Illness duration and treatment outcome of intensive cognitive-behavioral therapy in adolescents with anorexia nervosa.

OBJECTIVE: This study aimed to compare the effectiveness of an intensive treatment based on enhanced cognitive-behavioral therapy (CBT-E) in patients aged between 12 and 18 years with anorexia nervosa with a duration of illness <3 versus ≥3 years. METHODS: One hundred and fifty-nine consecutively treated patients (n = 122 with illness duration <3 years and n = 37 ≥ 3 years) were enrolled in a 20-week intensive CBT-E program. All patients underwent assessment at admission, end of treatment (EOT), and 20-week follow-up. The following measures were used: body mass index (BMI)-for-age percentile and percentage of expected body weight (EBW), Eating Disorder Examination Questionnaire, Brief Symptom Inventory, and Clinical Impairment Assessment. RESULTS: Approximately 81% of eligible patients began the program, with over 80% successfully completing it. Patients with a longer or shorter duration of illness did not show significantly different treatment outcomes. In detail, BMI-for-age percentile and percentage of EBW outcomes were significantly improved from baseline to EOT, remaining stable until 20-week follow-up in both groups. Similarly, in both groups, scores for eating disorder psychopathology, general psychopathology, and clinical impairment decreased significantly at EOT and remained stable from EOT to follow-up. Furthermore, a substantial percentage of adolescents in both groups achieved a good BMI outcome at EOT and 20-week follow-up, with approximately 60% maintaining a full response at the latter time point. DISCUSSION: These findings suggest that intensive CBT-E appears to be an effective treatment for severely ill adolescent patients with anorexia nervosa, regardless of whether the duration of illness is shorter or longer than 3 years. PUBLIC SIGNIFICANCE: Existing treatment outcome studies in adolescents, whether randomized controlled trials or longitudinal investigations, typically involve patients with less than 3 years of illness, while data on the treatment outcomes for adolescents with anorexia nervosa with an illness duration of 3 years or over is very limited. Our findings suggest that adolescents with anorexia nervosa, irrespective of the duration of their illness, can derive similar benefits from intensively CBT-E.

The impact of the COVID-19 pandemic on intensive cognitive behavioral therapy outcomes in patients with anorexia nervosa-A cohort study.

OBJECTIVE: This study aimed to assess the impact of the COVID-19 pandemic on the efficacy of an intensive treatment based on enhanced cognitive behavioral therapy (CBT-E) in patients with anorexia nervosa. METHODS: This cohort study analyzed 57 patients with anorexia nervosa who experienced the COVID-19 pandemic during intensive CBT-E, comparing their outcomes (body mass index [BMI], eating-disorder and general psychopathology, and clinical impairment) with those of patients with anorexia nervosa matched by gender, age, and BMI given the same treatment before the COVID-19 outbreak as controls. Patients were assessed at baseline, at the end of treatment and after 20 weeks of follow-up. RESULTS: More than 75% of patients during the pandemic versus 85% of controls completed the treatment, a difference that was not significant. BMI, eating disorder and general psychopathology and clinical impairment scores improved significantly from baseline to 20-week follow-up in both groups. However, the improvement was more marked in controls than in those treated during the COVID-19 pandemic. CONCLUSION: Patients with anorexia nervosa given intensive CBT-E during the COVID-19 pandemic had significantly improved psychopathology, albeit to a lesser extent than patients given the same treatment before the COVID-19 pandemic. PUBLIC SIGNIFICANCE STATEMENT: In this study, the outcome of 57 patients with anorexia treated with intensive enhanced cognitive behavior therapy during the COVID-19 pandemic was compared with a matched group treated before the pandemic hit. The rate of remission from anorexia nervosa was similar between the two groups. However, patients exposed to the COVID-19 pandemic showed lesser improvement than those not exposed.

Effectiveness of enhanced cognitive behaviour therapy for patients aged 14 to 25: A promising treatment for anorexia nervosa in transition-age youth.

OBJECTIVE: The study aimed to evaluate the effectiveness of enhanced cognitive behaviour therapy (CBT-E) on patients with anorexia nervosa (AN) aged 14 to 25 treated in a real-world setting. METHOD: One hundred and fifteen patients with AN (n = 61, age <18 years) were recruited from consecutive referrals to a clinical eating disorder service offering outpatient CBT-E. Body Mass Index (BMI), BMI centiles, Eating Disorder Examination Questionnaire, Brief Symptom Inventory, and Clinical Impairment Assessment scores were recorded at admission, at the end of treatment, and at 20-week follow-up. RESULTS: The seventy-two patients (62.6%) who finished the programme showed considerable weight gain and reduced scores for clinical impairment and eating-disorder and general psychopathology. Changes remained stable at 20 weeks. A comparison between adolescent and adult patients indicates similar improvements in eating-disorder psychopathology. CONCLUSIONS: The benchmark data yielded by this study suggest that CBT-E is a well-accepted and promising treatment that could be adopted to ensure continuity of care across the transitional age.

Changes in specific and nonspecific psychopathology network structure after intensive cognitive behavior therapy in patients with anorexia nervosa.

OBJECTIVE: This study aimed to compare eating disorder-specific and nonspecific clinical features in patients with anorexia nervosa before and after intensive enhanced cognitive behavior therapy (CBT-E) via network analysis. METHODS: All consecutive patients admitted to intensive CBT-E were eligible, and the sample comprised patients aged ≥16 years who completed a 20-week intensive CBT-E program. Body mass index (BMI), Eating Disorder Examination Questionnaire and Brief Symptoms Inventory responses were gathered at baseline and end of treatment, and used to generate statistical networks of the connections between symptoms (nodes) and the strength and centrality thereof. RESULTS: A total of 214 patients were included. Most nodes had relatively similar centrality compared to other nodes in the networks. "Eating concern" and "phobic anxiety" showed the greatest bridge centrality at both time points. No differences were found between baseline and the end of treatment in either global network or individual connection strengths. CONCLUSION: These findings suggest that some clinical expressions not specific to eating-disorder psychopathology remain strongly connected in the generalized network of patients with anorexia nervosa after CBT-E. Future research should examine whether additional procedures specifically designed to target these symptoms should be integrated into this and other treatments.

Day-hospital enhanced cognitive behavior therapy for adults with eating disorders: Immediate and follow-up effects.

OBJECTIVE: To assess outcomes in adult patients with eating disorders administered enhanced cognitive behavioral therapy (CBT-E) in a day-hospital setting. METHOD: Forty-three consecutive patients with eating disorders (86% females; mean age 28.8 [SD = 11.8]) were admitted to a 13-week day-hospital CBT-E program. Twenty-five (58.1%) patients were underweight (i.e., body mass index [BMI] <18.5 kg/m2 ; BMI 15.4 [SD = 2.2]) and 18 not (mean BMI 23.1 [SD = 6.3]) at baseline. All patients responded poorly to prior outpatient treatment. Body mass index and Eating Disorder Examination Questionnaire (EDE-Q), Brief Symptom Inventory (BSI), and Clinical Impairment Assessment (CIA) scores were recorded at baseline, end of treatment, and 20-week follow-up. RESULTS: In 37 patients (86.0%) who completed the treatment, there were substantial improvements in eating-disorder features, general psychopathology, clinical impairment, and body weight (only in underweight patients), which were well maintained at follow-up. DISCUSSION: Day-hospital CBT-E is a promising treatment for adults with eating disorders.

The clinical perfectionism questionnaire: psychometric properties of the Italian version in patients with eating disorders.

BACKGROUND: Problematic perfectionism has been traditionally conceptualized as a multidimensional construct, and specific instruments have been developed to capture its various dimensions. However, the Clinical Perfectionism Questionnaire (CPQ) was recently designed to measure a unidimensional construct called "clinical perfectionism", but the questionnaire has not yet been validated in Italian. AIM: This study aimed to propose the Italian version of the CPQ and examine its psychometric properties. METHODS: The CPQ was translated into Italian using translation and back-translation procedures. Then, it was administered to 188 Italian-speaking patients with eating disorders and 126 non-eating disorder group (excluded if the Italian version of the Eating Attitudes Test-26 was ≥ 20). The clinical group also completed the Italian versions of the Frost Multidimensional Perfectionism Scale (FMPS), the Eating Disorder Examination Questionnaire (EDE-Q), and the Brief Symptom Inventory (BSI). RESULTS: Confirmatory factor analysis revealed a good fit for the bifactor structure of the 10-item version. Internal consistency was high for the general clinical perfectionism factor, and test-retest reliability was good. Convergent validity was acceptable for the general clinical perfectionism and 'overvaluation of striving' group factors. The CPQ showed significantly higher scores in patients with eating disorders than in the non-eating disorder group. CONCLUSIONS: Overall, the study demonstrated the good psychometric properties of the Italian version of the CPQ, and validated its use in Italian-speaking patients with eating disorders. Although further research is required, the CPQ has promising evidence as a reliable and valid measure of clinical perfectionism in its Italian version. LEVEL OF EVIDENCE: Level V, Descriptive study.

McArdle disease in a patient with anorexia nervosa: a case report.

BACKGROUND: McArdle disease is an autosomal recessive genetic disorder caused by a deficiency of the glycogen phosphorylase (myophosphorylase) enzyme, which muscles need to break down glycogen into glucose for energy. Symptoms include exercise intolerance, with fatigue, muscle pain, and cramps being manifested during the first few minutes of exercise, which may be accompanied by rhabdomyolysis. CASE PRESENTATION: This case report describes for the first time the clinical features, diagnosis and management of a 20 year-old patient with anorexia nervosa and McArdle disease, documented by means of muscle biopsy. CONCLUSION: Anorexia nervosa and McArdle disease interact in a detrimental bidirectional way. In addition, some laboratory parameter alterations (e.g., elevated values of creatine kinase) commonly attributed to the specific features of eating disorders (e.g., excessive exercising) may delay the diagnosis of metabolic muscle diseases. On the other hand, the coexistence of a chronic disease, such as McArdle disease, whose management requires the adoption of a healthy lifestyle, can help to engage patients in actively addressing their eating disorder.

Change in eating-disorder psychopathology network structure in patients with anorexia nervosa treated with intensive cognitive behavior therapy.

OBJECTIVE: This study was designed to compare the change in eating-disorder feature networks in patients with anorexia nervosa after treatment with intensive enhanced cognitive behavior therapy (CBT-E). METHODS: Patients seeking treatment for anorexia nervosa were consecutively recruited from January 2016 to September 2020. All patients aged ≥16 years who completed a 20-week intensive CBT-E program (13 weeks of inpatient followed by 7 weeks of day-hospital treatment) were included in the study. Body mass index (BMI) was measured, and the Eating Disorder Examination Questionnaire completed for each patient, both at baseline and the end of treatment. RESULTS: The sample comprised 214 patients with anorexia nervosa. Treated patients showed significant improvements in BMI and eating-disorder psychopathology. Network analysis revealed a significant reduction in the network global and connection strengths at the end of treatment. The most central and highly interconnected nodes in the network at baseline were related to the drive for thinness, but at the end of treatment to body image concerns. Some edge connections were significantly stronger at baseline than at the end of treatment, while others were significantly stronger at the end of treatment than at baseline. DISCUSSION: CBT-E reduces the psychopathology network connectivity over time in patients with anorexia nervosa. The differences in central nodes and edge connections between baseline and end of treatment, not detected by classical inferential analysis, may be informative for understanding the centrality of symptoms in the psychopathology network, and how a specific treatment may act to reduce symptoms and change their connections over time.

Intensive Cognitive Behavioral Therapy for Adolescents with Anorexia Nervosa Outcomes before, during and after the COVID-19 Crisis.

Studies comparing treatment outcomes in patients with eating disorders before and during the coronavirus (COVID-19) pandemic have yielded conflicting results. Furthermore, no study has yet evaluated treatment outcomes in adolescent patients with anorexia nervosa before, during and after the crisis. Hence, this study investigated the outcomes of an intensive Cognitive Behavioral Therapy-Enhanced (CBT-E) program on adolescents with anorexia nervosa consecutively treated before (n = 64), during (n = 37) and after (n = 31) the period of emergency spanning 8 March 2020 to 31 March 2022. Results show consistent and similar improvements in eating disorder psychopathology, general psychopathology and body mass index-for-age percentiles across all three periods, with approximately 60% of patients maintaining a full response at the 20-week follow-up, suggesting that treatment efficacy remained robust. Overall, the study underscores the effectiveness of intensive CBT-E as a viable treatment option for adolescents with anorexia nervosa, even during and after unprecedented challenges such as those posed by the COVID-19 pandemic.

The Role of Weight Suppression in Intensive Enhanced Cognitive Behavioral Therapy for Adolescents with Anorexia Nervosa: A Longitudinal Study.

The study aimed to establish the role of weight suppression in a cohort of adolescents with anorexia nervosa treated with intensive enhanced cognitive behavioral therapy (CBT-E). One hundred and twenty-eight adolescent patients with anorexia nervosa (128 females and 2 males), aged between 14 and 19 years, were recruited from consecutive referrals to a community-based eating disorder clinic offering intensive CBT-E. Weight, height, Eating Disorder Examination Questionnaire, and Brief Symptom Inventory scores were recorded at admission, end-of-treatment, and at a 20-week follow-up. In addition, the developmental weight suppression (DWS, difference between one's highest premorbid and current z-BMI, i.e., BMI z-scores) was calculated. The mean baseline z-BMI was -4.01 (SD = 2.27), and the mean DWS was 4.2 (SD = 2.3). One hundred and seven patients (83.4%) completed the treatment and showed both considerable weight gain and reduced scores for eating-disorder and general psychopathology. Among completers, 72.9% completed the 20-week follow-up and maintained the improvement reached at the end-of-treatment. DWS was negatively correlated with end-of-treatment and follow-up z-BMI. This indicates that weight suppression is a predictor of the BMI outcome of intensive CBT-E and confirms that this treatment is promising for adolescents with anorexia nervosa.

Reply to Meule, A. Comment on "Calugi et al. The Role of Weight Suppression in Intensive Enhanced Cognitive Behavioral Therapy for Adolescents with Anorexia Nervosa: A Longitudinal Study. Int. J. Environ. Res. Public Health 2023, 20, 3221".

We read the comments by Meule on our article with great interest, and we thank the author for his thoughtful suggestions [...].

Weight Bias Internalization and Eating Disorder Psychopathology in Treatment-Seeking Patients with Obesity.

This study aimed to investigate the relationship between weight bias internalization and eating disorder psychopathology in treatment-seeking patients with severe obesity using a network approach. Two thousand one hundred and thirteen patients with obesity were consecutively admitted to a specialist clinical unit for obesity and were recruited from January 2016 to February 2023. Body mass index was measured, and each patient completed the Weight Bias Internalization Scale (WBSI) and the Eating Disorder Examination Interview (EDE). Network analysis showed that the most central and highly interconnected nodes in the network were related to the EDE items exposure avoidance, dissatisfaction with shape, and wanting an empty stomach. Bridge nodes were found, but the bootstrap difference test on expected bridge influence indicated non-significant centrality differences. Nevertheless, the eating disorder psychopathology and weight bias internalization network structure in patients seeking treatment for obesity indicate the prominent roles of body dissatisfaction and control of eating and weight in these psychological constructs. This finding, if replicated, could pave the way for a new understanding of the psychological mechanisms operating in patients with obesity.

The Impact of COVID-19 Lockdown on Patients with Obesity after Intensive Cognitive Behavioral Therapy-A Case-Control Study.

BACKGROUND: The COVID-19 lockdown may have negatively impacted the treatment of obesity. This study aimed to assess the effect of COVID-19 lockdown in patients with obesity treated with intensive residential cognitive behavioral therapy (CBT-OB). METHODS: This retrospective case-control study analyzed 129 patients with severe obesity who experienced COVID-19 lockdown in the 6 months after discharge from intensive residential CBT-OB, comparing their outcomes on weight loss, binge-eating episodes, and general health status with those in a sample of patients matched by gender, age, and body mass index given the same treatment before the COVID-19 outbreak as control. Patients were assessed at baseline and by phone interview 6-month follow-up. RESULTS: Both groups had lost more than 9% of their baseline bodyweight and reported a significant decrease in binge-eating episodes and similar general health status at 6-month follow-up. However, control patients achieved a significantly greater weight loss than those who experienced lockdown, although half of lockdown patients reported persisting with CBT-OB procedures after their discharge. CONCLUSION: Patients with obesity treated with CBT-OB and exposed to COVID-19 lockdown, despite achieving lower weight loss than non-exposed patients, had a healthy weight loss at 6-month follow-up and comparable reduction in binge-eating behaviors.