Proposal for increasing diagnostic clarity in research and clinical practice by renaming and reframing atypical anorexia nervosa as "Restrictive Eating Disorder" (RED).

Atypical anorexia nervosa (AAN) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), is characterized by meeting all criteria for anorexia nervosa (AN) except for weight being within or above the "normal" range despite significant weight loss. The current definition is plagued by several problems, resulting in widely heterogeneous operationalizations in research and clinical practice. As such, the poorly defined diagnosis of AAN negatively impacts affected individuals and frustrates research attempts to better understand the syndrome. We consider conceptual flaws in the AAN description and contend that the undefined weight range and nature of weight loss renders these two factors functionally inapplicable in research and practice. They also represent a departure from the originally intended use of the AAN category, i.e., arresting a negative weight trajectory likely to result in AN, making the target population, and the application of the label, unclear. We propose revised criteria and a new name, restrictive eating disorder (RED), intended to reduce stigma and encompass a wide but better-defined range of presentations. The RED criteria focus on clinically significant restrictive behavior that disrupts normal living (i.e., impairment), and cognitive symptoms of overevaluation, disturbed experience, and lack of recognition of illness seriousness. We believe that RED may enable more appropriate clinical application, but also inspire coordinated research toward a more valid psychiatric nosology in the eating disorders field.

Longitudinal experiences and impact of the COVID-19 pandemic among people with past or current eating disorders in Sweden.

The study aimed to document the impact of the COVID-19 pandemic on the health and well-being of individuals with past and current eating disorders (ED) in Sweden. We re-contacted participants with a known lifetime history of ED from two previous Swedish studies. Participants completed an online survey about health and functioning at baseline early in the pandemic (Wave 1 ca May/June 2020; N= 982) and six months later (Wave 2 Dec/Jan 2020/21; N= 646). Three important patterns emerged: 1) higher current ED symptoms were associated with greater anxiety, worry, and pandemic-related ED symptom increase; 2) patterns were fairly stable across time, although a concerning percentage (23%) who were symptom-free at Wave 1 reported the re-emergence of symptoms at Wave 2; and 3) only a minority of participants (<50%) with a current ED were in treatment, and of those in treatment, many reported fewer treatment sessions and decreased quality of care. The COVID-19 pandemic appears to pose serious health challenges for individuals with an ED, whether currently symptomatic or in remission. We encourage health service providers and patient advocates to be alert to the needs of individuals with ED and to take active measures to ensure access to appropriate evidence-based care both during and following the pandemic.

Initial self-blame predicts eating disorder remission after 9 years.

BACKGROUND: Research into predictors of outcome in eating disorders (ED) has shown conflicting results, with few studies of long-term predictors and the possible importance of psychological variables that may act as risk- and maintenance factors. AIM: To identify baseline predictors of ED remission nine years after initial clinical assessment using self-report measures of ED psychopathology, psychiatric symptoms, and self-image in a sample of adult ED patients (N = 104) treated at specialist units in Stockholm, Sweden. Sixty patients participated in the follow-up, of whom 41 patients (68%) had achieved remission. RESULTS: Results suggested that the only significant predictor of diagnostic remission after nine years was initial levels of self-blame. CONCLUSION: In order to ensure long-term recovery in ED it may be important for clinicians to widen their therapeutic repertoire and utilise techniques that reduce self-blame and increase self-compassion. It is difficult to predict how an eating disorder will develop, and research has found varying factors that affect the outcome of the condition. Recovery rates vary from nearly nil to over 90%. This variation could be explained by different research factors, but are more likely due to varying definitions of 'recovery', with less stringent definitions yielding high recovery rates and more stringent definitions yielding lower rates. The present study investigated whether the severity of eating disorder symptoms and other psychiatric symptoms could predict recovery nine years from first admission to specialised eating disorder care. Sixty patients at three eating disorder treatment units participated, and their scores on self-report measures of symptoms were used as predictor variables. Forty-one participants had no eating disorder diagnosis at nine-year follow-up. Most participants with binge-eating disorder had recovered, while the poorest outcome was found for anorexia nervosa with slightly over half of patients recovered after nine years. The only predictor for the nine-year outcome was a higher initial rating of self-blame, measured with the Structural Analysis of the Social Behavior. It was concluded that it may be important for clinicians to detect and address self-blame early in the treatment of eating disorders in order to enhance the possibility of recovery. Treatment should focus on reducing self-blame and increasing self-acceptance.

Eating disorder examination questionnaire: Norms and clinical reference data from adolescent boys and girls in Sweden.

The study investigated norms and clinical reference values for the 14-day time frame version of the Eating Disorders Examination Questionnaire (EDE-Q) specifically developed to suit adolescent populations. The EDE-Q is a self-report instrument measuring problematic eating behaviors and attitudes. A general population sample (N=487, 239 girls and 248 boys) and a clinical sample (N=1051, 989 girls and 62 boys) aged 12-14 years were analyzed. Descriptive statistics for EDE-Q subscales and Global scale, as well as key behaviors, are presented, along with sex differences and diagnostic differences (clinical sample). General population sample sex differences were consistent and medium to large, with some evidence of floor effects for boys. In the clinical sample there was a main effect of gender, with girls scoring higher overall. The covariate age accounted for more variance in EDE-Q subscale scores than did diagnostic group. Results are discussed in terms of the appropriateness of the EDE-Q for boys, and possible denial of illness among patients.

Emotion dysregulation, self-image and eating disorder symptoms in University Women.

BACKGROUND: We studied associations between emotion dysregulation, self-image and eating disorder (ED) symptoms in university women, and contrasted two indirect effect models to examine possible intervening mechanisms to produce ED symptoms. METHODS: 252 female Swedish university students completed the Difficulties in Emotion Regulation Scale (DERS), the Structural Analysis of Social Behavior (SASB) self-image measure, and the Eating Disorder Examination Questionnaire (EDE-Q). Correlations between scales were followed by five simple mediation analysis pairs with two possible pathways using five ED symptom variables as outcome. The models posited either self-image or emotion dysregulation as mediator or independent variable, respectively. ED symptoms were EDE-Q Global score, objective binge eating episodes (OBE), subjective binge eating episodes (SBE), and two variants of EDE-Q excessive exercise. RESULTS: Emotion dysregulation and self-image were strongly correlated, and both correlated moderately with EDE-Q Global score. There were distinct indirect effects through self-image on the relationship between emotion dysregulation and ED symptoms, but not vice versa. These indirect effects were evident in relation to cognitive ED symptoms and both OBE and SBE, but not in relation to excessive exercise. CONCLUSIONS: Results suggest that even if closely related, emotion dysregulation and self-image both contribute unique knowledge in relation to ED symptoms. Self-image as an intervening mechanism between emotion dysregulation and ED symptoms is relevant for models of the development, maintenance and treatment of ED, as well as treatment focus.

The enemy within: the association between self-image and eating disorder symptoms in healthy, non help-seeking and clinical young women.

BACKGROUND: Previous research has shown self-image according to the interpersonal Structural Analysis of Social Behavior model, to relate to and predict eating disorder symptoms and outcomes. METHODS: We examined associations between self-reported self-image and ED symptoms in three groups of 16-25 year old females: healthy (N = 388), non help-seeking (N = 227) and clinical (N = 6384). Analyses were divided into age groups of 16-18 and 19-25 years, and the patient sample was divided into diagnostic groups. RESULTS: Stepwise regressions with self-image aspects as independent variables and eating disorder symptoms as dependent showed that low self-love/acceptance and high self-blame were associated with more eating disorder symptoms in all groups, except older patients with bulimia nervosa where self-hate also contributed. Associations were generally weaker in the healthy groups and the older samples. CONCLUSIONS: We put forward that older age, low desirability of symptoms, poorly working symptoms, and being acknowledged as ill, may weaken the association, with implications for treatment and prevention.