for investigating exercise dependence and orthorexia nervosa in a sample of Crossfit athletes, as well as examining the mediating role of perfectionism in their manifestation.The sample consisted of 110 people who attended Crossfit programs and 131 active gym members. The Exercise Dependence Scale was used to assess exercise dependence, the ORTO-15 to assess orthorexic behavior and the Almost Perfect Scale to evaluate perfectionism.19.8% of crossfitters and 3.8% of gym members were at risk for exercise dependence. 11.7% of participants in the Crossfit group and 10% of participants in the control group had orthorexic symptoms. An association was found between the scores on the two behaviors. In addition, the dimension of perfectionism high standards predicted obligatory exercise and orthorexia nervosa, while the dimension of discrepancy predicted only exercise dependence.The study suggests that exercise dependence is more evident in Crossfit compared to gym athletes and may be accompanied by orthorexic symptoms. Orthorexia nervosa is a noticeable phenomenon in the population of active exercisers. Perfectionism is a risk factor for obligatory exercise and orthorexia. A more demanding selection of target populations is encouraged in order to better understand exercise dependence, orthorexia nervosa and their personality background.

Validation of the Greek ORTO-15 questionnaire for the assessment of orthorexia nervosa and its relation to eating disorders symptomatology.

PURPOSE: The aim of the study was the validation of the Greek version of the ORTO-15 questionnaire. An additional aim was to explore the relation between orthorexic and eating disorder behaviors in a sample of Greek students. METHODS: ORTO-15 was translated and adapted in the Greek language. After its final version was drafted, its test-retest reliability was checked. Then, the questionnaire was administered to 120 students of psychology along with EAT-26. Additionally, demographics, BMI and information related to eating disorders were collected. RESULTS: The Greek version of the ORTO-15 questionnaire showed acceptable internal consistency (Cronbach's a 0.7). Factor analysis produced a three-factor model similar to the original English version of the questionnaire. The correlation of ORTO-15 and EAT-26 revealed that higher measurements in the diet and bulimia EAT-26 scale were related to increased orthorexic symptomatology. Finally, there was no significant correlation between the 3 factors of the ORTO-15 (emotional, rational and behavioral) and age, education or Body Mass Index. CONCLUSIONS: This study is the first attempt to assess orthorexia nervosa in a Greek student population. ORTO-15 was found to be a reliable tool for the measurement of orthorexia in Greece. Finally, in accordance with other studies, orthorexic symptoms were partially related to eating disorder symptomatology, thus raising the question of possible similarities and overlap between the two clinical constructs. LEVEL OF EVIDENCE: Level V, Cross-sectional descriptive study.

Dialectical behavioral therapy: an update and review of the existing treatment models adapted for adults with eating disorders.

Despite the effectiveness of CBT in reducing shape/weight concerns and dietary restraint, research suggests that patients considered recovered may still exhibit emotional difficulties related to eating disorders (EDs). Dialectical behavior therapy (DBT) has been adapted for a variety of mental disorders characterized by emotion dysregulation and, more recently, for EDs specifically. The current review found that the majority of the research studies employed one of the following three adaptations of DBT for EDs: The Stanford Model, Radically Open-DBT (RO-DBT), or Multidiagnostic ED-DBT (MED-DBT). Therefore, this review sought to review and update the empirical research on each adaptation and (2) offer preliminary recommendations for when and which adaptation of DBT to use when treating adults with EDs. Findings from the empirical literature on DBT and EDs indicate that the Stanford Model has the most rigorous and numerous studies demonstrating efficacy and effectiveness in those diagnosed with binge eating disorder. Fewer studies have been conducted using the Stanford Model with bulimia nervosa; therefore, less strong assertions can be made about DBT with those diagnosed with bulimia. The MED-DBT model has been evaluated in several open trials within higher levels of care with promising results, but the lack of randomized clinically-controlled trials prevents a definitive statement about its efficacy. Finally, research on applying the RO-DBT model to anorexia-nervosa, restricting subtype is in its infancy, prohibiting solid conclusions or recommendations regarding its efficacy or effectiveness.

Combination therapy as a potential risk factor for the development of type 2 diabetes in patients with schizophrenia: the GOMAP study.

BACKGROUND: Schizophrenia (SCZ) is associated with increased risk of type 2 diabetes (T2D). The potential diabetogenic effect of concomitant application of psychotropic treatment classes in patients with SCZ has not yet been evaluated. The overarching goal of the Genetic Overlap between Metabolic and Psychiatric disease (GOMAP) study is to assess the effect of pharmacological, anthropometric, lifestyle and clinical measurements, helping elucidate the mechanisms underlying the aetiology of T2D. METHODS: The GOMAP case-control study (Genetic Overlap between Metabolic and Psychiatric disease) includes hospitalized patients with SCZ, some of whom have T2D. We enrolled 1653 patients with SCZ; 611 with T2D and 1042 patients without T2D. This is the first study of SCZ and T2D comorbidity at this scale in the Greek population. We retrieved detailed information on first- and second-generation antipsychotics (FGA, SGA), antidepressants and mood stabilizers, applied as monotherapy, 2-drug combination, or as 3- or more drug combination. We assessed the effects of psychotropic medication, body mass index, duration of schizophrenia, number of hospitalizations and physical activity on risk of T2D. Using logistic regression, we calculated crude and adjusted odds ratios (OR) to identify associations between demographic factors and the psychiatric medications. RESULTS: Patients with SCZ on a combination of at least three different classes of psychiatric drugs had a higher risk of T2D [OR 1.81 (95% CI 1.22-2.69); p = 0.003] compared to FGA alone therapy, after adjustment for age, BMI, sex, duration of SCZ and number of hospitalizations. We did not find evidence for an association of SGA use or the combination of drugs belonging to two different classes of psychiatric medications with increased risk of T2D [1.27 (0.84-1.93), p = 0.259 and 0.98 (0.71-1.35), p = 0.885, respectively] compared to FGA use. CONCLUSIONS: We find an increased risk of T2D in patients with SCZ who take a combination of at least three different psychotropic medication classes compared to patients whose medication consists only of one or two classes of drugs.

A study on the interplay between emerging adulthood and eating disorder symptomatology in young adults.

PURPOSE: The primary aim of this study was to investigate the interplay between Arnett's five features of emerging adulthood and ED symptomatology. The secondary aim of the study was to investigate possible gender differences concerning the relation between emerging adulthood and ED symptomatology. METHODS: 337 university students (252 females and 85 males) participated in this study. Each participant was asked to anonymously complete the following questionnaires: Inventory of the Dimensions of Emerging Adulthood (IDEA), Eating Attitudes Test (EAT-26), and Social Physique Anxiety Scale (SPAS). RESULTS: The female group scored higher in the EAT-26 diet, SPAS, IDEA self-focus and IDEA total score measurements. Additionally, in the female group, identity exploration was correlated with EAT-26 total and bulimia, experimentation/possibilities with EAT-26 total and diet, and negativity/instability with EAT-26 total, diet and bulimia as well as SPAS score. In the male groups, the only significant correlation was between SPAS and instability/negativity. Finally, identity exploration could predict a higher probability of developing ED (EAT ≥ 20) for both the female and male groups. CONCLUSIONS: Emerging adulthood and ED were found to have a close relationship, especially for females. Identity exploration was the emerging adulthood factor that showed the highest relation to ED symptomatology in both the male and female groups. More research is necessary to investigate the specifics of this relationship. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Retinal and choroidal alterations in patients with anorexia nervosa without vision loss.

OBJECTIVE: Evaluate the alterations of retinal anatomy and function, as well as choroidal thickness changes, in patients with anorexia nervosa (AN). METHOD: 13 female AN patients (26 eyes) and 20 female controls (40 eyes) were included. Assessment of the retinal and choroidal anatomy was performed by optical-coherence-tomography, while multifocal-electroretinogram was used for measurements of the electrical activity of the macula. Statistical analysis was performed using t-test. RESULTS: Central macular thickness was found to be thinner in AN (140.04 ± 14.45, 150.85 ± 16.03, p = 0.007), likewise the ganglion cell complex and outer retinal layer (ORL) at most areas. ORL superiorly was thicker in AN (169.12 ± 2.55, 163.00 ± 8.70, p < 0.001), while retinal nerve fiber layer was not different between the two groups, except the inferior region (121.08 ± 18.52, 137.60 ± 7.30, p < 0.001). Choroidal thickness was evenly diminished in the anorectic group (p = 0.001-0.027). Multifocal-electroretinogram showed lower P1-retinal response density amplitude of ring 1 in AN (159.04 ± 60.83, 292.43 ± 11.59, p < 0.001), but no significant difference concerning the P1-response density amplitude of ring 2 (79.04 ± 21.89, 82.63 ± 9.10, p = 0.36). DISCUSSION: In AN patients, even without vision loss, significant changes occur in retinal and choroidal thickness, as well as in the electrical activity of the macula. However, this is a pilot study in a small sample that needs replication.

Quality of care and its determinants in longer term mental health facilities across Europe; a cross-sectional analysis.

BACKGROUND: The Quality Indicator for Rehabilitative Care (QuIRC) is an international, standardised quality tool for the evaluation of mental health facilities that provide longer term care. Completed by the service manager, it comprises 145 items that assess seven domains of care: living environment; treatments and interventions; therapeutic environment; self-management and autonomy; social interface; human rights; and recovery based practice. We used the QuIRC to investigate associations between characteristics of longer term mental health facilities across Europe and the quality of care they delivered to service patients. METHODS: QuIRC assessments were completed for 213 longer term mental health units in ten countries that were at various stages of deinstitutionalisation of their mental health services. Associations between QuIRC domain scores and unit descriptive variables were explored using simple and multiple linear regression that took into account clustering at the unit and country level. RESULTS: We found wide variation in QuIRC domain scores between individual units, but across countries, fewer than a quarter scored below 50 % on any domains. The quality of care was higher in units that were smaller, of mixed sex, that had a defined expected maximum length of stay and in which not all patients were severely disabled. CONCLUSIONS: This is the first time longer term mental health units across a number of European countries have been compared using a standardised measure. Further use of the QuIRC will allow greater understanding of the quality of care in these units across Europe and provide an opportunity to monitor pan-European quality standards of care for this vulnerable patient group.

Sexual function of women suffering from anorexia nervosa and bulimia nervosa.

The cross-sectional study aimed at examining the sexual function of young adult women suffering from eating disorders. The authors interviewed 53 women (26 with anorexia nervosa and 27 with bulimia nervosa) and 58 female students. Each participant was administered the Female Sexual Function Index, the Eating Attitudes Test, the Body Shape Questionnaire, and the Beck Depression Inventory. Comparisons among the 3 groups showed that patients with anorexia nervosa scored lower in each Female Sexual Function Index subscale than did healthy controls. There was no significant difference between bulimia nervosa and healthy controls. Sexual functionality of patients with anorexia nervosa was correlated only with body mass index (r = 0.5, p =.01). Sexual functionality of patients with bulimia nervosa was correlated only with the Beck Depression Inventory (r = -0.4, p =.03) Patients with anorexia nervosa had more disturbed sexual function than did controls. Sexual function can be related to the level of starvation and symptoms of depression.

Validation of the Greek version of the Accommodation and Enabling Scale for Eating Disorders (AESED).

Eating disorders-related research has shown that families, in order to alleviate family conflict and stress, accommodate the symptoms of individuals with eating disorders. It has been argued that by tolerating or alleviating symptoms, the latter may gradually be reinforced or even fully accepted, as the family becomes increasingly "trapped" in specific eating patterns, weight control behaviors, and body shape worries. The Accommodation and Enabling Scale for Eating Disorders was created in 2009, aiming to assess family adaptability of individuals with eating disorders. The purpose of the present research was to test the psychometric properties of the Greek version of the scale in a sample of parents of individuals with eating disorders. The translation procedure was carried out based on the forward-backward method, while the study was conducted at the Eating Disorders Clinic of the First Psychiatric Clinic of Aiginiteion Hospital. The convenience sampling methods were used for the sample's recruitment. Respondents reported on their basic demographic characteristics, and completed the General Health Questionnaire-28, and the Accommodation and Enabling Scale for Eating Disorders. The final study's sample consisted of 125 parents of individuals with eating disorders (69.6% women), with a mean age of 55.2 years. Factor analysis revealed a five-factor model, similar to that of the original version of the scale, with the model explaining 63.3% of the total variance. Internal consistency was judged to be high, with Cronbach's coefficient a being 0.93 for the scale's total score, while Cronbach's α for the five subscales ranged from 0.78 to 0.90. Convergent validity was tested with the Spearman's coefficient rho, which revealed a statistically significant correlation of the weighted scale with the General Health Questionnaire (rho=0.33, p<0.5). The results showed that the Greek version of the Accommodation and Enabling Scale for Eating Disorders is a valid and reliable tool for assessing the adaptability of families of people suffering from eating disorders. Application of the tool to larger samples will validate its psychometric properties on a larger scale.

Using Electroencephalogram-Extracted Nonlinear Complexity and Wavelet-Extracted Power Rhythm Features during the Performance of Demanding Cognitive Tasks (Aristotle's Syllogisms) in Optimally Classifying Patients with Anorexia Nervosa.

Anorexia nervosa is associated with impaired cognitive flexibility and central coherence, i.e., the ability to provide an overview of complex information. Therefore, the aim of the present study was to evaluate EEG features elicited from patients with anorexia nervosa and healthy controls during mental tasks (valid and invalid Aristotelian syllogisms and paradoxes). Particularly, we examined the combination of the most significant syllogisms with selected features (relative power of the time-frequency domain and wavelet-estimated EEG-specific waves, Higuchi fractal dimension (HFD), and information-oriented approximate entropy (AppEn)). We found that alpha, beta, gamma, theta waves, and AppEn are the most suitable measures, which, when combined with specific syllogisms, form a powerful tool for efficiently classifying healthy subjects and patients with AN. We assessed the performance of triadic combinations of "feature-classifier-syllogism" via machine learning techniques in correctly classifying new subjects in these two groups. The following triads attain the best classifications: (a) "AppEn-invalid-ensemble BT classifier" (accuracy 83.3%), (b) "Higuchi FD-valid-linear discriminant" (accuracy 75%), (c) "alpha amplitude-valid-SVM" (accuracy 83.3%), (d) "alpha RP-paradox-ensemble BT" (accuracy 85%), (e) "beta RP-valid-ensemble" (accuracy 85%), (f) "gamma RP-valid-SVM" (accuracy 85%), and (g) "theta RP-valid-KNN" (accuracy 80%). Our findings suggest that anorexia nervosa has a specific information-processing style across reasoning tasks in the brain as measured via EEG activity. Our findings also contribute to further supporting the view that entropy-oriented, i.e., information-based features (the AppEn measure used in this study) are promising diagnostic tools (biomarkers) in clinical applications related to medical classification problems. Furthermore, the main EEG-specific frequency waves are extremely enhanced and become powerful classification tools when combined with Aristotle's syllogisms.

Updating Prospective Self-Efficacy Beliefs About Cardiac Interoception in Anorexia Nervosa: An Experimental and Computational Study.

Patients with anorexia nervosa (AN) typically hold altered beliefs about their body that they struggle to update, including global, prospective beliefs about their ability to know and regulate their body and particularly their interoceptive states. While clinical questionnaire studies have provided ample evidence on the role of such beliefs in the onset, maintenance, and treatment of AN, psychophysical studies have typically focused on perceptual and 'local' beliefs. Across two experiments, we examined how women at the acute AN (N = 86) and post-acute AN state (N = 87), compared to matched healthy controls (N = 180) formed and updated their self-efficacy beliefs retrospectively (Experiment 1) and prospectively (Experiment 2) about their heartbeat counting abilities in an adapted heartbeat counting task. As preregistered, while AN patients did not differ from controls in interoceptive accuracy per se, they hold and maintain 'pessimistic' interoceptive, metacognitive self-efficacy beliefs after performance. Modelling using a simplified computational Bayesian learning framework showed that neither local evidence from performance, nor retrospective beliefs following that performance (that themselves were suboptimally updated) seem to be sufficient to counter and update pessimistic, self-efficacy beliefs in AN. AN patients showed lower learning rates than controls, revealing a tendency to base their posterior beliefs more on prior beliefs rather than prediction errors in both retrospective and prospective belief updating. Further explorations showed that while these differences in both explicit beliefs, and the latent mechanisms of belief updating, were not explained by general cognitive flexibility differences, they were explained by negative mood comorbidity, even after the acute stage of illness.

Validation of the Eating Habits Questionnaire in Greek adults.

Healthy eating has gained ground in people's daily lives in modern society. However, an overwhelming preoccupation with healthy eating can lead to a pathological form setting the ground for orthorexia nervosa. This study aimed to validate the Greek version of the Eating Habits Questionnaire (EHQ) in adults 18 to 65 years old. The EHQ evaluates orthorexia nervosa traits. An online survey was conducted among adults of the general Greek population by administrating a battery of self-report instruments. The IPIP Big-Five personality questionnaire, Beck's Depression Inventory, the Obsessive-Compulsive Inventory-Revised, the Bulimic Investigatory Test, the Edinburg BITE, and the Eating Attitudes Test-13 were used. Internal consistency, test-retest reliability, and convergent and criterion validity were examined. A total of 551 adults (92.2% females) voluntarily participated in the study. Results suggest that the Greek version of the instrument has good psychometric properties. Analysis revealed a 3-factor model explaining 48.20% of the total variance. Cronbach's alphas ranged between 0.80 to 0.82, indicating good internal consistency. The test-retest reliability analysis showed no statistically significant difference between the measurements of the first and the post-2 weeks. Correlations with other eating disorder-related constructs were found to be weak to moderate. Body mass index was not significantly correlated with neither of the three EHQ subscales. The Greek version of EHQ is a robust instrument that could be used in clinical practice and research in the field of eating disorders in Greece.

Eating disorders in the era of the COVID-19 pandemic.

COVID-19 pandemic and its socio-economic consequences have been influencing considerably the Greek population and especially those people that are vulnerable or are actually suffering from a mental disorder. Considering eating disorders (ED) there are reports of a number of factors that increase the stress experienced by patients. The most important of them are:1 A. Quarantine and house confinement. Many ED patients report poor relationships with other family members or in some cases falling victims of some type of abusive behavior by other family members. Prolonged compulsory house confinement could have a negative impact in the course of ED. It should be noted that a similar negative impact of the pandemic has been observed in family members that have unsuccessfully tried to balance the need of the patients with the need of the rest of the family. B. Changes in exercising. Quarantine has severely influenced patients that have been doing vigorous and compulsive exercise. C. Food fear. During the first quarantine in March 2020, there were rumors of forthcoming extreme shortages of necessary products and food. D. Restrictions in the access to mental health facilities and therapists. In many countries, a substantial number of mental health programs were temporarily shut down during the first wave of the pandemic. E. Isolation of people residing alone in cities far away from the family home. F. Financial adversities due to slow down of economic activities causes by quarantine. g. Increase in obsessive fear concerning body health and food purity due to orthorexia nervosa onset or relapse.2 Research conducted during the pandemic showed that women suffering from ED reported more often than men increase in ED symptomatology, in the number of hours spent exercising and in the intensity of preoccupation with their body image and social appearance.2 A meta-analysis of ED studies during the pandemic showed that 65% of the patients reported a deterioration of ED symptomatology.3 Contrary to the above, the longitudinal studies that were included in the meta-analysis did not report any substantial difference in BMI and ed symptomatology before and after the first quarantine.3 Anorexia nervosa patients seemed to be more influenced than patients suffering from bulimia nervosa and ED non otherwise specified.3 Other longitudinal studies reported that bulimia nervosa patients were greatly influenced during the quarantine showing signs of slower remission or even relapse of the bulimic symptoms.4 Family conflict and intense fear for the life of loved ones could predict a relapse of the ED symptomatology.4 Young people were often caught in the following dilemma. On the one hand, consumption of palatable food could be used as a coping mechanism for regulating emotions such as anxiety, sorrow, and loneliness caused by prolonged house isolation. On the other hand, the increasing presence in the virtual reality environment of social networks has intensified the need for a perfect slim and fit body that could attract more followers and ensure social approval and success.5,6 A special interest group that was affected by the pandemic, was university students. ED symptomatology increased, especially among female students. Stress and depression related to social isolation and disruption of educational activities have been correlated with ED manifestation, especially bulimia nervosa.7 Fortunately, young patients seem to adjust adequately to internet-based treatments. There are indications that therapy through teleconference could prove quite effective for the treatment of ED.8 There are reports that this type of treatment is not attractive for anorexia nervosa patients, while all other ED patients are well adjusted to it.1 The consequences of the pandemic considerably affected mental health experts that have been treating ED patients as the number of new and relapsed clients raised dramatically. The situation was worsened by the fact that a large number of those patients had to be treated distantly. It has been reported that often conduct with other colleagues, the feeling of higher purpose or duty, recognition of their effort and supervision are some of the factors that can protect therapists from professional burn-out.1.

Common Genetic Variation and Age of Onset of Anorexia Nervosa.

Background: Genetics and biology may influence the age of onset of anorexia nervosa (AN). The aims of this study were to determine whether common genetic variation contributes to age of onset of AN and to investigate the genetic associations between age of onset of AN and age at menarche. Methods: A secondary analysis of the Psychiatric Genomics Consortium genome-wide association study (GWAS) of AN was performed, which included 9335 cases and 31,981 screened controls, all from European ancestries. We conducted GWASs of age of onset, early-onset AN (<13 years), and typical-onset AN, and genetic correlation, genetic risk score, and Mendelian randomization analyses. Results: Two loci were genome-wide significant in the typical-onset AN GWAS. Heritability estimates (single nucleotide polymorphism-h 2) were 0.01-0.04 for age of onset, 0.16-0.25 for early-onset AN, and 0.17-0.25 for typical-onset AN. Early- and typical-onset AN showed distinct genetic correlation patterns with putative risk factors for AN. Specifically, early-onset AN was significantly genetically correlated with younger age at menarche, and typical-onset AN was significantly negatively genetically correlated with anthropometric traits. Genetic risk scores for age of onset and early-onset AN estimated from independent GWASs significantly predicted age of onset. Mendelian randomization analysis suggested a causal link between younger age at menarche and early-onset AN. Conclusions: Our results provide evidence consistent with a common variant genetic basis for age of onset and implicate biological pathways regulating menarche and reproduction.

The development of the Quality Indicator for Rehabilitative Care (QuIRC): a measure of best practice for facilities for people with longer term mental health problems.

BACKGROUND: Despite the progress over recent decades in developing community mental health services internationally, many people still receive treatment and care in institutional settings. Those most likely to reside longest in these facilities have the most complex mental health problems and are at most risk of potential abuses of care and exploitation. This study aimed to develop an international, standardised toolkit to assess the quality of care in longer term hospital and community based mental health units, including the degree to which human rights, social inclusion and autonomy are promoted. METHOD: The domains of care included in the toolkit were identified from a systematic literature review, international expert Delphi exercise, and review of care standards in ten European countries. The draft toolkit comprised 154 questions for unit managers. Inter-rater reliability was tested in 202 units across ten countries at different stages of deinstitutionalisation and development of community mental health services. Exploratory factor analysis was used to corroborate the allocation of items to domains. Feedback from those using the toolkit was collected about its usefulness and ease of completion. RESULTS: The toolkit had excellent inter-rater reliability and few items with narrow spread of response. Unit managers found the content highly relevant and were able to complete it in around 90 minutes. Minimal refinement was required and the final version comprised 145 questions assessing seven domains of care. CONCLUSIONS: Triangulation of qualitative and quantitative evidence directed the development of a robust and comprehensive international quality assessment toolkit for units in highly variable socioeconomic and political contexts.

Factor structure and psychometric properties of a new 39-item version of the Criteria for Recovery from Eating Disorders questionnaire (CRED-39).

Eating disorders (ED) are a group of mental disorders, which are quite difficult to treat. In studies on the recovery process of ED, patients' experience is rarely been taken into account. In addition, there seems to be a gap between patients' objective improvement, as assessed by clinicians, and patients' own subjective evaluation of their recovery. Criteria for Recovery from Eating Disorders (CRED) is a questionnaire used to investigate recovery criteria which are considered important from the patients' perspective. The purpose of the present study was to examine the factorial structure of CRED and to evaluate its psychometric properties. A sample of 138 patients in ED treatment were asked to complete the CRED along with the WHO questionnaire on quality of life (WHOQoL-BREF) and the eating disorders questionnaire (EDE-Q). Exploratory factor analysis (EFA) was used to explore the factor structure of the CRED. Internal consistency assessment was based on Cronbach's α. Convergent validity was assessed through correlations of CRED with WHOQoL-BREF and EDE-Q. The EFA led to the removal of 13 items of the original CRED and yielded a conceptually justifiable seven factor model: Body Experience, Psychological Well-being, Social Relationships, Gastrointestinal Symptoms, Bodily Functions, Eating Behaviours, and Compensatory Behaviours. Cronbach's alphas of the total questionnaire and all seven factors ranged from 0.77 to 0.88. Convergent validity to WHOQoL-BREF and EDE-Q total scores and subscales were found to be quite satisfactory. Our analysis has, thus, led us to propose the CRED-39, a 39-item version of the CRED questionnaire, which seems to be a valid and reliable tool in assessing ED patients' own view of their recovery process. CRED-39 can be used in clinical practice to address personal needs and to direct individualised interventions.