The Utility and Acceptability of a Self-Help Smartphone Application for Eating Disorder Behaviors.

OBJECTIVE: Smartphone applications (apps) for eating disorders are a promising approach to assist individuals who do not receive traditional treatment. This study examines usage characteristics, perceptions regarding the acceptability of a new self-help intervention developed for users with eating disorders, and associations between attitudes and use patterns. METHODS: 189 individuals pilot-tested a personalized app-based program, and 133 completed the required components of the pilot-test over an 8-day period. Of these, 64 individuals (49%) completed an exit survey pertaining to acceptability. RESULTS: Seventy percent of those who pilot-tested the app-based program completed the required components, i.e. a baseline review and then a 1-week assessment. Body mass index was associated with the total number of recorded meal logs. Study participants rated the app as highly suitable and acceptable, providing evidence of the feasibility and appropriateness of the program. CONCLUSION: The app-based program demonstrated feasibility of deploying the app across user groups and high acceptability.

Subgrouping the users of a specialized app for eating disorders.

Although mobile technologies for eating disorders (EDs) are burgeoning, there is limited data about the clinical characteristics of individuals using specialized smartphone applications (apps) without accompanying traditional forms of treatment. This study evaluated whether the users of an ED app cluster in clinically meaningful groups. Participants were 1,280 app users (91.3% female; mean age 27) who reported not being in a weekly treatment for their ED. A hierarchical cluster analysis distinguished five groups of participants, all approximating DSM-5 ED categories. One cluster comprised of non-female, ethnically diverse users with Bulimia Nervosa features. Findings suggest that app users resemble known patient classifications.

A qualitative analysis of male eating disorder symptoms.

Insights into how males experience eating disorder symptoms early in the course of illness are important to improve detection efforts and may also provide valuable information for treatment. In this qualitative study, 10 adolescent males and 10 matched female patients completed standardized questionnaires and were interviewed. Results indicated that although there were many similarities between the genders, females were more likely to describe the involvement of family systems and males were more likely to describe involvement in sports as being catalysts for their disorders. Males in this study were more positive about being in treatment.

Using Technology to Improve Treatment Outcomes for Children and Adolescents with Eating Disorders.

Dissemination and implementation of evidence-based treatments are among the biggest challenges facing clinical psychiatry. Developing scalable evidence-based treatments is a major priority and fraught with challenges. This article describes the development of 3 technology-based innovations. It discusses the use of massive open online courses (MOOCs) and mobile applications. Three projects are presented: (1) the modification of a MOOC methodology for psychotherapy training clinicians in manualized family-based therapy (FBT) for adolescents with anorexia nervosa; (2) a modified MOOC platform for the delivery of FBT; and (3) the development of mobile applications for treatment augmentation and delivery.

Cognitive remediation therapy and cognitive behavioral therapy with an older adult with anorexia nervosa: A brief case report.

Cognitive remediation therapy represents a new approach to the treatment of anorexia nervosa (AN) emerging from research, suggesting that adults with chronic AN have specific neurocognitive inefficiencies. Specifically, adults with AN demonstrate an overly detailed cognitive processing bias (Roberts, Tchanturia, & Treasure, 2013) and difficulties shifting set quickly and efficiently (Roberts, Tchanturia, Stahl, Southgate, & Treasure, 2007). These characteristics manifest as rigid, rule-bound, and detail-focused cognitions, beliefs, and behaviors. Versions of these problems appear to persist after weight restoration (Tchanturia et al., 2004) and are observable in patient's healthy sisters (Roberts et al., 2013). Thus, central coherence difficulties and set-shifting problems have been proposed as endophenotypes and maintaining factors of AN (Roberts et al., 2013). (PsycINFO Database Record

Development of a smartphone application for eating disorder self-monitoring.

OBJECTIVE: This case report aims to (1) describe the development and refinement of a smartphone application for eating disorder self-monitoring; (2) characterize its users in terms of demographic and clinical characteristics; and (3) explore its feasibility and utilization as a self-monitoring tool. METHOD: We developed a mobile phone application through which people with eating disorders can self-monitor meals, emotions, behaviors, and thoughts. The application also included positive reinforcement, coping skill suggestions, social support, and feedback components. The app was made available on two Internet app stores. Data include number of downloads and subsequent usage statistics, consumer ratings on app-stores are used as indicators of satisfaction, anonymous aggregate demographic data and Eating Disorder Examination Questionnaire scores from 57,940 individuals collected over a two-year period. RESULTS: The app demonstrated population-level utilization with over 100,000 users over a two-year period. Almost 50% percent of users stated that they are not currently receiving clinical treatment and 33% reported they had not told anyone about their eating disorder. A surprising number of people with severe problems are using the app. DISCUSSION: Smartphone apps have the capacity to reach and engage traditionally underserved individuals with eating disorders at a large scale. Additional work is indicated for the evaluation of the clinical effectiveness of applications for specific user groups and in clinical treatment contexts.

Central coherence in adolescents with bulimia nervosa spectrum eating disorders.

BACKGROUND: Weak central coherence-a tendency to process details at the expense of the gestalt-has been observed among adults with bulimia nervosa (BN) and is a potential candidate endophenotype for eating disorders (EDs). However, as BN behaviors typically onset during adolescence it is important to assess central coherence in this younger age group to determine whether the findings in adults are likely a result of BN or present earlier in the evolution of the disorder. This study examines whether the detail-oriented and fragmented cognitive inefficiency observed among adults with BN is observable among adolescents with shorter illness duration, relative to healthy controls. METHOD: The Rey-Osterrieth Complex Figure Test (RCFT) was administered to a total of 47 adolescents with DSM5 BN, 42 with purging disorder (PD), and 25 healthy controls (HC). Performance on this measure was compared across the three groups. RESULTS: Those with BN and PD demonstrated significantly worse accuracy scores compared to controls in the copy and delayed recall condition with a moderate effect size. These findings were exacerbated when symptoms of BN increased. DISCUSSION: Poorer accuracy scores reflect a fragmented and piecemeal strategy that interferes with visual-spatial integration in BN spectrum disorders. This cognitive inefficiency likely contributes to broad difficulties in executive functioning in this population especially in the context of worsening bulimic symptoms. The findings of this study support the hypothesis that poor global integration may constitute a cognitive endophenotype for BN.

Validation of a six-item male body image concerns scale (MBICS).

Elevated body image concerns may be a risk factor for eating disorders among males and contribute to a range of other mental health problems. This study tested a 6-item measure of general male body image concerns in two studies with adolescent males ages 14-18 (total N = 122). The measure showed strong convergent validity, scale score reliability, and test-retest reliability, and was significantly correlated with the number of episodes of binge eating in the past month. A short scale will relieve participant burden and provide a useful research tool for studies with males at risk for or with eating disorders.

What variables are associated with successful weight loss outcomes for bariatric surgery after 1 year?

BACKGROUND: Prior evidence indicates that predictors of weight loss outcomes after gastric bypass surgery fall within 5 domains: 1) presurgical factors, 2) postsurgical psychosocial variables (e.g., support group attendance), 3) postsurgical eating patterns, 4) postsurgical physical activity, and 5) follow-up at postsurgical clinic. However, little data exist on which specific behavioral predictors are most associated with successful outcomes (e.g.,≥ 50% excess weight loss) when considering the 5 domains simultaneously. The objective of this study was to specify the behavioral variables, and their respective cutoff points, most associated with successful weight loss outcomes. METHODS: Signal detection analysis evaluated associations between 84 pre- and postsurgical behavioral variables (within the 5 domains) and successful weight loss at ≥ 1 year in 274 postgastric bypass surgery patients. RESULTS: Successful weight loss was highest (92.6%) among those reporting dietary adherence of>3 on a 9-point scale (median = 5) who grazed no more than once-per-day. Among participants reporting dietary adherence<3 and grazing daily or less, success rates more than doubled when highest lifetime body mass index was<53.7 kg/m(2). Success rates also doubled for participants with dietary adherence = 3 if attending support groups. No variables from the physical activity or postsurgical follow-up domains were significant, nor were years since surgery. The overall model's sensitivity = .62, specificity = .92. CONCLUSIONS: To our knowledge, this is the first study to simultaneously consider the relative contribution of behavioral variables within 5 domains and offer clinicians an assessment algorithm identifying cut-off points for behaviors most associated with successful postsurgical weight loss. Such data may inform prospective study designs and postsurgical interventions.

Do in-vivo behaviors predict early response in family-based treatment for anorexia nervosa?

The aim of the study is to explore whether identified parental and patient behaviors observed in the first few sessions of family-based treatment (FBT) predict early response (weight gain of 1.8 kg by session four) to treatment. Therapy film recordings from 21 adolescent participants recruited into the FBT arm of a multi-site randomized clinical trial were coded for the presence of behaviors (length of observed behavior divided by length of session recording) in the first, second and fourth sessions. Behaviors that differed between early responders and non-early responders on univariate analysis were entered into discriminant class analyses. Participants with fewer negative verbal behaviors in the first session and were away from table during the meal session less had the greatest rates of early response. Parents who made fewer critical statements and who did not repeatedly present food during the meal session had children who had the greatest rates of early response. In-vivo behaviors in early sessions of FBT may predict early response to FBT. Adaptations to address participant resistance and to decrease the numbers of critical comments made by parents while encouraging their children to eat might improve early response to FBT.

The Eating Disorder Examination Questionnaire (EDE-Q) among university men and women at different levels of athleticism.

The aim of the current study was to establish norms for the Eating Disorder (ED) Examination Questionnaire (EDE-Q) among competitive athletes and to explore the contribution of level of athletic involvement and gender to ED psychopathology, as measured by the EDE-Q. University students (n = 1637) from ten United States universities were recruited online via a social networking website and asked to complete an anonymous survey. The sample was then divided according to gender and level of sports participation. Females scored higher than males regardless of level of athleticism. Lower mean scores were frequently observed among those involved in competitive sports exclusively and highest scores among those involved in recreational sports (alone or in addition to competitive athletics). Recreational activity seems to be important in stratifying risk among competitive athletes; gender is an important interaction term in athletic populations.

Factor structure of the Eating Disorder Examination Questionnaire (EDE-Q) in male and female college athletes.

The study explored the psychometric properties of the Eating Disorder Examination Questionnaire (EDE-Q) among 1637 university students. Participants were divided into male (n=432) and female (n=544) competitive athletes, and male (n=229) and female (n=429) comparison groups comprised of individuals who had not engaged in competitive sports for at least one year. All groups were subjected to confirmatory factor analysis (CFA) to test the fit of the published factor structure in this population, and then exploratory FA (EFA). A three-factor solution was the best fit for three out of four groups, with a two-factor solution providing best fit for the male comparison group. The first factor for all groups resembled a combined Shape and Weight Concern subscale. The factor structure among male and female competitive athletes was remarkably similar; however, non-competitive athletic/low activity males appear qualitatively different from other groups.

A review of attention biases in women with eating disorders.

There is robust evidence that women with eating disorders (EDs) display an attention bias (AB) for disorder-salient stimuli. Emerging data suggest that the presence of these biases may be due, in part, to neurological deficits, such as poor set shifting and weak central coherence. While some have argued that these biases function to predispose and/or act to maintain disordered eating behaviours, evidence supporting this view has rarely been examined. This report summarises and integrates the existing literature on AB in EDs and other related psychiatric disorders to better understand its potential role in the development and maintenance of an ED. The domains reviewed include experimental data using the dot-probe and modified Stroop task and neurobiological findings on AB in women with EDs as well as the role of AB in current theoretical models. We conclude by proposing an integrated model on the role of AB in EDs and discuss treatment approaches aimed at modifying these biases.

Set-shifting among adolescents with bulimic spectrum eating disorders.

OBJECTIVE: Set-shifting difficulties are observed among adults with bulimia nervosa (BN). This study aimed to assess whether adolescents with BN and BN spectrum eating disorders exhibit set-shifting problems relative to healthy controls. METHODS: Neurocognitive data from 23 adolescents with BN were compared with those from 31 adolescents with BN-type eating disorder not otherwise specified and 22 healthy controls on various measures of set-shifting (Trail Making Task [shift task], Color-Word Interference, Wisconsin Card Sorting Test, and Brixton Spatial Anticipation Task). RESULTS: No significant differences in set-shifting tasks were found among groups (p >.35), and effect sizes were small (Cohen f < 0.17). CONCLUSIONS: Cognitive inflexibility may develop over time because of the eating disorder, although it is possible that there is a subset of individuals in whom early neurocognitive difficulty may result in a longer illness trajectory. Future research should investigate the existence of neurocognitive taxons in larger samples and use longitudinal designs to fully explore biomarkers and illness effects. TRIAL REGISTRATION: clinicaltrials.gov NCT00879151.

Are we asking the right questions? A review of assessment of males with eating disorders.

Most of the commonly used eating disorders (ED) assessments were normed and developed for females, and their status among male populations is rarely addressed in the literature. Recently, some male-specific instruments have been developed that may have some utility with this population. This article aims to: (a) briefly outline some special considerations and challenges when assessing ED in male populations; (b) review the utility of some of the most commonly used ED assessments with males; and (c) review some of the measures that have recently been developed to assess male-specific ED-related symptoms, with the hope that a greater understanding of male-specific presentation may be elucidated.

The Eating Disorders Examination in adolescent males with anorexia nervosa: how does it compare to adolescent females?

OBJECTIVE: The study aimed to explore the Eating Disorder Examination (EDE) for adolescent males with eating disorders (EDs) compared with adolescent females with EDs. METHOD: Data were collected from 48 males and matched on percent median body weight (MBW) and age to 48 females at two sites. RESULTS: Adolescent males with anorexia nervosa-type presentation scored significantly lower than matched females on Shape Concern, Weight Concern, and Global score. They also scored lower on a number of individual items. DISCUSSION: The EDE has clinical utility with adolescent males with anorexic-type presentation although males' scoring ranges are consistently lower than those from adolescent females with similar clinical presentations. Males scored significantly lower on a number of items representing core symptoms such as desire to lose weight. More research is needed to gain a better understanding of the experience of adolescent males with EDs, particularly in relation to the nature of shape concern.

Use of mirtazapine in an adult with refractory anorexia nervosa and comorbid depression: a case report.

The objective of this report was to describe an efficacious treatment of an adult with long-standing anorexia nervosa (AN). A 50-year-old woman with an over 7-year history of AN and comorbid major depression had been treated unsuccessfully with numerous psychotropic medications, manualized cognitive behavior therapy, and an intensive outpatient treatment program before referral. After treatment with mirtazapine, she gained weight and her depression improved. A 9-month follow-up revealed a maintenance of these benefits. Mirtazapine may be useful for older, chronically ill patients presenting with AN and comorbid depression.

All better? How former anorexia nervosa patients define recovery and engaged in treatment.

The purpose of this study was to explore how individuals with anorexia nervosa (AN) engage in treatment and define recovery. A mixed methods design was used to triangulate the experience of 20 women with a history of AN. Interview data were analysed thematically to explore frequency of emergent themes and current eating disorder psychopathology was assessed using standardized self-report measures. Participants' mean age was 29.35 (SD = 12.11). Participants' scores were indicative of persistent psychopathology. Those with more involvement in treatment choice had better motivation to change and normalized eating. Participants' definition of recovery mapped on well to current research conceptualizations, though a substantial proportion of the group expressed some ambivalence around the concept. Results are interpreted in the context of self-determination theory of motivation and suggest that patients should be involved collaboratively in the formulation of shared goals and concepts of recovery in treatment settings.

A clinical profile of participants in an online support group.

OBJECTIVE: To explore the clinical characteristics of users of an online support group for people with eating disorders (EDs). METHOD: One hundred and thirty-eight support group participants were recruited online and completed measures that were specifically adapted for internet administration. These included two subscales of the Eating Disorder Inventory-2 (EDI-2); the 26-item version of the Eating Attitudes Test (EAT-26); the Hospital Anxiety and Depression Scale (HADS); and the Rosenberg Self-Esteem Scale (RSE). RESULTS: Participants scored significantly higher than published normative data on all measures. In addition, while the group scored in line with traditional clinical samples, some self-reported diagnostic groups scored significantly higher on all of the factors. DISCUSSION: Participants demonstrated a clinical profile, in terms of reported distress, comparable to, and on some measures in excess of, samples diagnosed with an ED. Online support groups may be ideally placed to offer support and information to some people with EDs.