Factors predicting long-term weight maintenance in anorexia nervosa: a systematic review.

PURPOSE: Eating disorder recovery is a poorly defined concept, with large variations among researchers' definitions. Weight maintenance is a key aspect of recovery that remains relatively underexplored in the literature. Understanding the role of weight maintenance may help guide the development of treatments. This paper aims to address this by (1) investigating the factors predicting long-term weight maintenance in anorexia nervosa (AN) patients; (2) exploring differences in predictive factors between adolescent and adult populations; and (3) exploring how weight maintenance is conceptualised in the literature. METHODS: We conducted a systematic review following PRISMA guidelines to address our research questions. Five databases were searched and filtered according to our exclusion criteria. RESULTS: From the search, 1059 studies were yielded, and 13 studies were included for review. A range of weight, biological and psychological factors were found to predict weight maintenance among these papers. BMI at admission and discharge from inpatient treatment was the most common predictor among the papers. Few studies investigated biological factors and mixed evidence was found for psychological factors. We found no observable differences between adult and adolescent populations. Finally, weight maintenance was defined and measured differently across studies. CONCLUSION: This review's findings can help contribute to a well-rounded understanding of weight maintenance, and ultimately, of recovery. This can help support clinicians in tailoring interventions to improve long-term outcomes in AN. Future research should aim to replicate studies to better understand the relationship between the factors identified and weight maintenance. LEVEL I: Systematic review.

The use and misuse of the SCOFF screening measure over two decades: a systematic literature review.

PURPOSE: The SCOFF questionnaire was designed as a simple, memorable screening tool to raise suspicion that a person might have an eating disorder. It is over 20 years since the creation of the SCOFF, during which time it has been widely used. Considering this, we wish to review the use of the SCOFF in peer-reviewed scientific journals, and to assess whether it is being used appropriately in the manner in which it was originally devised and tested. METHODS: The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were followed, and all search strategies and methods were determined before the onset of the study. PubMed and Wiley Online Library were searched using the terms SCOFF and eating. Two reviewers were involved in the reviewing process. Criteria for appropriate use of the SCOFF were formalised with the tool's original authors. RESULTS: 180 articles were included in the final review. 48 articles had used the SCOFF appropriately, 117 articles inappropriately and 15 articles had been mixed in the appropriateness of their use. CONCLUSION: This systematic review highlights the inappropriate use of the SCOFF in diverse languages and settings. When used correctly the SCOFF has made a significant contribution to the understanding of eating disorders and its simplicity has been applauded and led to widespread use. However in over two-thirds of studies, the use of the SCOFF was inappropriate and the paper highlights how and in what way it was misused, Guidelines for the appropriate use of the SCOFF are stated. Future validation and avenues of research are suggested. LEVEL OF EVIDENCE: Level I.

Specific psychological therapies versus other therapies or no treatment for severe and enduring anorexia nervosa.

BACKGROUND: Anorexia nervosa is a psychological condition characterised by self-starvation and fear or wait gain or other body image disturbance. The first line of treatment is specific psychological therapy; however, there is no consensus on best practice for treating people who develop severe and enduring anorexia nervosa (SEAN). Notably, there is no universal definition of SEAN. OBJECTIVES: To evaluate the benefits and harms of specific psychological therapies for severe and enduring anorexia nervosa compared with other specific therapies, non-specific therapies, no treatment/waiting list, antidepressant medication, dietary counselling alone, or treatment as usual. SEARCH METHODS: We used standard, extensive Cochrane search methods. The last search date was 22 July 2022. SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs) of people (any age) with anorexia nervosa of at least three years' duration. Eligible experimental interventions were any specific psychological therapy for improved physical and psychological health in anorexia nervosa, conducted in any treatment setting with no restrictions in terms of number of sessions, modality, or duration of therapy. Eligible comparator interventions included any other specific psychological therapy for anorexia nervosa, non-specific psychological therapy for mental health disorders, no treatment or waiting list, antipsychotic treatment (with or without psychological therapy), antidepressant treatment (with or without psychological therapy), dietary counselling, and treatment as usual as defined by the individual trials. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcomes were clinical improvement (weight restoration to within the normal weight range for participant sample) and treatment non-completion. Results were presented using the GRADE appraisal tool. MAIN RESULTS: We found two eligible studies, but only one study provided usable data. This was a parallel-group RCT of 63 adults with SEAN who had an illness duration of at least seven years. The trial compared outpatient cognitive behaviour therapy for SEAN (CBT-SEAN) with specialist supportive clinical management for SEAN (SSCM-SE) over eight months. It is unclear if there is any difference between the effect of CBT-SEAN versus SSCM-SE on clinical improvement at 12 months (risk ratio (RR) 1.42, 95% confidence interval (CI) 0.66 to 3.05) or treatment non-completion (RR 1.72, 95% CI 0.45 to 6.59). There were no reported data on adverse effects. The trial was at high risk of performance and detection bias. We rated the GRADE level of evidence as very low-certainty for both primary outcomes, downgrading for imprecision and risk of bias concerns. AUTHORS' CONCLUSIONS: This review reports evidence from one trial that evaluated CBT-SEAN versus SSCM-SE. There was very low-certainty evidence of little or no difference in clinical improvement and treatment non-completion between the two therapies. There is a need for larger high-quality trials to determine the benefits of specific psychological therapies for people with SEAN. These should take into account the duration of illness as well as participants' previous experience with evidence-based psychological therapy for anorexia nervosa.

Self-esteem as a catalyst for change in adolescent inpatients with anorexia nervosa: a pilot randomised controlled trial.

PURPOSE: To determine the potential effectiveness of a six-session manualised self-esteem group using CBT approaches when given as an adjuvant to adolescent inpatients with Anorexia Nervosa (AN). METHODS: Using a randomised controlled design, 50 girls aged 12-17 years with AN were assigned to either self-esteem group with treatment as usual (TAU) (n = 25) or TAU alone (n = 25). 50/78 (64%) consented to be randomised. Both groups completed self-report measures of self-esteem and eating disorder psychopathology at three time points to measure the potential effectiveness of the treatment. Qualitative feedback was collected to assess acceptability. RESULTS: 29 participants completed the study: 15 self-esteem group with TAU, 14 TAU alone. Self-esteem group participants had greater improvement in all outcomes than TAU participants at all time points, the difference in self-report self-esteem at T2 is 1.12 (95% CI - 1.44-3.69; effect size = 0.21). Similar small effect sizes were found for the eating disorder psychopathology measure following completion of the intervention but not at four-week follow-up. Favourable qualitative feedback was gained. CONCLUSION: These findings demonstrate that the self-esteem group supplements an intensive treatment package which also addresses elements of low self-esteem. The self-esteem group was beneficial for addressing self-esteem and acted as a catalyst for change in eating disorder psychopathology. Positive qualitative feedback indicated the intervention was acceptable to users. Self-esteem group is a potential new adjuvant treatment for AN. EMB RATING: Level 1.

Disturbed families or families disturbed: a reconsideration.

BACKGROUND: The relationship between anorexia nervosa (AN) and family disturbance has been a subject of debate since its first description. What began as a clear view of the pathologically disturbed family causing AN has become ever more complex over the decades. OBJECTIVE: The aim of this review is to explore the literature to examine the changes and evolution of clinical opinion around family dysfunction and AN over the last 20 years. METHODS: A narrative review of heterogeneous studies in peer-reviewed publications sourced from the major databases, including PubMed and ScienceDirect, to illuminate the topic of family distress and AN by highlighting the conflicting and complementary ways it has been studied. RESULTS: This review has highlighted the complexity of the relationship between anorectic sufferers and their families. It has explored the literature about parental burden, emotions and cognitive mechanisms together with parental attitudes about weight and shape. It is clear that there is no consistent psycho-social pathology in families which has been shown to be causative. However, over the last twenty years, research has highlighted the distress and family dysfunction caused by having to look after an anoretic child with poor mentalisation skills, insecure attachment and emotion dysregulation. CONCLUSION: The area has become clearer over the last 20 years; research suggests a bi-directional relationship between AN and family dysfunction, with difficult dynamics becoming entrenched within the family. This is best addressed, the consensus suggests, by specialist family therapy and carer skills interventions. Longitudinal research is needed to definitively answer the question with rigorous scientific certainty. EMB RATING: Level V. LEVEL OF EVIDENCE: Level I: Evidence obtained from: at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies. Level II: Evidence obtained from well-designed controlled trials without randomization. Level III: Evidence obtained from well-designed cohort or case-control analytic studies. Level IV: Evidence obtained from with multiple time series analysis such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

A novel 'practical body image' therapy for adolescent inpatients with anorexia nervosa: a randomised controlled trial.

PURPOSE: To determine the potential effectiveness of a novel 10-week manualised Practical Body Image therapy (PBI) with mirror exposure (ME), when used as an adjuvant to an intensive treatment package (TAU) in adolescent inpatients with Anorexia Nervosa (AN). To evaluate the effectiveness of ME in an adolescent population. METHODS: Using a randomised control design, 40 girls aged 11-17 years with AN were assigned to PBI with TAU (n = 20) and TAU alone (n = 20). Both groups completed self-report measures of body image at week 1 and week 10 of the study to measure the potential effectiveness of PBI. The PBI group completed measures at week 7 to evaluate the ME component. RESULTS: 31 participants completed the study; 16 TAU, 15 PBI. PBI participants had greater improvement in all outcomes than TAU participants. Medium effect sizes were seen for self-reported weight concern, body image avoidance in terms of clothing and body image anxiety. ME produced effect sizes in self-reported body image avoidance in terms of clothing and grooming that were greater than 0.40, n = 14. CONCLUSION: The findings demonstrate that PBI supports an intensive inpatient treatment package and addresses elements of negative body image. PBI was beneficial for addressing body image dissatisfaction with improvements in weight concerns, body image avoidance and physical appearance trait anxiety following the ME component. The magnitude of the effect sizes is comparable to previous studies. Positive qualitative feedback indicated the intervention was acceptable to users. PBI is a promising new adjuvant treatment for AN. EMB RATING: Level I: randomized controlled trial.

Evaluation of Teen BodyWise: A pilot study of a body image group adapted for adolescent inpatients with anorexia nervosa.

PURPOSE: Body image disturbance is a key characteristic of anorexia nervosa (AN); however, research into these difficulties among adolescents with AN is limited and is yet to assess the best treatments for this population. METHODS: Fifty-two adolescents receiving inpatient treatment for AN attended Teen BodyWise, an eight-session body image group adapted for adolescents. Measures assessing shape and weight concerns, ability to discuss body image, sociocultural attitudes, body avoidance, body checking, and motivation were given before and after the group, and participant feedback was elicited. RESULTS: Significant improvements were found for shape and weight concerns, ability to discuss body image, body checking and sociocultural attitudes. Participants were generally satisfied with the group and found it helpful, yet some aspects were experienced as challenging. CONCLUSIONS: Teen BodyWise has potential benefits for adolescents with AN. Controlled research is needed to determine the effectiveness of Teen BodyWise. LEVEL OF EVIDENCE: Evidence obtained from multiple time series with or without the intervention, such as case studies, Level IV.

A meta-analysis of the relation between therapeutic alliance and treatment outcome in eating disorders.

The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, ßs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.

Rules of engagement: qualitative experiences of therapeutic alliance when receiving in-patient treatment for anorexia nervosa.

Recent research has emphasised the importance of therapeutic alliance to treatment outcomes for anorexia nervosa. This study aimed to examine the experiences of service users in developing therapeutic alliance whilst in treatment for their eating disorders. This qualitative study, using purposive sampling, recruited a sample of service users receiving treatment at a national eating disorders service. In-depth interviews were audiotaped and transcribed, with transcriptions being subject to interpretative phenomenological analysis. Participants were eight adult women receiving tertiary level eating disorder treatment in a specialist setting. The text analysis produced four dominant categories: alliance as a key experience; being active, not passive; taboo talking; and first impressions count. The development of therapeutic alliance is a core component of treatment. This study identifies important areas that contribute to the successful cultivation of positive therapeutic alliance.

Premature termination of treatment for anorexia nervosa: differences between patient-initiated and staff-initiated discharge.

OBJECTIVES: To investigate treatment drop-out by comparing clinical indicators of patients whose discharge was initiated by staff with those who initiated discharge themselves. METHOD: Ninety participants with anorexia completed questionnaires at admission and four weeks into hospitalized treatment. Weight data was collected over this same period. At discharge, participants were categorized into completer (n = 38) or patient-initiated (n = 36) /staff-initiated (n = 16) premature termination groups. RESULTS: Significant differences between staff-initiated and patient-initiated discharge groups were found at admission. Staff initiated groups were on average older (p = .035), and more likely to have had prior compelled treatment (p = .039). At 4 weeks those in the patient-initiated group had put on weight at a faster rate (p = .032) and reported a decrease in alliance (p = .017). At discharge, staff initiated discharge demonstrated greater time in treatment (p = .001), greater weight gain (p = .027), and a higher discharge BMI (p = .013). At discharge, staff-initiated drop-outs had comparable end-of-treatment outcomes to those who completed treatment as planned. DISCUSSION: There are key differences between those who prematurely discharge themselves from treatment, compared to those who are prematurely discharged by clinical staff. Future research into drop-out needs to take into account and recognize these differences.

Predicting premature termination of hospitalised treatment for anorexia nervosa: the roles of therapeutic alliance, motivation, and behaviour change.

OBJECTIVES: This study aims to investigate treatment drop-out, and the associated roles of motivation, alliance, and behaviour change exhibited over the first four weeks of hospitalised treatment for anorexia. METHODS: 90 participants meeting DSM-IV criteria for anorexia nervosa completed questionnaires at admission, and four weeks into treatment. Weight data was collected over this same time period. At the end of treatment, participants were categorised into completer or premature termination groups. RESULTS: The overall rate of premature termination was 57.8%. Those who prematurely terminated treatment demonstrated lower discharge BMI (p<.0005), and weight gain (p<.0005) than those who completed. Therapeutic alliance proved significantly different between outcome groups at admission (p=.004). DISCUSSION: End-of-treatment outcomes for those who do not complete treatment are invariably poor. Therapeutic alliance appears to be a particularly important factor in this area.

The St George's eating disorders service meal preparation group for inpatients and day patients pursuing full recovery: a pilot study.

This naturalistic cohort study evaluates a meal cookery group-based occupational therapy intervention for adult inpatients and day patients with severe eating disorders. It also evaluates the Eating and Meal Preparation Skills Assessment (EMPSA) as an outcome measure, allowing clients pursuing recovery to rate ability and motivation to perform tasks related to preparing and eating 'normal' meals. Twenty-seven participants completed EMPSAs at their first, 10th and final sessions, plus 1 year later. The Ability subscale of EMPSA indicated significant improvements (p < 0.001) by the 10th session, which was maintained 1 year later. The Motivation subscale of EMPSA indicated no significant changes at the 10th session but highly significant improvements (p < 0.001) between the 10th and final session, which was maintained 1 year later. Internal consistency for EMPSA was demonstrated by Cronbach's alpha of 0.71 for Ability subscale and 0.95 for Motivation subscale. We conclude that the meal preparation group is effective and durable.

Salinophagia in anorexia nervosa: case reports.

We report two cases of pathological ingestion of salt as a feature of anorexia nervosa, which we have previously termed "salinophagia." Both cases were young women with anorexia nervosa of the purging subtype and of sufficient severity to necessitate inpatient treatment. In both instances, excessive quantities of salt were ingested in the context of treatment programs requiring nutritional rehabilitation, and motivated by a wish to despoil the food and render it distasteful, to rob its ingestion of any hedonic qualities. In one instance, this behavior pattern was imitated by other patients on the unit. Having first briefly described salinophagia in 1999, the first author has received considerable correspondence from other specialists suggesting that this is not an isolated phenomenon. The issues of phenomenology and treatment are further discussed.

SCOFF, the development of an eating disorder screening questionnaire.

OBJECTIVE: This article describes the three-stage development of the SCOFF, a screening tool for eating disorders. METHOD: Study 1 details questionnaire development and testing on cases and controls. Study 2 examines reliability of verbal versus written administration in a student population. Study 3 validates the test as a screening tool in primary care. RESULTS: The SCOFF demonstrates good validity compared with DSM-IV diagnosis on clinical interview. In the primary care setting it had a sensitivity of 84.6% and a specificity of 89.6%, detecting all true cases of anorexia nervosa and bulimia nervosa and seven of nine cases of EDNOS. Reliability between written and verbal versions of the SCOFF was high, with a kappa statistic of 0.82. DISCUSSION: The SCOFF, which has been adapted for use in diverse languages, appears highly effective as a screening instrument and has been widely adopted to raise the index of suspicion of an eating disorder.

Cerebral palsy and anorexia nervosa.

OBJECTIVE: To describe the management of a woman with cerebral palsy and anorexia nervosa. METHOD: We carried out a literature search and gained consent and a history from the patient. We explored the etiological and ethical issues raised in this case. RESULTS: Etiological issues are raised, looking at the interaction between physical disability and self-image. Clinical and practical difficulties of caring for a patient with physical disability properly on an eating disorder unit are discussed, as well as ethical issues concerning mental capacity and the use of the mental health act in anorexia nervosa. CONCLUSION: This case reminds us again that we can learn much from listening to patients. In this instance, service and operational policies on managing disabilities on the unit, were shaped by her input.

Screening for eating disorders in primary care: EDE-Q versus SCOFF.

OBJECTIVE AND METHODS: The comparative validity of the Eating Disorder Examination Questionnaire (EDE-Q) (22 items) and SCOFF (five items) in screening for cases of the more commonly occurring eating disorders was examined in a primary care sample of young adult women (n=257). Diagnoses were confirmed in a sub-group of interviewed participants (n=147). RESULTS: Twenty-five cases, primarily variants of bulimia nervosa (BN) not meeting formal diagnostic criteria, were identified in the interviewed sample. An EDE-Q global score of >or= 2.80 yielded the optimal trade-off between sensitivity (Se) (0.80) and specificity (Sp) (0.80) (positive predictive value (PPV)=0.44), whereas a score of two or more positive responses on the SCOFF was optimal (Se=0.72, Sp=0.73, PPV=0.35). Validity coefficients for both measures varied as a function of participants' age and body weight, although these effects were more pronounced for the SCOFF. CONCLUSIONS: Both measures performed well in terms of their ability to detect cases and to exclude non-cases of the more commonly occurring eating disorders in a primary care setting. The EDE-Q performed somewhat better than the SCOFF and was more robust to effects on validity of age and weight. These findings need to be weighed against the advantage of the SCOFF in terms of its brevity.

Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: retrospective controlled study.

OBJECTIVE: Bulimia nervosa is common and treatable. An association between bulimia and obstetric complications has been suggested, but sample size and absence of control have limited previous studies. Our aim was to determine if active bulimia nervosa affects obstetric outcome. METHODS: This was a retrospective case-control comparison of obstetric complications in primigravidae previously treated for bulimia in a specialist eating disorder service. A cohort of 122 women with active bulimia during pregnancy was contrasted against 82 with quiescent bulimia, using structured interviews comprising the Eating Disorders Examination, Structured Clinical Interview for DSM-III-R, and systematic questions addressing obstetric complications. RESULTS: Odds ratios (ORs) for postnatal depression, miscarriage, and preterm delivery were 2.8 (95% confidence interval [CI], 1.2-6.2), 2.6 (95% CI, 1.2-5.6) and 3.3 (95% CI, 1.3-8.8) respectively. Risk of unplanned pregnancy was markedly elevated (OR, 30.0; 95% CI, 12.8-68.7). Risk estimates were not explained by differences in adiposity, demographics, alcohol/substance/laxative misuse, smoking, or year of birth, but relative contributions of bulimic behaviors were not discerned. CONCLUSIONS: Active bulimia during pregnancy is associated with postnatal depression, miscarriage, and preterm delivery. Bulimia may be a treatable cause of adverse obstetric outcome.

Childhood onset neuropsychiatric disorders in adult eating disorder patients. A pilot study.

BACKGROUND: Autism spectrum disorders (ASD) have been suggested to be overrepresented in anorexia nervosa. This study aimed to explore the comorbidity of ASD and other childhood onset neuropsychiatric disorders (COND) [attention-deficit/hyperactivity disorder (AD/HD) and tic disorders] in a group of severe eating disorder (ED) patients. METHOD: Thirty female ED patients from a specialist hospital clinic were examined on measures tapping into COND and personality disorders. RESULTS: In our group of longstanding ED, 53% had at least one COND diagnosis; 23% had ASD, 17% had AD/HD, and 27% had a tic disorder. CONCLUSIONS: These preliminary data suggest that COND may be common in patients with severe ED and should be kept in mind when treating these patients.

A prospective study of changes in bone turnover and bone density associated with regaining weight in women with anorexia nervosa.

Anorexia nervosa (AN) is a condition of self-induced weight loss, associated with an intense fear of gaining weight. Previous studies have shown that bone density may increase with regaining and maintaining normal weight; however, relatively little is known about the changes in bone metabolism that occur during weight restoration. We describe the effect of weight restoration and maintenance of weight over 1 year on bone mineral density (BMD) and bone turnover. We recruited women from the eating disorders services at the South West London and St George's Mental Health NHS Trust, and the Priory and Charter Nightingale Hospitals in London, UK. Details of their AN, fracture history, menstrual history and exercise were obtained by interview and case note review. Morning samples of blood and second void urine were taken for biochemical analysis. BMD was measured by DXA at the lumbar spine (LS), femoral neck (FN), distal radius (RD) and total body bone mineral content (BMC). Patients then entered the treatment program, which includes re-feeding, dietary education and psychotherapy. Over a period of 42 months, we recruited 55 women who agreed to participate in this study and underwent baseline investigations. Of these, 15 (27%) subjects achieved and then maintained their target weight for the duration of the study. At baseline for all subjects (n=55) estradiol levels were lower than the normal reference ranges (both follicular and luteal phases) in 91% of the women. Bone specific alkaline phosphatase (BSAP) concentrations were lower than the premenopausal reference range in 55% of women, and urinary deoxypyridinoline (DPD) was above the premenopausal reference range in 78% of women. Baseline lumbar spine BMD was positively related to BMI (Pearson's r=0.29, P=0.04) and inversely related to bone turnover markers: urinary DPD (Pearson's r=-0.39, P=0.01 and serum BSAP (Pearson's r=-0.3, P=0.06). The 15 patients who regained and maintained weight were followed-up for a mean duration of 69 weeks (SD 7.3, range 54 to 84 weeks). Mean BMI increased from 14.2 (1.7) to 20.2 (0.77) kg/m2 and remained stable throughout follow-up. Menstruation resumed in 8 of the 15 women. Total body BMC and LS BMD increased significantly over the duration of follow-up (by 4.3% each), but FN BMD and distal radius remained stable. Lumbar spine bone area also increased significantly, whereas FN and distal radius did not. These changes were associated with a significant increase in BSAP (P=0.01), and a non-significant trend for a decrease in DPD (P=0.10). Our findings suggest that when women are at low body weight they are in a hypo-estrogenic state, which is associated with imbalance of bone turnover (high bone resorption and low bone formation). This is reversed with weight gain and persists as target weight is maintained and is associated with increases in BMC and BMD.