Posttraumatic stress disorder (PTSD) and complex PTSD in eating disorder treatment-seekers: Prevalence and associations with symptom severity.

Although childhood trauma and posttraumatic stress disorder (PTSD) have been well-researched in eating disorder epidemiology, prevalence rates are unavailable for complex PTSD (CPTSD). Under recently introduced ICD-11 criteria, individuals with CPTSD have both PTSD symptoms and additional disturbances in self-organization (DSO). Using ICD-11 criteria, this study aimed to determine the prevalence of PTSD and DSO symptoms, diagnostic rates of PTSD and CPTSD, and childhood trauma exposure in eating disorder treatment-seekers. Participants (N = 217) were individuals attending residential, partial hospitalization, and outpatient services who completed measures of eating disorder- and trauma-related symptoms and childhood adverse experiences. One third of participants reported PTSD symptoms, and over half reported DSO symptoms, with probable ICD-11 diagnostic rates of 3.8% for PTSD and 28.4% for CPTSD. CPTSD was significantly more prevalent than PTSD and more common in higher levels of care. Both PTSD and DSO symptom severity were positively correlated with eating disorder symptoms and impairment, rs = .285-.642. DSO symptom severity was a significant and unique explanatory factor of eating disorder severity and impairment. The findings highlight the prevalence of CPTSD in eating disorder populations and the association between DSO symptoms and eating psychopathology independent of PTSD symptoms. Implications are discussed for adjunct treatment approaches for individuals with comorbid eating disorders and PTSD or CPTSD.

Evaluating the Role of Methylated Circulating Tumor DNA in Combination With Pathological Prognostic Factors for Predicting Recurrence of Colorectal Cancer.

Background: Colorectal cancer (CRC) has a high rate of recurrence, in particular for advanced disease, but prognosis based on staging and pathology at surgery can have limited efficacy. The presence of circulating tumor DNA (ctDNA) at diagnosis could be used to improve the prediction for disease recurrence. Objectives: To assess the impact of detecting methylated BCAT1/IKZF1 ctDNA at diagnosis in combination with demographic, lifestyle, clinical factors and tumor pathology, to assess predictive value for recurrence. Design: A retrospective cohort study. Methods: The cohort included 180 patients (36 with recurrent CRC), who had undergone complete treatment and surveillance for a minimum of 3 years. Participant clinical details and ctDNA methylated BCAT1/IKZF1 results were compared between those with and without recurrence, and cox regression analysis assessed each factor on disease-free survival. Results: Clinical factors independently associated with reduced disease-free survival included nodal involvement (HR = 3.83, 95% CI 1.56-9.43, P = .003), M1 stage (HR = 4.41, 95% CI 1.18-16.45, P = .027), a resection margin less than 2 mm (HR = 4.60, 95% CI 1.19-17.76, P = .027), perineural involvement (HR = 2.50, 95% CI 1.01-6.17, P = .047) and distal tumors (HR = 3.13, 95% CI 1.07-9.18, P = .037). Methylated BCAT1/IKZF1 was detected in 51.7% (93/180) of pre-treatment plasma samples. When a positive ctDNA finding was considered in combination with these clinical prognostic factors, there was improved predictive power of recurrence for patients with perineural involvement (HR = 4.44, 95% CI 1.92-10.26, P < .001), and it marginally improved the predictive factor for M1 stage (HR = 7.59, 95% CI 2.30-25.07, P = .001) and distal tumors (HR = 5.04, 95% CI 1.88-13.49, P = .001). Conclusions: Nodal invasion, metastatic disease, distal tumor site, low resection margins and perineural invasion were associated with disease recurrence. Pre-treatment methylated ctDNA measurement can improve the predictive value for recurrence in a subset of patients, particularly those with perineural involvement. Registration: Australian and New Zealand Clinical Trials Registry #12611000318987.

Association between gut microbiota development and allergy in infants born during pandemic-related social distancing restrictions.

BACKGROUND: Several hypotheses link reduced microbial exposure to increased prevalence of allergies. Here we capitalize on the opportunity to study a cohort of infants (CORAL), raised during COVID-19 associated social distancing measures, to identify the environmental exposures and dietary factors that contribute to early life microbiota development and to examine their associations with allergic outcomes. METHODS: Fecal samples were sequenced from infants at 6 (n = 351) and repeated at 12 (n = 343) months, using 16S sequencing. Published 16S data from pre-pandemic cohorts were included for microbiota comparisons. Online questionnaires collected epidemiological information on home environment, healthcare utilization, infant health, allergic diseases, and diet. Skin prick testing (SPT) was performed at 12 (n = 343) and 24 (n = 320) months of age, accompanied by atopic dermatitis and food allergy assessments. RESULTS: The relative abundance of bifidobacteria was higher, while environmentally transmitted bacteria such as Clostridia was lower in CORAL infants compared to previous cohorts. The abundance of multiple Clostridia taxa correlated with a microbial exposure index. Plant based foods during weaning positively impacted microbiota development. Bifidobacteria levels at 6 months of age, and relative abundance of butyrate producers at 12 months of age, were negatively associated with AD and SPT positivity. The prevalence of allergen sensitization, food allergy, and AD did not increase over pre-pandemic levels. CONCLUSIONS: Environmental exposures and dietary components significantly impact microbiota community assembly. Our results also suggest that vertically transmitted bacteria and appropriate dietary supports may be more important than exposure to environmental microbes alone for protection against allergic diseases in infancy.

New understandings meet old treatments: putting a contemporary face on established protocols.

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

In the field of eating disorders the most commonly used manualised treatments are nearly twenty years old. There has been much progress in the field since then in terms of technologies, understandings and social changes. In this paper, two experienced clinical psychologists describe some of the more recent developments in the field and highlight ways to incorporate the new learnings into clinical practice and research design.

Developmental and behavioural outcomes at 2 years in babies born during the COVID-19 pandemic: communication concerns in a pandemic birth cohort.

INTRODUCTION: The CORAL (Impact of Corona Virus Pandemic on Allergic and Autoimmune Dysregulation in Infants Born During Lockdown) study reported a reduction in social communication milestones in 12-month-old infants born into the COVID-19 pandemic. AIMS: To look at 24-month developmental and behavioural outcomes in the CORAL cohort. DESIGN: The CORAL study is a longitudinal prospective observational study of Irish infants born in the first 3 months of the pandemic. At 24 months of age, the Ages and Stages Developmental Questionnaire (ASQ24) and the Child Behaviour Checklist (CBCL) were completed and compared with prepandemic BASELINE (Babies After SCOPE: Evaluating the Longitudinal Impact Using Neurological and Nutritional Impact) cohort. RESULTS: 917 babies (312 CORAL infants and 605 BASELINE infants) were included. At 24 months of age, infants in the CORAL and BASELINE cohorts had similar developmental ASQ24 scores in fine motor, problem solving and personal and social domains but ASQ24 communication scores were significantly lower in the CORAL group compared with the BASELINE cohort (mean (SD) 49.5 (15.1) vs 53.7 (11.6), p<0.01). Infants from the CORAL cohort were more likely to score below standardised cut-offs for developmental concern in the communication domain (11.9% CORAL compared with 5.4% BASELINE, p<0.01). Unadjusted ASQ24 gross motor scores were lower for the pandemic cohort. Fewer CORAL infants fell under 2 SD cut-off in personal-social subdomain. For CBCL, there was no evidence of difference in scores between the cohorts on multivariable analysis. CONCLUSION: 24-month-old pandemic-born infants had largely similar developmental and behavioural scores compared with their prepandemic counterparts. Concerns have been raised in the communication developmental domain.

A multi-center, randomized, parallel-group study to compare the efficacy of enhanced cognitive behavior therapy (CBT-E) with treatment as usual (TAU) for anorexia nervosa: study protocol.

BACKGROUND: The superiority of Enhanced Cognitive Behavior Therapy (CBT-E) with regard to weight gain and improvement of psychopathology of eating disorders for patients with anorexia nervosa (AN) over other psychotherapies and treatment as usual (TAU) has not been demonstrated in randomized controlled trials (RCTs). However, a previous RCT showed that patients with AN whose baseline body mass index (BMI) was less than 17.5 kg/m2 gained more weight when treated with CBT-E than with other psychotherapies. The aim of the study is to compare the efficacy of CBT-E and TAU for patients with AN. It was hypothesized that CBT-E would be superior to TAU, at least in terms of weight gain, as most patients with AN are likely to have a BMI lower than 17.5 kg/m2. METHODS/DESIGN: A randomized parallel-group multicenter trial will be conducted in three teaching hospitals in Japan between January 2023 and March 2026. Patients with DSM-5 AN, aged 16 years and older, with a BMI equal to or above 14.0 and below 18.5 will be eligible to participate. 56 patients will be randomly and evenly assigned to two intervention groups (CBT-E and TAU). Those assigned to CBT-E will be offered 25-40 sessions in accordance with their initial BMI. Patients assigned to TAU will have at least one session every 2 weeks, with the number of sessions and treatment period not fixed in advance. The primary outcome is BMI at 40 weeks after treatment initiation. The secondary outcomes are the results from the Japanese version of the Eating Disorder Examination Questionnaire and Clinical Impairment Assessment questionnaire to measure eating disorder psychopathology and psychological impairment. The follow-up assessment will be performed 6 months after the 40-week assessment. DISCUSSION: This multi-center randomized controlled study will probably evaluate the efficacy of CBT-E compared with TAU for patients with more severe AN than in previous studies since Japanese patients are likely to have a lower BMI than those in Western countries. While it may be difficult to generalize the results of a study conducted in Japan, it would be valuable to clarify the efficacy of CBT-E as a treatment package. TRIAL REGISTRATION: UMIN, UMIN000048847. Registered 12 Sep 2022.

Case report: Varicella associated neuropsychiatric syndrome (VANS) in two pediatric cases.

Background: Viral or bacterial infections can trigger auto-immune inflammatory reactions and conditions in children. Self-reactivity arises due to similarities in molecular structures between pathogenic microorganisms and regular body structures with consequent immune-cross reactions. Reactivation of latent Varicella Zoster Virus (VZV) infections can cause neurological sequalae, including cerebellitis, post-herpetic neuralgias, meningo/encephalitis, vasculopathy and myelopathy. We propose a syndrome caused by auto-immune reactivity triggered by molecular mimicry between VZV and the brain, culminating in a post-infectious psychiatric syndrome with childhood VZV infections. Case presentation: Two individuals, a 6-year-old male and 10-year-old female developed a neuro-psychiatric syndrome 3-6 weeks following a confirmed VZV infection with intrathecal oligoclonal bands. The 6-year-old male presented with a myasthenic syndrome, behavior deterioration and regression in school, he was poorly responsive to IVIG and risperidone, however had a pronounced response to steroid treatment. The 10-year-old female presented with marked insomnia, agitation, and behavioral regression as well as mild bradykinesia. A trial of neuroleptics and sedatives resulted in a mild unsustained reduction in psychomotor agitation and IVIG was also unsuccessful, however the patient was very responsive to steroid therapy. Conclusion: Psychiatric syndromes with evidence of intrathecal inflammation temporally related to VZV infections that are responsive to immune modulation have not been described before. Here we report two cases demonstrating neuro-psychiatric symptoms following VZV infection, with evidence of persistent CNS inflammation following the resolution of infection, and response to immune modulation.

Collaborative dietetic and psychological care in Interprofessional Enhanced Cognitive Behaviour Therapy for adults with Anorexia Nervosa: a novel treatment approach.

Clinical practice guidelines for anorexia nervosa (AN) and atypical anorexia nervosa recommend treatment from a team including a mental health professional and a dietitian. To date, however, AN treatment models such as Enhanced Cognitive Behaviour Therapy (CBT-E) seldom include dietitians and have low to moderate treatment efficacy. Given interprofessional approaches to healthcare have been shown to improve treatment outcomes and enhance patient and clinician satisfaction, formalising collaborative dietetic and psychological treatment may be a feasible strategy to improve treatment outcomes and the patient and clinician experience of treatment. Moreover, malnutrition is a serious consequence of AN, and dietitians are considered experts in its diagnosis and treatment. This paper proposes a novel treatment approach, Interprofessional Enhanced Cognitive Behaviour Therapy (CBT-IE), an adaptation of CBT-E where dietitians deliver content related to malnutrition and dietary restraint and mental health professionals deliver content related to cognitive and behavioural change. The rationale for developing CBT-IE, treatment structure, and future research directions is discussed.

Fifteen-minute consultation: Diagnosing serious pathology in children with headaches presenting to the emergency department.

Headache is one of the most common presentations to the paediatric emergency department. Although challenging, it is important to differentiate serious secondary headaches requiring emergency treatment from primary headache disorders. A detailed history and neurological examination can be used to identify children at higher risk of serious underlying pathology. Neuroimaging decisions should be taken carefully, weighing risk versus benefit in each case. This article will discuss five patient scenarios highlighting red flags and differential diagnoses in children presenting with headache in the emergency department.

Social communication skill attainment in babies born during the COVID-19 pandemic: a birth cohort study.

INTRODUCTION: The SARS-CoV-2 (COVID-19) pandemic was managed with sustained mass lockdowns to prevent spread of COVID-19 infection. Babies born during the early stages of the pandemic missed the opportunity of meeting a normal social circle of people outside the family home. METHODS: We compared 10 parentally reported developmental milestones at 12-month assessment in a cohort of 309 babies born at the onset of the pandemic (CORAL cohort) and 1629 babies from a historical birth cohort (BASELINE cohort recruited between 2008 and 2011). RESULTS: Compared with a historical cohort, babies born into lockdown appeared to have some deficits in social communication. Fewer infants in the pandemic cohort had one definite and meaningful word (76.6% vs 89.3%), could point (83.8% vs 92.8%) or wave bye-bye (87.7% vs 94.4%) at 12-month assessment. Adjusted log-binomial regression analyses demonstrated significant differences in social communication in the CORAL cohort compared with the BASELINE cohort: one definite and meaningful word (relative risk (RR): 0.86 (95% CI: 0.80 to 0.92)), pointing (RR: 0.91 (95% CI: 0.86 to 0.96)) and waving bye-bye (RR: 0.94 (95% CI: 0.90 to 0.99)). DISCUSSION: Parentally reported developmental outcomes in a birth cohort of babies born into lockdown during the COVID-19 pandemic may indicate some potential deficits in early life social communication. It must be noted that milestones are parentally reported and comparison is with a historical cohort with associated limitations. Further studies with standardised testing is required to validate these findings. CONCLUSION: Pandemic-associated social isolation may have impacted on the social communication skills in babies born during the pandemic compared with a historical cohort. Babies are resilient and inquisitive by nature, and it is hoped that with societal re-emergence and increase in social circles, their social communication skills will improve.

Parenting a newborn baby during the COVID-19 pandemic: a qualitative survey.

OBJECTIVE: The COVID-19 pandemic caused long periods of lockdown, social isolation and intense challenges for parents. This study examines parenting in an infant cohort born at the pandemic onset. METHODS: The CORAL study is a prospective longitudinal observational study looking at allergy, immune function and neurodevelopmental outcome in babies born between March and May 2020. Demographic information was collected, babies were reviewed at 6-monthly intervals, and serology for COVID-19 infection was recorded. When babies were 12 months old, parents were asked for 3-5 words to describe raising a baby during the pandemic. Frequency of word usage was compared between first time parents and parents with other children, and parents of babies with and without a diagnosis of COVID-19 infection. RESULTS: 354 babies were recruited to CORAL study. Social circles were small. At 6 months the median number of people (including parents) who had kissed the baby was 3, and by 12 months one-quarter of babies had never met another child of similar age. 304 parents completed the word choice. Commonly reported words were lonely (44.4%), isolating (31.9%) and strong bond (15.8%). 12 of those 304 babies had COVID-19 in their first year of life and there was no significant difference in reported negative or positive word number compared with parents of babies without a COVID-19 infection, or by first time parents or those who already had children. CONCLUSION: The lockdowns and social restrictions made raising an infant challenging for all parents in Ireland. It is important parents know this was a shared experience.

An exploratory examination of executive functioning as an outcome, moderator, and predictor in outpatient treatment for adults with anorexia nervosa.

OBJECTIVE: People with anorexia nervosa often exhibit inefficiencies in executive functioning (central coherence and set shifting) that may negatively impact on treatment outcomes. It is unclear from previous research whether these inefficiencies can change over treatment. We aimed to (1) investigate whether executive functioning can improve over treatment, (2) determine whether baseline executive functioning moderates treatment outcome, and (3) examine whether baseline executive functioning predicts early change (i.e., increase in body mass index over the first 13 weeks of treatment) or remission. METHOD: We conducted linear mixed model and logistic regression analyses on data from the Strong Without Anorexia Nervosa trial (Byrne et al. in Psychol Med 47:2823-2833, 2017). This study was a randomised controlled trial of three outpatient treatments for people with anorexia nervosa: Enhanced Cognitive Behavioural Therapy, Maudsley Model Anorexia Nervosa Treatment for Adults, and Specialist Supportive Clinical Management. RESULTS: While set shifting clearly improved from baseline to end of treatment, the results for central coherence were less clear cut. People with low baseline central coherence had more rapid reductions in eating disorder psychopathology and clinical impairment than those with high baseline central coherence. Baseline executive functioning did not predict early change or remission. DISCUSSION: The detail-focused thinking style commonly observed among people with anorexia nervosa may aid treatment outcomes. Future research that is more adequately powered should replicate this study and examine whether the same pattern of results is observed among people with non-underweight eating disorders.

People with anorexia nervosa often have difficulty thinking flexibly and in terms of the big picture. We investigated whether these thinking styles (1) change over treatment, (2) influence response to treatment, or (3) predict whether people gain weight or overcome the eating disorder. We found that people were able to think more flexibly after treatment. We also found that people who had more difficulty seeing the big picture prior to treatment had a more rapid decrease in eating disorder symptoms and clinical impairment in treatment. Thinking styles did not predict whether people gained weight early in treatment or overcame the eating disorder. Our findings suggest that the detail-focused thinking style commonly observed among people with anorexia nervosa can be both a vulnerability and a strength.

Is guided self-help family-based treatment for parents of adolescents with anorexia nervosa on treatment waitlists feasible? A pilot trial.

OBJECTIVE: The aim of the study was to assess the feasibility (recruitment and retention) of an online 12-session guided self-help family-based treatment (GSH-FBT) for families on the waitlist for face-to-face FBT utilizing trainee psychologists to assist carers of children with anorexia nervosa (AN) or atypical AN. METHOD: The primary outcomes were feasibility of GSH-FBT for families on the waitlist and secondary exploratory outcomes examined improvement of child and parental function. RESULTS: Of 187 eligible families on the waitlist, 24 (13%) expressed interest in the study; 16 (67%) of these families completed baseline, 13 (54%) completed GSH-FBT over a 6-month recruitment period. Children (mean age = 13.92, SD = .86; mean body mass index [BMI] centile = 29.47, SD = 24.80) had an average weight gain of 6 kg (BMI centile effect size = 2.61, 95% CI: 1.77-3.44) and a decrease in eating disorder behaviors (effect size = 1.11, 95% CI: .27-1.95). Improvements also occurred for general mood and behaviors in the child, and the impact of eating disorder symptoms on their functioning. Parents reported improvements in knowledge, skills, and confidence in managing AN. DISCUSSION: Use of this low-cost intervention while families are on the waitlist for FBT is engaging and useful but strategies to improve initial recruitment are needed. PUBLIC SIGNIFICANCE STATEMENT: Although most eligible families did not enroll in an online 12-session guided self-help family-based treatment for families on the waitlist for face-to-face FBT for anorexia nervosa, families who participated found it engaging. The children experienced improvements in BMI centile, eating and behavior. Parents reported increased confidence, knowledge, and skills. We need to examine how families can be encouraged to participate on online training when on waitlists for treatment.

Emotion Dysregulation and Eating Disorder Symptoms: Examining Distinct Associations and Interactions in Adolescents.

Emotion dysregulation has been posited as a key transdiagnostic factor of mental health difficulties, including eating disorders. However, how this transdiagnostic factor interacts with the disorder-specific factor of weight and shape concerns remains unclear. The current study examined whether emotion dysregulation is associated with eating disorder behaviors over and above the association between weight and shape concerns and whether these two factors interacted. The current study used data from two samples, a community sample of high school students (n = 2699), and a clinical sample of adolescents receiving outpatient treatment for an eating disorder (n = 149). Participants completed self-report measures on their eating behaviors, weight/shape concerns, and emotion dysregulation. Findings showed that emotion dysregulation had a unique association with engaging in binge eating and purging (community sample only). Weight and shape concerns were found to have a unique association with engaging in binge eating, fasting, purging, and driven exercise (community sample only). Additionally, weight and shape concerns moderated the association between emotion dysregulation and the probability of engaging in binge eating and driven exercise, whereby the strongest association between emotion dysregulation and these behaviors were observed among adolescents with the lowest levels of weight and shape concerns. Regarding the frequency of eating disorder behaviors, emotion dysregulation had a unique association with severity of binge eating and fasting. Weight and shape concerns were uniquely associated with severity of fasting and driven exercise (community sample only). Findings suggest that emotion dysregulation is a distinct factor of eating disorder behaviors among adolescents.

Assessment of tumor burden and response to therapy in patients with colorectal cancer using a quantitative ctDNA test for methylated BCAT1/IKZF1.

Failure of colorectal cancer (CRC) treatment is due to residual disease, and its timely identification is critical for patient survival. Detecting CRC-associated mutations in patient circulating cell-free DNA is confounded by tumor mutation heterogeneity, requiring primary tumor sequencing to identify relevant mutations. In this study, we assessed BCAT1 and IKZF1 methylation levels to quantify circulating tumor DNA (ctDNA) and investigated whether this method can be used to assess tumor burden and efficacy of therapy. In 175 patients with CRC who were ctDNA-positive pretreatment, ctDNA levels were higher with advancing stage (P < 0.05) and correlated with tumor diameter (r = 0.35, P < 0.001) and volume (r = 0.58, P < 0.01). After completion of treatment (median of 70 days [IQR 49-109] after surgery, +/- radiotherapy, +/- chemotherapy), ctDNA levels were reduced in 98% (47/48) and were undetectable in 88% (42/48) of patients tested. For those with incomplete adjuvant chemotherapy after surgery, roughly half remained ctDNA-positive (11/21, 52.4%). The presence of ctDNA after treatment was associated with disease progression (HR 9.7, 95%CI 2.5-37.6) compared to no ctDNA. Assaying blood for ctDNA methylated in BCAT1/IKZF1 has the potential for identifying residual disease due to treatment failure, informing a potential need for therapy adjustment in advanced disease.

Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders.

OBJECTIVE: Only a small proportion of individuals with an eating disorder will receive targeted treatment for their illness. The aim of this study was to examine the length of delay to treatment-seeking and determine the barriers preventing earlier access and utilisation of eating disorder treatment for each diagnostic group - anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding or eating disorder. METHOD: Participants were recruited as part of the TrEAT multi-phase consortium study. One hundred and nineteen Australians (13-60 years; 96.9% female) with eating disorders currently accessing outpatient treatment for their illness completed an online survey comprised of self-report measures of eating disorder severity, treatment delay and perceived barriers to treatment-seeking. The treating clinician for each participant also provided additional information (e.g. body mass index and diagnosis). RESULTS: Overall, the average length of delay between onset of eating disorder symptoms and treatment-seeking was 5.28 years. Controlling for age, latency to treatment-seeking was significantly longer for individuals with bulimia nervosa and binge eating disorder compared to anorexia nervosa. However, when perceived barriers to treatment-seeking were investigated, there were no significant differences between the diagnostic groups in regard to the perceived barriers they experienced. Stigma was rated as the most impactful barrier for each diagnostic group. CONCLUSION: Findings suggest that individuals with eating disorders face substantial delays in accessing appropriate treatment and that latency to treatment-seeking is often magnified for counter-stereotypical eating disorder presentations. Further research is required to investigate other factors contributing to this delay.