'My dad was like "it's your brain, what are you doing?"': Participant experiences of repetitive transcranial magnetic stimulation treatment in severe enduring anorexia nervosa.

OBJECTIVE: Repetitive transcranial magnetic stimulation (rTMS) is a promising emerging treatment for anorexia nervosa (AN). However, to date, patients' views and experiences of this treatment have not been fully explored. To assess these, we integrated a qualitative study into a feasibility randomised controlled trial of rTMS in individuals with severe enduring AN. METHOD: Twenty-nine (of 34) trial participants contributed to this study. Semi-structured interviews were conducted 3-months following the completion of rTMS treatment (4-months post-randomisation), prior to unblinding. Transcripts were analysed using content analysis. RESULTS: rTMS was deemed an acceptable but time-consuming treatment. Many emphasised how their lives had changed to some extent during, but mainly after treatment by making them more positive, open-minded, flexible and willing to try new things in relation to their AN and other aspects of their lives. CONCLUSIONS: These qualitative data will be valuable in shaping participant information, recruitment and planning of future large-scale trials of rTMS in AN. TRIAL REGISTRATION: ISRCTN14329415, registered 23rd July 2015, https://www.isrctn.com/ISRCTN14329415.

A pilot study exploring the effect of repetitive transcranial magnetic stimulation (rTMS) treatment on cerebral blood flow and its relation to clinical outcomes in severe enduring anorexia nervosa.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is a novel treatment option for people with severe enduring anorexia nervosa (SE-AN), but associated neurobiological changes are poorly understood. This study investigated the effect of rTMS treatment on regional cerebral blood flow (CBF) and whether any observed changes in CBF are associated with changes in clinical outcomes in people with SE-AN. METHODS: As part of a randomised sham-controlled feasibility trial of 20 sessions of high-frequency rTMS to the left dorsolateral prefrontal cortex, 26 of 34 trial participants completed arterial spin labelling (ASL) functional magnetic resonance imaging (fMRI) to quantify regional and global resting state CBF before (pre-randomisation baseline) and after real or sham treatment (1-month post-randomisation). A group of healthy females (n = 30) were recruited for baseline comparison. Clinical outcomes, including BMI, and depression and anxiety symptoms, were assessed at baseline, 1-, 4-, and 18-months post-randomisation. RESULTS: No group differences in regional CBF were identified between the SE-AN and healthy comparison participants. A significant treatment-by-time interaction in a medial temporal lobe cluster with the maximal peak in the right amygdala was identified, reflecting a greater reduction in amygdala CBF following real rTMS compared to sham. Participants with the greatest rTMS-related reduction in amygdala CBF (i.e., between baseline and 1-month post-randomisation) showed the greatest sustained weight gain at 18-months post-randomisation. Higher baseline CBF in the insula predicted greater weight gain between baseline and 1-month post-randomisation and between baseline and 4-months post-randomisation. CONCLUSIONS: This exploratory pilot study identified rTMS treatment related changes in CBF in adults with SE-AN and these were associated with changes in weight. Our preliminary findings also suggest that CBF (as measured by ASL fMRI) may be a marker of rTMS treatment response in this patient group. Future rTMS studies in AN should employ longitudinal neuroimaging to further explore the neurobiological changes related to rTMS treatment. TRIAL REGISTRATION: ISRCTN14329415 , registered 23rd July 2015.

Repetitive transcranial magnetic stimulation (rTMS) is a novel treatment option for people with severe enduring anorexia nervosa (SE-AN). However, little is known about the neurobiological effects of this treatment. This study explored the effect of rTMS treatment on regional cerebral blood flow (CBF) and whether any observed changes in CBF are associated with changes in clinical outcomes in people with SE-AN. Participants completed arterial spin labelling (ASL) functional magnetic resonance imaging (fMRI) before and after receiving 20 sessions (over 4 weeks) of real or sham rTMS. We found a greater reduction in amygdala CBF following real rTMS compared to sham rTMS. Participants with the greatest rTMS-related reduction in amygdala CBF showed the greatest sustained weight gain at an 18-month follow-up. Higher baseline CBF in the insula predicted greater weight gain during treatment and at a 4-month follow-up. This suggests that CBF (as measured by ASL fMRI) may be a marker of rTMS treatment response in this patient group. Future rTMS studies in AN should use longitudinal neuroimaging to further explore the neurobiological changes related to rTMS treatment.

A preliminary exploration of the effect of concurrent antidepressant medication on responses to high-frequency repetitive transcranial magnetic stimulation (rTMS) in severe, enduring anorexia nervosa.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is a promising treatment option for people with severe, enduring anorexia nervosa (SE-AN). As depression is often comorbid with AN, antidepressant medication is commonly prescribed to this patient group. Concurrent antidepressant medications may affect the rTMS treatment response. Therefore, in a secondary analysis of data from a feasibility trial, we explored the effect of antidepressant medication on responses to rTMS in people with SE-AN. METHODS: Twenty-six participants with SE-AN received 20 sessions (over 4 weeks) of neuronavigated high-frequency real rTMS to the left dorsolateral prefrontal cortex. Eating disorder (ED) and general psychopathology symptoms were assessed at baseline, post-treatment and at a 4-month follow-up. RESULTS: Participants taking antidepressants (n = 16) for the duration of the rTMS treatment had a greater reduction in ED symptoms at the 4-month follow-up, compared to those not taking antidepressants (n = 10). Antidepressant status was not however associated with significant changes in mood outcomes. CONCLUSIONS: In people with SE-AN receiving rTMS treatment, preliminary findings suggest a potential synergistic effect of antidepressant medication in reducing ED symptomatology. There was however no associated reduction in affective symptoms i.e., the effect does not seem to be related to changes in mood. The sample in this exploratory study was small and heterogenous. However, the preliminary results provide a basis for hypothesis generation for future studies.

Clinicians' views on neuromodulation as a treatment for eating disorders: A qualitative study.

BACKGROUND: Neuromodulation techniques, such as repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS) and deep brain stimulation (DBS), are emerging as promising treatment options in eating disorders (EDs). To date, the views of ED clinicians regarding these interventions have not been explored. METHODS: Eighteen clinicians were recruited from a specialist ED Service in London, UK. Following a short educational presentation on rTMS, tDCS and DBS, they completed a semi-structured interview to explore their views on the use of these treatment options in EDs. RESULTS: Clinician knowledge of neuromodulation techniques was low. They raised safety and ethical (particularly capacity to consent) concerns mainly with regard to DBS. Neuromodulation treatments were considered most appropriate as an adjunct to psychotherapy and for patients with severe, enduring illness (who had completed previous psychological treatments). CONCLUSIONS: Improving clinicians' knowledge and understanding of neuromodulation is fundamental for bridging the gap between research and clinical work. This is especially so given the predominance of psychological theory and practice in the treatment of EDs.

Repetitive transcranial magnetic stimulation treatment in severe, enduring anorexia nervosa: An open longer-term follow-up.

OBJECTIVE: This study assessed longer-term outcomes from a randomised controlled feasibility trial of 20 sessions of real versus sham high-frequency repetitive transcranial magnetic stimulation (rTMS) to the left dorsolateral prefrontal cortex in adults with severe, enduring anorexia nervosa (SE-AN). METHODS: Thirty participants who completed the original study protocol were invited to take part in an open follow-up (18-months post-randomisation), assessing body mass index (BMI), eating disorder (ED) symptoms and other psychopathology. RESULTS: Twenty-four participants (12 each originally allocated to real/sham) completed the 18-month follow-up. Ten of 12 participants who originally received sham treatment had real rTMS at some stage during the follow-up. A medium between-group effect size was seen for BMI change from baseline to 18-months, favouring those originally allocated to real rTMS. In this group at 18-months, five participants were weight recovered (BMI ≥18.5 kg/m2 ), compared with one participant in the original sham group. Both groups showed further improvement in ED symptoms during the follow-up. Effects on mood were largely maintained at follow-up, with catch-up effects in the original sham group. CONCLUSIONS: Findings suggest that rTMS treatment effects on mood are durable and that BMI and ED symptom improvements need time to emerge. Large-scale trials are needed.

Symptom trajectories into eating disorders: A systematic review of longitudinal, nonclinical studies in children/adolescents.

BACKGROUND: Eating disorders (EDs) are serious mental illnesses that can be life-threatening. Stage of illness models and early intervention strategies could be informed by a better understanding of symptomatology that precedes the onset of an ED. This review aims to explore which symptoms (both ED and other psychiatric disorder-related) exist prior to the onset of an ED and whether there any prospective associations between these symptomatologies. METHODS: A systematic literature review was conducted in MEDLINE, Embase, and PsycINFO for large, longitudinal, prospective studies in nonclinical cohorts of children/adolescents that report symptoms prior to the onset of an ED. A quality assessment of included studies was conducted using the Newcastle-Ottawa Quality Assessment Scale. RESULTS: A total of 22 studies were included, and over half were assessed to be of good quality. Studies identified the presence of a broad range of ED and other psychiatric disorder-related symptoms prior to ED onset. Possible prospective associations were identified, including early eating and feeding difficulties in childhood, to ED-related symptoms (e.g., dieting and body dissatisfaction) and other psychiatric disorder-related symptoms (e.g., anxiety and depression) in childhood/early adolescence, progressing to severe symptomatology (e.g., extreme weight control behaviors and self-harm) in mid-adolescence/emerging adulthood. CONCLUSION: The trajectory of symptoms identified to precede and possibly predict onset of an ED may inform early intervention strategies within the community. Suggestions for further research are provided to establish these findings and the clinical implications of these discussed, in order to inform how best to target prodromal stages of EDs.

The effect of repetitive transcranial magnetic stimulation on food choice-related self-control in patients with severe, enduring anorexia nervosa.

OBJECTIVE: Individuals with anorexia nervosa (AN) pursue low-fat, low-calorie diets even when in a state of emaciation. These maladaptive food choices may involve fronto-limbic circuitry associated with cognitive control, habit, and reward. We assessed whether high-frequency repetitive transcranial magnetic stimulation (rTMS) to the left dorsolateral prefrontal cortex (DLPFC) influenced food-related choice behavior in patients with severe, enduring (SE)-AN. METHOD: Thirty-four females with SE-AN completed a Food Choice Task before and after 20 sessions of real or sham rTMS treatment and at a 4-month follow-up. During the task, participants rated high- and low-fat food items for healthiness and tastiness and then made a series of choices between a neutral-rated food and high- and low-fat foods. Outcomes included the proportion of high-fat and self-controlled choices made. A comparison group of 30 healthy women completed the task at baseline only. RESULTS: Baseline data were consistent with previous findings: relative to healthy controls, SE-AN participants showed a preference for low-fat foods and exercised self-control on a greater proportion of trials. There was no significant effect of rTMS treatment nor time on food choices related to fat content. However, among SE-AN participants who received real rTMS, there was a decrease in self-controlled food choices at post-treatment, relative to baseline. Specifically, there was an increase in the selection of tasty-unhealthy foods. DISCUSSION: In SE-AN, rTMS may promote more flexibility in relation to food choice. This may result from neuroplastic changes in the DLPFC and/or in associated brain areas.

Defining and predicting service utilisation in young adulthood following childhood treatment of an eating disorder.

BACKGROUND: Eating disorder services are often separated into child and adolescent eating disorder services (CAEDSs) and adult eating disorder services (AEDSs). Most patients in CAEDSs present with first-episode illness of short duration, which with appropriate treatment, have a good prognosis. However, some individuals receive further treatment as adults. Little is known about service utilisation in adulthood following childhood/adolescent treatment of an eating disorder. AIMS: This study aims (a) to estimate the proportion of patients in a CAEDS who use mental health services as young adults, (b) to delineate service utilisation following treatment in CAEDSs and (c) to identify factors in CAEDSs that predict service utilisation in young adulthood. METHOD: A consecutive cohort of 322 patients (aged 13-17 years) seen in a CAEDS in the UK over a 5-year period were included in this audit. Data regarding their use of UK-wide adult mental health services as young adults (i.e. when aged 18-25) were extracted from local and national hospital records. RESULTS: A total of 68.3% of CAEDS patients received no mental health treatment as young adults. Although 13% of people seen in a CAEDS had brief eating disorder treatment as young adults, 10% received longer/or more intensive eating disorder treatment. Overall, 10.8% transitioned directly to an AEDS and 7.6% were re-referred following discharge from CAEDS. In our sample, older age and increased use of CAEDSs predicted increased eating disorder treatment in young adulthood. CONCLUSIONS: Our results indicate that most people seen in CAEDSs do not receive further mental health treatment as young adults. Several features in CAEDSs distinguish mental health service utilisation in young adulthood, which were identified clinically and could be targeted during treatment.

Therapist written goodbye letters: evidence for therapeutic benefits in the treatment of anorexia nervosa.

BACKGROUND: Despite their use in clinical practice, there is little evidence to support the use of therapist written goodbye letters as therapeutic tools. However, preliminary evidence suggests that goodbye letters may have benefits in the treatment of anorexia nervosa (AN). AIMS: This study aimed to examine whether therapist written goodbye letters were associated with improvements in body mass index (BMI) and eating disorder symptomology in patients with AN after treatment. METHOD: Participants were adults with AN (n = 41) who received The Maudsley Model of Anorexia Treatment for Adults (MANTRA) in a clinical trial evaluating two AN out-patient treatments. As part of MANTRA, therapists wrote goodbye letters to patients. A rating scheme was developed to rate letters for structure and quality. Linear regression analyses were used to examine associations between goodbye letter scores and outcomes after treatment. RESULTS: Higher quality letters and letters that adopted a more affirming stance were associated with greater improvements in BMI at 12 months. Neither the overall quality nor the style of goodbye letters were associated with improvements in BMI at 24 months or reductions in eating disorder symptomology at either 12 or 24 months. CONCLUSIONS: The results highlight the potential importance of paying attention to the overall quality of therapist written goodbye letters in the treatment of AN, and adopting an affirming stance.

First episode rapid early intervention for eating disorders: A two-year follow-up.

AIM: We describe 2-year outcomes of a novel first episode early intervention service for young adults with a recent onset eating disorder (FREED). Outcomes in FREED patients with anorexia nervosa (AN) were compared with those from patients previously seen in our service [treatment as usual (TAU) cohort], matched for age, illness duration and diagnosis. METHODS: Electronic case records of FREED-AN (n = 22) and TAU-AN patients (n = 35) were examined to identify service utilisation and clinical outcomes over 24 months. RESULTS: Outpatient service utilisation was similar in both groups, but FREED-AN patients needed intensive (in- or day-patient) treatment less frequently than TAU-AN (23% vs 32%). FREED-AN patients had a higher estimated mean body mass index [19.2 kg/m2 ; 95% CI (18.21, 20.16)] than TAU patients [18.0 kg/m2 ; 95% CI (16.90, 19.15)] at last contact. CONCLUSION: Introduction of FREED led to a more complete recovery in patients with AN at 24 months.

Bad Things Come to Those Who Do Not Wait: Temporal Discounting Is Associated With Compulsive Overeating, Eating Disorder Psychopathology and Food Addiction.

The tendency to act on immediate pleasure-driven desires, due to the devaluation of future rewards [a process known as temporal discounting (TD)], has been associated with substance use disorders (SUD) and with conditions characterised by compulsive overeating. The study involved a large inclusive participant sample (i.e., no diagnostic or exclusion criteria were applied). They were recruited/assessed online and we investigated whether TD was related to compulsive overeating and associated problems. Participants [N = 432, (48 males)] completed an online survey, which included a hypothetical monetary TD task, the Eating Disorder Examination-Questionnaire (EDE-Q), the Yale Food Addiction Scale (YFAS) and the Depression Anxiety and Stress Scales (DASS). TD correlated with frequency of compulsive overeating and compensatory behaviours, with eating disorder psychopathology, with scores on the YFAS, and with body mass index (BMI). As our study shows that elevated rates of TD are associated with a range of behaviours/measures, we propose that it is more likely that elevated TD rates are a predisposing factor rather than a consequence of the behaviour, i.e., elevated rates of TD contribute to pathological eating-related behaviours; however, a bi-directional explanation is also possible. Future research should investigate whether interventions aimed at reducing TD have clinical potential for treating problematic eating behaviours.

Randomised controlled feasibility trial of real versus sham repetitive transcranial magnetic stimulation treatment in adults with severe and enduring anorexia nervosa: the TIARA study.

OBJECTIVE: Treatment options for severe, enduring anorexia nervosa (SE-AN) are limited. Non-invasive neuromodulation is a promising emerging intervention. Our study is a feasibility randomised controlled trial of repetitive transcranial magnetic stimulation (rTMS) in individuals with SE-AN, which aims to inform the design of a future large-scale trial. DESIGN: Double-blind, parallel group, two-arm, sham-controlled trial. SETTING: Specialist eating disorders centre. PARTICIPANTS: Community-dwelling people with anorexia nervosa, an illness duration of ≥3 years and at least one previous completed treatment. INTERVENTIONS: Participants received 20 sessions (administered over 4 weeks) of MRI-guided real or sham high-frequency rTMS to the left dorsolateral prefrontal cortex in addition to treatment-as-usual. OUTCOMES: Primary outcomes were recruitment, attendance and retention rates. Secondary outcomes included body mass index (BMI), eating disorder symptoms, mood, quality of life and rTMS safety and tolerability. Assessments were conducted at baseline, post-treatment and follow-up (ie, at 0 month, 1 month and 4 months post-randomisation). RESULTS: Thirty-four participants (17 per group) were randomly allocated to real or sham rTMS. One participant per group was withdrawn prior to the intervention due to safety concerns. Two participants (both receiving sham) did not complete the treatment. rTMS was safe and well tolerated. Between-group effect sizes of change scores (baseline to follow-up) were small for BMI (d=0.2, 95% CI -0.49 to 0.90) and eating disorder symptoms (d=0.1, 95% CI -0.60 to 0.79), medium for quality of life and moderate to large (d=0.61 to 1.0) for mood outcomes, all favouring rTMS over sham. CONCLUSIONS: The treatment protocol is feasible and acceptable to participants. Outcomes provide preliminary evidence for the therapeutic potential of rTMS in SE-AN. Largest effects were observed on variables assessing mood. This study supports the need for a larger confirmatory trial to evaluate the effectiveness of multi-session rTMS in SE-AN. Future studies should include a longer follow-up period and an assessment of cost-effectiveness. TRIAL REGISTRATION NUMBER: ISRCTN14329415; Pre-results.

A pilot evaluation of a novel First Episode and Rapid Early Intervention service for Eating Disorders (FREED).

This pilot study assesses the impact of FREED (First Episode Rapid Early Intervention for Eating Disorders [ED]), a novel transdiagnostic service for emerging adults with recent ED onset, on clinical outcomes. Data were collected from 56 patients and 19 carers for 12 months following enrolment. FREED patients showed significant improvements in ED and other symptoms across time. Carers also showed psychological improvements. For FREED anorexia nervosa (AN) patients, body mass index (BMI) at initial clinical assessment was similar to that of comparable patients (audit cohort) seen in our service before (16.4 vs 16.1 kg/m2 ). By start of treatment, because of their shorter wait, FREED-AN had gained weight whereas audit patients had lost (16.7 vs 15.8 kg/m2 ). This difference continued throughout treatment, and at 12 months, nearly 60% FREED-AN patients returned to a BMI of 18.5 or greater. FREED shows promise as a service model for emerging adults with EDs.

The FREED Project (first episode and rapid early intervention in eating disorders): service model, feasibility and acceptability.

AIM: Eating disorders (EDs) are disabling disorders, predominantly affecting adolescents and young adults. Untreated symptoms have lasting effects on brain, body and behaviour. Care pathway-related barriers often prevent early detection and treatment of ED. The aim of this study was to assess the feasibility and acceptability of FREED (First Episode and Rapid Early Intervention for Eating Disorder), a novel service for young people (aged 18-25 years) with recent ED onset (≤3 years), embedded in a specialist adult National Health Service ED service. Specifically, we assessed the impact of FREED on duration of time until specialist service contact (DUSC), duration of untreated ED (DUED) and wait-times for assessment and treatment compared with patients seen earlier in our service. Acceptability of FREED was also assessed. METHODS: Sixty individuals were recruited from September 2014 to August 2015. Fifty-one of these were compared with 89 patients seen earlier. RESULTS: FREED patients, from areas with minimal National Health Service gatekeeping (14/51), had markedly shorter DUSC and DUED than controls (DUSC: 12.4 months vs. 16.2 months; DUED 13.0 months vs. 19.1 months), whereas those with complex gatekeeping (37/51) had shorter DUED (17.7 months), but longer DUSC (16.9 months) than controls. FREED patients waited significantly less time for both assessment and treatment than controls, had significantly better treatment uptake and were highly satisfied with the process of starting treatment. CONCLUSIONS: FREED is a feasible and acceptable service which successfully reduced waiting times. Reductions in DUSC and DUED depend on gatekeeping arrangements. More research is required to establish clinical outcomes of FREED.

Single-Session Transcranial Direct Current Stimulation Temporarily Improves Symptoms, Mood, and Self-Regulatory Control in Bulimia Nervosa: A Randomised Controlled Trial.

BACKGROUND: Evidence suggests that pathological eating behaviours in bulimia nervosa (BN) are underpinned by alterations in reward processing and self-regulatory control, and by functional changes in neurocircuitry encompassing the dorsolateral prefrontal cortex (DLPFC). Manipulation of this region with transcranial direct current stimulation (tDCS) may therefore alleviate symptoms of the disorder. OBJECTIVE: This double-blind sham-controlled proof-of-principle trial investigated the effects of bilateral tDCS over the DLPFC in adults with BN. METHODS: Thirty-nine participants (two males) received three sessions of tDCS in a randomised and counterbalanced order: anode right/cathode left (AR/CL), anode left/cathode right (AL/CR), and sham. A battery of psychological/neurocognitive measures was completed before and after each session and the frequency of bulimic behaviours during the following 24-hours was recorded. RESULTS: AR/CL tDCS reduced eating disorder cognitions (indexed by the Mizes Eating Disorder Cognitions Questionnaire-Revised) when compared to AL/CR and sham tDCS. Both active conditions suppressed the self-reported urge to binge-eat and increased self-regulatory control during a temporal discounting task. Compared to sham stimulation, mood (assessed with the Profile of Mood States) improved after AR/CL but not AL/CR tDCS. Lastly, the three tDCS sessions had comparable effects on the wanting/liking of food and on bulimic behaviours during the 24 hours post-stimulation. CONCLUSIONS: These data suggest that single-session tDCS transiently improves symptoms of BN. They also help to elucidate possible mechanisms of action and highlight the importance of selecting the optimal electrode montage. Multi-session trials are needed to determine whether tDCS has potential for development as a treatment for adult BN.

A systematic review of temporal discounting in eating disorders and obesity: Behavioural and neuroimaging findings.

OBJECTIVE: Eating Disorders (ED) and obesity are suggested to involve a spectrum of self-regulatory control difficulties. Temporal discounting (TD) tasks have been used to explore this idea. This systematic review examines behavioural and neuroimaging TD data in ED and obesity. METHOD: Using PRISMA guidelines, we reviewed relevant articles in MEDLINE, PsycINFO and Embase from inception until 17th August 2016. Studies that reported behavioural differences in TD and/or TD neuroimaging data in ED/obesity were included. RESULTS: Thirty-one studies were included. Limited data suggest that BN, BED and obesity are associated with increased TD, whilst data in AN are mixed. Aberrant neural activity in frontostriatal circuitry is implicated. TD tasks vary widely and TD in ED/obesity may vary according to factors such as illness stage. CONCLUSION: Our findings suggest altered self-regulatory control in ED and obesity. TD tasks are heterogeneous, limiting generalisability of findings. Research into whether TD is multidimensional, along with transdiagnostic neuroimaging research is needed. Assessment of TD may be useful in psychoeducation, outcome prediction and treatment of ED/obesity.

Written case formulations in the treatment of anorexia nervosa: Evidence for therapeutic benefits.

OBJECTIVE: Case formulation is a core component of many psychotherapies and formulation letters may provide an opportunity to enhance the therapeutic alliance and improve treatment outcomes. This study aimed to determine if formulation letters predict treatment satisfaction, session attendance, and symptom reductions in anorexia nervosa (AN). It was hypothesized that higher quality formulation letters would predict greater treatment satisfaction, a greater number of attended sessions, and greater improvement in eating disorder symptoms. METHOD: Patients were adult outpatients with AN (n = 46) who received Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) in the context of a clinical trial. A Case Formulation Rating Scheme was used to rate letters for adherence to the MANTRA model and use of a collaborative, reflective, affirming stance. Analyses included linear regression and mixed models. RESULTS: Formulation letters that paid attention to the development of the AN predicted greater treatment acceptability ratings (p = 0.002). More reflective and respectful letters predicted greater reductions in Eating Disorder Examination scores (p = 0.003). DISCUSSION: Results highlight the potential significance of a particular style of written formulation as part of treatment for AN. Future research should examine applicability to other psychiatric disorders. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:874-882).

Increased temporal discounting in bulimia nervosa.

OBJECTIVE: There is evidence that people with eating disorders display altered intertemporal choice behavior (the degree of preference for immediate rewards over delayed rewards). Compared to healthy controls (HC), individuals with anorexia nervosa and binge-eating disorder show decreased and increased rates of temporal discounting (TD; the devaluation of delayed rewards), respectively. This is the first study to investigate TD in people with bulimia nervosa (BN). METHOD: Thirty-nine individuals with BN (2 men) and 53 HC (9 men) completed a hypothetical monetary TD task. Over 80 binary choices, participants chose whether they would prefer to receive a smaller amount of money available immediately or a larger amount available in 3 months. Self-reported ability to delay gratification (the behavioral opposite of TD) was also measured. RESULTS: Individuals with BN showed greater TD (i.e., a preference for smaller-sooner rewards) and a decreased self-reported capacity to delay gratification relative to HC. Experimental groups did not differ in age, gender ratio, or BMI. DISCUSSION: Increased rates of TD may contribute to some of the core symptoms of BN that appear to involve making choices between immediate and delayed rewards (i.e., binge-eating and compensatory behaviors). Altered intertemporal choice behavior could therefore be a relevant target for intervention in this patient group. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1077-1081).

Two-year follow-up of the MOSAIC trial: A multicenter randomized controlled trial comparing two psychological treatments in adult outpatients with broadly defined anorexia nervosa.

OBJECTIVE: This study reports follow-up data from a multicenter randomized controlled trial (n = 142) comparing the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with broadly defined anorexia nervosa (AN). At 12 months postrandomization, all patients had statistically significant improvements in body mass index (BMI), eating disorder (ED) symptomatology and other outcomes with no differences between groups. MANTRA was more acceptable to patients. The present study assessed whether gains were maintained at 24 months postrandomization. METHODS: Follow-up data at 24 months were obtained from 73.2% of participants. Outcome measures included BMI, ED symptomatology, distress, impairment, and additional service utilization during the study period. Outcomes were analyzed using linear mixed models. RESULTS: There were few differences between groups. In both treatment groups, improvements in BMI, ED symptomatology, distress levels, and clinical impairment were maintained or increased further. Estimated mean BMI change from baseline to 24 months was 2.16 kg/m(2) for SSCM and 2.25 kg/m(2) for MANTRA (effect sizes of 1.75 and 1.83, respectively). Most participants (83%) did not require any additional intensive treatments (e.g., hospitalization). Two SSCM patients became overweight through binge-eating. DISCUSSION: Both treatments have value as outpatient interventions for patients with AN. © 2016 Crown copyright. International Journal of Eating Disorders. (Int J Eat Disord 2016; 49:793-800).