Ethical implications of defining longstanding anorexia nervosa.

The label severe and enduring anorexia nervosa (SE-AN) is widely used in the literature on longstanding anorexia nervosa (AN). However, the process of constructing the criteria and the use of the label SE-AN has ethical implications that have not been taken into account. Through combining existing literature and lived experience perspective, this paper addresses to what extent the current criteria do and do not reflect the lived experience. Arguments are presented on why the process of constructing the criteria for SE-AN and the application of the label can be both identified as, and give rise to, epistemic injustice. Epistemic injustice is an injustice that is done to a person as an individual with the capacity of acquiring and sharing knowledge. This type of injustice can occur at any stage of an interaction between people in which knowledge is shared with one another. The paper concludes by giving suggestions on how to pursue epistemic justice in the process of defining longstanding AN.

Some patients with anorexia nervosa (AN) develop a longstanding eating disorder. Over the years different labels, such as 'chronic AN' or 'treatment resistant AN', have been used to describe longstanding AN. Currently, the label that is used most often in scientific literature is 'severe and enduring AN' (SE-AN) and criteria for what entails SE-AN have been proposed. This paper looks at the possible ethical issues that have arisen in the process of constructing the criteria and possible ethical problems that may result from using the label SE-AN. The paper focuses on injustice that may arise when people with specific experiences, such as lived experience of longstanding AN, are not acknowledged as people with important knowledge to share. The paper concludes by giving suggestions on how to overcome this type of injustice.

Examining anxious temperament in anorexia nervosa: Behavioural inhibition and intolerance of uncertainty and their contribution to trait anxiety in adolescents with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a serious and complex psychiatric disorder yet treatment results are suboptimal. Insight into the etiology of this illness is much needed. Research highlights the implication of anxiety-related traits in the development and maintenance of AN. This study investigates firstly, behavioural inhibition and intolerance for uncertainty (IU) in adolescents with and without AN, and secondly relations between these traits. METHODS: In a cross-sectional study, 165 adolescent girls (AN = 94, HC = 71) completed questionnaires measuring behavioural inhibition, IU and trait anxiety. ANOVAs tested differences between AN and HC groups, and mediation models with IU as a mediator between behavioural inhibition and trait anxiety were run. RESULTS: AN adolescents reported significantly higher levels of behavioural inhibition, IU and trait anxiety compared to their peers. In both AN and HC, a direct and a total effect of behavioural inhibition on trait anxiety was found. However, only in the AN group IU partially mediated the relation between behavioural inhibition and trait anxiety. LIMITATIONS: Data is cross-sectional and longitudinal studies are required. A mean illness duration of nearly 2 years may mean early effects of malnourishment and habituation and future studies should include patients with shorter illness duration. CONCLUSIONS: Results highlight that behavioural inhibition and IU may contribute to anxiety in AN whilst their peers may have developed better executive and social-emotional skills to manage uncertainty. Adolescents with AN may benefit from interventions targeting behavioural inhibition and IU.

Exploring the intersection of autism spectrum disorder and eating disorders: understanding the unique challenges and treatment considerations for autistic women with eating disorders.

PURPOSE OF REVIEW: Autistic women struggle with high levels of both autistic eating behaviours and disordered eating behaviours , which might make them particularly vulnerable to develop eating disorders. Research investigating the presence and characteristics of eating disorders in autistic women is however limited, as is research examining the role of autism in the treatment and recovery of an eating disorder in autistic women. RECENT FINDINGS: The link between autism and eating disorders has mainly been investigated from the field of eating disorder research, with studies finding an overrepresentation of autism or autistic traits in eating disorders populations. Findings also suggest that autism or autistic traits are associated with a more serious presentation of the eating disorders, including a higher chance of a chronic course of the eating disorders. Most studies however lack comprehensive autism assessments, making it difficult to determine the actual prevalence of autism and its role in women with eating disorders. SUMMARY: Autistic women with an eating disorder seem to suffer from more complex eating disorders and seem to not benefit from current treatment modalities. This could be partly related to specific autism characteristics such as sensory sensitivities, which are not being considered by current treatment protocols. Future research needs to shed light on what underlies the eating behaviours of autistic women with an eating disorder, in order to help to adapt current treatment modalities to meet the unique needs of these women.

Shifting the Focus: A Pilot Study on the Effects of Positive Body Exposure on Body Satisfaction, Body Attitude, Eating Pathology and Depressive Symptoms in Female Patients with Eating Disorders.

One of the most commonly used techniques for the treatment of body image problems in eating disorders (ED) is body exposure (BE). However, evidence of its effectiveness in clinical populations is scarce. In the Positive Body Experience (PBE) protocol, the focus of positive BE is on aesthetic, functional and tactile aspects of the body. The current study evaluates the outcomes of positive BE with regard to changes in attitudinal body image and eating pathology, as well as the factors that influence these changes, in a sample of 84 adult female patients with different EDs who did not receive any other treatment for their EDs during the period in which BE treatment occurred. The results show significant positive changes in attitudinal body image, ED behaviors and depressive symptoms, with depressive symptoms at baseline mediating the changes in attitudinal body image. This study indicates that the PBE protocol is a suitable intervention for reducing negative attitudinal body image in anorexia and bulimia nervosa patients, as well as those with binge eating disorder. Furthermore, the results suggest that positive non-weight-related and functional body satisfaction are strong catalysts for change and that depressive symptoms play an important role in the ability to change. Additional RCTs are needed to gain more insight into the effects of PBE.

Brain Structure in Acutely Underweight and Partially Weight-Restored Individuals With Anorexia Nervosa: A Coordinated Analysis by the ENIGMA Eating Disorders Working Group.

BACKGROUND: The pattern of structural brain abnormalities in anorexia nervosa (AN) is still not well understood. While several studies report substantial deficits in gray matter volume and cortical thickness in acutely underweight patients, others find no differences, or even increases in patients compared with healthy control subjects. Recent weight regain before scanning may explain some of this heterogeneity. To clarify the extent, magnitude, and dependencies of gray matter changes in AN, we conducted a prospective, coordinated meta-analysis of multicenter neuroimaging data. METHODS: We analyzed T1-weighted structural magnetic resonance imaging scans assessed with standardized methods from 685 female patients with AN and 963 female healthy control subjects across 22 sites worldwide. In addition to a case-control comparison, we conducted a 3-group analysis comparing healthy control subjects with acutely underweight AN patients (n = 466) and partially weight-restored patients in treatment (n = 251). RESULTS: In AN, reductions in cortical thickness, subcortical volumes, and, to a lesser extent, cortical surface area were sizable (Cohen's d up to 0.95), widespread, and colocalized with hub regions. Highlighting the effects of undernutrition, these deficits were associated with lower body mass index in the AN sample and were less pronounced in partially weight-restored patients. CONCLUSIONS: The effect sizes observed for cortical thickness deficits in acute AN are the largest of any psychiatric disorder investigated in the ENIGMA (Enhancing Neuro Imaging Genetics through Meta Analysis) Consortium to date. These results confirm the importance of considering weight loss and renutrition in biomedical research on AN and underscore the importance of treatment engagement to prevent potentially long-lasting structural brain changes in this population.

The effects of polyunsaturated fatty acid (PUFA) administration on the microbiome-gut-brain axis in adolescents with anorexia nervosa (the MiGBAN study): study protocol for a longitudinal, double-blind, randomized, placebo-controlled trial.

BACKGROUND: Anorexia nervosa (AN) is a severe psychiatric disease that often takes a chronic course due to insufficient treatment options. Emerging evidence on the gut-brain axis offers the opportunity to find innovative treatments for patients with psychiatric disorders. The gut microbiome of patients with AN shows profound alterations that do not completely disappear after weight rehabilitation. In previous studies, the administration of polyunsaturated fatty acids (PUFA) resulted in effects that might be beneficial in the treatment of AN, affecting the microbiome, body weight and executive functions. Therefore, the MiGBAN study aims to examine the effects of a nutritional supplementation with PUFA on the gut microbiome and body mass index (BMI) in patients with AN. METHODS: This is a longitudinal, double-blind, randomized, placebo-controlled trial. Within 2 years, 60 adolescent patients aged 12 to 19 years with AN will receive either PUFA or placebo for 6 months additional to treatment as usual. After 1 year, the long-term effect of PUFA on the gut microbiome and consecutively on BMI will be determined. Secondary outcomes include improvement of gastrointestinal symptoms, eating disorder psychopathology, and comorbidities. Additionally, the interaction of the gut microbiome with the brain (microbiome-gut-brain axis) will be studied by conducting MRI measurements to assess functional and morphological changes and neuropsychological assessments to describe cognitive functioning. Anti-inflammatory effects of PUFA in AN will be examined via serum inflammation and gut permeability markers. Our hypothesis is that PUFA administration will have positive effects on the gut microbiota and thus the treatment of AN by leading to a faster weight gain and a reduction of gastrointestinal problems and eating disorder psychopathology. DISCUSSION: Due to previously heterogeneous results, a systematic and longitudinal investigation of the microbiome-gut-brain axis in AN is essential. The current trial aims to further analyse this promising research field to identify new, effective therapeutic tools that could help improve the treatment and quality of life of patients. If this trial is successful and PUFA supplementation contributes to beneficial microbiome changes and a better treatment outcome, their administration would be a readily applicable additional component of multimodal AN treatment. TRIAL REGISTRATION: German Clinical Trials Register DRKS00017130 . Registered on 12 November 2019.

Problematic eating behaviours of autistic women-A scoping review.

AIM: Eating and feeding behaviours of autistic individuals and related consequences have been mainly investigated in autistic children or in autistic adults with intellectual disabilities. Behaviours such as food selectivity or food neophobia have been shown to persist into adolescence and adulthood and are associated with aversive consequences. However, much less is known about the eating behaviours of autistic adults without intellectual disabilities, especially those of women. By means of a scoping review, we aim to assess the extent of the scientific literature on what is known about the eating behaviours of these women and the possible consequences of such eating behaviour. METHOD: Medline, Cochrane, PubMed and PsycInfo databases were searched according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Five studies met the eligibility criteria and were included in this review. Autistic women not only reported high levels of eating behaviour frequently seen in autism spectrum disorders (ASD), but also high levels of disordered eating behaviour, similar to that of women with eating disorders. CONCLUSIONS: Autistic women seem to exhibit high levels of eating behaviour frequently seen in ASD as well as disordered eating behaviour. Future research needs to shed light on what underlies these problematic eating behaviours, in order to help to adapt current treatment modalities to meet the unique needs of these women.

Increase in admission rates and symptom severity of childhood and adolescent anorexia nervosa in Europe during the COVID-19 pandemic: data from specialized eating disorder units in different European countries.

BACKGROUND: The COVID-19 pandemic, associated with confinement and social isolation, seems to have impacted the course of many mental disorders in children and adolescents. An increase in hospital admission rates for juvenile anorexia nervosa (AN) has been documented in many regions of the world. However, data from Europe are scarce. METHODS: We asked clinicians in specialized eating disorder units in hospitals of maximum care in France, Germany, Italy, Spain, Sweden, and the Netherlands to report on (i) overall (inpatient and outpatient) and (ii) inpatient admission rates for adolescents with AN during 2019 and 2020. Additionally, a modified version of the COVID Isolation Eating Scale (CIES) was used to assess the child and adolescent psychiatrists' estimations of a possible increase in symptom severity in children and adolescents with AN during the COVID-19 pandemic and to (iii) inquire about the contributing factors perceived by the caring professionals. RESULTS: Four out of six representatives of European hospitals described a higher rate of overall admissions during the pandemic. Three hospitals out of six reported an increase in inpatient admissions, and two centres had constant high numbers of admissions of both outpatients and inpatients. The clinicians perceived a higher symptom severity in 2020 than in 2019, especially involving more frequent use of social media, longer duration of exercising, and more restrictive eating. They supposed an increase in social media consumption, a perceived "loss of control", and a lack of in-person assessments and weight controls as the main contributing factors for the deterioration in AN numbers and symptomatology. CONCLUSIONS: The COVID-19 pandemic seems to have had a deep impact on symptom severity in AN, which is mirrored by a large increase in admission rates across Europe. An increase in exercise, social media consumption, a perceived "loss of control", and a lack of face-to-face health care seem to have contributed to this development. Further investigation is required to identify which factors may lead to the increase in incidence and deterioration of childhood and adolescent AN. Possible preventive means for the future could include educating paediatricians and health care workers about AN, regular weight assessment, and home-based treatments.

Evaluation of the cognitive behavioural theory of eating disorders: A network analysis investigation.

OBJECTIVE: One of the prevailing theories of eating disorders (ED) is the transdiagnostic cognitive behavioural theory of eating disorders, which suggests that certain ED symptoms, such as over-valuation of eating, shape, and weight, may be more central than others. In the present study, network analyses were used to evaluate these assumptions in a patient sample. METHODS: Participants were 336 individuals receiving treatment at an expert center for ED in the Netherlands. Eating disorder symptoms were used to create transdiagnostic and diagnosis-specific networks and assess symptom centrality and density of the networks. RESULTS: Networks for patients with bulimia nervosa and binge eating disorder confirmed that over-valuation of shape, weight, and eating is the most central symptom in the network. A transdiagnostic network of ED symptoms and separate networks for patients with anorexia nervosa and bulimia nervosa showed that strict dieting was an additional central ED symptom. An exploratory analysis revealed that, although eating disorder symptoms decreased, there were no differences in density of the eating disorder networks before and after treatment with cognitive behavioural therapy. DISCUSSION: In conclusion, the current study confirmed that over-valuation of shape, weight, and eating is a central symptom across eating disorders, in agreement with the transdiagnostic cognitive behavioural model of eating disorders. Specifically targeting this symptom in treatment could lead to other symptoms improving as a result.

Externalizing your eating disorder: a qualitative interview study.

BACKGROUND: Anorexia nervosa (AN) is a psychiatric disorder with an ego-syntonic nature, causing many patients to perceive their AN as part of their personal identity. Therefore, an important part of treatment is the externalization of the eating disorder, in order to help patients to perceive AN as an external influence. Studies on patient experiences of externalization in treatment for AN are sadly missing. The aims of this study were to investigate, first, patients' perspectives on the relation between identity and anorexia nervosa (AN) and second, their experiences of an externalizing approach during treatment. METHOD: A qualitative interview study was conducted including fourteen patients with AN in either Family Based Treatment, the Maudsley Model for Anorexia Nervosa Treatment for Adults, Specialist Supportive Clinical Management-Severe Enduring or Cognitive Behavioural Therapy-Enhanced. RESULTS: There are important differences in participants' perceptions on how AN is related to identity. AN was perceived as part of identity, as alien or as a different side of the self. Patients' experiences towards an externalizing approach were ambivalent. Externalization was considered helpful, whilst also evoking a negative response. Participants reported feeling as if all their behaviour was referred to as part of AN, which elicited feelings of not being taken seriously or being wrongfully accused of being dishonest. CONCLUSIONS: First, there is considerable variation in the perceived relation between AN and identity. Second, an externalizing approach within treatment may lead to so called epistemic injustice. Awareness of these two facts is of importance for clinicians and the therapeutic relationship because that will help them to refrain from actions that can be perceived as epistemic injustice.

Many patients with anorexia nervosa (AN) have the experience that their eating disorder is part of who they are. Therefore, in the treatment of AN, healthcare professionals try to make clear to patients that there is a distinction between who they are and their AN. Through labelling certain thoughts and behaviour as stemming from AN, healthcare professionals guide patients in recognizing what is AN and what is not. This process is called externalization. In this study, fourteen patients with AN were interviewed on their thoughts about the relation between their identity and their eating disorder, and their experiences of externalization of AN within treatment. What becomes clear in these interviews is that patients' perceptions on the relation between AN and their identity varies greatly, from experiencing AN as part of who they are to AN as something completely alien to them. Externalization is sometimes experienced as helpful, yet at the same time patients felt as if all behaviour was labelled as part of AN, which made them feel as if they were wrongly accused of being dishonest or not taken seriously. For healthcare professionals it is important to know that these side effects may arise when externalizing AN in treatment.

Relationships between educational achievement, intelligence, and perfectionism in adolescents with eating disorders.

OBJECTIVE: High performance at school is associated with the risk of eating disorders (EDs), and perfectionism is proposed as an explanatory factor for this association. This study aims to evaluate (a) potential discrepancies between the measured IQ of adolescents with EDs and the IQ that is expected given their educational track, and (b) to what extent perfectionism was associated with educational achievement independent from IQ. METHOD: WISC-III Verbal IQ, Performance IQ, and Full Scale IQ of 386 adolescent ED patients were compared with population norms for their educational track, using one-sample t tests. The association between self-oriented perfectionism (Eating Disorder Inventory-2) and educational achievement, adjusted for IQ, was determined with sequential ordinal regression analyses. RESULTS: Over 50% of the patients received pre-university education, the most complex educational track. For patients receiving education in the second most complex track, IQ-scores were lower than normative data for that track. For patients receiving pre-university education, the verbal IQ was lower than the norm for that track. Self-oriented perfectionism was associated with educational achievement independent from intelligence. DISCUSSION: This study suggests that high educational achievement is common in adolescents with EDs. Particularly for patients who receive education in the most complex tracks the demands at school may be higher than they can handle, based on their IQ. Self-oriented perfectionism contributed to educational achievement independent from IQ. Our results indicate that treatment for EDs should include awareness for the possibility of a too high target level of patients at school and perfectionism.

Measuring body satisfaction in women with eating disorders and healthy women: appearance-related and functional components in the Body Cathexis Scale (Dutch version).

PURPOSE: Differentiating the concept of body satisfaction, especially the functional component, is important in clinical and research context. The aim of the present study is to contribute to further refinement of the concept by evaluating the psychometric properties of the Dutch version of the Body Cathexis Scale (BCS). Differences in body satisfaction between clinical and non-clinical respondents are also explored. METHOD: Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to investigate whether functional body satisfaction can be distinguished as a separate factor, using data from 238 adult female patients from a clinical sample and 1060 women from two non-clinical samples in the Netherlands. Univariate tests were used to identify differences between non-clinical and clinical samples. RESULTS: EFA identified functionality as one of three factors, which was confirmed by CFA. CFA showed the best fit for a three-factor model, where functionality, non-weight, and weight were identified as separate factors in both populations. Internal consistency was good and correlations between factors were low. Women in the non-clinical sample scored significantly higher on the BCS than women with eating disorders on all three subscales, with high effect sizes. CONCLUSIONS: The three factors of the BCS may be used as subscales, enabling researchers and practitioners to use one scale to measure different aspects of body satisfaction, including body functionality. Use of the BCS may help to achieve a more complete understanding of how people evaluate body satisfaction and contribute to further research on the effectiveness of interventions focussing on body functionality. LEVEL OF EVIDENCE: Cross-sectional descriptive study, Level V.

Developments in the psychological treatment of anorexia nervosa and their implications for daily practice.

PURPOSE OF REVIEW: Our aim is to give an overview of the recent literature on psychological treatment for young adults and adults with anorexia nervosa and to discuss the implications of the findings for clinical practice. RECENT FINDINGS: Three systematic reviews and meta-analyses have recently been published on psychological treatments for anorexia nervosa. Treatment outcomes are still modest and mainly focus on weight outcome, although outcomes for eating disorder disease and quality of life have also been reported. Adhering to a treatment protocol might lead to faster and better results. SUMMARY: For children and adolescents with anorexia nervosa, the major guidelines recommend a family-based treatment. The treatments of choice for young adults and adults with anorexia nervosa are the Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), Cognitive Behaviour Therapy-Enhanced (CBT-E) and Specialist Supportive Clinical Management (SSCM), but none of these treatments seem to be superior. In search of other ways to improve outcome, shared decision making may be a way to help patients become more involved in their treatment, enhance their motivation and consequently improve the outcome.

Cognitive Remediation Therapy Does Not Enhance Treatment Effect in Obsessive-Compulsive Disorder and Anorexia Nervosa: A Randomized Controlled Trial.

BACKGROUND: Guideline-recommended therapies are moderately successful in the treatment of obsessive-compulsive disorder (OCD) and anorexia nervosa (AN), leaving room for improvement. Cognitive inflexibility, a common trait in both disorders, is likely to prevent patients from engaging in treatment and from fully benefiting from existing therapies. Cognitive remediation therapy (CRT) is a practical augmentation intervention aimed at ameliorating this impairing cognitive style prior to disorder-specific therapy. OBJECTIVE: To compare the effectiveness of CRT and a control treatment that was not aimed at enhancing flexibility, named specialized attention therapy (SAT), as add-ons to treatment as usual (TAU). METHODS: In a randomized controlled multicenter clinical trial, 71 adult patients with OCD and 61 with AN were randomized to ten twice-weekly sessions with either CRT or SAT, followed by TAU. Patients were evaluated at baseline, post-CRT/SAT, and after 6 and 12 months, with outcomes being quantified using the Yale-Brown Obsessive Compulsive Scale for OCD and the Eating Disorder Examination Questionnaire for AN. RESULTS: Across study groups, most importantly CRT+TAU was not superior to control treatment (SAT)+TAU in reducing OCD and AN pathology. Contrary to expectations, SAT+TAU may have been more effective than CRT+TAU in patients being treated for OCD. CONCLUSIONS: CRT did not enhance the effect of TAU for OCD and AN more than SAT. Unexpectedly, SAT, the control condition, may have had an augmentation effect on TAU in OCD patients. Although this latter finding may have been due to chance, the effect of SAT delivered as a pretreatment add-on intervention for adults with OCD and AN merits future efforts at replication.

Insensitivity to Losses: A Core Feature in Patients With Anorexia Nervosa?

BACKGROUND: Patients with anorexia nervosa (AN) demonstrate aberrations in choice behavior, including impairments in laboratory measures of decision making. Although a wealth of studies suggest that these aberrations arise from alterations in value processing, it remains unclear by which core component of value processing this is mediated. METHODS: We fit trial-by-trial data of patients with AN (n = 60 first cohort, n = 216 second cohort) and healthy control participants (n = 55) performing the Iowa Gambling Task to a computational model based on prospect utility theory. We determined, per participant, the best-fit model parameters and compared these between the groups. RESULTS: Analyses revealed a decreased estimate of model parameter λ in patients with AN, indicative of an attenuation of loss-aversive behavior in the Iowa Gambling Task. In comparison, measures of reward sensitivity, value-based learning, and exploration versus exploitation were unaltered in patients with AN. A measurement in a second independent cohort replicated the finding that loss aversion, typically observed in healthy individuals, is reduced in patients with AN. CONCLUSIONS: We show that patients with AN, in contrast to healthy control participants, demonstrate reduced loss-aversive behavior. This finding provides important fundamental insights into the decision-making capacity of patients with AN, suggesting alterations in the mechanisms involved in value processing related to negative feedback.

Self-injurious behaviour in patients with anorexia nervosa: a quantitative study.

BACKGROUND: Many patients with an eating disorder report difficulties in regulating their emotions and show a high prevalence of self-injurious behaviour. Several studies have stated that both eating disorder and self-injurious behaviour help emotion regulation, and are thus used as coping mechanisms for these patients. We aimed to determine the prevalence of self-injurious behaviour, its characteristics and its emotion-regulation function in patients with anorexia nervosa or an eating disorder not otherwise specified (n = 136). METHODS: A cross-sectional design using a self-report questionnaire. Mann-Whitney U-tests were conducted to compare the background and clinical variables between patients with self-injurious behaviour and patients without this type of behaviour. Changes in emotional state before and after self-injurious behaviour were tested by Wilcoxon signed rank tests. RESULTS: Our results showed a 41% prevalence of self-injurious behaviour in the previous month. Patients who performed self-injurious behaviour had a statistically significant longer treatment history for their eating disorder than those who did not. Whereas 55% of self-injuring patients had a secondary psychiatric diagnosis, only 21% of participants without self-injurious behaviour did. Regarding the impact of self-injurious behaviour, our results showed a significant increase in "feeling relieved" and a significant decrease in "feeling angry at myself", "feeling anxious" and "feeling angry at others". This indicates that self-injurious behaviour can be regarded as an emotion-regulation behaviour. Participants were usually aware of the causes of their self-injurious behaviour acts. CONCLUSIONS: Professionals should systematically assess the occurrence of self-injurious behaviour in eating disorder patients, pay special attention to patients with more severe and comorbid psychopathology, and those with a long treatment history. This assessment should be followed by a functional analysis of the self-injurious behaviour and by effective therapeutic interventions alongside the eating disorder treatment.

Assessment of mental capacity to consent to treatment in anorexia nervosa: A comparison of clinical judgment and MacCAT-T and consequences for clinical practice.

Informed consent requires adequate mental capacity to consent to treatment. Mental capacity (MC) to consent to treatment refers to the ability to make medical decisions. MC is assessed in a general psychiatric interview, but this clinical assessment is known to overestimate mental capacity in patients and the inter rater reliability is low. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) has emerged as the gold standard to assess mental capacity to consent to treatment. The MacCAT-T is a semi-structured interview designed to aid clinicians in this assessment and has shown good inter rater reliability in patients with schizophrenia and other mental disorders, but has hardly been studied in patients with anorexia nervosa. Patients with anorexia nervosa (AN) regularly avoid treatment, even when severely ill and discussion includes assessing MC to consent to treatment. The aim of this study is to compare clinical judgment and the MacCAT-T in evaluating MC in patients with AN which in turn may influence use of the MacCAT-T in daily practice. In a sample of 70 consecutively referred severely ill patients with AN with a mean BMI of 15.5 kg/m2 and a mean duration of illness of 8.6 years, clinical assessment of MC by experienced psychiatrists and the outcome of the MacCAT-T interview were compared. Agreement (κ-value) was calculated. Agreement between clinical assessment and outcome of the MacCAT-T was questionable (κ 0.23). Unlike in other psychiatric populations, clinicians judged a high proportion of patients with AN as having diminished MC. The MacCAT-T can be useful in assessing MC in AN when used in addition to clinical judgment to aid clinicians in complex cases. Why clinicians judge a relatively high proportion of patients with AN as having diminished MC, in contrast to lower proportions in other psychiatric disorders, is an area in need of further research.

Relapse prevention in anorexia nervosa: Experiences of patients and parents.

One of the main aims of treatment after successful recovery from anorexia nervosa (AN) is to prevent a relapse. The Guideline Relapse Prevention (GRP) Anorexia Nervosa offers a structured approach to relapse prevention. This study explores how patients and their parents experience working with the guideline. It also describes the factors that support or hinder successful application of the guideline. A descriptive qualitative research design was chosen involving in-depth interviews with seventeen patients with anorexia nervosa and six sets of parents. Patients and family members were generally satisfied with the support provided by the GRP. It contributed significantly to a better understanding of the personal process of relapse. Patients and families valued being able to keep in touch with their professional during the aftercare programme. The GRP supports the patient's use of self-management strategies for relapse prevention.

Development and Validation of a Decision Tool for Early Identification of Adult Patients with Severe and Complex Eating Disorder Psychopathology in Need of Highly Specialized Care.

Patients with complex and severe eating disorders often receive a number of ineffective or/and insufficient treatments. Direct referral of these patients to highly specialized tertiary treatment facilities in an earlier stage of the disorder is likely to be more (cost)-effective. The aim of the study was to develop a decision tool that aids clinicians in early identification of these patients. After identification of criteria that were indicative of severity and complexity of eating disorder psychopathology by means of a systematic review of literature and consultation of a focus group, a Delphi method was applied to obtain consensus from experts on the list of relevant criteria. Finally, the decision tool was validated in clinical practice, and cut-off criteria were established. The tool demonstrated good feasibility and validity to identify patients for highly specialized tertiary care. The final decision tool consisted of five criteria that can easily be implemented in clinical practice. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Mental capacity to consent to treatment and the association with outcome: a longitudinal study in patients with anorexia nervosa.

BACKGROUND: Relevance of diminished mental capacity in anorexia nervosa (AN) to course of disorder is unknown. AIMS: To examine prognostic relevance of diminished mental capacity in AN. METHOD: A longitudinal study was conducted in 70 adult female patients with severe AN. At baseline, mental capacity was assessed by psychiatrists, and clinical and neuropsychological data (decision-making) were collected. After 1 and 2 years, clinical and neuropsychological assessments were repeated, and remission and admission rates were calculated. RESULTS: People with AN with diminished mental capacity had a less favourable outcome with regard to remission and were admitted more frequently. Their appreciation of illness remained hampered. Decision-making did not improve, in contrast to people with full mental capacity. CONCLUSIONS: People with AN with diminished mental capacity seem to do less well in treatment and display decision-making deficiencies that do not ameliorate with weight improvement. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.