Distance to home does not influence treatment success during and after inpatient treatment in adolescents with anorexia nervosa.

Current treatment guidelines recommend that inpatients with eating disorders-particularly adolescents with anorexia nervosa-should receive treatment at facilities within close distance to their home. However, whether distance to home actually influences short- and long-term treatment outcome in adolescents with anorexia nervosa has not been investigated yet. We re-analyzed data at admission, discharge, and 1-year follow up from a recent study with N = 142 female, adolescent inpatients with anorexia nervosa. Distance to home did not moderate changes in body weight, eating disorder symptoms, depressive symptoms, compulsive exercise, and life satisfaction. This is the first analysis that indicates that specialized inpatient treatment for adolescents with anorexia nervosa is effective both close to and away from home.

Pathways between childhood maltreatment and life satisfaction in adolescents with eating disorders: A network analysis.

OBJECTIVE: This study explored the association between Childhood maltreatment (CM) experiences and life satisfaction in adolescents with eating disorders (EDs). METHODS: Adolescent inpatients with EDs completed the Childhood Trauma Questionnaire, the Satisfaction With Life Scale, the Brief Symptom Inventory and the Eating Disorder Inventory-2 at admission (n = 361) and discharge (n = 354). A network analysis was conducted to identify the shortest pathways between different types of CM and life satisfaction at admission and discharge. RESULTS: General psychopathology, life satisfaction, and ED symptoms improved from admission to discharge. At admission, emotional abuse and emotional neglect were included in the pathway between sexual/physical abuse and life satisfaction. Emotional neglect was directly connected with life satisfaction while emotional abuse was connected through feeling disliked by others, feelings of inferiority and worthlessness. At discharge, only the direct negative connection between emotional neglect and perception of excellent conditions in the life persisted. CONCLUSIONS: Emotional maltreatment experiences and general psychopathology, but not disordered eating symptoms, are involved in the association between sexual/physical CM and life satisfaction in adolescents with EDs. Emotional neglect may affect life satisfaction regardless of symptoms severity. These findings inform clinicians for assessment and treatment of maltreated adolescents with EDs.

Comparing illness duration and age as predictors of treatment outcome in female inpatients with anorexia nervosa.

It has been widely assumed that longer illness duration predicts poorer treatment outcome in persons with anorexia nervosa (AN). However, studies on the prognostic effects of illness duration have produced mixed results. Thus, the aim of the current study was to examine the relationship between illness duration and short-term treatment outcome in a large sample of female inpatients with AN (n = 902, aged 12-73 years). Treatment outcome variables included body mass index, therapist-rated global functioning (Global Assessment of Functioning scale and Clinical Global Impression-Improvement scale) and subscales of the Eating Disorder Inventory-2. Longer illness duration predicted smaller weight gain, smaller improvements in global functioning, and smaller decreases in self-reported eating disorder symptoms. However, illness duration was almost perfectly correlated with patients' age (r = .81, 95% CI [.76, .85]), and comparing regression models revealed that models using either illness duration or age were indistinguishable. Results suggest that longer illness duration does indeed relate to worse short-term treatment outcome in inpatients with AN. This effect, however, does not add significant information above and beyond patients' age and, thus, the importance of illness duration for anticipating treatment outcome both in research and in clinical practice must be critically examined.

Psychometric properties of the Compulsive Exercise Test in a large sample of female adolescent and adult inpatients with anorexia nervosa and bulimia nervosa.

OBJECTIVE: The Compulsive Exercise Test (CET) was developed to assess compulsive exercise in patients with eating disorders (EDs), but originally validated in a nonclinical sample, and psychometric properties were only investigated in small clinical samples. Therefore, the aim of this study was to examine its psychometric properties in a large clinical sample of adolescent and adult inpatients with anorexia nervosa and bulimia nervosa. METHOD: A sample of 2,535 German female inpatients with EDs completed the CET and other instruments at admission and discharge. Factor structure (confirmatory [CFA] and exploratory factor analyses [EFA]), internal consistency and construct validity, measurement invariance across age and diagnostic groups, group comparisons of means, as well as sensitivity to change during treatment were assessed. RESULTS: The CET showed high internal consistency, very good construct validity, and sensitivity to change. CFA indicated a better fit of four-factor and three-factor solutions compared to the original five-factor model. However, subsequent EFA identified an optimum for a five-factor model. Only three subscales were satisfactorily invariant to measurement, but not the CET total score. Only small differences in scores between patient groups were observed. DISCUSSION: Results support internal consistency, construct validity, and sensitivity to change, whereas factor structure remains inconclusive, questioning the theoretical basis of the CET. There is limited support for using the lack of enjoyment subscale, and only moderate support for using the rigidity subscale in patients with EDs. It is recommended to further explore and/or revise the original CET, including investigation in other samples, for example, male samples.

Early within-person weight gain and variability during inpatient treatment for anorexia nervosa: Age-dependent effects on treatment outcome.

OBJECTIVE: Early weight gain during inpatient treatment for anorexia nervosa (AN) is a dynamic process characterised by within-person variability that may be age-dependent. We examined whether age moderates the effect of within-person weight gain and variability on treatment outcome. METHOD: Within-person level estimates of N = 2881 underweight adolescents and adults with AN for daily average weight gain (linear slope) and variability (root mean squared errors) were obtained using random-effects modelling. Between-person level regression analyses were calculated to assess effects on weight, eating disorder psychopathology and attaining normal body weight (body mass index [BMI]: 18.5-25 kg/m2 ). RESULTS: Higher weight gain during first 2 weeks of inpatient treatment predicted higher weight, lower drive for thinness and lower body dissatisfaction at discharge, but not lower bulimic symptoms. Moreover, it predicted a higher probability of discharge weight within normal range. Younger age was associated with stronger effects of early weight gain on weight, drive for thinness and body dissatisfaction at discharge. Weight variability was not associated with any outcome. CONCLUSIONS: Age moderated effects of early weight gain on treatment outcomes, with larger effects for younger patients. Weight variability alone did not influence treatment across age and should be of lesser clinical concern during early inpatient treatment.

Emotion regulation in adolescents with anorexia and bulimia nervosa: Differential use of adaptive and maladaptive strategies compared to healthy adolescents.

OBJECTIVE: Adolescents with anorexia (AN) and bulimia nervosa (BN) often struggle with emotion regulation (ER). These difficulties have predominantly been assessed across emotions, without considering adaptive and maladaptive ER separately. We compared adolescents with AN or BN to healthy adolescents (HCs) regarding the adaptive and maladaptive ER of three emotions. METHOD: A treatment-seeking sample of 197 adolescents (atypical/full-threshold AN: N = 118, atypical/full-threshold BN: N = 32; HC: N = 47) reported emotion-specific ER with the FEEL-KJ questionnaire. Mixed models were calculated for adaptive and maladaptive ER to assess differences between emotions (anxiety, anger, and sadness) and groups (AN, BN, and HC). RESULTS: Main effects of emotion (p < .001) and group (p < .001) were found, but no interaction effects were found (p > .05). Post hoc tests showed lower maladaptive and higher adaptive ER for anxiety than anger or sadness (p < .001). AN and BN reported lower adaptive (p < .001) and higher maladaptive ER than HCs (p < .001). BN showed the highest levels of maladaptive ER (p = .009). DISCUSSION: The differences between AN and BN in adaptive and maladaptive ER should be considered. Furthermore, investigating differences in ER of other emotions in eating disorders might be promising.

A call to experimentally study acute affect-regulation mechanisms specific to driven exercise in eating disorders.

Driven exercise (i.e., feeling compelled to exercise to control one's weight or shape, to obtain other positive consequences of exercising, or to avoid other negative consequences of not exercising) is a common phenomenon in individuals with eating disorders (EDs), typically associated with negative clinical outcomes. Current theoretical models of driven exercise highlight the short-term affect-regulating outcome of acute driven exercise, which is implicated to maintain this symptom either by positive or negative reinforcement. However, few studies have actually investigated cognitive, affective, and psychobiological mechanisms related to acute driven exercise. In particular, experimental studies that directly test mechanisms leading to the short-term affective improvement after acute driven exercise are scarce. In this article, we therefore propose potential cognitive, affective, and psychobiological mechanisms that could explain the affect-regulating function of driven exercise in individuals with EDs. In addition, we suggest examples of experimental studies that could directly test these mechanisms in individuals with EDs, as recent studies have demonstrated the safety of supervised exercise in EDs research. Our aim of stimulating research on the underlying causes and maintenance factors of driven exercise in EDs has the potential to critically inform treatment development for this high-risk population.

Body image avoidance affects interpersonal distance perception: A virtual environment experiment.

OBJECTIVE: Eating disorders have a considerable influence on social contacts. The avoidance towards the own body may result in the avoidance of others. Previous research has found a preference for larger interaction distances in individuals with eating disorders (ED) as compared to control participants (CG). We aimed to replicate these findings and to investigate whether the body weight of the interactant moderates the effect. METHOD: We recruited a female sample with mixed ED subtypes (n = 21) and a female CG (n = 28). Participants were immersed in a virtual environment and engaged in a number of fictitious social interactions. They approached a virtual person until a comfortable distance for interaction was reached. The approached virtual persons differed with respect to body weight in five levels (underweight to obese). RESULTS: Our results indicate that interpersonal distance varies as a U-shaped function of the avatar's body weight, and that higher levels of body avoidance, present in ED individuals, magnify this effect. CONCLUSIONS: We discuss our results with regard to the role of perspective and disgust to provide a useful framework and to motivate future studies in the domain of body avoidance in social interactions.

Testing an emotion regulation model of physical activity in adolescents with anorexia nervosa: A pilot ecological momentary assessment.

OBJECTIVE: Adolescents with anorexia nervosa (AN) often show increased levels of exercise and physical activity. Psychological models suggest that physical activity in AN might attenuate momentary negative affect. However, this has not been directly tested in adolescents with AN, and it remains unclear whether this is a distinct mechanism of physical activity in AN compared with healthy controls (HCs). METHOD: In a 1-day ecological momentary assessment, 32 adolescent inpatients with AN and 30 HCs responded to hourly questions on momentary affect while wearing an actigraph to objectively assess physical activity. RESULTS: Linear mixed models identified that adolescents with AN experienced more aversive tension, more negative affect, and less positive affect throughout the day than HCs. Preliminary evidence for a momentary association of higher levels of physical activity with positive affect were found for both groups, whereas higher levels of physical activity were associated with less negative affect in adolescents with AN only. When correcting for multiple testing, interactions did not hold statistical significance. DISCUSSION: Our results indicate a down-regulation effect of physical activity on negative affect for AN and a more general up-regulation effect of positive affect. However, our sample size was small, and replication of our findings is needed.

Aversive tension in female adolescents with Anorexia Nervosa: a controlled ecological momentary assessment using smartphones.

BACKGROUND: Current models of Anorexia Nervosa (AN) emphasize the role of emotion regulation. Aversive tension, described as a state of intense arousal and negative valence, is considered to be a link between emotional events and disordered eating. Recent research focused only on adult patients, and mainly general emotion regulation traits were studied. However, the momentary occurrence of aversive tension, particularly in adolescents with AN, has not been previously studied. METHOD: 20 female adolescents with AN in outpatient treatment and 20 healthy adolescents aged 12 to 19 years participated in an ecological momentary assessment using their smartphones. Current states of aversive tension and events were assessed hourly for two consecutive weekdays. Mean and maximum values of aversive tension were compared. Multilevel analyses were computed to test the influence of time and reported events on aversive tension. The effect of reported events on subsequent changes of aversive tension in patients with AN were additionally tested in a multilevel model. RESULTS: AN patients showed higher mean and maximum levels of aversive tension. In a multilevel model, reported food intake was associated with higher levels of aversive tension in the AN group, whereas reported school or sport-related events were not linked to specific states of aversive tension. After food intake, subsequent increases of aversive tension were diminished and decreases of aversive tension were induced in adolescents with AN. CONCLUSIONS: Aversive tension may play a substantial role in the psychopathology of AN, particular in relation with food intake. Therefore, treatment should consider aversive tension as a possible intervening variable during refeeding. Our findings encourage further research on aversive tension and its link to disordered eating. TRIAL REGISTRATION: German register of clinical trials (DRKS): DRKS00005228 (Date of registration: September 2, 2013).

Pathways between Child Maltreatment, Psychological Symptoms, and Life Satisfaction: A Network Analysis in Adolescent Inpatients.

Child maltreatment is a risk factor for mental disorders and decreased life satisfaction during adolescence. We investigated whether child maltreatment would link to life satisfaction both directly and through psychological symptoms, whether these relations would change from admission to discharge after treatment, and which types of maltreatment, symptoms and facets of life satisfaction would be most influential in adolescent inpatients with internalizing mental disorders. N = 896 adolescent receiving inpatient psychotherapeutic treatment completed questionnaires on child maltreatment experiences, current psychopathology and subjective life satisfaction at admission and discharge (n = 765). Main diagnoses were affective (n = 322), eating (n = 447), obsessive-compulsive (n = 70) and anxiety disorders (n = 57). Network models of child maltreatment, psychopathology and life satisfaction nodes were estimated at admission and discharge and compared using network comparison tests. Potential causal shortest pathways were investigated using directed acyclic graphs.Network models were stable with no significant differences between admission and discharge. Strongest nodes of each cluster were "emotional abuse" (child maltreatment), "worthlessness", "thinking about dying" and "feeling lonely" (psychopathology) and "satisfied with life" (life satisfaction) at both admission and discharge. Emotional neglect showed direct connections to life satisfaction, indicating its relevance for therapeutic interventions. At both admission and discharge, "sexual abuse" indirectly predicted lower life satisfaction through psychological symptoms. In conclusion, child maltreatment is directly and indirectly connected to life satisfaction in adolescents with mental disorders. Emotional abuse and neglect were especially important in linking child maltreatment to life satisfaction and psychopathology.

Effects of acceptance-based strategies on psychological responses to disorder-relevant stimuli in inpatients with obsessive-compulsive disorder: An experimental study.

BACKGROUND AND OBJECTIVES: Preliminary findings suggest that acceptance and commitment therapy-informed exposure therapy may be an effective treatment for obsessive-compulsive disorder (OCD). However, there is a lack of experimental studies that have examined immediate effects of acceptance-based strategies during exposure to disorder-relevant stimuli in persons with OCD. METHODS: Fifty-three inpatients (64% female) with OCD participated in an experimental study during which they were exposed to obsessive-compulsive washing-relevant pictures and were instructed to either passively view these pictures for 5 s (neutral condition), to accept their feelings (acceptance condition) or to intensify their feelings (exposure condition) for 90 s each. RESULTS: The acceptance condition led to higher acceptance and lower unpleasantness of patients' current feelings compared to the neutral condition and to lower strength of obsessions and urge to perform compulsions but only when compared to the exposure condition. Higher self-reported OCD symptom severity related to higher unpleasantness and strength of obsessions, particularly in the neutral condition. LIMITATIONS: Future studies need to test whether the current findings translate to other stimuli and other forms of obsessions and compulsions. Due to the short duration, the exposure condition might have only mimicked the early phase of exposure and response prevention. CONCLUSIONS: Acceptance-based strategies during cue exposure immediately increase acceptance of and reduce unpleasant feelings. In line with the rationale of acceptance-based treatment approaches, which do not aim at immediate disorder-specific symptom reductions, effects on obsessions and compulsions may be more delayed or require repeated training sessions.

Depressive symptoms and weight change in inpatients with anorexia nervosa: A cross-lagged panel model.

OBJECTIVE: Anorexia nervosa (AN) is marked by a high rate of comorbid depression, which raises the question whether depressive symptoms may adversely affect treatment outcome. Thus, we examined whether depressive symptoms at admission would predict weight change from admission to discharge in a large sample of inpatients with AN. In addition, we also explored the reverse direction, that is, whether body mass index (BMI) at admission would predict changes in depressive symptoms. METHODS: A sample of 3011 adolescents and adults with AN (4% male) who received inpatient treatment at four Schoen Clinics was analyzed. Depressive symptoms were measured with the Patient Health Questionnaire-9. RESULTS: BMI significantly increased and depressive symptoms significantly decreased from admission to discharge. BMI and depressive symptoms were unrelated at admission and discharge. Higher BMI at admission predicted smaller decreases in depressive symptoms and higher depressive symptoms at admission predicted larger weight gain. The latter effect, however, was mediated by longer length of stay. CONCLUSION: Results indicate that depressive symptoms do not adversely affect weight gain during inpatient treatment in persons with AN. Instead, higher BMI at admission is predictive of smaller improvements in depressive symptoms but this effect seems to be negligible in terms of clinical relevance.

Validation of a Latin-American Spanish version of the Body Esteem Scale for Adolescents and Adults (BESAA-LA) in Colombian and Nicaraguan adults.

BACKGROUND: Body dissatisfaction (BD) is a growing concern in Latin America; reliable and culturally appropriate scales are necessary to support body image research in Spanish speaking Latin American countries. We sought to validate a Latin-American Spanish version of the Body Esteem Scale for Adolescents and Adults (BESAA; Mendelson et al. 2001). METHODS: The BESAA was translated, culturally adapted, and validated in a sample of adults in Colombia (N = 525, 65% women, Mage 24.4, SD = 9.28). We assessed factor structure (using confirmatory factor analysis (CFA), exploratory factor analysis (EFA) and exploratory structural equation model (ESEM)), internal reliability (using Cronbach's alpha and omega), validity (using the Body Appreciation Scale BAS and Sociocultural Attitudes Towards Appearance Questionnaire SATAQ), test-retest stability in a small subsample (N = 84, using Intraclass correlations ICC) and measurement invariance across gender. To evaluate the generalizability of the scale, we assessed reliability, validity, and factor structure in a second sample from rural Nicaragua (N = 102, 73% women, Mage 22.2, SD = 4.72), and assessed measurement invariance across Nicaraguan and Colombian participants. RESULTS: The scale showed good internal reliability and validity in both samples, and there was evidence of adequate test-retest stability in the Colombian sample. EFA showed a three-factor structure with subscales we labelled 'appearance-positive', 'appearance-negative' and 'weight', that was confirmed using CFA and ESEM in the Colombian sample. Measurement invariance was confirmed across the Colombian and Nicaraguan samples, and across gender within the Colombian sample. CONCLUSION: The Latin-American Spanish version of the BESAA (BESAA-LA) appears to be a psychometrically sound measure with good reliability, validity and invariance across gender and countries. These results support the use of this scale to measure body satisfaction/dissatisfaction in Latin American adult populations.

An update on the epidemiology of eating disorders in Latin America: current findings and future challenges.

PURPOSE OF REVIEW: We systematically reviewed the recent literature on the epidemiology of eating disorders in Latin America. RECENT FINDINGS: Most screened articles only investigated risk for eating disorders or disordered eating behaviors. Four studies reported prevalence for eating disorders. One study reported age-standardized prevalence ranging from 0.04% [95% confidence interval, CI (0.03, 0.06)] to 0.09% [95% CI (0.07, 0.13)] for anorexia nervosa and from 0.13% [95% CI (0.08, 0.17)] to 0.27% [95% CI (0.18, 0.37)] for bulimia nervosa. Three additional studies conducted in Brazil identified a general eating disorder point-prevalence of 0.40% in children aged 6--14 years and a point-prevalence of 0.7 % [95% CI (0.34, 1.55)] for bulimia nervosa, 1.4% [95% CI (0.81, 2.43)] for binge-eating disorder and 6.2% [95% CI (3.10, 5.27)] for recurrent binge eating. SUMMARY: Since 2020, only few studies were published on the epidemiology of full-threshold eating disorders in Latin America. Prevalence was in a comparable range to previous findings. No studies regarding new DSM-5 eating disorder diagnoses were identified, and studies investigating the impact of the COVID-19 pandemic on prevalence or incidence of eating disorders in these countries are needed.

Weight suppression and body mass index at admission interactively predict weight trajectories during inpatient treatment of anorexia nervosa.

OBJECTIVE: Weight suppression refers to the difference between an individual's current and highest body weight at their current height. Higher weight suppression has been found to predict weight gain in both non-clinical samples and patients with eating disorders. Few studies also have reported interactive effects between weight suppression and current body mass index when predicting weight gain. METHODS: In this retrospective study, we analyzed clinical records of inpatients with anorexia nervosa (N = 2191, 97% female) and tested whether weight suppression and body mass index at admission would interactively predict different weight trajectories during treatment. RESULTS: Body weight increased non-linearly during treatment. Higher weight suppression predicted larger weight gain but the nature of this effect depended on body mass index at admission. In patients with a relatively low body weight at admission, those with high weight suppression started at a lower weight and showed a nearly linear and steeper weight gain than those with low weight suppression. In patients with a relatively high body weight at admission, those with high weight suppression started at a similar weight and showed a non-linear and larger weight gain than those with low weight suppression. CONCLUSION: Findings further support that weight suppression is a robust predictor of weight gain in addition to-and in interaction with-current body weight. As weight suppression can easily be assessed at admission, it may help to anticipate treatment course and outcome in patients with anorexia nervosa.

The Spanish Body Image State Scale: Factor Structure, Reliability and Validity in a Colombian Population.

OBJECTIVE: Body image is a construct highly dependent on culture and ethnicity. Furthermore, recent studies reveal that body image is not only a trait, but also a momentary state subject to change in diverse situational contexts. However, cultural influences on momentary body image have not been sufficiently investigated. To assess the influence of Latin American culture on momentary body image and to enable its comparison to Western countries, the Spanish translation of an existing state body image scale such as the Body Image States Scale (BISS) is needed. In addition, the factor structure, reliability and general validity of the Spanish BISS (S-BISS) should be evaluated prior to its application in diverse situational contexts. METHOD: We conducted a cross-sectional study evaluating 1137 individuals between the ages of 18 and 28 years from Barranquilla, Colombia, South America. The original BISS, which assesses body satisfaction, was translated from English to Spanish. Factorial structure, scale score reliability and convergent/divergent validity were assessed. RESULTS: Exploratory and confirmatory factor analyses revealed that a one-factor model with correlated items best described the factorial structure present in the BISS questionnaire. The coefficient of scale score reliability was α = 0.92 (McDonalds ω = 0.93), with similar results for men and women. Significant differences between males and females were found with lesser body satisfaction in females (W = 163260, p = 0.016). Lower S-BISS scores indicating less body satisfaction were associated with higher BMI (r = -0.287, p < 0.001) and obtained in participants who were currently on a diet (t 1135 = -3.98, p < 0.001). The S-BISS was negatively correlated with a trait body image measurement assessing body dissatisfaction (Body Shape Questionnaire, r = -0.577, p < 0.001) and a psychopathology questionnaire (Brief Symptom Inventory 53, r = -0.331, p < 0.001). CONCLUSION: The S-BISS is a valid and reliable instrument to assess body image in the Colombian population, and exhibits similar psychometric properties to those of the original version. Future studies should examine whether the S-BISS captures change in state body image when applied in diverse situational contexts.

Seasonal variation of BMI at admission in German adolescents with anorexia nervosa.

OBJECTIVE: Recent preliminary studies indicated a seasonal association of BMI at admission to inpatient treatment for anorexia nervosa (AN), indicating lower BMI in the cold season for restrictive AN. An impaired thermoregulation was proposed as the causal factor, based on findings in animal models of AN. However, findings regarding seasonality of BMI and physical activity levels in the general population indicate lower BMI and higher physical activity in summer than in winter. Therefore, we aimed to thoroughly replicate the findings regarding seasonality of BMI at admission in patients with AN in this study. METHOD: AN subtype, age- and gender-standardized BMI scores (BMI-SDS) at admission, mean daily sunshine duration and ambient temperature at the residency of 304 adolescent inpatients with AN of the multi-center German AN registry were analyzed. RESULTS: A main effect of DSM-5 AN subtype was found (F(2,298) = 6.630, p = .002), indicating differences in BMI-SDS at admission between restrictive, binge/purge and subclinical AN. No main effect of season on BMI-SDS at admission was found (F(1,298) = 4.723, p = .025), but an interaction effect of DSM-5 subtype and season was obtained (F(2,298) = 6.625, p = .001). Post-hoc group analyses revealed a lower BMI-SDS in the warm season for restrictive AN with a non-significant small effect size (t(203.16) = 2.140, p = .033; Hedges'g = 0.28). Small correlations of mean ambient temperature (r = -.16) and daily sunshine duration (r = -.22) with BMI-SDS in restrictive AN were found. However, the data were widely scattered. CONCLUSIONS: Our findings are contrary to previous studies and question the thermoregulatory hypothesis, indicating that seasonality in AN is more complex and might be subject to other biological or psychological factors, for example physical activity or body dissatisfaction. Our results indicate only a small clinical relevance of seasonal associations of BMI-SDS merely at admission. Longitudinal studies investigating within-subject seasonal changes might be more promising to assess seasonality in AN and of higher clinical relevance.

Smartphone-Enhanced Low-Threshold Intervention for adolescents with Anorexia Nervosa (SELTIAN) waiting for outpatient psychotherapy: study protocol of a randomised controlled trial.

INTRODUCTION: As smartphones are widely distributed nowadays, mental health apps seem to be a promising treatment tool. First self-help apps for eating disorders have been developed recently. However, studies assessing the efficacy of such apps are scarce. A smartphone app could prevent further weight reduction and increase commitment during waiting time for outpatient treatment, especially for adolescents with anorexia nervosa (AN). In this study protocol, a randomised controlled trial to assess the efficacy of a smartphone-enhanced low-threshold intervention for AN during waiting time is described. METHODS AND ANALYSIS: 30 adolescents with AN aged 12-19 years will be recruited at three child and adolescent psychiatry centres in Germany. All participants will be randomised to consultations only or consultations and the use of the Jourvie Research app. The app will be installed either on their own smartphone or on a research device. The participants will receive biweekly to monthly consultations for 3 months to review meal plans and weight management with a clinician. In addition, the Jourvie Research app for meal, behaviour and emotion protocolling will be provided to the intervention group. The protocols will be discussed with a clinician during the consultations. Dialectical behaviour therapy-informed skills for tension regulation to increase compliance with the meal plan will be taught in the intervention group and the app will remind the participant of a skill in a moment of need. The primary outcome is the age-adjusted and height-adjusted weight gain in standard deviation score after 3 months. ETHICS AND DISSEMINATION: Results will be disseminated at conferences and through peer-reviewed publications. The trial was approved by the ethics review board of the local medical association, Mainz, Germany, under the reference number 837.338.15. TRIAL REGISTRATION NUMBER: German clinical trials register, reference number DRKS00008946.

Momentary emotion identification in female adolescents with and without anorexia nervosa.

Individuals with anorexia nervosa (AN) often report difficulties in identifying emotions, which have been mostly studied as an alexithymia trait. In a controlled two-day ecological momentary assessment, we studied the influence of time of day and aversive tension on self-reported momentary emotion identification. Analysis on an aggregated level revealed a significant lower mean emotion identification in the AN group. In a mixed model analysis, the AN group showed lower emotion identification than the control group (HC). Both a general and a group effect of time of day were found, indicating that emotion identification improved during the day in HC, whereas a negligible decrease of the emotion identification over time was observed in the AN group. Age was associated positively with emotion identification in general, but no specific effect on a group level was found. No effect of aversive tension was found. Our results indicate that an improvement during the day might be a natural process of emotion identification, which is hindered in AN. Future research should focus on temporal relations between emotion identification and disordered eating behavior to further evaluate the clinical relevance of emotion identification difficulties in AN.