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.

A framework for conceptualising early intervention for eating disorders.

OBJECTIVE: This paper outlines the evidence base for early intervention for eating disorders; provides a global overview of how early intervention for eating disorders is provided in different regions and settings; and proposes policy, service, clinician and research recommendations to progress early intervention for eating disorders. METHOD AND RESULTS: Currently, access to eating disorder treatment often takes many years or does not occur at all. This is despite neurobiological, clinical and socioeconomic evidence showing that early intervention may improve outcomes and facilitate full sustained recovery from an eating disorder. There is also considerable variation worldwide in how eating disorder care is provided, with marked inequalities in treatment provision. Despite these barriers, there are existing evidence-based approaches to early intervention for eating disorders and progress is being made in scaling these. CONCLUSIONS: We propose action steps for the field that will transform eating disorder service provision and facilitate early detection, treatment and recovery for everyone affected by eating disorders, regardless of age, socioeconomic status and personal characteristics.

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.

Outpatient therapy for adult anorexia nervosa: Early weight gain trajectories and outcome.

OBJECTIVE: The purpose of the study was to identify latent classes of trajectory of change in body mass index (BMI) between the initial and thirteenth session of outpatient treatment for adult anorexia nervosa and identify the association with outcome. METHOD: Participants (n = 120) were randomised to one of three outpatient therapies. RESULTS: Four latent classes were identified; two classes (higher, rapid and higher, moderate) had BMI > 17 kg/m2 at initial assessment, and both gained significantly more weight over the 13 sessions compared to the other two classes. The third and fourth classes (middle, stable and low, stable) had an initial BMI of 16.44 and 15.31, respectively, and neither gained weight over the first 13 sessions. Compared to the other three classes, the higher, rapid class (N = 19, 16%) showed a significantly greater BMI increase over the first 13 sessions of therapy and a significantly higher rate of remission at end of treatment and 12-month follow-up (18-22 months post-randomisation). CONCLUSIONS: The group with the greatest early weight gain had significantly higher levels of remission. Higher BMI at baseline without substantial early weight gain was insufficient to produce higher levels of remission than those with lower weight at baseline.

ANZAED practice and training standards for mental health professionals providing eating disorder treatment.

INTRODUCTION: The Australia & New Zealand Academy for Eating Disorders (ANZAED) recently developed general principles and clinical practice standards recommended for mental health clinicians and dietitians providing treatment for people with eating disorders. Separate mental health practice and training standards were then devised as a foundation for strengthening the workforce and providing guidance to professional training programs and service providers on the minimal standards required for practice in the eating disorder field. RECOMMENDATIONS: The present recommendations for mental health professionals providing eating disorder treatment describe the following practice and training standards: eating disorder treatment foundations (including co-ordination of services, establishing a positive therapeutic alliance, professional responsibility and knowledge of levels of care), assessment, diagnosis, intervention (including evidence-based intervention, managing psychiatric risk and managing co-morbid mental health problems), and monitoring and evaluation. CONCLUSIONS: Further work is required to disseminate these standards to clinicians providing services across Australia to people with eating disorders, and to support adherence in the clinic room where they can translate to improved outcomes for clients. Pathways to supporting adherence include expert supervision of practice, incorporation in training and supervised practice in university settings, and support with checklists that can be used by consumers and referring professionals.

ANZAED eating disorder treatment principles and general clinical practice and training standards.

INTRODUCTION: Eating disorders are complex to manage, and there is limited guidance around the depth and breadth of knowledge, skills and experience required by treatment providers. The Australia & New Zealand Academy for Eating Disorders (ANZAED) convened an expert group of eating disorder researchers and clinicians to define the clinical practice and training standards recommended for mental health professionals and dietitians providing treatment for individuals with an eating disorder. General principles and clinical practice standards were first developed, after which separate mental health professional and dietitian standards were drafted and collated by the appropriate members of the expert group. The subsequent review process included four stages of consultation and document revision: (1) expert reviewers; (2) a face-to-face consultation workshop attended by approximately 100 health professionals working within the sector; (3) an extensive open access online consultation process; and (4) consultation with key professional and consumer/carer stakeholder organisations. RECOMMENDATIONS: The resulting paper outlines and describes the following eight eating disorder treatment principles: (1) early intervention is essential; (2) co-ordination of services is fundamental to all service models; (3) services must be evidence-based; (4) involvement of significant others in service provision is highly desirable; (5) a personalised treatment approach is required for all patients; (6) education and/or psychoeducation is included in all interventions; (7) multidisciplinary care is required and (8) a skilled workforce is necessary. Seven general clinical practice standards are also discussed, including: (1) diagnosis and assessment; (2) the multidisciplinary care team; (3) a positive therapeutic alliance; (4) knowledge of evidence-based treatment; (5) knowledge of levels of care; (6) relapse prevention; and (7) professional responsibility. CONCLUSIONS: These principles and standards provide guidance to professional training programs and service providers on the development of knowledge required as a foundation on which to build competent practice in the eating disorder field. Implementing these standards aims to bring treatment closer to best practice, and consequently improve treatment outcomes, reduce financial cost to patients and services and improve patient quality of life.

Efficacy of a brief group intervention for carers of individuals with eating disorders: A randomized control trial.

OBJECTIVE: Interventions for carers of individuals with eating disorders are often time and resource intensive, which may be a barrier for service providers or attendees. This study aimed to evaluate the efficacy of a very brief, two-session psychoeducation and communication skills-based intervention for carers of individuals with eating disorders. METHOD: Carers (N = 44) were randomized to attend two 2.5 hr sessions delivered 1 week apart or waitlist control. Carer burden, self-efficacy, skills, knowledge, expressed emotion (emotional overinvolvement and critical comments), distress (anxiety and depression), and accommodating and enabling behaviors were assessed at preintervention and postintervention and 1-month follow-up. RESULTS: Carer burden, self-efficacy, skills, knowledge, and one component of expressed emotion (critical comments) improved significantly more in the treatment group compared to the waitlist. Changes in anxiety, depression, and accommodating and enabling behaviors did not significantly differ between groups. DISCUSSION: These results demonstrated that substantial improvements can be made from a very brief carers' intervention. More intensive and targeted interventions might be required to address carers' emotional symptoms and to reduce accommodating and enabling behaviors.

The development and validation of a measure of eating disorder-specific interpersonal problems: The Interpersonal Relationships in Eating Disorders (IR-ED) Scale.

Clinical reports suggest that interpersonal problems are associated with the onset and maintenance of eating pathology, but existing measures of such problems have limited links to eating pathology. Therefore, the aim of this study was to develop an eating-specific measure of interpersonal problems. The new measure, the Interpersonal Relationships in Eating Disorders scale (IR-ED), was administered to a large community sample, a nonclinical replication sample, and a clinical group of eating disorder patients. In Study 1, the psychometric properties of the IR-ED were established, and they were tested using confirmatory analyses in Study 2. Study 3 determined the validity of the test score interpretations in a clinical sample. The final 15-item version of the IR-ED demonstrated 3 distinct factors with reliability of test scores-Food-Related Isolation; Avoidance of Body Evaluation; and Food-Related Interpersonal Tension. Study 2 demonstrated that the IR-ED comprises a common Interpersonal Problems factor and a specific group factor-Avoidance of Body Evaluation. Study 3 showed that the clinical group had higher IR-ED scores than a nonclinical group. Across the studies, Avoidance of Body Evaluation was the strongest correlate of eating pathology in this group. The IR-ED has strong psychometric properties and its test scores appear to be more valid than those of a generic measure of interpersonal problems. Avoidance of Body Evaluation is the strongest facet of such interpersonal problems, and has meaningful links to models of eating psychopathology. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A single session assessment and psychoeducational intervention for eating disorders: Impact on treatment waitlists and eating disorder symptoms.

OBJECTIVE: Long waitlists are common in eating disorder services and can have a detrimental impact on patients. We examined the effect on waitlist length, attendance, and eating disorder symptoms, of a 75-90 min single session intervention (SSI), attended a median of 16 days after referral to a specialist eating disorders clinic. METHOD: Sequential referrals (N = 448) to a public outpatient eating disorders program were tracked from referral until a decision was made on patients entering treatment. One group ("SSI cohort") received a protocol incorporating assessment and psychoeducation about eating disorders before being placed on a waitlist, after which they received further assessment and entered treatment. Data on patient flow indices were collected from this cohort and compared to data from a "Pre-SSI" cohort who had not received the SSI. Symptom change was examined in the SSI cohort. RESULTS: Waitlist length reduced and the proportion of referrals attending assessment and being allocated to treatment increased. Eating disorder symptoms and impairment decreased. Underweight patients (Body Mass Index [BMI] < 18.5 kg/m2 ) gained weight. DISCUSSION: These findings suggest that a single session psychoeducational assessment may reduce waiting times, increase the likelihood of patients entering treatment, and facilitate early reductions in eating disorder symptoms. However, there may be other explanations for the changes observed.

Severe and enduring anorexia nervosa? Illness severity and duration are unrelated to outcomes from cognitive behaviour therapy.

OBJECTIVE: The present study aimed to examine whether Anorexia Nervosa (AN) illness severity or duration is associated with retention or treatment response in outpatient, enhanced cognitive-behavioral therapy (CBT-E). METHOD: Patients with a confirmed AN diagnosis (N = 134) completed measures of eating disorder symptoms and quality of life, and had their BMI objectively measured before, during, and after treatment. We evaluated whether illness severity or duration predicted treatment outcomes, using longitudinal regression models. RESULTS: Greater levels of illness severity and duration were not associated with poorer treatment outcomes. CONCLUSIONS: Patients with more severe or long-standing AN illness did just as well in CBT-E as any other patient starting treatment. Therefore, classifying individuals as "severe and enduring" appears to lack clinical utility in CBT-E. Clinicians should continue to administer evidence-supported treatments such as CBT-E for patients with AN, regardless of duration or severity of AN illness. (PsycINFO Database Record

Socializing problems and low self-esteem enhance interpersonal models of eating disorders: Evidence from a clinical sample.

OBJECTIVE: The present study evaluated the relative clinical validity of two interpersonal models of the maintenance of eating disorders, IPT-ED (Rieger et al., ) and the interpersonal model of binge eating (Wilfley, MacKenzie, Welch, Ayres, & Weissman, ; Wilfley, Pike, & Striegel-Moore, ). While both models propose an indirect relationship between interpersonal problems and eating disorder symptoms via negative affect, IPT-ED specifies negative social evaluation as the key interpersonal problem, and places greater emphasis on the role of low self-esteem as an intermediate variable between negative social evaluation and eating pathology. METHOD: Treatment-seeking individuals (N = 306) with a diagnosed eating disorder completed measures of socializing problems, generic interpersonal problems, self-esteem, eating disorder symptoms, and negative affect (depression and anxiety). Structural equation models were run for both models. RESULTS: Consistent with IPT-ED, a significant indirect pathway was found from socializing problems to eating disorder symptoms via low self-esteem and anxiety symptoms. There was also a direct pathway from low self-esteem to eating disorder symptoms. Using a socializing problems factor in the model resulted in a significantly better fit than a generic interpersonal problems factor. Inconsistent with both interpersonal models, the direct pathway from socializing problems to eating disorder symptoms was not supported. DISCUSSION: Interpersonal models that included self-esteem and focused on socializing problems (rather than generic interpersonal problems) explained more variance in eating disorder symptoms. Future experimental, prospective, and treatment studies are required to strengthen the case that these pathways are causal.

The Anorexia Nervosa Genetics Initiative: Study description and sample characteristics of the Australian and New Zealand arm.

OBJECTIVES: Anorexia nervosa is a severe psychiatric disorder with high mortality rates. While its aetiology is poorly understood, there is evidence of a significant genetic component. The Anorexia Nervosa Genetics Initiative is an international collaboration which aims to understand the genetic basis of the disorder. This paper describes the recruitment and characteristics of the Australasian Anorexia Nervosa Genetics Initiative sample, the largest sample of individuals with anorexia nervosa ever assembled across Australia and New Zealand. METHODS: Participants completed an online questionnaire based on the Structured Clinical Interview Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) eating disorders section. Participants who met specified case criteria for lifetime anorexia nervosa were requested to provide a DNA sample for genetic analysis. RESULTS: Overall, the study recruited 3414 Australians and 543 New Zealanders meeting the lifetime anorexia nervosa case criteria by using a variety of conventional and social media recruitment methods. At the time of questionnaire completion, 28% had a body mass index ⩽ 18.5 kg/m2. Fasting and exercise were the most commonly employed methods of weight control, and were associated with the youngest reported ages of onset. At the time of the study, 32% of participants meeting lifetime anorexia nervosa case criteria were under the care of a medical practitioner; those with current body mass index < 18.5 kg/m2 were more likely to be currently receiving medical care (56%) than those with current body mass index ⩾ 18.5 kg/m2 (23%). Professional treatment for eating disorders was most likely to have been received from general practitioners (45% of study participants), dietitians (42%) and outpatient programmes (42%). CONCLUSIONS: This study was effective in assembling the largest community sample of people with lifetime anorexia nervosa in Australia and New Zealand to date. The proportion of people with anorexia nervosa currently receiving medical care, and the most common sources of treatment accessed, indicates the importance of training for general practitioners and dietitians in treating anorexia nervosa.

Stomaching uncertainty: Relationships among intolerance of uncertainty, eating disorder pathology, and comorbid emotional symptoms.

Intolerance of uncertainty (IU) is proposed to be a transdiagnostic vulnerability factor for various emotional disorders. There is robust evidence for the role of IU in anxiety and depressive disorders, but a paucity of evidence in eating disorders (ED). This study evaluated the factorial validity, internal consistency, and convergent validity of the Intolerance of Uncertainty Scale-Short Form (IUS-12; Carleton, Norton, & Asmundson, 2007), and examined whether IU is associated with ED pathology and comorbid emotional symptoms, in a clinical sample with EDs (N=134). A unitary factor solution provided the best fit. The IUS-12 showed excellent internal consistency, and good convergent validity. IU had an indirect effect on dietary restraint, purging, and emotional symptoms via overvaluation of eating, weight, and shape. The indirect effect was not significant for bingeing. Findings provide partial support for the notion that IU is a vulnerability factor for ED pathology and support the notion that IU is a transdiagnostic vulnerability factor for emotional symptoms. Limitations, research implications, and future directions for research are discussed.

Therapist adherence in the strong without anorexia nervosa (SWAN) study: A randomized controlled trial of three treatments for adults with anorexia nervosa.

OBJECTIVE: To develop a psychotherapy rating scale to measure therapist adherence in the Strong Without Anorexia Nervosa (SWAN) study, a multi-center randomized controlled trial comparing three different psychological treatments for adults with anorexia nervosa. The three treatments under investigation were Enhanced Cognitive Behavioural Therapy (CBT-E), the Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), and Specialist Supportive Clinical Management (SSCM). METHOD: The SWAN Psychotherapy Rating Scale (SWAN-PRS) was developed, after consultation with the developers of the treatments, and refined. Using the SWAN-PRS, two independent raters initially rated 48 audiotapes of treatment sessions to yield inter-rater reliability data. One rater proceeded to rate a total of 98 audiotapes from 64 trial participants. RESULTS: The SWAN-PRS demonstrated sound psychometric properties, and was considered a reliable measure of therapist adherence. The three treatments were highly distinguishable by independent raters, with therapists demonstrating significantly more behaviors consistent with the actual allocated treatment compared to the other two treatment modalities. There were no significant site differences in therapist adherence observed. DISCUSSION: The findings provide support for the internal validity of the SWAN study. The SWAN-PRS was deemed suitable for use in other trials involving CBT-E, MANTRA, or SSCM.

Interpersonal problems across restrictive and binge-purge samples: data from a community-based eating disorders clinic.

Contemporary models of eating disorders suggest that interpersonal problems contribute to the maintenance of eating disorders. This study examined whether baseline interpersonal problems differed across eating disorder diagnoses and across eating disorder subtypes ("restrictors" vs. "binge-purge" patients) in a large clinical sample. Patients with a primary eating disorder diagnosis (N=406) completed measures of interpersonal problems, eating disorder symptoms, and mood prior to treatment at a specialist eating disorder clinic. Across the sample, more severe eating disorder psychopathology was associated with significantly greater difficulty socializing. Anorexia Nervosa (AN)/restrictor patients reported significantly greater difficulty socializing than Bulimia Nervosa (BN)/binge-purge patients. AN patients reported significantly greater difficulty on a measure of competitiveness/assertiveness compared to BN and Eating Disorder Not Otherwise Specified patients. All findings were significant after controlling for comorbid depression and anxiety symptoms. Interpersonal problems appear to be unique risk factors for eating disorders. Specific interpersonal mechanisms include difficulties socializing and being assertive, which were most pronounced in AN patients. These findings provide potential avenues for enhancing interventions, such as adjunctive assertiveness training for AN.

Therapeutic alliance in Enhanced Cognitive Behavioural Therapy for bulimia nervosa: probably necessary but definitely insufficient.

The present paper assessed therapeutic alliance over the course of Enhanced Cognitive Behavioural Therapy (CBT-E) in a community-based sample of 112 patients with a diagnosis of bulimia nervosa (BN) or atypical BN. Temporal assessment of alliance was conducted at three time points (the start, middle and end of treatment) and the relationship between alliance and treatment retention and outcome was explored. Results indicated that the alliance between patient and therapist was strong at all stages of CBT-E, and even improved in the early stages of treatment when behaviour change was initiated (weekly in-session weighing, establishing regular eating, and ceasing binge-eating and compensatory behaviours). The present study found no evidence that alliance was related to treatment retention or outcomes, or that symptom severity or problematic interpersonal styles interacted with alliance to influence outcomes. Alliance was also unrelated to baseline emotional or interpersonal difficulties. The study provides no evidence that alliance has clinical utility for the prediction of treatment retention or outcome in CBT-E for BN, even for individuals with severe symptoms or problematic interpersonal styles. Early symptom change was the best predictor of outcome in CBT-E. Further research is needed to determine whether these results are generalizable to patients with anorexia nervosa.

Eating disorders: a hidden phenomenon in outpatient mental health?

BACKGROUND: Eating disorders are common but underdiagnosed illnesses. Help-seeking for co-occurring issues, such as anxiety and depression, are common. OBJECTIVES: To identify the prevalence of eating problems, using the SCOFF, and eating disorders when screening positive on the SCOFF (i.e., ≥2), among patients seeking help for anxiety and depression at a community-based mental health service. METHOD: Patients (N = 260) consecutively referred and assessed for anxiety and depression treatment were administered the SCOFF screening questionnaire and a semi-structured standardized diagnostic interview during routine intake. RESULTS: 18.5% (48/260) scored ≥2 on the SCOFF, indicating eating problems. Of these, 41% (19/48) met criteria for an eating disorder. Thus, overall, 7.3% (19/260) of the sample met criteria for a DSM-IV eating disorder. Those scoring ≥2 on the SCOFF were more likely to: be female (p = 0.001), younger (p = 0.003), and have a history of self-harm (p < 0.001). DISCUSSION: This study confirms that eating disorders are a hidden phenomenon in general outpatient mental health. By using a standardized diagnostic interview to establish diagnosis rather than self- or staff-report, the study builds on limited previous findings. The naturalistic study setting shows that screening for eating disorders can be easily built into routine intake practice, and successfully identifies treatment need.

Interpersonal problems across anxiety, depression, and eating disorders: a transdiagnostic examination.

OBJECTIVES: Integrative models of psychopathology suggest that quality of interpersonal relationships is a key determinant of psychological well-being. However, there is a relative paucity of research evaluating the association between interpersonal problems and psychopathology within cognitive behavioural therapy. Partly, this may be due to lack of brief, well-validated, and easily interpretable measures of interpersonal problems that can be used within clinical settings. The aim of the present study was to evaluate the psychometric properties, factor invariance, and external validity of the Inventory of Interpersonal Problems 32 (IIP-32) across anxiety, depression, and eating disorders. METHODS: Two treatment-seeking samples with principal anxiety and depressive disorders (AD sample, n = 504) and eating disorders (ED sample, n = 339) completed the IIP-32 along with measures of anxiety, depression, and eating disorder symptoms, as well as quality of life (QoL). RESULTS: The previously established eight-factor structure of the IIP-32 provided the best fit for both the AD and ED groups, and was robustly invariant across the two samples. The IIP-32 also demonstrated excellent external validity against well-validated measures of anxiety, depression, and eating disorder symptoms, as well as QoL. CONCLUSION: The IIP-32 provides a clinically useful measure of interpersonal problems across emotional and ED.

Prognostic value of rapid response to enhanced cognitive behavioral therapy in a routine clinic sample of eating disorder outpatients.

OBJECTIVE: This study examined whether rapid response to enhanced cognitive behavioral therapy (CBT-E) was associated with superior treatment outcomes in a transdiagnostic sample of patients with an eating disorder. METHOD: Participants were 105 patients with a primary eating disorder diagnosis who received individual CBT-E at a community-based outpatient clinic. Patients completed measures of eating disorder and related pathology at baseline and post-treatment. The Eating Disorder Examination-Questionnaire (EDE-Q) was administered at baseline and again, on average, 4.6 weeks after commencing treatment to assess rapid response to CBT-E. Patients achieving reliable change on the EDE-Q at this point were classified as rapid responders. RESULTS: No baseline differences distinguished rapid and nonrapid responders. Rapid responders had significantly lower scores on EDE-Q global at post-treatment, were more likely to achieve full remission, and required significantly fewer treatment sessions than nonrapid responders. One-quarter of the nonrapid responders went on to achieve full remission. There were no group differences on measures of anxiety and depression symptoms at the end of treatment. DISCUSSION: Early change in treatment is encouraged to achieve the best possible prognosis in CBT-E. Those who did not achieve rapid response still had an overall significant improvement in symptoms from pretreatment to post-treatment, but a lower rate of full remission. Nonrapid responders are an important group of patients to study because they offer researchers an opportunity to improve clinical decision-making and treatment outcomes for patients who are at risk of suboptimal response.

Treatment engagement in eating disorders: who exits before treatment?

OBJECTIVE: Traditionally, drop-out has been investigated subsequent to treatment entry; yet some individuals "exit early," attending assessment but failing to commence the treatment offered. Early exit burdens administrative and clinical resources and means that individuals may not receive the care needed for recovery. This study aimed to describe the prevalence and characteristics associated with early exit at a statewide, outpatient eating disorder service. METHOD: From a pool of 972 consecutive referrals of adults and youth (16+ years), two groups were formed; an "early exit" group of individuals who attended assessment but chose to exit the service prior to treatment entry and a "non-early exit" group that attended assessment and entered treatment. The groups were compared on sociodemographic, clinical, and administrative features. RESULTS: The prevalence of early exit was 18.7%. The early exit group exhibited less pathology compared with the non-early exit group; specifically, a lower presence of Axis I comorbidity (p = .04) and self-induced vomiting (p = .04). DISCUSSION: The findings, considered in the context of previous research, suggest that there are no measured features to date that are robustly associated with early exit from outpatient eating disorder services. Future research should investigate decision-making processes at assessment, to inform patient-centered approaches that optimize transition to treatment.