Illness duration and treatment outcome of intensive cognitive-behavioral therapy in adolescents with anorexia nervosa.

OBJECTIVE: This study aimed to compare the effectiveness of an intensive treatment based on enhanced cognitive-behavioral therapy (CBT-E) in patients aged between 12 and 18 years with anorexia nervosa with a duration of illness <3 versus ≥3 years. METHODS: One hundred and fifty-nine consecutively treated patients (n = 122 with illness duration <3 years and n = 37 ≥ 3 years) were enrolled in a 20-week intensive CBT-E program. All patients underwent assessment at admission, end of treatment (EOT), and 20-week follow-up. The following measures were used: body mass index (BMI)-for-age percentile and percentage of expected body weight (EBW), Eating Disorder Examination Questionnaire, Brief Symptom Inventory, and Clinical Impairment Assessment. RESULTS: Approximately 81% of eligible patients began the program, with over 80% successfully completing it. Patients with a longer or shorter duration of illness did not show significantly different treatment outcomes. In detail, BMI-for-age percentile and percentage of EBW outcomes were significantly improved from baseline to EOT, remaining stable until 20-week follow-up in both groups. Similarly, in both groups, scores for eating disorder psychopathology, general psychopathology, and clinical impairment decreased significantly at EOT and remained stable from EOT to follow-up. Furthermore, a substantial percentage of adolescents in both groups achieved a good BMI outcome at EOT and 20-week follow-up, with approximately 60% maintaining a full response at the latter time point. DISCUSSION: These findings suggest that intensive CBT-E appears to be an effective treatment for severely ill adolescent patients with anorexia nervosa, regardless of whether the duration of illness is shorter or longer than 3 years. PUBLIC SIGNIFICANCE: Existing treatment outcome studies in adolescents, whether randomized controlled trials or longitudinal investigations, typically involve patients with less than 3 years of illness, while data on the treatment outcomes for adolescents with anorexia nervosa with an illness duration of 3 years or over is very limited. Our findings suggest that adolescents with anorexia nervosa, irrespective of the duration of their illness, can derive similar benefits from intensively CBT-E.

The Benefit of Healthy Lifestyle in the Era of New Medications to Treat Obesity.

Incretin-based medications for treating obesity produce substantial short- and long-term weight loss and improve obesity-related comorbidities. However, associating lifestyle modification with new medications to treat obesity is generally advisable for several reasons. Firstly, healthy eating patterns and physical activity may offer important additional benefits, enhancing the patient's health and well-being. In addition, regular specialist counselling in lifestyle modification can help patients maintain their motivation levels and develop specific skills for addressing obstacles during the lengthy process of weight loss and maintenance, potentially improving outcomes in the long term. Given the high efficacy of the new weight-loss drugs, it would be timely to streamline and simplify the current gold standard of obesity management based on lifestyle modification. For example, it now seems redundant to prescribe strict diets or meal replacements to reduce calorie intake, or to recommend patients practice 200 to 300 minutes of moderate-to-vigorous-intensity exercise for enhanced weight loss. Moderate calorie restriction and, at least 150 minutes of moderate-intensity aerobic exercise and two sessions of muscle-strengthening activities per week may be more achievable and appropriate goals for sustainable weight loss in most patients on pharmaceutical obesity treatment. As regards lifestyle modification counselling, future studies should assess its optimal intensity and duration in the "new medications for obesity era".

Reply to Meule, A. Comment on "Calugi et al. The Role of Weight Suppression in Intensive Enhanced Cognitive Behavioral Therapy for Adolescents with Anorexia Nervosa: A Longitudinal Study. Int. J. Environ. Res. Public Health 2023, 20, 3221".

We read the comments by Meule on our article with great interest, and we thank the author for his thoughtful suggestions [...].

Effectiveness of enhanced cognitive behaviour therapy for patients aged 14 to 25: A promising treatment for anorexia nervosa in transition-age youth.

OBJECTIVE: The study aimed to evaluate the effectiveness of enhanced cognitive behaviour therapy (CBT-E) on patients with anorexia nervosa (AN) aged 14 to 25 treated in a real-world setting. METHOD: One hundred and fifteen patients with AN (n = 61, age <18 years) were recruited from consecutive referrals to a clinical eating disorder service offering outpatient CBT-E. Body Mass Index (BMI), BMI centiles, Eating Disorder Examination Questionnaire, Brief Symptom Inventory, and Clinical Impairment Assessment scores were recorded at admission, at the end of treatment, and at 20-week follow-up. RESULTS: The seventy-two patients (62.6%) who finished the programme showed considerable weight gain and reduced scores for clinical impairment and eating-disorder and general psychopathology. Changes remained stable at 20 weeks. A comparison between adolescent and adult patients indicates similar improvements in eating-disorder psychopathology. CONCLUSIONS: The benchmark data yielded by this study suggest that CBT-E is a well-accepted and promising treatment that could be adopted to ensure continuity of care across the transitional age.

Weight Bias Internalization and Eating Disorder Psychopathology in Treatment-Seeking Patients with Obesity.

This study aimed to investigate the relationship between weight bias internalization and eating disorder psychopathology in treatment-seeking patients with severe obesity using a network approach. Two thousand one hundred and thirteen patients with obesity were consecutively admitted to a specialist clinical unit for obesity and were recruited from January 2016 to February 2023. Body mass index was measured, and each patient completed the Weight Bias Internalization Scale (WBSI) and the Eating Disorder Examination Interview (EDE). Network analysis showed that the most central and highly interconnected nodes in the network were related to the EDE items exposure avoidance, dissatisfaction with shape, and wanting an empty stomach. Bridge nodes were found, but the bootstrap difference test on expected bridge influence indicated non-significant centrality differences. Nevertheless, the eating disorder psychopathology and weight bias internalization network structure in patients seeking treatment for obesity indicate the prominent roles of body dissatisfaction and control of eating and weight in these psychological constructs. This finding, if replicated, could pave the way for a new understanding of the psychological mechanisms operating in patients with obesity.

Eating disorders in weight-related therapy (EDIT): Protocol for a systematic review with individual participant data meta-analysis of eating disorder risk in behavioural weight management.

The Eating Disorders In weight-related Therapy (EDIT) Collaboration brings together data from randomised controlled trials of behavioural weight management interventions to identify individual participant risk factors and intervention strategies that contribute to eating disorder risk. We present a protocol for a systematic review and individual participant data (IPD) meta-analysis which aims to identify participants at risk of developing eating disorders, or related symptoms, during or after weight management interventions conducted in adolescents or adults with overweight or obesity. We systematically searched four databases up to March 2022 and clinical trials registries to May 2022 to identify randomised controlled trials of weight management interventions conducted in adolescents or adults with overweight or obesity that measured eating disorder risk at pre- and post-intervention or follow-up. Authors from eligible trials have been invited to share their deidentified IPD. Two IPD meta-analyses will be conducted. The first IPD meta-analysis aims to examine participant level factors associated with a change in eating disorder scores during and following a weight management intervention. To do this we will examine baseline variables that predict change in eating disorder risk within intervention arms. The second IPD meta-analysis aims to assess whether there are participant level factors that predict whether participation in an intervention is more or less likely than no intervention to lead to a change in eating disorder risk. To do this, we will examine if there are differences in predictors of eating disorder risk between intervention and no-treatment control arms. The primary outcome will be a standardised mean difference in global eating disorder score from baseline to immediately post-intervention and at 6- and 12- months follow-up. Identifying participant level risk factors predicting eating disorder risk will inform screening and monitoring protocols to allow early identification and intervention for those at risk.

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.

Efficacy and tolerability of a specific blend of amino acids in patients with anorexia nervosa treated in a hospital setting: study protocol for a randomized controlled trial.

BACKGROUND: Specific blends of essential amino acids (EAA) containing a high percentage of branched-chain amino acids preserves mitochondrial metabolism and higher physical resistance in elderly mice, increasing their survival and improving physical performance and cognitive functions in malnourished elderly patients. However, no study has been yet done on patients with anorexia nervosa (AN) who regain weight with specialized intensive treatment. The present study aims to evaluate the efficacy of supplementation with EAA on the change in lean body mass (LBM) and other physical and psychological outcomes in patients with AN who are undergoing specialist treatment for eating disorders. METHODS: This is a 13-week randomized, double-blind, placebo-controlled study. Patients will be randomized to either a mixture of a complex blend of EAA and intermediates of the tricarboxylic acid (TCA) cycle (citrate, malate, succinate) supplementation (or placebo) upon admission at the intensive residential and day-hospital treatment for eating disorders. Ninety-two participants with AN aged 16-50 years will be recruited from a specialized intensive treatment of eating disorders. Double-blind assessment will be conducted at baseline (T0) and the end of the 13 weeks of treatment (T1). The study's primary aim is to evaluate the efficacy of supplementation with EAA and TCA intermediates on the change in lean body mass (LBM) with weight restoration in patients with AN who are undergoing specialist treatment for eating disorders. The secondary aims of the study are to assess the effect of dietary supplementation on physical fitness, weight restoration, modification of AN and general psychopathology, and psychosocial impairment. DISCUSSION: The study's results will inform researchers and clinicians on whether supplementing a mixture of EAA and TCA cycle intermediates will improve the increase of LBM and other important physical and psychological outcomes in patients with AN who regain weight with specialized intensive treatment. TRIAL REGISTRATION: NCT, NCT05290285. Registered on 22 March 2022.

The Role of Weight Suppression in Intensive Enhanced Cognitive Behavioral Therapy for Adolescents with Anorexia Nervosa: A Longitudinal Study.

The study aimed to establish the role of weight suppression in a cohort of adolescents with anorexia nervosa treated with intensive enhanced cognitive behavioral therapy (CBT-E). One hundred and twenty-eight adolescent patients with anorexia nervosa (128 females and 2 males), aged between 14 and 19 years, were recruited from consecutive referrals to a community-based eating disorder clinic offering intensive CBT-E. Weight, height, Eating Disorder Examination Questionnaire, and Brief Symptom Inventory scores were recorded at admission, end-of-treatment, and at a 20-week follow-up. In addition, the developmental weight suppression (DWS, difference between one's highest premorbid and current z-BMI, i.e., BMI z-scores) was calculated. The mean baseline z-BMI was -4.01 (SD = 2.27), and the mean DWS was 4.2 (SD = 2.3). One hundred and seven patients (83.4%) completed the treatment and showed both considerable weight gain and reduced scores for eating-disorder and general psychopathology. Among completers, 72.9% completed the 20-week follow-up and maintained the improvement reached at the end-of-treatment. DWS was negatively correlated with end-of-treatment and follow-up z-BMI. This indicates that weight suppression is a predictor of the BMI outcome of intensive CBT-E and confirms that this treatment is promising for adolescents with anorexia nervosa.

The impact of the COVID-19 pandemic on intensive cognitive behavioral therapy outcomes in patients with anorexia nervosa-A cohort study.

OBJECTIVE: This study aimed to assess the impact of the COVID-19 pandemic on the efficacy of an intensive treatment based on enhanced cognitive behavioral therapy (CBT-E) in patients with anorexia nervosa. METHODS: This cohort study analyzed 57 patients with anorexia nervosa who experienced the COVID-19 pandemic during intensive CBT-E, comparing their outcomes (body mass index [BMI], eating-disorder and general psychopathology, and clinical impairment) with those of patients with anorexia nervosa matched by gender, age, and BMI given the same treatment before the COVID-19 outbreak as controls. Patients were assessed at baseline, at the end of treatment and after 20 weeks of follow-up. RESULTS: More than 75% of patients during the pandemic versus 85% of controls completed the treatment, a difference that was not significant. BMI, eating disorder and general psychopathology and clinical impairment scores improved significantly from baseline to 20-week follow-up in both groups. However, the improvement was more marked in controls than in those treated during the COVID-19 pandemic. CONCLUSION: Patients with anorexia nervosa given intensive CBT-E during the COVID-19 pandemic had significantly improved psychopathology, albeit to a lesser extent than patients given the same treatment before the COVID-19 pandemic. PUBLIC SIGNIFICANCE STATEMENT: In this study, the outcome of 57 patients with anorexia treated with intensive enhanced cognitive behavior therapy during the COVID-19 pandemic was compared with a matched group treated before the pandemic hit. The rate of remission from anorexia nervosa was similar between the two groups. However, patients exposed to the COVID-19 pandemic showed lesser improvement than those not exposed.

The clinical perfectionism questionnaire: psychometric properties of the Italian version in patients with eating disorders.

BACKGROUND: Problematic perfectionism has been traditionally conceptualized as a multidimensional construct, and specific instruments have been developed to capture its various dimensions. However, the Clinical Perfectionism Questionnaire (CPQ) was recently designed to measure a unidimensional construct called "clinical perfectionism", but the questionnaire has not yet been validated in Italian. AIM: This study aimed to propose the Italian version of the CPQ and examine its psychometric properties. METHODS: The CPQ was translated into Italian using translation and back-translation procedures. Then, it was administered to 188 Italian-speaking patients with eating disorders and 126 non-eating disorder group (excluded if the Italian version of the Eating Attitudes Test-26 was ≥ 20). The clinical group also completed the Italian versions of the Frost Multidimensional Perfectionism Scale (FMPS), the Eating Disorder Examination Questionnaire (EDE-Q), and the Brief Symptom Inventory (BSI). RESULTS: Confirmatory factor analysis revealed a good fit for the bifactor structure of the 10-item version. Internal consistency was high for the general clinical perfectionism factor, and test-retest reliability was good. Convergent validity was acceptable for the general clinical perfectionism and 'overvaluation of striving' group factors. The CPQ showed significantly higher scores in patients with eating disorders than in the non-eating disorder group. CONCLUSIONS: Overall, the study demonstrated the good psychometric properties of the Italian version of the CPQ, and validated its use in Italian-speaking patients with eating disorders. Although further research is required, the CPQ has promising evidence as a reliable and valid measure of clinical perfectionism in its Italian version. LEVEL OF EVIDENCE: Level V, Descriptive study.

McArdle disease in a patient with anorexia nervosa: a case report.

BACKGROUND: McArdle disease is an autosomal recessive genetic disorder caused by a deficiency of the glycogen phosphorylase (myophosphorylase) enzyme, which muscles need to break down glycogen into glucose for energy. Symptoms include exercise intolerance, with fatigue, muscle pain, and cramps being manifested during the first few minutes of exercise, which may be accompanied by rhabdomyolysis. CASE PRESENTATION: This case report describes for the first time the clinical features, diagnosis and management of a 20 year-old patient with anorexia nervosa and McArdle disease, documented by means of muscle biopsy. CONCLUSION: Anorexia nervosa and McArdle disease interact in a detrimental bidirectional way. In addition, some laboratory parameter alterations (e.g., elevated values of creatine kinase) commonly attributed to the specific features of eating disorders (e.g., excessive exercising) may delay the diagnosis of metabolic muscle diseases. On the other hand, the coexistence of a chronic disease, such as McArdle disease, whose management requires the adoption of a healthy lifestyle, can help to engage patients in actively addressing their eating disorder.

Changes in specific and nonspecific psychopathology network structure after intensive cognitive behavior therapy in patients with anorexia nervosa.

OBJECTIVE: This study aimed to compare eating disorder-specific and nonspecific clinical features in patients with anorexia nervosa before and after intensive enhanced cognitive behavior therapy (CBT-E) via network analysis. METHODS: All consecutive patients admitted to intensive CBT-E were eligible, and the sample comprised patients aged ≥16 years who completed a 20-week intensive CBT-E program. Body mass index (BMI), Eating Disorder Examination Questionnaire and Brief Symptoms Inventory responses were gathered at baseline and end of treatment, and used to generate statistical networks of the connections between symptoms (nodes) and the strength and centrality thereof. RESULTS: A total of 214 patients were included. Most nodes had relatively similar centrality compared to other nodes in the networks. "Eating concern" and "phobic anxiety" showed the greatest bridge centrality at both time points. No differences were found between baseline and the end of treatment in either global network or individual connection strengths. CONCLUSION: These findings suggest that some clinical expressions not specific to eating-disorder psychopathology remain strongly connected in the generalized network of patients with anorexia nervosa after CBT-E. Future research should examine whether additional procedures specifically designed to target these symptoms should be integrated into this and other treatments.

Day-hospital enhanced cognitive behavior therapy for adults with eating disorders: Immediate and follow-up effects.

OBJECTIVE: To assess outcomes in adult patients with eating disorders administered enhanced cognitive behavioral therapy (CBT-E) in a day-hospital setting. METHOD: Forty-three consecutive patients with eating disorders (86% females; mean age 28.8 [SD = 11.8]) were admitted to a 13-week day-hospital CBT-E program. Twenty-five (58.1%) patients were underweight (i.e., body mass index [BMI] <18.5 kg/m2 ; BMI 15.4 [SD = 2.2]) and 18 not (mean BMI 23.1 [SD = 6.3]) at baseline. All patients responded poorly to prior outpatient treatment. Body mass index and Eating Disorder Examination Questionnaire (EDE-Q), Brief Symptom Inventory (BSI), and Clinical Impairment Assessment (CIA) scores were recorded at baseline, end of treatment, and 20-week follow-up. RESULTS: In 37 patients (86.0%) who completed the treatment, there were substantial improvements in eating-disorder features, general psychopathology, clinical impairment, and body weight (only in underweight patients), which were well maintained at follow-up. DISCUSSION: Day-hospital CBT-E is a promising treatment for adults with eating disorders.

Validity and reliability of the Dietary Rules Inventory (DRI).

BACKGROUND: Dietary rules are common in patients with eating disorders, and according to transdiagnostic cognitive behavioural theory for eating disorders, represent a key behaviour maintaining eating-disorder psychopathology. The aim of this study was to describe the design and validation of the Dietary Rules Inventory (DRI), a new self-report questionnaire that assesses dietary rules in patients with eating disorders. METHODS: A transdiagnostic sample of 320 patients with eating disorders, as well as 95 patients with obesity and 122 healthy controls were recruited. Patients with eating disorders also completed the Dutch Eating Behaviour Questionnaire (DEBQ), the Eating Disorder Examination Questionnaire, the Brief Symptoms Inventory and the Clinical Impairment Assessment. Dietary rules were rated on a continuous Likert-type scale (0-4), rating how often (from never to always) they had been applied over the previous 28 days. RESULTS: DRI scores were significantly higher in patients with eating disorders than in patients with obesity and healthy controls. Principal factor analysis identified that 55.8% of the variance was accounted for by four factors, namely 'what to eat', 'social eating', 'when and how much to eat' and 'caloric level'. Both global score and subscales demonstrated high internal and test-retest reliability. The DRI global score was significantly correlated with the DEBQ 'restrained eating' subscale, as well as eating-disorder and general psychopathology and clinical impairment scores, demonstrating good convergent validity. CONCLUSIONS: These findings suggest that the DRI is a valid self-report questionnaire that may provide important clinical information regarding the dietary rules underlying dietary restraint in patients with eating disorders. LEVEL OF EVIDENCE: V, descriptive study.

Enhanced cognitive behaviour therapy (CBT-E) for severe and extreme anorexia nervosa in an outpatient eating disorder unit at a public hospital: a quality-assessment study.

BACKGROUND: The aim of this quality-assessment study was to determine the outcome of patients with severe and extreme anorexia nervosa (AN) in a real-world outpatient setting. METHODS: Twenty-one adults with AN and a body mass index (BMI) of < 16 were recruited from consecutive referrals to an outpatient clinic at a public hospital in Western Norway. All enrolled patients were provided with enhanced cognitive behaviour therapy (CBT-E) to treat their AN, commencing between January 2013 and December 2016. Their BMI was recorded at baseline, at the end of CBT-E and 1 year after the end of treatment. RESULTS: Ten patients completed the CBT-E treatment and achieved a large weight gain with the change remaining stable at follow-up. Eleven patients did not complete the treatment but had a significant increase in BMI at the premature end of treatment. One year after end of therapy 14/21 (66.7%) of the patients had BMI above 18.5 kg/m2. No severe complications were observed during therapy. CONCLUSIONS: Although 52.4% of the patients did not complete outpatient CBT-E, the findings of this quality-assessment study support previous findings indicating that CBT-E may represent a valid alternative to inpatient treatment in patients with severe and extreme AN.

Childhood Memories in Eating Disorders: An Explorative Study Using Diagnostic Imagery.

Together with socio-cultural components, the family environment and early parent-child interactions play a role in the development of eating disorders. The aim of this study was to explore the nature of early parent-daughter relationships in a sample of 49 female inpatients with an eating disorder. To acquire a detailed image description of the childhood experiences of the patient, we used diagnostic imagery, a schema therapy-derived experiential technique. This procedure allows exploring specific contents within the childhood memory (i.e., emotions and unmet core needs), bypassing rational control, commonly active during direct verbal questioning. Additionally, patients completed self-report measures to assess for eating disorder severity, general psychopathology, and individual and parental schemas pervasiveness. Finally, we explored possible differences in the diagnostic imagery content and self-report measures in two subgroups of patients with anorexia nervosa and bulimia nervosa. The results showed that the most frequently reported unmet needs within the childhood memories of patients were those of safety/protection, care/nurturance, and emotional expression, referred specifically to the maternal figure. Overall, mothers were described as more abandoning, but at the same time particularly enmeshed in the relationship with their daughters. Conversely, patients perceived their fathers as more emotionally inhibited and neglecting. Imagery-based techniques might represent a powerful tool to explore the nature of early life experiences in eating disorders, allowing a more detailed case conceptualization and addressing intervention on early-life vulnerability aspects in disorder treatment.

The Impact of COVID-19 Lockdown on Patients with Obesity after Intensive Cognitive Behavioral Therapy-A Case-Control Study.

BACKGROUND: The COVID-19 lockdown may have negatively impacted the treatment of obesity. This study aimed to assess the effect of COVID-19 lockdown in patients with obesity treated with intensive residential cognitive behavioral therapy (CBT-OB). METHODS: This retrospective case-control study analyzed 129 patients with severe obesity who experienced COVID-19 lockdown in the 6 months after discharge from intensive residential CBT-OB, comparing their outcomes on weight loss, binge-eating episodes, and general health status with those in a sample of patients matched by gender, age, and body mass index given the same treatment before the COVID-19 outbreak as control. Patients were assessed at baseline and by phone interview 6-month follow-up. RESULTS: Both groups had lost more than 9% of their baseline bodyweight and reported a significant decrease in binge-eating episodes and similar general health status at 6-month follow-up. However, control patients achieved a significantly greater weight loss than those who experienced lockdown, although half of lockdown patients reported persisting with CBT-OB procedures after their discharge. CONCLUSION: Patients with obesity treated with CBT-OB and exposed to COVID-19 lockdown, despite achieving lower weight loss than non-exposed patients, had a healthy weight loss at 6-month follow-up and comparable reduction in binge-eating behaviors.

Change in eating-disorder psychopathology network structure in patients with anorexia nervosa treated with intensive cognitive behavior therapy.

OBJECTIVE: This study was designed to compare the change in eating-disorder feature networks in patients with anorexia nervosa after treatment with intensive enhanced cognitive behavior therapy (CBT-E). METHODS: Patients seeking treatment for anorexia nervosa were consecutively recruited from January 2016 to September 2020. All patients aged ≥16 years who completed a 20-week intensive CBT-E program (13 weeks of inpatient followed by 7 weeks of day-hospital treatment) were included in the study. Body mass index (BMI) was measured, and the Eating Disorder Examination Questionnaire completed for each patient, both at baseline and the end of treatment. RESULTS: The sample comprised 214 patients with anorexia nervosa. Treated patients showed significant improvements in BMI and eating-disorder psychopathology. Network analysis revealed a significant reduction in the network global and connection strengths at the end of treatment. The most central and highly interconnected nodes in the network at baseline were related to the drive for thinness, but at the end of treatment to body image concerns. Some edge connections were significantly stronger at baseline than at the end of treatment, while others were significantly stronger at the end of treatment than at baseline. DISCUSSION: CBT-E reduces the psychopathology network connectivity over time in patients with anorexia nervosa. The differences in central nodes and edge connections between baseline and end of treatment, not detected by classical inferential analysis, may be informative for understanding the centrality of symptoms in the psychopathology network, and how a specific treatment may act to reduce symptoms and change their connections over time.