Patients' perceptions of post-treatment factors that influenced skill use after cognitive-behavioral therapy for bulimia nervosa spectrum disorders.

OBJECTIVE: Deterioration rate among patients with bulimia-spectrum eating disorders (BN-EDs) after receiving enhanced cognitive-behavioral therapy (CBT-E) remains high. Previous studies identified body image concerns, environmental triggers, lack of social support, lack of resources, comorbidity, and discontinued skill use as predictors of deterioration. However, no studies have qualitatively explored patients' perceptions of how these factors influenced their skill use and led to deterioration after receiving outpatient CBT. METHODS: This study aimed to qualitatively explore (1) what post-treatment factors patients believe contributed to deterioration, and (2) whether patients continued to practice the CBT skills they learned from treatment and identify motivators and barriers to post-treatment skill use. Twelve participants who had previously completed 16 sessions of CBT for their BN-EDs and experienced at least modest treatment responses participated in the qualitative interviews. RESULTS: Four themes were identified from the qualitative interviews. Post-treatment deterioration was primarily driven by decreased skill use due to a perceived sudden loss of accountability and continued body dissatisfaction after treatment ended. Discontinued practice of binge analysis led to decreased awareness of the relationship between poor skill use and ED behaviors. Difficulty accessing resources impeded participants from receiving external help to address challenges in skill practice, thus also contributing to deterioration. DISCUSSION: Findings suggested that outpatient treatment for BN-EDs patients should emphasize more on body image concern, and deterioration prevention for outpatient CBT-E should focus on building self-accountability to keep practicing skills after treatment ends. PUBLIC SIGNIFICANCE: This study was the first to qualitatively explore post-treatment factors influencing skill use and deterioration in patients with bulimia-spectrum eating disorders after they completed outpatient CBT. Findings indicated that decreased skill use was a primary driver of post-treatment deterioration, and that relapse prevention for outpatient CBT for BN-EDs should focus on enhancing patients' self-accountability to continue practicing therapeutic skills independently after treatment ended.

Early reduction in anxiety sensitivity predicts greater reduction in disordered eating and trait anxiety during treatment for bulimia nervosa.

OBJECTIVE: Anxiety sensitivity (AS), the trait-like fear of symptoms of anxiety, has been associated with eating disorder (ED) pathology broadly, bulimia nervosa (BN) symptoms specifically, and the anxiety disorders that are commonly comorbid with BN. AS, especially for physical symptoms specifically, maybe a risk and maintenance factor for BN and comorbid anxiety. METHOD: Adult participants with BN (n = 44) in a clinical trial comparing CBT to mindfulness and acceptance-based treatment (MABT) reported ED symptoms, trait anxiety, and AS through treatment and follow-up. We predicted that greater early reduction (i.e., within the first month of treatment) in AS would predict greater reductions in ED symptoms and trait anxiety at post-treatment and follow-up. RESULTS: Early reductions in AS for physical concerns predicted lower ED symptoms and trait anxiety at post-treatment but not follow-up. Exploratory analyses indicated that treatment groups did not differ in either early or total change in AS, controlling for baseline AS. DISCUSSION: Early reductions in AS may be an important treatment target for BN, and may additionally support reductions in anxiety. Future research should identify which components of CBT and MABT best target AS, to deliver these components early in treatment, when they can have maximum effect. PUBLIC SIGNIFICANCE: Anxiety sensitivity, the fear of symptoms of anxiety, is associated with eating disorders (ED). In this study, participants in treatment for bulimia nervosa reported ED symptoms, trait anxiety, and anxiety sensitivity through treatment and follow-up. Greater early reductions in anxiety sensitivity predicted lower ED symptoms and trait anxiety at post-treatment. Future research should identify which elements of treatment best target anxiety sensitivity, to deliver them early in treatment.

Physiological, body composition, and body mass measures show that a developmental measure of weight suppression is more valid than the traditional measure.

OBJECTIVE: The traditional measure of weight suppression (TWS; the difference between an individual's highest past weight at adult height and current weight), has been associated with many psychological, behavioral and biological variables in those with eating disorders. A new measure of weight suppression, called developmental weight suppression (DWS), corrects two major problems in the original measure. Initial research indicates that DWS represents a superior operationalization of the construct weight suppression was originally designed to measure (Lowe [1993, Psychol Bull, 114: 100]). This study is the first to examine the relation between both WS measures and weight history, body composition and a variety of metabolic hormones. METHODS: Data were collected in 91 women with bulimia nervosa (BN) or BN-spectrum disorders. RESULTS: Both weight suppression indices were related to multiple hormones. However, multiple regression analyses showed that the independent effects of DWS differed from the independent effects of TWS in that only DWS was negatively related to: (1) current z-BMI, (2) body fat percentage, and (3) insulin, leptin, T3 free, and TSH. This differential pattern also occurred when results were corrected for multiple comparisons. DISCUSSION: Findings provide stronger biological support for the construct validity of DWS than TWS and suggest that: (1) from the perspective of individuals with BN, high DWS embodies success at food restriction and weight loss, (2) elevated DWS may trap individuals with BN in a powerful biobehavioral bind, and (3) DWS is the preferred measure of weight suppression in future research on eating disorders. PUBLIC SIGNIFICANCE: Most individuals with bulimia nervosa lose substantial weight in the process of developing their disorder. Such weight suppression is related to many characteristics of those with the eating disorder bulimia nervosa. This study shows why a new measure of weight suppression, based on an individual's growth during development, is more biologically valid than the traditional measure of weight suppression.

Multiple marginalization, discrimination, and disordered eating among youth aged 10-11.

OBJECTIVE: Although rates of weight discrimination are on-par with racial, ethnic, and gender discrimination, comparatively less work has examined impacts of weight-based discrimination in youth, including on disordered eating. Knowing whether experiences of weight-based discrimination, including in youth with multiply-marginalized identities, are associated with disordered eating could identify vulnerable youth and inform intervention efforts. METHOD: Youth (N = 11,875) ages 10-11 were recruited through the Adolescent Brain Cognitive Development (ABCD) study. Logistic regressions using cross-sectional data examined discrimination experiences (weight, perceived sexual orientation, race/ethnicity, national origin) and disordered eating (binge-eating, vomiting, weight-gain fear, weight self-worth). Models included race/ethnicity, age, sex, parental income, and degree of elevated weight. Raked poststratification weights were used. RESULTS: Rates of weight-based discrimination (6.2%) were similar to rates of race/ethnicity (4.4%) and sexual orientation discrimination (4.5%). Weight-based discrimination was associated with more disordered eating. Youth reporting multiple experiences of discrimination had significantly increased disordered eating compared to youth who did not report discrimination. DISCUSSION: Weight-based discrimination is common in youth and associated with disordered eating. Youth with elevated weight are more likely to be multiply marginalized and experience disordered eating. These findings suggest discrimination, including weight-based discrimination, is a critical intervention target to prevent and treat eating disorders. PUBLIC SIGNIFICANCE: Experiences of discrimination contribute to poorer health; however, weight-based discrimination is relatively understudied. Data from a large sample of youth ages 10-11 showed that youth with elevated weight reported experiencing multiple types of discrimination, and multiply-marginalized youth had increased odds of disordered eating with each additional type of discrimination. Together, this suggests that weight-based discrimination is a critical target to prevent and treat eating disorders, especially in multiply-marginalized youth.

Psychotic-like anomalous self-experiences in feeding and eating disorders: Their role in eating psychopathology through the mediation of body uneasiness and embodiment and identity disorders.

BACKGROUND: Psychotic-like anomalous self-experiences (ASEs) are core and early features of schizophrenia spectrum disorders, which have been recently also postulated to underlie embodiment disturbance in feeding and eating disorders (FEDs). The present study was aimed at investigating the interplay between ASEs and specific psychopathology in FED. METHODS: Ninety persons with Anorexia Nervosa and 41 with Bulimia Nervosa were evaluated with the inventory of psychotic-like anomalous self-experiences (IPASE), identity and eating disorders (IDEA), body uneasiness test (BUT), and eating disorder examination questionnaire (EDE-Q). The same assessment was performed for 92 subjects recruited from the general population. Structural equation modelling was employed to test the role of embodiment/identity disorders in mediating the relationship between ASEs and ED psychopathology. RESULTS: Patients with FED displayed high scores on IPASE, comparable with people with schizophrenia spectrum disorders. A significant correlation was also demonstrated between IPASE, BUT and EDE-Q. All IPASE domains were strongly related to feeling extraneous from one's own body by IDEA. All IPASE domains demonstrated a high relationship with BUT Depersonalization scale. A strong correlation was also reported between total scores of IPASE and IDEA. The mediation model confirmed that ASEs impact on FED symptomatology through the mediation of both embodiment/identity disorders and body image. DISCUSSION: Anomalous interoceptive processes may represent the first step of a maladaptive process-impairing embodiment, selfhood, and identity in FED. Assessment of ASEs might be a valid tool to identify an early-shared vulnerability of severe disorders characterized by embodiment alterations.

The use and misuse of the SCOFF screening measure over two decades: a systematic literature review.

PURPOSE: The SCOFF questionnaire was designed as a simple, memorable screening tool to raise suspicion that a person might have an eating disorder. It is over 20 years since the creation of the SCOFF, during which time it has been widely used. Considering this, we wish to review the use of the SCOFF in peer-reviewed scientific journals, and to assess whether it is being used appropriately in the manner in which it was originally devised and tested. METHODS: The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were followed, and all search strategies and methods were determined before the onset of the study. PubMed and Wiley Online Library were searched using the terms SCOFF and eating. Two reviewers were involved in the reviewing process. Criteria for appropriate use of the SCOFF were formalised with the tool's original authors. RESULTS: 180 articles were included in the final review. 48 articles had used the SCOFF appropriately, 117 articles inappropriately and 15 articles had been mixed in the appropriateness of their use. CONCLUSION: This systematic review highlights the inappropriate use of the SCOFF in diverse languages and settings. When used correctly the SCOFF has made a significant contribution to the understanding of eating disorders and its simplicity has been applauded and led to widespread use. However in over two-thirds of studies, the use of the SCOFF was inappropriate and the paper highlights how and in what way it was misused, Guidelines for the appropriate use of the SCOFF are stated. Future validation and avenues of research are suggested. LEVEL OF EVIDENCE: Level I.

Bidirectional association between eating disorder and temporomandibular joint disorder: A retrospective longitudinal nationwide population-based cohort study.

Background/purpose: An increasing body of evidence indicates correlations between the symptoms of temporomandibular disorder and those of eating disorder (ED). However, further investigation is required to elucidate the temporal and causal relationships between the aforementioned disorders. Materials and methods: This retrospective cohort study was conducted using data from the Taiwan National Health Insurance Research Database. Temporomandibular joint disorder (TMJD) was analyzed both as the cause and consequence of ED. We collected the data (from January 1, 1998, to December 31, 2011) of patients with antecedent TMJD (N = 15,059) or ED (N = 1219) and their respective controls (1:10), matched by age, sex, income level, residential location, and comorbidities. This study included patients who had received a new diagnosis of an ED or a TMJD between January 1, 1998, and December 31, 2013. Cox regression models were used to assess the risk of ED or TMJD development in patients with antecedent TMJD or ED. Results: TMJD patients had an approximately 3.70-fold (95 % confidence interval [CI]: 1.93-7.10) risk of ED development. Similarly, patients with ED had an approximately 4.78-fold (95 % CI: 2.52-9.09) risk of TMJD development. Subgroup analyses based on ED subtypes indicated antecedent TMJD and bulimia nervosa as the predictors of increased bulimia nervosa and TMJD risks (hazard ratios: 6.41 [95 % CI: 2.91 to 14.11] and 5.84 [95 % CI: 2.75 to 12.41]), respectively. Conclusion: Previous TMJD and ED are associated with increased risks of subsequent ED and TMJD; these findings suggest the presence of a bidirectional temporal association between TMJD and ED.

Association Between Type 1 Diabetes Mellitus and Eating Disorders: A Systematic Review and Meta-Analysis.

BACKGROUND: Previous meta-analyses have shown mixed results regarding the association between eating disorders (EDs) and type 1 diabetes mellitus (T1DM). Our paper aimed to analyse different EDs and disordered eating behaviours that may be practiced by patients with T1DM. METHODS: A literature search of PubMed, Scopus and Web of Science was conducted on 17 January 2023, using the key terms "T1DM," "Eating Disorders" and "Bulimia." Only observational controlled studies were included. The Revman software (version 5.4) was used for the analysis. RESULTS: T1DM was associated with increased risk of ED compared with nondiabetic individuals (RR = 2.47, 95% CI = 1.84-3.32, p-value < 0.00001), especially bulimia nervosa (RR = 2.80, 95% CI = 1.18-6.65, p-value = 0.02) and binge eating (RR = 1.53, 95% CI = 1.18-1.98, p-value = 0.001). Our analysis has shown that increased risk of ED among T1DM persisted regardless of the questionnaire used to diagnose ED; DM-validated questionnaires (RR = 2.80, 95% CI = 1.91-4.12, p-value < 0.00001) and generic questionnaires (RR = 2.03, 95% CI = 1.27-3.23, p-value = 0.003). Prevalence of insulin omission/misuse was 10.3%; diabetic females demonstrated a significantly higher risk of insulin omission and insulin misuse than diabetic males. CONCLUSION: Our study establishes a significant and clear connection between EDs and T1DM, particularly bulimia and binge eating, with T1DM. Moreover, female diabetics are at higher risk of insulin misuse/omission. Early proactive screening is essential and tailored; comprehensive interventions combining diabetes and ED components are recommended for this population, with referral to a specialised psychiatrist.

From early relational experiences to non-suicidal self-injury in anorexia and bulimia nervosa: a structural equation model unraveling the role of impairments in interoception.

PURPOSE: Individuals with anorexia nervosa (AN) and bulimia nervosa (BN) frequently exhibit Non-Suicidal Self-Injury (NSSI), yet their co-occurrence is still unclear. To address this issue, the aim of this study was to elucidate the role of impairments in interoception in explaining the NSSI phenomenon in AN and BN, providing an explanatory model that considers distal (insecure attachment/IA and traumatic childhood experiences/TCEs) and proximal (dissociation and emotional dysregulation) risk factors for NSSI. METHOD: 130 patients with AN and BN were enrolled and administered self-report questionnaires to assess the intensity of NSSI behaviors, interoceptive deficits, IA, TCEs, emotional dysregulation and dissociative symptoms. RESULTS: Results from structural equation modeling revealed that impairments in interoception acted as crucial mediators between early negative relational experiences and factors that contribute to NSSI in AN and BN, particularly emotional dysregulation and dissociation. Precisely, both aspects of IA (anxiety and avoidance) and various forms of TCEs significantly exacerbated interoceptive deficits, which in turn are associated to the emergence of NSSI behaviors through the increase in levels of dissociation and emotional dysregulation. CONCLUSIONS: The proposed model provided a novel explanation of the occurrence of NSSIs in patients with AN and BN by accounting for the significance of interoception. LEVEL OF EVIDENCE: Level V-Cross-sectional observational study.

Prevalence of Eating Disorders and Comorbidity With Depression Among Adolescents in Saudi Arabia: A Cross-Sectional Study.

Background Patients diagnosed with eating disorders (EDs) have demonstrated elevated levels of eating psychopathology, including distorted body image, and general psychopathology, encompassing depression, anxiety, impulsivity, and low self-esteem, surpassing anticipated levels. However, the measurement of EDs' prevalence related to depression and mental disorders in Saudi society remains insufficient. There is a clear need for additional studies to establish and substantiate the relationship between these issues and their frequency. In response to this gap, the current study delves into the psychosocial implications of disordered eating in Saudi Arabian adolescents and adults. The primary objective of this study is to contribute to an expanded understanding of the psychosocial effects associated with EDs, shedding light on their prevalence and interconnectedness with mental health concerns among adolescents in Saudi Arabia. Methodology A cross-sectional study was conducted in Saudi Arabia among adolescents based on self-report questionnaires, including the Patient Health Questionnaires for Eating Disorders and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for the presence of EDs. To analyze the obtained data, we calculated the responses from participants who met the following criteria: adolescents (ages 10 to 18 years) from all regions in Saudi Arabia who were ethnically Saudi and included both male and female individuals. Those older than 18 years were excluded from the study. Results We collected data from 422 participants; however, 43 responses were excluded because the respondent was under 10 years or over 18 years old. According to the Patient Health Questionnaire 9 (PHQ-9), the prevalence of depression was 83.9%; 36.7% of the participants had severe depression, 23.2% had moderate depression, and 24% had mild depression. According to the Patient Health Questionnaire Eating Disorders Scale, the prevalence of EDs was 23.5%, with the prevalence of binge eating disorder and bulimia nervosa being 14.8% and 8.7%, respectively. We found a significant correlation between EDs and depression, and the severity of depression (P=0.005). The prevalence of depression among patients with EDs was 93.3%: 17.9% of patients with EDs had mild depression, 21.3% had moderate depression, and 54.1% had severe depression. Conclusion There is an alarming finding of the high prevalence of both EDs and depression among young adolescents in elementary school, which requires urgent intervention. The study found a significant relationship between EDs and depression: the more severe the depressive symptoms, the higher the prevalence of EDs.

Transitions from child and adolescent to adult mental health services for eating disorders: an in-depth systematic review and development of a transition framework.

BACKGROUND: Eating disorders (EDs) peak in mid-to-late adolescence and often persist into adulthood. Given their early onset and chronicity, many patients transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) for ongoing, speciality ED care. This transition typically occurs at 18 years of age, when important biological, psychosocial, and vocational changes take place. Thus, smooth and effective transitions are paramount for ensuring service continuity, as well as reducing the risk of ED relapse and premature death. Here, we synthesized evidence on transitions from CAMHS to AMHS for young people with EDs, aiming to inform future research, clinical practice, and healthcare policy. METHODS: A systematic review of the literature was conducted. This adhered to PRISMA guidelines. PubMed, Embase, and Scopus electronic databases were queried from inception to December 3, 2023. Leveraging the PICOS framework, study eligibility was evaluated in the qualitative synthesis. Data regarding methodology, analytic approach, and associated outcomes were then extracted. The quality of evidence was examined using critical appraisal tools. Finally, concept mapping was applied to organize findings into a transition framework. RESULTS: The search returned 76 articles. Of these, 14 were included in the final review. Articles were grouped into 'qualitative' (n = 10), 'cross-sectional' (n = 2), and 'longitudinal cohort' (n = 2) studies based on research design. Overall, ED transitions were complex, multifaceted, and challenging for patients, caregivers, and providers alike. This resulted from an interplay of temporal- (e.g., timing of ED onset and transition), stakeholder- (e.g., patient ambivalence towards recovery) and systemic- (e.g., differences between services) related factors. Most studies were of moderate-to-high quality. Findings informed the development of five transition strategies designed to facilitate effective transfers across ED care: Timely talks, Readiness, Inclusion, Preparation, and Synergy (TRIPS). CONCLUSIONS: Transitions from CAMHS to AMHS appear problematic for young people with EDs and other involved stakeholders. The field stands to benefit from TRIPS, an actionable, evidence-based framework that aims to alleviate challenges of transitioning and subsequently improve ED trajectories. As a logical next step, future work should empirically test the TRIPS framework, exploring its predictive utility and clinical value.

Eating disorders often develop in youth and persist into adulthood. Given this, many young people transition from pediatric to adult care for ongoing treatment. This usually occurs at 18 years of age, when important life changes take place, such as leaving home or pursuing higher education. Hence, smooth and effective transitions are critical for mental health. The present review summarized studies investigating transitions from pediatric to adult care for young people with eating disorders, and subsequently developed an evidence-informed transition framework (TRIPS). Based on the 14 studies included in the review, transitions from pediatric to adult care are challenging for young people with eating disorders, as well as for caregivers and providers. This is due to several factors related to the timing of transitions, the types of stakeholders involved, and the differences between care. Looking ahead, the field may benefit from the TRIPS framework that aims to improve transitions and clinical outcomes.

Individual differences in motivation to change in individuals with eating disorders: A systematic review.

OBJECTIVE: Motivation to change has been suggested to significantly impact treatment outcomes in eating disorders (EDs). This review will investigate factors associated with motivation to change in EDs with the aim of supporting clinicians to be aware and sensitive to factors that might obstruct recovery and to inform motivation-based interventions. METHOD: Using PRISMA guidelines, this article identified 24 studies through database searches meeting eligibility criteria. Only correlates of motivation were identified, limiting the ability of this review to identify causal relationships. Factors that changed alongside changes in motivation were identified from longitudinal studies. RESULTS: This review identified factors such as individual characteristics, co-morbid psychopathology, lack of treatment autonomy and relationships with others to be associated with motivation to change in individuals with EDs. In addition, motivation to change significantly increased alongside self-esteem and identity re-negotiation when measured longitudinally. DISCUSSION: Motivational interviewing can typically focus on exploring ambivalence to treatment, identifying goals and values, and increasing self-efficacy. However, this review identifies individual and relational factors to be particularly significant and may obstruct recovery from an ED. As such, evidence-based targets have been identified to inform clinicians and motivation-based interventions. PUBLIC SIGNIFICANCE: Knowledge of factors associated with motivation to change in EDs is important to understand those who may have poorer treatment outcomes. Motivation may be improved by supporting individuals' relationship with others and tailoring interventions according to temperament and personality traits. Utilizing an individual's social support as they enter ED treatment may be effective in maximizing motivation to recover.

OBJETIVO: Se ha sugerido que la motivación al cambio impacta significativamente en los resultados del tratamiento en los trastornos de la conducta alimentaria (TCAs). Esta revisión investigará los factores asociados con la motivación al cambio en los TCAs con el objetivo de apoyar a los clínicos para que estén conscientes y sensibles a los factores que podrían obstaculizar la recuperación e informar las intervenciones basadas en la motivación. MÉTODO: Siguiendo las guías PRISMA, este artículo identificó 24 estudios a través de búsquedas en bases de datos que cumplían con los criterios de elegibilidad. Solo se identificaron correlatos de la motivación, lo que limita la capacidad de esta revisión para identificar relaciones causales. Los factores que cambiaron junto con los cambios en la motivación se identificaron a partir de estudios longitudinales. RESULTADOS: Esta revisión identificó factores como características individuales, psicopatología comórbida, falta de autonomía en el tratamiento y relaciones con otros como asociados con la motivación al cambio en individuos con TCAs. Además, la motivación al cambio aumentó significativamente junto con la autoestima y la renegociación de la identidad cuando se midió longitudinalmente. DISCUSIÓN: La entrevista motivacional típicamente puede centrarse en explorar la ambivalencia hacia el tratamiento, identificando metas y valores, y aumentando la autoeficacia. Sin embargo, esta revisión identifica factores individuales y relacionales como particularmente significativos y que pueden obstaculizar la recuperación de un TCA. Como tal, se han identificado objetivos basados en evidencia para informar a los clínicos y a las intervenciones basadas en la motivación.

The current sociocultural background of eating disorders.

Eating disorders (EDs) are complex phenomena that are partly influenced by sociocultural factors. The thin body ideal of Western civilization, disseminated by mass media and reinforced by the fashion industry, plays a significant role. In this cultural environment, the social perception of the human body has undergone a change.

The maltreated eco-phenotype of eating disorders: A new diagnostic specifier? A systematic review of the evidence and comprehensive description.

This systematic review aimed to summarize the evidence on the existence of a distinct phenotypic expression of Eating Disorders (EDs) associated with childhood maltreatment (CM), the so-called maltreated eco-phenotype of EDs. PRISMA standards were followed. Articles providing data about the characteristics of individuals with an ED reporting CM were included. Relevant results were extracted and summarized. A quality assessment was performed. A total of 1207 records were identified and screened, and 97 articles published between 1994 and 2023 were included. Findings revealed distinct biological and clinical features in patients with EDs reporting CM, including neuroanatomical changes, altered stress responses, ghrelin levels, inflammation markers, and gut microbiota composition. Clinically, CM correlated with severer eating behaviors, higher psychiatric comorbidity, impulsivity, emotional dysregulation, and risky behaviors. Additionally, CM was associated with poorer treatment outcomes, especially in general psychopathology and psychiatric comorbidities. This review highlighted the need to move towards an etiologically informed nosography, recognizing CM not merely as a risk factor, but also as an etiologic agent shaping different eco-phenotypic variants of EDs.

Temperament impact on eating disorder symptoms and habit formation: a novel model to inform treatment.

BACKGROUND: Temperament has long been described as the biological dimension of personality. Due to advancing brain-imaging technology, our understanding of temperament has deepened and transformed over the last 25 years. Temperament combines genetic, neurobiological and trait research. Temperament has been included peripherally in some eating disorder (ED) treatment approaches but has been ignored by most. Temperament fills a fundamental treatment gap by clarifying who is more vulnerable to develop ED and why some individuals are susceptible to specific ED symptoms while others are not. In addition, temperament targets possible treatment solutions. MAIN TEXT: There is a need for a novel model that incorporates and explores the role of temperament in ED treatment intervention. This paper is a metaphoric temperament model to inform treatment intervention. It describes how temperament traits influences new decisions which impact new behavioural responses. In turn, it neurobiologically tracks how and why the brain efficiently transforms new decisions into new habits. This model integrates both temperament and habit research to explore (a) what temperament is; (b) how new decisions develop into habits neurobiologically; (c) that the brain wires destructive symptoms into habits in the same way that it wires healthy/productive behaviours into habits; (d) traits that trigger ED symptoms are the same traits that influence productive behaviours; and in regard to treatment implications (e) when treatment structure and intervention target client temperaments, the potential for new healthy "trait-syntonic" habits could develop. CONCLUSIONS: This paper introduces a metaphoric model that synthesizes and integrates temperament neurobiological and trait findings with ED symptoms, habits, and client trait-based solutions. The model synthesizes and integrates different research domains to establish a brain-based foundation to inform treatment intervention. The model targets clients' temperament traits as central collections of innate self-expressions that could be utilized as tools to redirect client trait-syntonic ED responses into trait-syntonic productive outcomes. The brain bases of temperament and habit formation serve as a biological foundation for ED treatment intervention.

Temperament is the biological, or brain-basis of our personality. It defines who we are and who we are not. Temperament influences how each person thinks, feels, and responds differently. Traits are one's natural personality expressions. For example a person may have natural tendencies, or traits, to be extroverted and determined. A person could express the same traits differently ranging from healthy/productive through unhealthy/destructive responses. Research has found that some traits, when expressed in destructive ways, influence the development of eating disorder symptoms. Some of those traits include perfectionism, impulsivity, and anxiety. However, these very same traits could be expressed in productive ways. In essence, traits are the biological triggers beneath one's responses and set the stage for productive to destructive habitual behaviours. Persons cannot eliminate their traits, but they can express them differently. Treatment could capitalize on client traits to help clients explore productive responses instead of turning to destructive habitual symptoms. Productive habits that are aligned with one's traits could more naturally persist and form long-term habits. Working with a client's temperament, verses overlooking it, holds hope for habitual productive change to replace ED symptoms.

Examining negative urgency as a predictor of eating disorder maintenance in purging syndromes.

OBJECTIVES: Negative urgency is associated with short-term maintenance of binge eating and purging in unselected samples. The current study used an eating disorder sample to test the hypothesis that negative urgency maintains bulimia nervosa (BN) and purging disorder (PD) at long-term follow-up. It was also hypothesized that baseline differences in negative urgency between BN and PD would remain at follow-up. METHODS: Secondary analyses were conducted on a sample of women who engaged in recurrent self-induced vomiting (n = 68; 52.9% BN; 47.1% PD). Women completed diagnostic interviews and questionnaires at baseline and at a mean (SD) of 5.95 (1.58) years follow-up (range = 2.51-9.62; retention rate = 75%). RESULTS: Negative urgency did not predict eating disorder diagnostic status, recovery status, or global eating pathology at follow-up (p's = .06-.83). There were no significant differences in negative urgency across women with BN and PD at follow-up (p = .16). However, post hoc analyses indicated that negative urgency was not stable across time (ICC = .102). Increases in negative urgency from baseline to follow-up were associated with greater global eating pathology at follow-up (p = .002). CONCLUSION: Results suggest negative urgency does not predict long-term eating disorder maintenance. Negative urgency may not be a stable personality trait but rather an indicator of overall poor emotion regulation. Future research should confirm that changes in negative urgency predict chronic eating pathology over long durations of follow-up in women who have increasing negative urgency across time.

Neuromodulation of Eating Disorders: A Review of Underlying Neural Network Activity and Neuromodulatory Treatments.

Eating disorders are a group of psychiatric conditions that involve pathological relationships between patients and food. The most prolific of these disorders are anorexia nervosa, bulimia nervosa, and binge eating disorder. The current standard of care involves psychotherapy, pharmacotherapy, and the management of comorbid conditions, with nutritional rehabilitation reserved for severe cases of anorexia nervosa. Unfortunately, many patients often fail to respond, leaving a concerning treatment gap between the current and requisite treatments for eating disorders. To better understand the neurobiology underlying these eating disorders, investigations have been undertaken to characterize the activity of various neural networks, primarily those activated during tasks of executive inhibition, reward processing, and self-reference. Various neuromodulatory techniques have been proposed to stimulate these networks with the goal of improving patients' BMI and mental health. The aim of this review is to compile a comprehensive summarization of the current literature regarding the underlying neural connectivity of anorexia nervosa, bulimia nervosa, and binge eating disorder as well as the numerous neuromodulatory modalities that have been investigated. Importantly, we aimed to summarize the most significant clinical trials to date as well as to provide an updated assessment of the role of deep brain stimulation, summarizing numerous recently published clinical studies that have greatly contributed to the literature. In this review, we found therapeutic evidence for transcranial magnetic stimulation and transcranial direct current stimulation in treating individuals suffering from anorexia nervosa, bulimia nervosa, and binge eating disorder. We also found significant evidence for the role of deep brain stimulation, particularly as an escalatory therapy option for the those who failed standard therapy. Finally, we hope to provide promising directions for future clinical investigations.

Clinical effectiveness, cost-effectiveness and process evaluation of group schema therapy for eating disorders: study protocol for a multicenter randomized controlled trial.

BACKGROUND: Eating disorders (EDs), such as (atypical) Anorexia (AN) and Bulimia Nervosa (BN), are difficult to treat, causing socioeconomic impediments. Although enhanced cognitive behavioral therapy (CBT-E) is widely considered clinically effective, it may not be the most beneficial treatment for (atypical) AN and BN patients who do not show a rapid response after the first 4 weeks (8 sessions) of a CBT-E treatment. Alternatively, group schema therapy (GST) may be a valuable treatment for this ED population. Even though GST for EDs has yielded promising preliminary findings, the current body of evidence requires expansion. On top of that, data on cost-effectiveness is lacking. In light of these gaps, we aim to describe a protocol to examine whether GST is more (1) clinically effective and (2) cost-effective than CBT-E for (atypical) AN and BN patients, who do not show a rapid response after the first 4 weeks of treatment. Additionally, we will conduct (3) process evaluations for both treatments. METHODS: Using a multicenter RCT design, 232 Dutch (atypical) AN and BN patients with a CBT-E referral will be recruited from five treatment centers. Clinical effectiveness and cost-effectiveness will be measured before treatment, directly after treatment, at 6 and at 12 months follow-up. In order to rate process evaluation, patient experiences and the degree to which treatments are implemented according to protocol will be measured. In order to assess the quality of life and the achievement of personalized goals, interviews will be conducted at the end of treatment. Data will be analyzed, using a regression-based approach to mixed modelling, multivariate sensitivity analyses and coding trees for qualitative data. We hypothesize GST to be superior to CBT-E in terms of clinical effectiveness and cost-effectiveness for patients who do not show a rapid response to the first 4 weeks of a CBT-E treatment. DISCUSSION: To our knowledge, this is the first study protocol describing a multicenter RCT to explore the three aforementioned objectives. Related risks in performing the study protocol have been outlined. The expected findings may serve as a guide for healthcare stakeholders to optimize ED care trajectories. TRIAL REGISTRATION: clinicaltrials.gov (NCT05812950).

GLP-1 receptor agonists: A novel pharmacotherapy for binge eating (Binge eating disorder and bulimia nervosa)? A systematic review.

Objective: Systematically review evidence on using GLP-1RAs for reducing BEB in BED and BN. Methods: Comprehensive literature search (PubMed and Google Scholar) conducted for studies evaluating GLP-1Ras for BEB. Extracted data on study characteristics, efficacy, and safety. Results: Studies show that GLP-1RAs (liraglutide and dulaglutide) reduce BE frequency and comorbidities in addition to favorable psychiatric side effect profile compared to current options. However, large-scale, blinded placebo-controlled trials are lacking. Conclusion: Early findings suggest promising effects of GLP-1RAs on BEB. However, rigorous clinical trials are needed to firmly establish efficacy, dosing, safety, and comparative effectiveness before considering GLP-1RAs a viable novel approach.

Gastrointestinal diagnoses in patients with eating disorders: A retrospective cohort study 2010-2020.

BACKGROUND AND AIMS: Gastrointestinal (GI) disorders are common in patients with eating disorders. However, the temporal relationship between GI and eating disorder symptoms has not been explored. We aimed to evaluate GI disorders among patients with eating disorders, their relative timing, and the relationship between GI diagnoses and eating disorder remission. METHODS: We conducted a retrospective analysis of patients with an eating disorder diagnosis who had a GI encounter from 2010 to 2020. GI diagnoses and timing of eating disorder onset were abstracted from chart review. Coders applied DSM-5 criteria for eating disorders at the time of GI consult to determine eating disorder remission status. RESULTS: Of 344 patients with an eating disorder diagnosis and GI consult, the majority (255/344, 74.2%) were diagnosed with an eating disorder prior to GI consult (preexisting eating disorder). GI diagnoses categorized as functional/motility disorders were most common among the cohort (57.3%), particularly in those with preexisting eating disorders (62.5%). 113 (44.3%) patients with preexisting eating disorders were not in remission at GI consult, which was associated with being underweight (OR 0.13, 95% CI 0.04-0.46, p < 0.001) and increasing number of GI diagnoses (OR 0.47 per diagnosis, 95% CI 0.26-0.85, p = 0.01). CONCLUSIONS: Eating disorder symptoms precede GI consult for most patients, particularly in functional/motility disorders. As almost half of eating disorder patients are not in remission at GI consult. GI providers have an important role in screening for eating disorders. Further prospective research is needed to understand the complex relationship between eating disorders and GI symptoms.