Change in food choice during acute treatment and the effect on longer-term outcome in patients with anorexia nervosa.

BACKGROUND: Restriction of food intake is a central pathological feature of anorexia nervosa (AN). Maladaptive eating behavior and, specifically, limited intake of calorie-dense foods are resistant to change and contribute to poor long-term outcomes. This study is a preliminary examination of whether change in food choices during inpatient treatment is related to longer-term clinical course. METHODS: Individuals with AN completed a computerized Food Choice Task at the beginning and end of inpatient treatment to determine changes in high-fat and self-controlled food choices. Linear regression and longitudinal analyses tested whether change in task behavior predicted short-term outcome (body mass index [BMI] at discharge) and longer-term outcome (BMI and eating disorder psychopathology). RESULTS: Among 88 patients with AN, BMI improved significantly with hospital treatment (p < 0.001), but Food Choice Task outcomes did not change significantly. Change in high-fat and self-controlled choices was not associated with BMI at discharge (r = 0.13, p = 0.22 and r = 0.10, p = 0.39, respectively). An increase in the proportion of high-fat foods selected (ß = 0.91, p = 0.02) and a decrease in the use of self-control (ß = -1.50, p = 0.001) predicted less decline in BMI over 3 years after discharge. CONCLUSIONS: Short-term treatment is associated with improvement in BMI but with no significant change, on average, in choices made in a task known to predict actual eating. However, the degree to which individuals increased high-fat choices during treatment and decreased the use of self-control over food choice were associated with reduced weight loss over the following 3 years, underscoring the need to focus on changing eating behavior in treatment of AN.

Reduced dorsal fronto-striatal connectivity at rest in anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a serious psychiatric illness that remains difficult to treat. Elucidating the neural mechanisms of AN is necessary to identify novel treatment targets and improve outcomes. A growing body of literature points to a role for dorsal fronto-striatal circuitry in the pathophysiology of AN, with increasing evidence of abnormal task-based fMRI activation within this network among patients with AN. Whether these abnormalities are present at rest and reflect fundamental differences in brain organization is unclear. METHODS: The current study combined resting-state fMRI data from patients with AN (n = 89) and healthy controls (HC; n = 92) across four studies, removing site effects using ComBat harmonization. First, the a priori hypothesis that dorsal fronto-striatal connectivity strength - specifically between the anterior caudate and dlPFC - differed between patients and HC was tested using seed-based functional connectivity analysis with small-volume correction. To assess specificity of effects, exploratory analyses examined anterior caudate whole-brain connectivity, amplitude of low-frequency fluctuations (ALFF), and node centrality. RESULTS: Compared to HC, patients showed significantly reduced right, but not left, anterior caudate-dlPFC connectivity (p = 0.002) in small-volume corrected analyses. Whole-brain analyses also identified reduced connectivity between the right anterior caudate and left superior frontal and middle frontal gyri (p = 0.028) and increased connectivity between the right anterior caudate and right occipital cortex (p = 0.038). No group differences were found in analyses of anterior caudate ALFF and node centrality. CONCLUSIONS: Decreased coupling of dorsal fronto-striatal regions indicates that circuit-based abnormalities persist at rest and suggests this network may be a potential treatment target.

Eating disorder symptom non-endorsers in hospitalised patients with anorexia nervosa: Who are they?

OBJECTIVE: Impaired insight and illness denial are common in anorexia nervosa (AN). Missing an AN diagnosis may delay treatment and negatively impact outcomes. METHOD: The current retrospective study examined the prevalence and characteristics of AN symptom non-endorsement (i.e., scoring within the normal range on the Eating Disorder Examination Questionnaire [EDE-Q] or the Eating Disorder Examination [EDE] interview) in three independent samples of hospitalised patients with AN (N1 = 154; N2 = 300; N3 = 194). A qualitative chart review of a subsample of non-endorsers (N4 = 32) extracted reports of disordered eating behaviours observed by the treatment team. RESULTS: The prevalence of non-endorsement ranged from 11% to 34% across sites. Non-endorsers were more likely to be diagnosed with AN restricting type (AN-R) and reported fewer symptoms of co-occurring psychopathology than endorsers. Groups benefitted equally from treatment. The qualitative chart review indicated that objective symptoms of AN were recorded by staff in over 90% of non-endorsers. CONCLUSIONS: Eating disorder symptom assessments using the EDE-Q or EDE may miss symptomatology in up to a third of individuals hospitalised with AN. This study highlights the potential utility of multi-modal assessment including patient interviews, collateral informants, and behavioural observation to circumvent non-endorsement.

The next stages of treatment-oriented research: Commentary on Wade et al. (2023).

Treatments for eating disorders have established benefits; yet, current psychotherapies focus specifically on the cognitions and behaviors of the eating disorder. Wade et al. (2023) propose that the myriad symptoms and disorders that occur together with eating disorders merit specific attention in treatment research protocols. We seek to amplify the authors' call to take a fresh look at the characterization of eating disorders, and the need for treatment research to consider both the role of symptoms that occur as part and parcel of an eating disorder (such as mood, anxiety, and obsessionality) and the role of co-occurring disorders (such as obsessive-compulsive disorder and substance use disorders). We discuss additional aspects in the care of patients with eating disorders that were beyond the scope of Wade et al., such as the impact of systems of care, and consideration of medication trials. We propose that current research priorities (mechanism-based treatment development, transdiagnostic symptoms, and patient perspectives) can be leveraged to advance treatment research and develop a systematic approach to evaluation and treatment planning.

Perspectives on relapse prevention following intensive treatment of anorexia nervosa: A focus group study.

OBJECTIVE: Including the perspectives of individuals with lived experience of mental health issues is a critical step in research and treatment development. Focus groups with patients with a history of treatment for anorexia nervosa (AN) were conducted in anticipation of a clinical trial of Relapse Prevention and Changing Habits (REACH+). METHODS: Seven female adults (23-51 years) who had previously received inpatient treatment for AN, now in remission, participated in one of two semistructured focus groups. Rapid qualitative analysis was used to examine participants' contributions and identify common topics. RESULTS: Transcript analysis yielded three topics related to relapse prevention: (1) recovery aids, including a sense of agency in treatment decisions and finding new interests/passions, (2) recovery hindrances, such as lack of access to care, and (3) identification of members of support system. Aspects of REACH+ received positive feedback, such as continuity of care from the inpatient setting and the use of telehealth. Viewpoints differed with respect to the helpfulness of obtaining patient weights in treatment. The REACH+ online platform received positive comments regarding content and usability, as well as suggestions for additional content. DISCUSSION: Qualitative feedback from patients with a history of AN highlighted the value of engaging patients in their own treatment decisions, as well as in treatment design and innovation. Within this small group, there were differences of opinion about treatment components, specifically weight assessment, that suggest the need for further data. User-centered design provides opportunities to improve the acceptability and, therefore, dissemination of novel treatments. PUBLIC SIGNIFICANCE: Relapse prevention is a critical treatment need for patients with anorexia nervosa, as this illness too often follows a protracted course. There are challenges in both obtaining specialized care and in retaining patients in treatment. Here, patient perspectives on these challenges offer input to allow for optimization of relapse prevention treatment. Shared decision-making may be particularly valuable to support an individual's sense of agency and engagement in care.

Evaluation of an online modular eating disorders training (PreparED) to prepare healthcare trainees: a survey study.

BACKGROUND: Eating disorders (EDs) are serious, complex disorders for which broad-based clinical training is lacking. This study aimed to evaluate the efficacy of a free, brief, web-based curriculum, PreparED, in increasing comfort and confidence with, and knowledge about EDs in healthcare trainees, and to obtain program feedback from key stakeholders (i.e., learners). METHODS: This programmatic evaluation study was designed as a quantitative, repeated measures (i.e., pre- and post-test intervention) investigation. A convenience sample of two groups of healthcare trainees across geographically diverse training sites completed an anonymous survey pre- and post- engagement with PreparED. The survey included items to assess prior exposure to EDs, as well as program feasibility. The main educational outcomes included (1) Confidence and Comfort with EDs and (2) Knowledge of EDs. User experience variables of interest were likeability, usability, and engagement with the training modules. Mixed effects linear regression was used to assess the association between PreparED and educational outcome variables. RESULTS: Participants (N = 67) included 41 nutrition graduate students and 26 nurse practitioner students recruited from Teacher's College/Columbia University in New York, NY, USA, Columbia University School of Nursing in New York, NY, USA and North Dakota State University School of Nursing in Fargo, ND, USA. Confidence/Comfort scores and Knowledge scores significantly improved following engagement with PreparED (ß = for effect of intervention = 1.23, p < 0.001, and 1.69, p < 0.001, respectively). Neither training group nor prior exposure to EDs moderated the effect on outcomes. All learners agreed the program was easy to follow; the overwhelming majority (89.4%) felt the length of the modules was "just right." All participants perceived that PreparED had increased their knowledge of EDs, and the majority (94.0%) reported greater confidence in and comfort with caring for people with these disorders, including assessment of symptoms, awareness of associated medical complications, and likelihood of future screening. CONCLUSIONS: Findings suggest that brief, user-friendly, online courses can improve knowledge and attitudes about EDs, filling a critical gap in healthcare training.

The impact of open versus closed weighing on rate of weight gain and length of stay among inpatients with anorexia nervosa.

Anorexia nervosa (AN) is a serious illness associated with significant morbidity and mortality. Few data exist to guide practice regarding sharing daily weight information (open weighing) or withholding it (closed weighing) from patients. We investigated the effect of open versus closed weighing on weight-related outcomes among inpatients with AN. Data were collected during a 4-month period when 43 patients were not told their daily weight, and a consecutive 4-month period when 41 patients were told their weights during rounds. There was no significant difference in mean overall weight change (3.6 ± 2.7 kg vs. 3.5 ± 2.5 kg), hospital duration (14.3 ± 10.0 vs. 14.2 ± 7.6 days), or rate of weight gain (0.26 ± 0.11 vs. 0.25 ± 0.13 kg) between groups. It is possible that one weighing procedure may not be preferable with respect to certain clinical outcomes for inpatients with AN, suggesting there may be multiple ways to navigate the discussion of weight progress in weight restoration programs.

Eating Disorders: Identification and Management in General Medical and Psychiatric Settings.

OBJECTIVE: Eating disorders (EDs) are serious, complex illnesses with both behavioral and physical health features. EDs have high rates of medical and psychiatric morbidity, and a 6% mortality rate, the highest of any mental illness. Early detection of EDs offers the best opportunity for recovery; yet, estimates are that as few as one in 10 individuals with an ED receive treatment. The purpose of this article is to provide an ED identification and management overview for inpatient nurse clinicians in general psychiatric and medical settings, helping to facilitate timely recognition and care. METHOD: An overview of ED diagnostic criteria and two evidence-based ED tools are introduced for consideration. RESULTS: Opportunities to identify and help manage an ED are numerous. Most individuals with an ED make several health care visits in either medical or psychiatric settings without ever being screened for an ED. General ED screening and assessment tool familiarization can facilitate a treatment trajectory for these patients, improve overall quality of life, and may potentially result in a life-saving intervention for this often-deadly cluster of medical and psychiatric disorders. CONCLUSION: Screening and assessment in general clinical settings, identifying patients with undiagnosed EDs, beginning basic treatment plans, and referrals for appropriate follow-up care, have the potential to reduce ED recidivism and related health care costs. Simultaneously, and most important, long-term outcomes for patients with EDs may improve.

Psychopharmacologic Management of Eating Disorders.

PURPOSE OF REVIEW: Identifying medications that may be used as therapeutic agents for eating disorders is a longstanding focus of research, with varying degrees of success. The present review consolidates the most recent findings on pharmacological treatment of three eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). RECENT FINDINGS: Recent research suggests that olanzapine demonstrates positive effects on weight gain among outpatients with AN. There are fewer recent advances in psychopharmacological treatment for BN and BED, likely due to the relative success of prior medication trials. Olanzapine is the first medication to safely promote weight gain among individuals with AN. Fluoxetine is FDA-approved for BN treatment, and lisdexamfetamine is FDA-approved for BED treatment. BN and BED also generally respond well to SSRIs prescribed off-label. Research on psychopharmacological treatments for other eating disorders, such as avoidant-restrictive food intake disorder and other specified feeding and eating disorders, are sorely needed.

Optimizing relapse prevention and changing habits (REACH+) in anorexia nervosa.

INTRODUCTION: Relapse rates in anorexia nervosa (AN) are high, even after full weight restoration. This study aims to develop a relapse prevention treatment that specifically addresses persistent maladaptive behaviors (habits). Relapse Prevention and Changing Habits (REACH+) aims to support patients in developing routines that promote weight maintenance, encourage health, and challenge habits that perpetuate illness. The clinical trial design uses the Multiphase Optimization STrategy (MOST) framework to efficiently identify which components of treatment contribute to positive outcomes. METHODS: Participants will be 60 adults with AN who have achieved weight restoration in an inpatient setting. Treatment will consist of 6 months of outpatient telehealth sessions. REACH+ consists of behavior, cognitive, and motivation components, as well as food monitoring and a skill consolidation phase. A specialized online platform extends therapy between sessions. Participants will be randomly assigned to different versions of each component in a fractional factorial design. Outcomes will focus on maintenance of remission, measured by rate of weight loss and end-of-trial status. Interventions that contribute to remission will be included in an optimized treatment package, suitable for a large-scale clinical trial of relapse prevention in AN.

Use of high-frequency repetitive transcranial magnetic stimulation to probe the neural circuitry of food choice in anorexia nervosa: A proof-of-concept study.

Repetitive transcranial magnetic stimulation (rTMS) is used to modulate neural systems and provides the opportunity for experimental tests of hypotheses regarding mechanisms underlying anorexia nervosa (AN). The present pilot study has investigated whether high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) to a region of the right dorsolateral prefrontal cortex (DLPFC) might be associated with change in food selection among adult inpatients with AN. Ten women received one session of sham and one session of HF-rTMS targeting the right DLPFC while completing a computerized Food Choice Task. Compared to sham, HF-rTMS was associated with changes in food ratings and food choice: inpatients reported higher healthiness ratings of low- and high-fat foods and selected a significantly greater proportion of high-fat foods over a neutrally rated reference item while receiving HF-rTMS. Findings suggest that HF-rTMS to the right DLPFC was associated with a reduction of fat avoidance on a food choice task among inpatients with AN and provide additional support for the possibility that this region, and related neural circuits, may underlie restrictive food choice. Research using rTMS to experimentally test neural mechanisms is needed to elucidate the underpinnings of AN and supports the development of novel treatment targets.

Don't shortchange a long illness: A commentary on Severe and Enduring Anorexia Nervosa.

Wonderlich et al.'s manuscript "Severe and Enduring Anorexia Nervosa: Update and Observations about the Current Clinical Reality" reviews Severe and Enduring Anorexia Nervosa (SE-AN) from several perspectives, hoping to stimulate discussion among clinicians, researchers, and other stakeholders about needed next steps for furthering the science relevant to the severe and enduring form of illness that affects a subgroup of individuals with AN. Among the important reasons for a new discussion of SE-AN is that health care has evolved in ways that have reduced comprehensive services for those who are more seriously affected. It is critical that adults with SE-AN be examined empirically to help identify effective strategies for clinical management and that health care policies assure parity for this seriously affected group.

Weight suppression and weight maintenance following treatment of anorexia nervosa.

OBJECTIVE: The value of weight suppression (WS) in predicting the course of anorexia nervosa (AN) is uncertain. The objective of this study was to determine, using data from a previously published study, whether patients who remain weight suppressed following restoration to a minimally normal weight are at greater risk for relapse. METHOD: Following weight restoration, 93 women with AN were randomly assigned to receive fluoxetine or placebo along with cognitive behavioral therapy for 1 year. WS (highest adult weight minus current weight), body mass index (BMI), and their interaction were assessed as predictors of change in weight over the first 28 days, of successful weight maintenance at 6 and 12 months, and of time to relapse. RESULTS: Neither WS nor its interaction with BMI predicted successful weight maintenance at 6 and 12 months, time to relapse, or weight change over the first 28 days following discharge. DISCUSSION: This study found that WS does not substantially impact the likelihood of successful weight maintenance or time to relapse following restoration to a minimally normal weight in AN.

Between wellness, relapse, and remission: Stages of illness in anorexia nervosa.

OBJECTIVE: Psychiatric illnesses, like medical illnesses, can sometimes be considered as progressing through stages. Understanding these stages can lead to a better understanding of pathophysiology, and clarification of prognosis and treatment needs. Opinions from experts in the field of anorexia nervosa (AN) were sought to create a model of stages of illness. METHOD: The Delphi approach was used to achieve consensus from a panel of 31 individuals from a range of disciplines with expertise in AN. Over three iterative rounds, participants rated agreement with statements about an overall staging framework and definitions of specific stages. RESULTS: Agreement was reached about a longitudinal progression including Subsyndromal, Full Syndrome, Persistent Illness, and Partial and Full Remission. The panel achieved consensus in defining Subsyndromal AN as characterized by body image disturbance and mild to moderate restrictive eating. Overall, there was consensus that restrictive eating is central to the behavioral features of all stages of AN, and agreement that its absence is essential to any stage of health. There was little consensus about biological markers, other than body mass index, and no consensus about quality of life indices associated with different stages. DISCUSSION: This panel discussion yielded an expert-informed staging model for AN. This model now needs to be tested for its validity. The lack of consensus in several areas highlighted other research questions to address in order to develop an empirically valid and scientifically useful model of the progression of AN.

Peer mentorship as an adjunct intervention for the treatment of eating disorders: A pilot randomized trial.

OBJECTIVE: Peer mentorship has been shown to be helpful for other mental health conditions, but it has been understudied for patients with eating disorders. The goal of the present study was to evaluate the feasibility and efficacy of peer mentorship for individuals with eating disorders by conducting a randomized controlled trial (RCT). TRIAL DESIGN: Parallel three-arm pilot RCT with 1:1:1 allocation to peer mentorship, social support mentorship (active comparison intervention), and waiting list. METHOD: Sixty outpatients with anorexia nervosa (AN), bulimia nervosa (BN), or binge-eating disorder (BED) were randomly assigned to a condition. Outcome measures, including eating disorder symptoms and general psychopathology, were completed at baseline, mid-, and postintervention. RESULTS: Session attendance and acceptability ratings were higher in peer mentorship than social support mentorship. More participants in social support mentorship (39%) dropped out compared to peer mentorship (5%). In intent-to-treat analysis, peer mentorship showed greater reductions in body dissatisfaction and anxiety compared with both control groups. Compared with social support mentorship, peer mentorship had greater reductions in depression. Compared with waiting list, peer mentorship had greater reduction in binge eating days/week in patients with BN/BED and restriction days/week in patients with AN. Peer mentorship did not impact body mass index or reentry into higher level of care. DISCUSSION: This pilot RCT provides preliminary evidence that peer mentorship is effective for some cognitive and behavioral symptoms of eating disorders as an adjunct to outpatient treatment. Additional studies are needed to evaluate the efficacy of peer mentorship in absence of treatment.

Steps of care for adolescents with anorexia nervosa-A Delphi study.

OBJECTIVE: Anorexia nervosa (AN) commonly develops during adolescence. Existing literature offers some treatment guidelines, but clear clinical criteria for initial recommendations and steps of care are needed. The aim of the present study was to develop expert consensus for a stepped-care algorithm for treatment of adolescents with AN. METHOD: The Delphi approach was used to identify clinical parameters that guide initial treatment recommendations and recommendations for transitions between levels of care. The Delphi approach provides a useful expert consensus when empirical data are limited. Individuals with at least 10 years of experience in the field of adolescent AN and membership in one of three professional organizations were recruited. Twenty-five panelists participated in three rounds of iterative online questionnaires. RESULTS: Consensus was achieved on several features of a treatment algorithm. Hospitalization is recommended when medical instability, suicidality, or acute food refusal are present at any point in treatment. Family-based treatment (FBT) is recommended as the first-line treatment, with a few exceptions. Consensus was not reached on when to transition from a higher level of care to a lower level of care. DISCUSSION: Expert opinion was used to develop a consensus-based algorithm for care of adolescents with AN. Future research is needed to test whether these recommendations can be used to optimize outcomes for adolescents with AN.

Fat preference and fat intake in individuals with and without anorexia nervosa.

Fat restriction is a characteristic eating behavior among individuals with anorexia nervosa (AN), and laboratory meal studies demonstrate restricted fat intake among low-weight patients. The Geiselman Food Preference Questionnaire-I© (FPQ) is a validated self-report measure that yields a fat preference score (FPS). Prior research reported that patients with AN had a significantly lower FPS than did healthy control (HC) participants. The goal of the current study was to compare self-reported fat preference (FPS) to fat intake (multi-item meal (MIM) study) in low-weight ANs and HCs. Specific aims were 1) to determine if the FPS differed between ANs and HCs; 2) to determine if fat and energy intakes differed between ANs and HCs; and 3) to determine if the FPS was associated with fat and energy intakes in ANs and HCs. Forty-four female AN inpatients and 48 female HCs completed the FPQ and participated in a MIM study. Compared to HCs, ANs consumed less energy (469.1 ±â€¯397.7 vs. 856.4 ±â€¯346.8 kcal, p < 0.001), less fat (16.4 ±â€¯20.4 vs. 36.7 ±â€¯18.9 g, p < 0.001), and a smaller percentage of calories from fat (22.9 ±â€¯13.8 vs. 36.6 ±â€¯8.0%, p < 0.001) at the MIM. Compared to HCs, ANs also had a lower FPS (79.7 ±â€¯27.4 vs. 102.3 ±â€¯18.9, p < 0.001). The FPS was significantly and positively correlated with caloric intake (r = 0.481, p < 0.01), total fat (r = 0.453, p < 0.01), and the percentage of calories from fat (r = 0.37, p < 0.05) in ANs as well as in HCs (kcal: r = 0.583, p < 0.001; fat: r = 0.621, p < 0.001; % fat kcal: r = 0.601, p < 0.001). The FPS is related to objective measures of energy and fat intake in patients with AN as well as in healthy individuals.

Targeting habits in anorexia nervosa: a proof-of-concept randomized trial.

BACKGROUND: Habits are behavioral routines that are automatic and frequent, relatively independent of any desired outcome, and have potent antecedent cues. Among individuals with anorexia nervosa (AN), behaviors that promote the starved state appear habitual, and this is the foundation of a recent neurobiological model of AN. In this proof-of-concept study, we tested the habit model of AN by examining the impact of an intervention focused on antecedent cues for eating disorder routines. METHODS: The primary intervention target was habit strength; we also measured clinical impact via eating disorder psychopathology and actual eating. Twenty-two hospitalized patients with AN were randomly assigned to 12 sessions of either Supportive Psychotherapy or a behavioral intervention aimed at cues for maladaptive behavioral routines, Regulating Emotions and Changing Habits (REaCH). RESULTS: Covarying for baseline, REaCH was associated with a significantly lower Self-Report Habit Index (SRHI) score and significantly lower Eating Disorder Examination-Questionnaire (EDE-Q) global score at the end-of-treatment. The end-of-treatment effect size for SRHI was d = 1.28, for EDE-Q was d = 0.81, and for caloric intake was d = 1.16. CONCLUSIONS: REaCH changed habit strength of maladaptive routines more than an active control therapy, and targeting habit strength yielded improvement in clinically meaningful measures. These findings support a habit-based model of AN, and suggest habit strength as a mechanism-based target for intervention.

A longitudinal functional magnetic resonance imaging study of task control circuits and bulimic symptoms over adolescence.

BACKGROUND: Previous cross-sectional findings from adolescents and adults with Bulimia Nervosa (BN) suggest disturbances in fronto-striatal and cingulo-opercular task control circuits that support self-regulatory processes, including the resolution of cognitive conflict. Herein, we used longitudinal data to examine the developmental trajectories of such disturbances and how the functioning of these circuits relates to changes in BN symptoms over adolescence. METHODS: Thirty-two adolescent females with BN symptoms and 28 healthy control (HC) adolescents participated in the study. Functional magnetic resonance images (fMRI) during performance of a Simon task were acquired at three time points within 2-year intervals over adolescence. From the initial sample, 70% and 30% of the participants completed the second and third time points, respectively. Participants who completed all study time points did not differ from those lost to attrition on baseline demographic characteristics or any outcome measures. Using a region-of-interest approach, growth curve models tested group differences in the trajectory of conflict-related activation in task control circuits over time. Cross-lagged panel models examined transactional relationships between conflict-related activation in the same regions and BN symptoms over time. RESULTS: Growth curve models revealed different trajectories of conflict-related activation in right task control regions across BN and HC adolescents, such that HC but not BN adolescents showed activation decreases over time. These group differences were greatest when including only the BN adolescents whose symptoms remitted over time. Cross-lagged panel models revealed that less frequent bulimic episodes at first follow-up predicted later increases in conflict-related activation in bilateral task control regions. CONCLUSIONS: These longitudinal findings suggest overengagement of task control circuits in BN adolescents, especially those most resilient to persistent illness. Such overengagement may compensate for regulatory disturbances, allowing them to regulate eating behaviors over development. Thus, task control circuits may constitute targets for early interventions that enhance self-regulatory control.

Altered cortical thickness and attentional deficits in adolescent girls and women with bulimia nervosa.

BACKGROUND: Frontostriatal and frontoparietal abnormalities likely contribute to deficits in control and attentional processes in individuals with bulimia nervosa and to the persistence of dysregulated eating across development. This study assessed these processes and cortical thickness in a large sample of adolescent girls and women with bulimia nervosa compared with healthy controls. METHODS: We collected anatomical MRI data from adolescent girls and women (ages 12-38 yr) with full or subthreshold bulimia nervosa and age-matched healthy controls who also completed the Conners Continuous Performance Test-II (CPT-II). Groups were compared on task performance and cortical thickness. Mediation analyses explored associations among cortical thickness, CPT-II variables, bulimia nervosa symptoms and age. RESULTS: We included 60 girls and women with bulimia nervosa and 54 controls in the analyses. Compared with healthy participants, those with bulimia nervosa showed increased impulsivity and inattention on the CPT-II, along with reduced thickness of the right pars triangularis, right superior parietal and left dorsal posterior cingulate cortices. In the bulimia nervosa group, exploratory analyses revealed that binge eating frequency correlated inversely with cortical thickness of frontoparietal and insular regions and that reduced frontoparietal thickness mediated the association between age and increased symptom severity and inattention. Binge eating frequency also mediated the association between age and lower prefrontal cortical thickness. LIMITATIONS: These findings are applicable to only girls and women with bulimia nervosa, and our cross-sectional design precludes understanding of whether cortical thickness alterations precede or result from bulimia nervosa symptoms. CONCLUSION: Structural abnormalities in the frontoparietal and posterior cingulate regions comprising circuits that support control and attentional processes should be investigated as potential contributors to the maintenance of bulimia nervosa and useful targets for novel interventions.