Performing well but not appreciating it - A trait feature of anorexia nervosa.

Background: Despite advances in the etiology of anorexia nervosa (AN), a large subgroup of individuals does not profit optimally from treatment. Perfectionism has been found to be a risk factor predicting the onset, severity, and duration of AN episodes. To date, perfectionism has been studied predominantly by the use of self-report questionnaires, a useful approach that may, however, be impacted by demand characteristics, or other distortions of introspective or metacognitive access. Methods: Here we circumvent these problems via a behavioral paradigm in which participants perform a modified Go/NoGo task, whilst self-evaluating their performance. We compared a group of 33 adolescent females during their first episode of AN (age = 16.0) with 29 female controls (age = 16.2), and 23 adolescent girls recovered from AN (age = 18.3) with 23 female controls (age = 18.5). The controls were closely matched by intelligence quotient and age to the two clinical groups. Results: First-episode AN and control participants performed equally well on the task (reaction time and errors of commission), whereas the recovered group displayed significantly faster reaction times but incurred the same error rate. Despite performing at least as good as and predominantly better than control groups, both clinical groups evaluated their performances more negatively than controls. Conclusion: We offer a novel behavioral method for measuring perfectionism independent of self-report, and we provide tentative evidence that this behavioral manifestation of perfectionism is evident during first-episode AN and persists even after recovery.

Families tackling adolescent anorexia nervosa: family wellbeing in family-based treatment or other interventions. A scoping review.

PURPOSE: Family-based treatment (FBT) has contributed significantly to the treatment of anorexia nervosa (AN) in young people (YP). However, parents are concerned that FBT and the active role of parents in the task of refeeding may have a negative impact on family relations. The aim of the review is to assess whether families engaged in FBT for AN are more or less impacted in their family wellbeing and caregiver burden, compared to families with a YP diagnosed with AN, who are not undergoing treatment with FBT. METHOD: Computerized searches across six databases complemented by a manual search resulted in 30 papers being included in the scoping review. RESULTS: The review identified 19 longitudinal studies on change in family wellbeing in families in FBT-like treatments, and 11 longitudinal studies on change in family wellbeing in treatment where parents are not in charge of refeeding. Only three randomized controlled studies directly compare FBT to treatment without parent-led refeeding. CONCLUSION: The available research suggests no difference between intervention types regarding impact on family wellbeing. Approximately half of the studies find improvements in family wellbeing in both treatment with and without parent-led refeeding, while the same proportion find neither improvement nor deterioration. As parents play a pivotal role in FBT, there is a need for good quality studies to elucidate the impact of FBT on family wellbeing. Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Predictors for and duration of hospitalization among children and adolescents with eating disorders.

OBJECTIVE: The objective of this study was to investigate the predictive value of sex, age, body mass index (BMI), Eating Disorder Examination (EDE) score, social risk factors, and psychiatric comorbidities for hospitalization and hospitalization duration among children and adolescents suffering from eating disorders. METHOD: This prospective cohort study involved 522 consecutive patients who had been referred to a specialized eating disorder unit between January 1, 2009 and December 31, 2015; participants were followed up until August 1, 2016 by medical records. We used regression analyses to evaluate the prognostic value of sex, age, BMI, EDE, eating disorder diagnoses, social risk factors, and psychiatric comorbidities concerning inpatient hospitalization and hospitalization duration. RESULTS: We found that younger age, higher EDE global score, lower BMI percentile, anorexia nervosa, a higher number of social risk factors, and the presence of diagnosed self-harm increased the odds of being hospitalized, while being female and having a comorbid autism spectrum condition increased the duration of hospitalization. No other psychiatric comorbidity was found to significantly predict hospitalization or duration of hospitalization. DISCUSSION: The odds of being hospitalized were predicted by the severity of anorexia nervosa and indicators of social risk factors in the family, whereas the duration of hospitalization was predicted by having a comorbid autism spectrum condition, indicating a difference between the factors affecting the risk of hospitalization and the factors affecting the duration of hospitalization. This calls for further exploration of tailored treatments for eating disorders. PUBLIC SIGNIFICANCE STATEMENT: This study finds that hospitalization for an eating disorder is predicted by the severity of the illness, self-harm, and social risk factors. Duration of hospitalization is predicted by having a comorbid autism spectrum condition. These findings indicate that the treatment of eating disorders may require different treatment approaches depending on the presentation of the individual patient to reduce both the need for hospitalization and the length of inpatient stay.

Case series of family-based treatment for restrictive-type eating disorders and comorbid autism: What can we learn? A brief report.

OBJECTIVE: Autism is more prevalent among persons with Restrictive type eating disorders (R-ED) compared to the general population and is associated with poorer outcomes across treatment modalities. Knowledge is sparse with regard to whether poorer outcomes are also associated with Family-based treatment (FBT), which is recommended as the first choice of treatment for young persons (YPs) with R-ED. This case series compares outcome between groups with and without autism in a large consecutive series of YPs with R-ED treated with FBT. METHOD: In an earlier described consecutive series of 157 YPs with R-ED treated with FBT, we compared the outcomes of the subgroup with (N = 16) and without (N = 141) comorbid autism. Primary ICD-10 diagnoses were typical (50.0) or atypical anorexia nervosa (AN) (F50.1), the latter implying a condition as typical AN but with a failure to meet one of the diagnostic criteria. Autism diagnoses were clinically assigned. The outcomes were receiving intensified care, weight normalisation and overall successful treatment. RESULTS: 10.2% (N = 16) of the sample had autism. 2.5% (N = 4) had autism diagnosed prior to the Eating Disorder (ED), and an additional 7.7% (N = 12) were diagnosed with autism during ED treatment. Significantly more YPs with autism (50%, N = 8) compared with YPs without autism (16%, N = 23) received intensified care (day programme or inpatient treatment) during their treatment. No significant difference between groups regarding neither weight normalisation nor successful ending of the treatment were found. CONCLUSION: This small sample of YPs with autism suggests that comparable proportions of YPs with and without autism may restore normal weight and end the treatment successfully within 12 months. However, more YPs with comorbid autism needed more intensive treatment, indicating that outpatient treatment delivery may not be sufficient to bring about desired change in this patient group. Findings need confirmation in a larger sample with a systematic screening for autism.

Anorexia nervosa: Outpatient treatment and medical management.

Anorexia nervosa (AN) is a disabling, costly and potentially deadly illness. Treatment failure and relapse are common after completing treatment, and a substantial proportion of patients develop severe and enduring AN. The time from AN debut to the treatment initiation is normally unreasonably long. Over the past 20 years there has been empirical support for the efficacy of several treatments for AN. Moreover, outpatient treatment with family-based therapy or individual psychotherapy is associated with good outcomes for a substantial proportion of patients. Early intervention improves outcomes and should be a priority for all patients. Outpatient treatment is usually the best format for early intervention, and it has been demonstrated that even patients with severe or extreme AN can be treated as outpatients if they are medically stable. Inpatient care is more disruptive, more costly, and usually has a longer waiting list than does outpatient care. The decision as to whether to proceed with outpatient treatment or to transfer the patient for inpatient therapy may be difficult. The core aim of this opinion review is to provide the knowledge base needed for performing safe outpatient treatment of AN. The scientific essentials for outpatient treatment are described, including how to assess and manage the medical risks of AN and how to decide when transition to inpatient care is indicated. The following aspects are discussed: early intervention, outpatient treatment of AN, including outpatient psychotherapy for severe and extreme AN, how to determine when outpatient treatment is safe, and when transfer to inpatient healthcare is indicated. Emerging treatments, ethical issues and outstanding research questions are also addressed.

A psychometric investigation of the multiple-choice version of Animated Triangles Task to measure Theory of Mind in adolescence.

The Animated Triangles Task (AT) is commonly used to measure Theory of Mind (ToM). AT can be scored by clinicians based on participants' verbal responses (AT-verbal) or using a multiple-choice paradigm (AT-MCQ). This study aimed to evaluate the validity of the less time-consuming AT-MCQ. To do this, we examined agreement and correlations between the AT-MCQ and the original AT-verbal scores in 1546 adolescents from a population-based sample. As a supplementary analysis of known-groups validity, we examined if AT-MCQ was as sensitive as AT-verbal in detecting ToM-limitations in 54 adolescents with autism spectrum disorder (ASD), using register-data. The agreement between AT-verbal and AT-MCQ varied markedly across test items. Scores on the two scoring methods were weakly correlated. Both scoring methods weakly detected differences between adolescents with and without ASD in this population-based sample. Most participants had appropriate responses on both AT-MCQ and AT-verbal, which yielded overall acceptable agreement. However, the feasibility of using either scoring methods to measure ToM-limitations in adolescents from the general population is questionable.

An evaluation of family-based treatment for restrictive-type eating disorders, delivered as standard care in a public mental health service.

BACKGROUND: Family-based treatment (FBT) has demonstrated efficacy for anorexia nervosa (AN) in youth in randomized, controlled trials. It is important to assess if it shows a similar effectiveness when implemented in standard care. AIM: To evaluate outcomes of FBT for restrictive-type eating disorders, delivered as standard care in a public mental health service. Outcomes are remission, frequency of hospital admissions and day-patient treatment, and frequency of other adaptations within 12 months from commencement of treatment. Second, to compare the collaborative clinical decisions of successful treatment in standard care made by family therapist at the end of treatment, with more objective definitions of recovery. METHODS: The design is a prospective, uncontrolled study of a consecutive series of patients with restrictive-type eating disorders, treated with FBT in a specialty unit at the Child and Adolescent Mental Health Centre in the Capital Region of Denmark. RESULTS: FBT was successfully completed within 12 months by 57% of participants, and 47% completed with 20 sessions or fewer. Weight restoration was achieved by 75% within 12 months, and 46% achieved both normalisation of body weight and behavioural symptoms of AN within 12 months. A total of 20% needed intensified treatment. All aspects of remission were often not present simultaneously, and the collaborative clinical decisions of successful treatment only partly aligned with other parameters of remission. CONCLUSION: FBT showed good results when implemented as standard care, and it can be adapted to the specifics of local service organisation without compromising effectiveness.

We evaluated the outcome of family-based treatment for young people with anorexia nervosa and similar restrictive-type eating disorders, treated in a public mental health service with easy access to treatment. More than half of the young people had successfully terminated treatment within 12 month, and three quarters were weight-restored within 12 months although some were still in treatment. However, one in five young people needed a period of more intensive care. The study suggests that this form of treatment is effective outside of research trials and can be successfully implemented in diverse settings. While this treatment is effective for a majority, we need more knowledge about the needs of those who do not benefit enough, and we need information on how to identify them early in treatment.

The autism diagnostic observation schedule: Patterns in individuals with anorexia nervosa.

OBJECTIVE: Studies have used the Autism Diagnostic Observation Schedule (the ADOS-2) in individuals with anorexia nervosa (AN), but the patterns of scores have not been assessed. We examined which subset of the ADOS-2 items best discriminate individuals with AN from healthy controls (HC), and assessed the potential clustering of AN participants based on different profiles of the ADOS-2 item scores. METHOD: We combined datasets from two previous studies, and (a) compared mean ranks between young AN participants (N = 118) and HC (N = 42), (ii) replicated the item selection procedure of the existing ADOS-2 algorithm to assess sensitivity of items in the AN group, and (c) applied a two-step clustering analysis in the AN group (N = 149). RESULTS: AN participants displayed significantly higher mean ranks than HC participants in five of 32 items. All five items are part of the existing ADOS-2 algorithm. We found two clusters of AN participants; one representing normal social behaviour, comprising 68% of the individuals with AN, and one representing less efficient social behaviour, comprising 32% of individuals with AN. CONCLUSIONS: The items comprising the social affective cluster of the existing ADOS-2 algorithm are well suited to assess difficulties with social functioning in individuals with AN.

Disordered eating behaviours and autistic traits-Are there any associations in nonclinical populations? A systematic review.

OBJECTIVE: The objective of this study is to critically review existing literature concerning the possible association between autistic-like behaviours and problematic eating behaviours in nonclinical populations. METHOD: We performed a systematic literature search in three large databases. Studies were included if they assessed any association between a broad range of autistic-like behaviours and problematic eating behaviours in nonclinical samples. RESULTS: Sixteen eligible studies were found covering 3,595 participants in total, including five studies on children/adolescents (n = 685). All studies were cross-sectional, and thus, only concurrent associations could be evaluated. Several autistic-like behaviours were found to be associated with problematic eating behaviours, with the overall "autism spectrum quotient," deficiencies in set-shifting, and theory of mind showing the strongest associations. CONCLUSIONS: The existing literature indicates concurrent associations between specific autistic-like behaviours and problematic eating behaviours in nonclinical samples across ages. Large prospective longitudinal studies are needed for insight into the temporal order of these associations.

Impairment of Social Function in Young Females With Recent-Onset Anorexia Nervosa and Recovered Individuals.

PURPOSE: A subgroup of individuals with anorexia nervosa (AN) displays social difficulties; however, it is not clear if individuals with comorbid autism spectrum disorders account for these difficulties. METHODS: We compared social function using the Autism Diagnostic Observation Schedule in 43 young females with first-episode AN who did not have comorbid autism spectrum disorder, 28 individuals recovered from adolescent-onset AN, and 41 healthy comparison individuals (age range 14-22 years). We measured adaptive behavior with the Vineland-II parent questionnaire, and aspects of social cognition with psychological tests, such as the Reading-the-Mind-in-the-Eyes test, Profile of Nonverbal Sensitivity short version, The Awareness of Social Inference Test, Animated Triangles, and the CANTAB Affective Go/No-go task. RESULTS: Participants with first-episode AN and those recovered from AN displayed difficulties in social function, which were not associated with body mass index or other state factors of the disorder in those with first-episode AN. Mood problems and anxiety were not associated with these difficulties. Parents rated participants with first-episode AN lower than recovered and control participants on the Socialization Domain of Vineland-II. Finally, only participants recovered from AN demonstrated deficits in specific domains of social cognition: perceiving nonverbal bodily gesture and vocal prosody. CONCLUSIONS: Young females with first-episode AN and those recovered from AN displayed impairments in social function, which may represent more stable traits of the disorder. Only participants recovered from AN demonstrated deficits in social cognition.

Neurocognitive functions and social functioning in young females with recent-onset anorexia nervosa and recovered individuals.

BACKGROUND: Young individuals with anorexia nervosa (AN) or recovered from AN display impairments of social function. To date, however, it is not clear whether they differ from controls with respect to neurocognitive performance and whether those functions contribute to the compromised social function observed in individuals with AN. METHODS: We included 43 young females with first-episode AN, 28 individuals recovered from adolescent-onset AN, and 41 control individuals (14-22 yr), all without comorbid autism spectrum disorder. We compared the performance of participants across groups in seven neurocognitive functions relevant to social functioning: set-shifting, local processing, processing speed, working memory, sustained attention, verbal memory, and verbal abstraction. Further, we tested the association between neurocognitive function and social function, measured by Autism Diagnostic Observation Schedule (ADOS), with an ordinal logistic regression model. RESULTS: First, participants did not differ on any neurocognitive function across groups. Second, only the neurocognitive function "verbal memory" was significantly associated with social function. Higher performance in verbal memory was associated with lower odds of impaired social function. Diagnostic group remained a significant factor, but the absence of an interaction between group and neurocognitive performance indicated that the association between verbal memory and social function was independent of group membership. CONCLUSION: Young individuals with AN and those recovered from AN did not differ from controls with respect to neurocognitive performance. Verbal memory was associated with social function in all groups.

Heightened Olfactory Sensitivity in Young Females with Recent-Onset Anorexia Nervosa and Recovered Individuals.

INTRODUCTION: Olfaction may be related to food restriction and weight loss. However, reports regarding olfactory function in individuals with anorexia nervosa (AN) have been inconclusive. OBJECTIVE: Characterize olfactory sensitivity and identification in female adolescents and young adults with first-episode AN and young females recovered from AN. METHODS: We used the Sniffin' Sticks Odor Threshold Test and Odor Identification Test to assess 43 participants with first-episode AN, 27 recovered participants, and 39 control participants. Participants completed the Importance of Olfaction questionnaire, the Beck Youth Inventory and the Eating Disorder Inventory. We also conducted a psychiatric diagnostic interview and the Autism Diagnostic Observation Schedule with participants. RESULTS: Both clinical groups showed heightened olfactory sensitivity. After excluding participants with depression, participants with first-episode AN identified more odors than recovered participants. CONCLUSION: Heightened olfactory sensitivity in AN may be independent of clinical status, whereas only individuals with current AN and without depression show more accurate odor identification.

Are Weight Status and Cognition Associated? An Examination of Cognitive Development in Children and Adolescents with Anorexia Nervosa 1 Year after First Hospitalisation.

OBJECTIVE: The aim of this study was to characterise the association between the cognitive profile and weight restoration in children and adolescents with anorexia nervosa. METHODS: The study was a longitudinal, matched case-control, multicentre study. An assessment of cognitive functions was conducted by using the Wechsler Intelligence Scale for Children-III/the Wechsler Adult Intelligence Scale-III, the Test of Memory and Learning-second edition, Trail Making Tests A and B, the Rey-Osterrieth Complex Figure Test and the Cambridge Neuropsychological Test Automated Battery. RESULTS: One hundred twenty individuals, 60 patients with anorexia nervosa with mean age of 14.65 (SD 1.820) years and 60 healthy controls with mean age of 14.76 (SD 1.704) years, participated. No association was found between weight recovery and cognitive functions. However, a significant increase in motor speed was found in Trail Making Test A (p = 0.004), Reaction Time (RTI) five-choice movement time (p = 0.002) and RTI simple movement time (p = 0.011), resulting in a normalisation corresponding to that found in healthy controls. Furthermore, a significantly lower score in the perceptual organization index (p = 0.029) was found at follow-up. CONCLUSIONS: Weight recovery appears not to be associated with cognition. Copyright © 2016 The Authors European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd.

Autism spectrum disorder in individuals with anorexia nervosa and in their first- and second-degree relatives: Danish nationwide register-based cohort-study.

BACKGROUND: Clinical and population-based studies report increased prevalence of autism spectrum disorders (ASD) in individuals with anorexia nervosa and in their relatives. No nationwide study has yet been published on co-occurrence of these disorders. AIMS: To investigate comorbidity of ASD in individuals with anorexia nervosa, and aggregation of ASD and anorexia nervosa in their relatives. METHOD: In Danish registers we identified all individuals born in 1981-2008, their parents, and full and half siblings, and linked them to data on hospital admissions for psychiatric disorders. RESULTS: Risk of comorbidity of ASD in probands with anorexia nervosa and aggregation of ASD in families of anorexia nervosa probands were increased. However, the risk of comorbid and familial ASD did not differ significantly from comorbid and familial major depression or any psychiatric disorder in anorexia nervosa probands. CONCLUSIONS: We confirm aggregation of ASD in probands with anorexia nervosa and in their relatives; however, the relationship between anorexia nervosa and ASD appears to be non-specific.

Cognitive profile of children and adolescents with anorexia nervosa.

OBJECTIVE: Few studies of cognitive functioning in children and adolescents with anorexia nervosa (AN) have been conducted. The aim of this study was to examine the neurocognitive and intelligence profile of this clinical group. METHOD: The study was a matched case-control (N = 188), multi-centre study including children and adolescents with AN (N = 94) and healthy control participants (N = 94). RESULTS: The results suggest that Full Scale Intelligence Quotient (Wechsler Intelligence Scale for Children-III/Wechsler Adult Intelligence Scale-III) in this patient group is close to the normal population mean of 100. Individuals with AN exhibited significantly worse performance in nonverbal intelligence functions (i.e. Wechsler Intelligence Scale for Children-III/Wechsler Adult Intelligence Scale-III, Perceptual Organization Index) and in verbal memory (Test of Memory and Learning-Second Edition, Memory for Stories) and motor speed (Cambridge Neuropsychological Test Automated Battery, Simple and Choice Reaction Time) compared with healthy control participants. No significant difference in set-shifting ability (Cambridge Neuropsychological Test Automated Battery, Intra-Extra Dimensional Set Shift and Trail Making Test B) was found. CONCLUSIONS: Inefficiency in nonverbal intelligence functions and in specific cognitive functions was found in this study of children and adolescents with AN.