Clinicians as a critical link: Understanding health professionals' beliefs and attitudes toward anorexia nervosa, bulimia nervosa, and binge eating disorder.

Understanding the perspectives of health professionals remains an understudied issue, yet may help bridge research-practice gaps and pinpoint important areas for education, training, and research. This study investigated attitudes toward anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) among Nordic health professionals specialized within the eating disorder (ED) field. Participants (n = 144) completed a modified ED-version of the Illness Perception Questionnaire which assessed attitudes and beliefs toward perceived symptom controllability, severity, treatment effectiveness, and views on the prognosis of AN, BN, and BED. Personal enjoyment and level of comfort working with AN, BN, and BED were also assessed. The majority agreed or strongly agreed that patients with AN, BN, and BED were not responsible for their illness, and viewed the illnesses as psychological rather than medical in etiology. AN was viewed as the most severe and enduring, followed by BN, then BED. Treatment for BN was viewed as being more highly effective than treatments for either AN or BED. Professionals rated significantly less enjoyment and less confidence working with BED. To conclude, both commonalities and differences in attitudes toward AN, BN and BED were found in terms of perceived symptom controllability, views on severity, treatment effectiveness, and anticipated prognosis. In particular, findings emphasized the need for additional training in the management of BED among Nordic healthcare professionals.

Treatment interventions for Severe and Enduring Eating Disorders: Systematic review.

OBJECTIVE: Approximately 20% of people with Anorexia Nervosa (AN) and 10% with Bulimia Nervosa (BN) will eventually develop a long-standing illness. Although there is no set definition for Severe and Enduring eating Disorder (SE-ED), the common criteria relate to a long duration of the disorder and a number of unsuccessful treatment attempts. Research evidence for treatment of SE-ED remains limited, thus the objective of this systematic review was to describe different treatment interventions and their effects on SE-ED-related outcomes. METHOD: A systematic search for quantitative treatment studies of adult participants with SE-ED was conducted in June 2019 (PROSPERO, CRD42018115802) with no restriction on eating disorder type. Altogether, 2,938 studies were included for title and abstract screening. RESULTS: After systematic searches and article screening, 23 studies (3 randomized controlled trials, 3 open-label studies, 8 naturalistic follow-up studies, 8 case series and case studies, and 1 partially blinded pilot study) were included in the analysis and data extraction. Methodological quality of the included studies was generally low. Inpatient treatment programs (n = 5) were effective in short-term symptom reduction, but long-term results were inconsistent. Outpatient and day-hospital treatment programs (n = 5) seemed promising for symptom reduction. Drug interventions (n = 5) showed some benefits, especially as adjuvant therapies. Brain stimulation (n = 6) led to improvements in depressive symptoms. Other treatments (n = 2) produced mixed results. DISCUSSION: This is the first systematic review to examine all of the different treatment interventions that have been studied in SE-ED. The results will inform future interventions in research and clinical practice.

Body dissatisfaction and disordered eating symptoms in Finnish preadolescents.

To evaluate whether body dissatisfaction is associated with disordered eating symptoms in Finnish preadolescents, and to assess the moderator effects of gender and body mass index on this association. We included 10,526 9- to 12-year-old preadolescents at baseline from the Finnish Health in Teens cohort. We used the Children's Eating Attitudes Test for assessing disordered eating symptoms and a pictoral instrument for evaluating body dissatisfaction, comparing self-assessment of wanted and current body shape. Odds ratio (OR) for disordered eating symptoms were estimated using unconditional logistic regression. A high percentage of preadolescents reported body dissatisfaction: 30.0% wanted a smaller body and 9.3% wanted a larger body. Only 2.2% of the participants had disordered eating symptoms. Preadolescents who wanted a larger (OR = 2.83; 95% confidence intervals (CI): 1.68-4.78) or smaller body (OR = 4.48; 95% CI: 3.20-6.26) had a higher risk of having disordered eating symptoms, compared to preadolescents satisfied with their body. Among preadolescents who wanted a smaller body, the effect of body dissatisfaction was more pronounced among girls (OR = 5.00; 95% CI: 3.25-7.70) than boys, and among normal-weight (OR = 6.82; 95% CI: 4.53-10.25) and underweight (OR = 23.23; 95% CI: 5.31-101.61) than overweight preadolescents. Body dissatisfaction is associated with disordered eating symptoms especially among girls, and those who are underweight and normal-weight. Our study suggests that, in the prevention of eating disorders, special attention should be given to preadolescents with body dissatisfaction.

Are eating disorders and their symptoms increasing in prevalence among adolescent population?

BACKGROUND: A debate concerns whether eating disorders are increasing in prevalence. The role of socio-economic status (SES) for adolescent eating disorders (ED) is another matter of debate. AIMS: To ascertain whether self-reported eating disorders or their symptoms have increased in prevalence in adolescent population from the early 2000s to early 2010s. METHODS: A person-identifiable classroom survey, Adolescent Mental Health Cohort study, was carried out among the 9th graders in comprehensive schools in Tampere, Finland, during academic year 2002-2003, and replicated among then 9th graders during academic years 2012-2013. Eating disorders were elicited with questionnaires tailored according to DSM-IV criteria for anorexia nervosa and bulimia nervosa. RESULTS: No changes were observed between 2002-2003 and 2012-2013 in the prevalence of anorexia and bulimia, most of the symptoms of anorexia and bulimia, or the proportion of adolescents having received treatment due to eating disorders among the girls or the boys. Eating disorders, treatment contacts due to eating disorders, and eating disorder symptoms were not systematically associated with either low or high parental socio-economic status. CONCLUSION: Based on this dataset, eating disorders are not increasing in the adolescent population. Adolescent eating disorders are not associated with socio-economic status of their family.

Social phobia, depression and eating disorders during middle adolescence: longitudinal associations and treatment seeking.

BACKGROUND: Longitudinal associations between social phobia (SP), depression and eating disorders (EDs), and the impact of antecedent SP and depression on subsequent treatment seeking for EDs have rarely been explored in prospective adolescent population studies. AIM: We aimed to examine these associations in a large-scale follow-up study among middle adolescents. METHOD: We surveyed 3278 Finnish adolescents with a mean age of 15 years for these disorders. Two years later, 2070 were reached and again surveyed for psychopathology and treatment seeking. Longitudinal associations between the self-reported disorders and treatment-seeking patterns for self-acknowledged ED symptoms were examined in multivariate analyses, controlling for SP/depression comorbidity and relevant socioeconomic covariates. RESULTS: Self-reported anorexia nervosa (AN) at age 15 years predicted self-reported depression at age 17 years. Furthermore, self-reported SP at age 15 years predicted not seeking treatment for bulimia nervosa (BN) symptoms, while self-reported depression at age 15 years predicted not seeking treatment for AN symptoms during the follow-up period. CONCLUSIONS: Adolescents with AN should be monitored for subsequent depression. Barriers caused by SP to help seeking for BN, and by depression for AN, should be acknowledged by healthcare professionals who encounter socially anxious and depressive adolescents, especially when they present with eating problems.

Development and preliminary validation of a Finnish version of the Eating Disorder Examination Questionnaire (EDE-Q).

BACKGROUND: Eating behaviour can be viewed as a continuum, ranging from extremely restrictive to extremely disinhibited eating. Valid and reliable instruments are needed to ensure detection of individuals with risk for eating disorders (ED). Self-report methods are the most feasible, cost, and time efficient. One of the most widely used self-reports is the Eating Disorder Examination Questionnaire (EDE-Q). AIM: The aim of this study was to develop a Finnish version of the EDE-Q version 6.0 and to assess its psychometric properties in adolescents, adults, and ED patients. METHODS: The present study utilized data from three different samples: adolescents (n = 242), adults (n = 133), and ED patients (n = 52). The patient group comprised different EDs, but individual ED diagnoses were not studied separately. Data was collected January 2014 through June 2015. RESULTS: The Finnish version of the EDE-Q showed acceptable-to-excellent internal consistency on all sub-scales in all three samples and discriminated patients from healthy individuals. Female participants generally scored higher than male and sex differences were more pronounced among the younger age group. CONCLUSIONS: The Finnish version of the EDE-Q can, based on this study, be regarded as reliable, valid, and functional. Further studies are needed to evaluate the population norms and to test the validity in individual ED diagnoses.

Decrease in self-esteem mediates the association between symptoms of social phobia and depression in middle adolescence in a sex-specific manner: a 2-year follow-up of a prospective population cohort study.

BACKGROUND: Social phobia and depression are common, highly comorbid disorders in middle adolescence. The mechanism underlying this comorbidity, however, is unclear. Decrease in self-esteem caused by the initial disorder might play a decisive role in the development of the subsequent disorder. The present study aimed to determine whether the association between symptoms of social phobia and depression is mediated by decrease in self-esteem in mid-adolescent girls and boys. METHODS: As a part of the prospective Adolescent Mental Health Cohort (AMCH), subjects of this study were 9th grade pupils (mean age, 15.5) responding to a survey conducted in 2002-2003 (T1) and to a 2-year follow-up survey in 2004-2005 (T2) (N = 2070, mean age 17.6 years, 54.5% girls). RESULTS: Symptoms of social phobia without symptoms of depression at age 15 and symptoms of depression at age 17 were associated only among boys, and this association was mediated by decrease in self-esteem. Symptoms of depression without symptoms of social phobia at age 15 and symptoms of social phobia at age 17 were associated only among girls, and this association was partially mediated by decrease in self-esteem. CONCLUSIONS: Decrease in self-esteem plays a decisive role in the association between social phobia and depression. Self-esteem should be a key focus in interventions for adolescents suffering from social phobia or depression. Efficient intervention for the first disorder might help to prevent the decline in self-esteem and thus the incidence of the subsequent disorder. These findings are based on a sample of Finnish adolescents and should be confirmed in other jurisdictions or in more ethnically diverse samples.

And then what happened? A 5-year follow-up of eating disorder patients.

BACKGROUND: Eating disorders (EDs) show a varying course and outcome. Within 10 years, between half and three-quarters of patients recover from their disorder. There is, however, a lack of consensus in how to define recovery. AIMS: The aim of the present naturalistic study was to assess clinical and full recovery in ED patients 5 years after initiated treatment at a specialized outpatient unit for EDs. METHODS: Data was collected at three time points: after the investigation period (T1), at the end of treatment (T2) and 5 years after the beginning of treatment (T3). Data at T1 and T2 were collected from patient records, and at T3 using a questionnaire. The number of participants was 71 and response rate 78%. RESULTS: At T3, the proportion in clinical recovery was 83.1%, with no significant differences between diagnostic groups. The proportion in full recovery, i.e. in addition to a subjective account of being fully recovered, presenting no physical, behavioural or psychological ED symptoms, was 40.8%. CONCLUSIONS: For most ED patients, outpatient treatment is sufficient to enable recovery. How to define and measure recovery still warrants discussion.

Validation of the eating pathology symptoms inventory (EPSI) in Swedish adolescents.

BACKGROUND: Eating disorders (ED) are associated with symptoms across body image, disordered eating, and exercise-related domains, and while predominantly affecting females, ED in males is also a significant concern. However, popular self-report methods insufficiently capture male presentations. This study aimed (1) to validate the first Swedish translation of the Eating Pathology Symptoms Inventory (EPSI), which was designed to overcome limitations in previous measures, and (2) compare genders gender-specific manifestations of eating pathology, depression, and anxiety in Swedish high-school students. METHODS: Participants were 359 high-school students (47% males) aged 17.0 years (range 15-21). RESULTS: Confirmatory factor analysis and correlation patterns showed support for the 8-factor structure and convergent validity, but poorer discriminant validity may suggest caution in interpreting single scales as evidence of ED pathology. Gender comparisons were broadly consistent with previous research. CONLUSIONS: The Swedish EPSI may be used to asses ED symptoms, but caution is suggested in interpreting some scales in isolation as indicative of ED pathology.

Indivudals with eating disorders (ED) experience symptoms that have to do with body image, disordered eating, and physical exercise. Most who get an ED are female, but males are also affected. However, many symptom questionnaires do not capture how males experience their illness very well. In this study, we wanted to (1) test a Swedish translation of the Eating Pathology Symptoms Inventory (EPSI), which was designed to overcome some limitations in other questionnaires, and (2) compare male and female Swedish high-school students on ED symptoms, depression, and anxiety. Participants were 359 students (47% males) aged ≈ 17 years (range 15­21). Statistical analysis showed that the 8 suggested scales of the EPSI overall function as expected, and that the EPSI seems to measure ED symptoms well, but that it also has some overlap with depressive and anxiety symptoms. Males and females differed from one another in ways that resembled what other researchers have found. We conclude that the Swedish EPSI works well, but that some of the scales might not, on their own, suggest that a person has problems with ED, unless other more ED-specific scales also indicate such symptoms.

Latent anxiety and depression dimensions differ amongst patients with eating disorders: A Swedish nationwide investigation.

OBJECTIVE: Anxiety and depression symptoms are common in individuals with eating disorders. To study these co-occurrences, we need high-quality self-report questionnaires. The 19-item self-rated Comprehensive Psychopathological Rating Scale for Affective Syndromes (CPRS-S-A) is not validated in patients with eating disorders. We tested its factor structure, invariance, and differences in its latent dimensions. METHOD: Patients were registered by 45 treatment units in the Swedish nationwide Stepwise quality assurance database for specialised eating disorder care (n = 9509). Patients self-reported their anxiety and depression symptoms on the CPRS-S-A. Analyses included exploratory and confirmatory factor analyses (CFA) in split samples, and testing of invariance and differences in subscales across eating disorder types. RESULTS: Results suggested a four-factor solution: Depression, Somatic and fear symptoms, Disinterest, and Worry. Multigroup CFA indicated an invariant factor structure. We detected the following differences: Patients with anorexia nervosa binge-eating/purging subtype scored the highest and patients with unspecified feeding and eating disorders the lowest on all subscales. Patients with anorexia nervosa or purging disorder show more somatic and fear symptoms than individuals with either bulimia nervosa or binge-eating disorder. CONCLUSION: Our four-factor solution of the CPRS-S-A is suitable for patients with eating disorders and may help to identify differences in anxiety and depression dimensions amongst patients with eating disorders.

Obesity and eating disturbances are common in 15-year-old adolescents. A two-step interview study.

A two-step interview study of eating disorders (EDs) and sub-clinical EDs in 15-year-old adolescents was carried out in western Finland. The sample consisted of all ninth graders in a well-defined catchment area (n=606, 98.2% of eligible students). In the first step, a self-report questionnaire was administered at schools regarding mental health problems and life circumstances. The questions concerning anorectic and bulimic eating pathology were formulated according to the DSM-IV diagnostic criteria of EDs. The second step consisted of a semi-structured interview Rating of Anorexia and Bulimia-Teenager version (RAB-T) to which 128 subjects were invited, on the basis of their answers to questions about eating pathology in the questionnaire. The participation rate in the interview was 88.3%. The lifetime prevalence rate for anorexia nervosa (AN) in 15-year-old girls was 1.8% and the point prevalence rate 0.7%. No cases of AN were found among the boys. All criteria fulfilling cases of bulimia nervosa (BN) were not found in our sample. High rates of AN not otherwise specified (AN-NOS; 4.9%) and sub-clinical EDs (4.9%) were found among the girls; 6.7% of girls and 0.6% of boys were regarded as being "at risk" of developing EDs. Data on height and weight are based on current measurements taken at school healthcare; 22% of boys were overweight or obese compared with 16% of girls.

Psychological distress and risk for eating disorders in subgroups of dieters.

OBJECTIVE: The aim of the present study was to predict the risk of developing an eating disorder in subgroups of dieters, based on the adolescents own accounts of the reason for starting to diet. METHOD: Eighty-one dieters from a cohort of 595 adolescents (318 boys and 288 girls) aged 15 participated in the present prospective study. Personal interviews at both base-line and follow-up were combined with questionnaire data on depression, social phobia and self-esteem. RESULTS: Four mutually exclusive groups of dieters were identified: vanity dieters, overweight dieters, depressed dieters and feeling fat dieters. Depressed and feeling-fat dieters had a 15-fold risk of having a lifetime eating disorder at age 18 compared to vanity and overweight dieters. CONCLUSION: Typical teenage vanity dieting and dieting among overweight adolescents appears to be a benign practice, but adolescents dieting because of psychological distress have high-risk of developing an eating disorder.

The prevalence, incidence and development of eating disorders in Finnish adolescents: a two-step 3-year follow-up study.

OBJECTIVE: To investigate the prevalence, incidence and development of eating disorders and subclinical eating pathology. METHOD: A two-step three-year follow-up study on eating disorders in adolescence (N = 595) was conducted in western Finland. A screening questionnaire followed by a semi-structured interview was used to determine the prevalence, incidence and development of eating disorders. RESULTS: The lifetime prevalence rates for females age 18 were 2.6% for anorexia nervosa (AN), 0.4 for bulimia nervosa (BN), 7.7% for AN-NOS, 1.3% for BN-NOS and 8.5% for subclinical eating disorders. No prevalent case of DSM-IV eating disorders was found among the male participants. The incidence rate of any eating disorder in females age 15-18 was 1641 per 100 000 person-years. CONCLUSION: Eating disorders are relatively common in female adolescents. As many as one in five adolescent females are or have been struggling with eating disorder related issues during their teenage years.

Letter to the editor: health professionals' attitudes toward individuals with eating disorders: who do we think they are?

Health professionals are not immune to stigmatizing attitudes and stereotypes found in society-at-large. Along with patients and their loved ones, treatment providers are important stakeholders - and gatekeepers - in the successful delivery of mental healthcare. Prevailing attitudes among professionals can facilitate timely recognition, enable access to care and uptake of evidence-based practices, or undermine help-seeking and therapeutic engagement. At an interactive activity at the 2016 Nordic Eating Disorders Society (NEDS) meeting, we asked health professionals to describe individuals with eating disorders. The most common descriptive term used was "anxiety" followed by "thin", "sad", "control", "female", and "suffering/pain". Further research on professionals' attitudes toward individuals with eating disorders is necessary to inform education, awareness, and advocacy efforts following the diagnostic revisions in the DSM-5.

Posttraumatic stress disorder in eating disorder patients: The roles of psychological distress and timing of trauma.

Exposure to traumatic events may be a risk factor for subsequent development of an eating disorder (ED). In a previous study, we showed that trauma exposure impacted symptom load in ED patients. We also saw an effect of trauma on general psychological distress. The aim of the present study was to investigate the association between Posttraumatic stress disorder (PTSD) and ED severity, to focus on the mediating role of psychological distress for the association, and to assess the role of timing of trauma in relation to emergence of ED. Participants were Swedish adult ED patients with a history of traumatic exposure (N=843, Mean age 27.2, 97.3% female). One fourth (24.1%) of the participants had a lifetime diagnosis of PTSD. PTSD had an impact on ED severity, but the impact was mediated by psychological distress. When stratifying the sample based on timing of trauma a significant effect was present only in those with trauma within a year of emergence of ED. The results suggest emotion regulation as a possible underlying factor of interest in future research.

The prevalence and impact of trauma history in eating disorder patients.

BACKGROUND: Early experiences of traumatic events (TEs) may be associated with subsequent eating disturbance. However, few studies have investigated overall exposure and trauma-type frequency in various types of eating disorders (EDs). OBJECTIVE: This study aimed to investigate the prevalence and type of TEs in a nationally representative sample of Swedish ED patients. METHOD: Data from a database (Stepwise) for specialized ED care were used. Trauma history was assessed as a part of the routine, initial assessment. Participants over the age of 18 with a diagnosed DSM-IV ED were included (N=4,524). RESULTS: The number of patients having experienced at least one TE was 843 (18.6%), and 204 (24.2%) reported at least one additional trauma. Sexual trauma was the most common form of TE (6.3%). There was no difference in overall traumatic exposure or in type of experienced trauma between the ED diagnostic subgroups (AN, BN, EDNOS, and BED). Overall traumatic exposure was linked to self-reported severity of ED symptoms, more secondary psychosocial impairment, psychiatric comorbidity, and negative self-image. CONCLUSIONS: Trauma history in ED patients merits attention. Results are partly in line with and partly in contrast to previous research. Measurement of trauma history has varied substantially in research on EDs, and this study adds to the indistinct literature on trauma history in ED.

How low is low? Low self-esteem as an indicator of internalizing psychopathology in adolescence.

Schools are among the most important setting for preventive interventions among adolescents. There are evidence-based intervention programs for adolescents at risk for and with early signs of mental health problems but one demanding task is to detect the ones who are in need of an intervention. The aim of the present study was to analyze associations between self-esteem, depressive symptoms, and social anxiety in order to determine clinically relevant cut-points for male and female adolescents' self-esteem as measured with the Rosenberg Self-Esteem Scale (RSES). The participants of the present prospective study, started in 2002-2003, were 2070 adolescents aged 15 years (1,167 girls and 903 boys) at two study sites in Finland who participated at both baseline and 2-year follow-up. Self-esteem was related to depressive symptoms and social anxiety, and the RSES was able to discriminate between cases of depression and social phobia. The present study suggests a cutoff of 25 points to classify low self-esteem in both girls and boys. Low self-esteem may function as an indicator of various forms of internalizing psychopathology. The RSES is worth further examination as a potential screening tool for adolescents in risk of psychopathology.

Longitudinal concomitants of incorrect weight perception in female and male adolescents.

The aim of the present study was to analyse the longitudinal concomitants of incorrect weight perception, depressive symptoms, social anxiety, self-esteem, and eating disorders in adolescents. A prospective follow-up study on 283 female and 312 male adolescents aged 15 comprising questionnaires directed at the whole study population and subsequent personal interviews with adolescents found to be screen-positive for eating disorders, at both baseline and three-year follow-up. Body mass index was combined with weight perception to classify adolescents with incorrect weight perception. Twenty-nine percent of females incorrectly perceived themselves as overweight and 14% of males incorrectly as underweight. Incorrect weight perception was in females related to depressive symptoms, social anxiety, eating disorders, and low self-esteem. Males with incorrect weight perception experienced more social anxiety at the follow-up than their counterparts with correct weight perception. Recognition of incorrect weight perception is important for prevention of depression, social anxiety, and eating disorders.