Every mistake is a treasure: Lessons learned from the TRIANGLE trial for anorexia nervosa.

BACKGROUND: Despite several decades of treatment research for anorexia nervosa (AN), many of the same questions remain: how to boost enrollment, engage participants, prevent attrition, and meet the needs of a diverse patient population within the rigorous framework of a randomized controlled trial (RCT). METHODS: In this research forum, we highlight some of the challenges and opportunities observed over the course of TRIANGLE, the largest RCT for severe AN treatment in the UK to date. We discuss strategies for addressing common challenges and avoiding common pitfalls and propose solutions to future researchers seeking to conduct treatment research in AN. RESULTS: Our experience underscores the value of involving people with lived experience at every stage of intervention research. We offer additional recommendations for treatment researchers, including, (1) early qualitative research to identify patient barriers and obstacles, (2) clear, systematic collaboration with clinical sites for patient recruitment and passive data collection, (3) careful consideration of assessment metrics, including repeated measurement of quality of life, (4) adopting a flexible, patient-centered approach to clinical trial research, and (5) considering the unique needs and obstacles that might impact carer participation in research and their ability to provide support to their loved ones. DISCUSSION: We hope that these lessons learned will prove fruitful for the next generation of researchers embarking on treatment research for AN. PUBLIC SIGNIFICANCE: Using the TRIANGLE trial as an illustrative case study, we highlight the value of lived experience and codesign for developing and testing interventions for AN. We offer several lessons learned over the course of the trial, pertaining to trial enrollment, retention and engagement, measurement of outcomes, and research adaptations for real-world settings, and hope that these recommendations facilitate future treatment research for AN.

Persistent avoidance of virtual food in anorexia nervosa-restrictive type: Results from motion tracking in a virtual stopping task.

OBJECTIVE: Food avoidance is central to patients with anorexia nervosa-restrictive type (AN-R). Competing accounts in experimental psychopathology research suggest that food avoidance may result from automatic, habitual responses or from elevated inhibitory control abilities. This study investigated behavioral trajectories of food avoidance in a novel virtual reality stopping task. METHOD: Sixty patients with AN-R and 29 healthy controls with normal weight were investigated using a novel, kinematic task in virtual reality. We recorded spatial displacement in stop- and go-trials to virtual food and control objects. Inhibitory control abilities were operationalized by the VR task in stopping performance (i.e., interrupted movement in stop-trials), whereas we also measured habitual avoidance of virtual food across both go- and stop-trials (i.e., delayed movement relative to nonfood objects). RESULTS: In patients with AN-R, hand displacements were shorter to food versus nonfood across stop- and go-trials, reflected in a Stimulus × Group interaction. Healthy controls showed no differences. Importantly, the food-specific effect in AN-R was identical across stop- and go-trials, indicating habitual food avoidance. Moreover, stop error rates (i.e., stop-trials with response) were lower in patients with AN-R. DISCUSSION: The findings suggest food-specific habitual avoidance and heightened generalized inhibitory control in AN-R. The continuously delayed displacements during active hand movements across stop- and go-trials indicated the persistence of patients' avoidance of food. PUBLIC SIGNIFICANCE: Experimental research investigates the mechanisms underlying mental disorders such as anorexia nervosa. In this study, we measured interrupted hand movements in response to food pictures or neutral pictures (shoes) in patients with anorexia nervosa and healthy controls. A virtual reality scenario was used. Findings indicated that patients were slower at approaching food, interrupted or not. Key mechanisms of food avoidance can be translated into habit-based treatment options in future research.

Virtual food exposure with positive mood induction or social support to reduce food anxiety in anorexia nervosa: A feasibility study.

OBJECTIVE: Aversive emotions toward food and the consequences of eating are at the core of anorexia nervosa. Exposure therapy is effective to reduce anxiety and avoidance toward feared stimuli. Based on the inhibitory learning framework, this study examined the feasibility to induce social support or positive mood to enhance the impact of a single session virtual food exposure on food-related anxiety in anorexia nervosa. METHOD: One hundred and forty-five patients were randomized to: (1) virtual food exposure (i.e., baseline condition), (2) virtual food exposure plus positive mood induction (i.e., positive mood condition), or (3) virtual food exposure plus social support (i.e., social support condition). They completed self-report assessments of anxiety toward virtual foods, general anxiety, positive mood, social support, and hunger, before and after virtual food exposure. Number of eye gazes and touches toward foods were recorded during the virtual reality exposure. RESULTS: Patients had lower levels of anxiety toward virtual foods in the positive mood condition, compared to the baseline condition [F(2,141) = 4.36, p = .015; medium effect size]. They also touched food items more often in the baseline condition. No other significant changes were found. DISCUSSION: Virtual food exposure enhanced by positive mood induction seems a feasible approach to strengthen the impact of food exposure in anorexia nervosa. PUBLIC SIGNIFICANCE: This research contributes to the understanding of how patients with anorexia nervosa can be supported to overcome fear and anxiety around food. Virtual reality enables patients to expose themselves to difficult situations (e.g., kitchen with foods of various calorie contents) while experiencing positive stimuli, such as a loving and kind pet or a supportive avatar.

Recognition of others' interoceptive states in those with and without eating disorders.

BACKGROUND: The ability to recognize one's own emotions is associated with one's ability to recognize others' emotions. Beyond the domain of emotion, however, the relationship between recognition of one's own internal states (interoception) and others' interoceptive states has not been investigated, either in the typical population or clinical groups with interoceptive difficulties (e.g. eating disorders; EDs). METHOD: This study investigated recognition of one's own and others' internal states in adults with and without eating disorders, using a high frequency visual noise paradigm. Participants completed self-report measures of interoception, alexithymia (difficulties recognising one's own emotional internal states) and ED symptomatology, and the Heartbeat Counting Task measure of cardiac interoceptive accuracy. RESULTS: Alexithymia was significantly negatively correlated with recognition of others' interoceptive states. EDs were not associated with difficulties recognising others' interoceptive states. CONCLUSIONS: The ability to recognise one's own emotional internal states is associated with the recognition of others' interoceptive states, which may contribute to social skills and the ability to care for others.

Amplifying the voices of Black racial minorities in mental health research through public involvement and engagement: The importance of advisory roles.

INTRODUCTION: Ensuring adequate representation and the active, meaningful and visible involvement of groups likely to be most impacted by research findings and/or the lack of research inquiry are increasingly acknowledged. This is particularly relevant for Black racially minoritised groups who are less visible as research participants and in patient and public involvement and engagement (PPIE) roles. Our viewpoint article sought to discuss reflections and insights on their involvement experience, with particular attention to perceived barriers and enablers to PPIE involvement. METHODS: Qualitative data were collected as part of facilitated group discussions from nine Black racially minoritised experts-by-experience involved in a PPIE advisory group. Data were subjected to thematic analysis to identify key themes. RESULTS: Five main themes were identified that reflected factors linked to practicalities: role unfamiliarity, benefits for the larger community, acknowledgement of previous harm and mental health stigma. CONCLUSION: Given the existence and importance of the direct links between research and service and treatment innovations in health and social care, ensuring that those from underrepresented Black racial communities are meaningfully and equitably supported to have roles in advising and influencing research programmes should be prioritised and an ongoing consideration for different stakeholders, including research funders, researchers, healthcare providers and community leaders/representatives. PATIENT OR PUBLIC CONTRIBUTION: This viewpoint article is a collaboration between lived experience stakeholders and researchers, comprising conceiving the original idea for the paper, its conceptualisation and data generation and the coproduction including editing of the manuscript.

Food-related aversion in a female sample of people with anorexia nervosa: Cognitive-behavioural correlates, somatic and subjective anxiety, and early experiences.

OBJECTIVE: Food-related anxiety and avoidance are key features of anorexia nervosa, and among the most arduous maintaining processes to address in treatment. This study gathered information on the behavioural and cognitive correlates of food-related anxiety, including their associations with early experiences of aversive learning related to food, and more general anxiety. METHODS: One-hundred and forty-four patients with anorexia nervosa were recruited from clinical services in Italy. They completed online questionnaires to assess food-related anxiety, eating disorder psychopathology, eating disorder safety behaviours and threat cognitions, early experience of aversive learning related to food, and somatic anxiety. RESULTS: Experiences of food-related aversive learning were recalled by the majority of the sample (87.86%), with negative psychological consequences following eating being the most often reported (75%). Safety behaviours and threat cognitions related to the consequences of eating were also reported (14.29%-87.86%, and 36.43-90% respectively, depending on the behaviour/cognition). Eating disorder psychopathology was predicted by both somatic anxiety and negative psychological consequences following eating, whereas self-reported food anxiety was only predicted by somatic anxiety. CONCLUSION: Findings validate an anxiety-based model of anorexia nervosa which establishes the role of safety behaviours, threat cognitions, early aversive learning experiences, and anxiety in the psychopathology of the illness. Exposure-based interventions have the potential to target these factors, and inhibit food-related fear.

Food induced distractibility in restrictive anorexia nervosa: Different motor patterns for different foods as revealed by a mouse tracker evaluation.

An altered automatic processing of food stimuli may contribute to the maintenance of calorie restriction in patients with restrictive Anorexia Nervosa (AN-R). The present study aimed to assess whether task-irrelevant food distractors elicited a different interference effect in the motor actions of patients with AN-R compared to healthy controls (HC). 40 patients with acute AN-R and 40 HC performed an irrelevant distractor task in which they were required to perform a reaching movement from a starting point to a green dot, while an irrelevant distractor (a high-calorie food, low-calorie food, or neutral object) was presented in the middle of the screen. Mouse trajectories and response times (RT) were recorded. The analyses conducted on the kinematic variables revealed that while the trajectories of HC veered similarly toward the three categories of stimuli, AN-R patients showed an increased deviation toward low-calorie foods and a reduced deviation toward high-calorie foods compared to neutral objects. No significant results emerged as regards RT. The pattern of responses observed in patients with AN-R (deviation increased toward low-calorie and reduced toward high-calorie) is consistent with their eating habits and may thus represent an implicit mechanism sustaining calorie restriction in patients with AN-R.

Easy to get, difficult to avoid: Behavioral tendencies toward high-calorie and low-calorie food during a mobile approach-avoidance task interact with body mass index and hunger in a community sample.

In recent years, different studies highlighted the importance of assessing behavioral tendencies toward different food stimuli in healthy and pathological samples. However, heterogeneities in experimental approaches and small sample sizes make this literature rather inconsistent. In this study, we used a mobile approach-avoidance task to investigate the behavioral tendencies toward healthy and unhealthy foods compared to neutral objects in a large community sample. The role of some contextual and stable subjective variables was also explored. The sample included 204 participants. The stimuli comprised 15 pictures of unhealthy foods, 15 pictures of healthy foods, and 15 pictures of neutral objects. Participants were required to approach or avoid stimuli by respectively pull or push the smartphone toward or away from themselves. Accuracy and reaction time of each movement were calculated. The analyses were conducted using a generalized linear mixed-effect model (GLMMs), testing the two-way interaction between the type of movement and the stimulus category and the three-way interactions between type of movement, stimulus, and specific variables (BMI, time passed since the last meal, level of perceived hunger). Our results evidenced faster approaching movement toward food stimuli but not toward neutrals. An effect of BMI was also documented: as the BMI increased, participants became slower in avoiding unhealthy compared to healthy foods, and in approaching healthy compared to unhealthy stimuli. Moreover, as hunger increased, participants became faster in approaching and slower in avoiding healthy compared to unhealthy stimuli. In conclusion, our results show an approach tendency toward food stimuli, independent from caloric content, in the general population. Furthermore, approach tendencies to healthy foods decreased with increasing BMI and increased with perceived hunger, indicating the possible influence of different mechanisms on eating-related behavioral tendencies.

A network analysis in adolescent anorexia nervosa exploring the connection between both patient and carer reactions and outcome.

OBJECTIVE: This paper used network analysis to test the associations between eating disorder-related psychopathology and carers' responses to anorexia nervosa symptoms in adolescents. Additionally, the prognostic value of central and bridge network nodes was explored. METHOD: This is a secondary analysis of a three-armed randomised-controlled-trial of adolescents with anorexia nervosa (n = 149) and their primary carer (n = 149) who were allocated to either treatment as usual (TAU), or one of two versions of a carer skills intervention (ECHO) added to TAU. A network analysis was run in the full sample. The prognostic role of central and bridge nodes was tested through multiple regression analyses. RESULTS: Carers' depression and emotional over-involvement, as well as patients' depression showed the highest strength centrality. Patients' depression and carers' accommodation exhibited the highest bridge expected influence. Across the full sample, and in the ECHO group, carers' accommodation predicted patients' higher body mass index (BMI), while patients' depression predicted worse psychosocial functioning at 1-year follow-up. In the ECHO group, higher carers' depression also predicted lower BMI. CONCLUSIONS: Carers' accommodation and depression in both carers and patients were involved in the maintenance of psychopathology in adolescents with anorexia nervosa. Depression in both patients and carers is a potential treatment target for family interventions.

Strategic avoidance of food stimuli in patients with restrictive anorexia nervosa: An eye-tracking evaluation.

OBJECTIVE: A biased attentional processing of food stimuli may represent a disorder maintenance factor in patients with anorexia nervosa (AN). The present study aimed at investigating the temporal course of attentional deployment towards both high-calorie and low-calorie foods in patients with AN using eye-tracking. METHOD: Fifty-two patients with restrictive AN and 54 healthy controls (HC) performed a dot-probe task while their gaze was recorded with an eye-tracking system. The direction bias (percentage of trials in which the gaze was directed towards the food at first fixation, 500, and 1500 ms), and the duration bias (percentage of time spent looking at the food) were extracted. RESULTS: Regarding the direction bias, a group by time interaction emerged (F = 3.29, p = 0.038): while in the control group the bias continued to increase over the course of the trial, patients with AN showed a reduction of the bias between the 500 and 1500 ms. No group differences were observed on the duration bias. CONCLUSIONS: In advanced stages of attentional deployment patients with AN start to differ from HC by diverting their attention away from food stimuli, a strategic process that may contribute to food avoidance and calorie restriction.

Patient and mentor language style matching as a predictor of working alliance, engagement with treatment as usual, and eating disorders symptoms over the course of an online guided self-help intervention for anorexia nervosa.

OBJECTIVE: The aim of this study was to examine the processes involved in a guided self-help (GSH) pre-treatment intervention (RecoveryMANTRA) for patients with anorexia nervosa (AN), by measuring the levels of patient/mentor Language Style Matching (LSM). RecoveryMANTRA was supported by student mentors or peer mentors (recovered individuals) over six weekly chat-based sessions. We examined whether LSM during RecoveryMANTRA predicted patients'working alliance with the clinic therapist, motivation, eating disorder (ED) and general psychopathology. A further aim was to examine differences in LSM between student mentors and peer mentors. METHOD: 87 AN adults received RecoveryMANTRA plus treatment as usual. The LSM algorithm was used to calculate verbal attunement between patient and mentor. Participants were assessed at baseline and at the end of the intervention. RESULTS: Both early (1st session) and late (6th session) LSM predicted higher working alliance with the clinic therapist. Moreover, late LSM predicted lower EDs symptoms at the end of the RecoveryMANTRA intervention. Patient/peer mentor dyads showed higher late verbal attunement than patient/student mentor dyads. CONCLUSIONS: These findings suggests that in the early phase of treatment relational aspects can impact on engagement with treatment. Verbal attunement in a GSH for AN is associated with working alliance and better clinical outcome.

Changes in the eating disorder voice over time and the association of voice characteristics at baseline with clinical symptoms in patients with anorexia nervosa.

OBJECTIVE: Patients with eating disorders report the experience of living with an eating disorder voice, a second- or third-person, negative commentary about eating, weight, shape and their implications for self-esteem. Qualitative and cross-sectional studies suggest that the severity and characteristics of the eating disorder voice might play a role in the maintenance of eating disorder symptoms. The goal of this study was to expand the evidence base as to how the eating disorder voice changes over time and whether the characteristics of the voice are associated with changes in eating disorder symptoms during treatment. METHOD: Seventy-two patients with anorexia nervosa receiving intensive eating disorder treatment were recruited. They completed self-report measures of eating disorder symptoms, psychological distress and eating disorder voice's severity and characteristics (e.g., malevolence, benevolence and omnipotence) at baseline and approximately 6 months later. RESULTS: Over time, patients reported lower levels of eating and weight concern (small effect size), shape concern (large effect size) and anxiety (small effect size). They also reported a reduction in the severity, perceived malevolence (medium effect size) and omnipotence (small effect size) of the eating disorder voice. Greater severity and malevolence of the voice, and lower benevolence at baseline predicted greater reductions in eating disorder symptoms (i.e., restraint and shape concern). CONCLUSION: Beliefs about the eating disorder voice (i.e., malevolence) and severity of the voice appear to be malleable to treatment and are associated with a reduction of eating disorder symptoms. The potential of using dialogical approaches to target the eating disorder voice is discussed.

Improvement in binge eating and alexithymia predicts weight loss at 9-month follow-up of the lifestyle modification program.

PURPOSE: The aim of this longitudinal study was to examine the extent to which improved levels of binge eating (BE) behaviors, alexithymia, self-esteem, and psychological distress would predict a reduction in body mass at 9-month follow-up, following a lifestyle modification program for weight loss in obese or overweight patients. METHODS: A convenience sample of 120 obese or overweight patients were recruited. Body mass index (BMI), binge eating (BES), levels of alexithymia (TAS-20), perceived stress (PSS), depressive symptoms (SDS), and self-esteem (RSE) were assessed during their first medical examination (T1), and after a weight-loss treatment period of 9 months (T2). RESULTS: Compared with unimproved patients, improved patients reported a significant decrease in binge eating (p = 0.04) and perceived stress symptoms (p = 0.03), and a significant improvement in self-esteem (p = 0.02) over time. After controlling for gender, self-esteem, depressive symptoms, and perceived stress, baseline BMI (OR = 1.11, 95% CI [1.04,1.19]), ΔBES (OR = 0.99, 95% CI [0.98,0.99]), and ΔTAS-20 (OR = 1.03, 95% CI [1.01,1.05]) significantly and independently predicted a ≥ 5% reduction in body mass from baseline. CONCLUSIONS: Our finding supports the suggestion to consider psychological outcomes such as emotional aspects and dysfunctional eating behaviors when planning a weight loss programs to prevent a negative outcome. LEVEL OF EVIDENCE:  Level III, case-control analytic study.

Targeting binge eating in bulimia nervosa and binge eating disorder using inhibitory control training and implementation intentions: a feasibility trial.

BACKGROUND: This trial examined the feasibility, acceptability, and effect sizes of clinical outcomes of an intervention that combines inhibitory control training (ICT) and implementation intentions (if-then planning) to target binge eating and eating disorder psychopathology. METHODS: Seventy-eight adult participants with bulimia nervosa or binge eating disorder were randomly allocated to receive food-specific, or general, ICT and if-then planning for 4 weeks. RESULTS: Recruitment and retention rates at 4 weeks (97.5% and 79.5%, respectively) met the pre-set cut-offs. The pre-set adherence to the intervention was met for the ICT sessions (84.6%), but not for if-then planning (53.4%). Binge eating frequency and eating disorder psychopathology decreased in both intervention groups at post-intervention (4 weeks) and follow-up (8 weeks), with moderate to large effect sizes. There was a tendency for greater reductions in binge eating frequency and eating disorders psychopathology (i.e. larger effect sizes) in the food-specific intervention group. Across both groups, ICT and if-then planning were associated with small-to-moderate reductions in high energy-dense food valuation (post-intervention), food approach (post-intervention and follow-up), anxiety (follow-up), and depression (follow-up). Participants indicated that both interventions were acceptable. CONCLUSIONS: The study findings reveal that combined ICT and if-then planning is associated with reductions in binge eating frequency and eating disorder psychopathology and that the feasibility of ICT is promising, while improvements to if-then planning condition may be needed.

Cognitive bias modification training of attention and interpretation to reduce expectations of social rejection in adolescents with eating disorders: A small efficacy randomized controlled trial.

OBJECTIVE: This study aimed to investigate whether a computerized cognitive bias modification training delivered remotely would reduce expectations of rejection in adolescents with eating disorders. METHOD: Sixty-seven adolescents aged 12-18 (99.5% female) with an eating disorder diagnosis (94% anorexia nervosa) and receiving specialist treatment were recruited. Participants were randomized to an intervention condition (n = 37) which included treatment as usual (TAU) supplemented by nine sessions of online cognitive bias modification training for social stimuli (CBMT + TAU), or a control condition (n = 30), which included TAU only. Participants were invited to complete assessments at baseline and post-intervention. RESULTS: In the intervention condition, 22/37 participants completed six or more training sessions and post-intervention measures, the pre-defined criteria to be considered "completers." In the control condition, 28/30 participants completed the post-intervention measures. Participants who completed the intervention displayed a significantly greater reduction in negative interpretations of ambiguous social scenarios, with a medium effect size (p = .048, ηp2 = .090), and eating disorder psychopathology, with a medium effect size (p = .027, ηp2 = .105), compared to participants in the control condition. No significant between-group differences were found on emotional response to criticism, and anxiety and depression symptoms post-intervention (ps > .05; small effect sizes). DISCUSSION: Enhancing treatment as usual with CBMT targeting expectations of social rejection might be feasible and effective to reduce expectations of social rejection and eating disorder psychopathology in adolescents with eating disorders. Training adaptations might be necessary to impact on emotional processing and comorbid psychological distress. PUBLIC SIGNIFICANCE: Adolescents with eating disorders who completed a brief (4-week) online cognitive training intervention, alongside their usual treatment, reported greater reductions in expectations of social rejection and eating disorder psychopathology after the intervention, compared to a separate group of patients who received their usual treatment only. This brief and accessible intervention may be a helpful treatment adjunct for adolescents with eating disorders.

App-based food-specific inhibitory control training as an adjunct to treatment as usual in binge-type eating disorders: A feasibility trial.

Current treatments for binge eating disorder (BED) and bulimia nervosa (BN) only show moderate efficacy, warranting the need for novel interventions. Impairments in food-related inhibitory control contribute to BED/BN and could be targeted by food-specific inhibitory control training (ICT). The aim of this study was to establish the feasibility and acceptability of augmenting treatment for individuals with BN/BED with an ICT app (FoodT), which targets motor inhibition to food stimuli using a go/no-go paradigm. Eighty patients with BED/BN receiving psychological and/or pharmacological treatment were randomly allocated to a treatment-as-usual group (TAU; n = 40) or TAU augmented with the 5-min FoodT app daily (n = 40) for 4 weeks. This mixed-methods study assessed feasibility outcomes, effect sizes of clinical change, and acceptability using self-report measures. Pre-registered cut-offs for recruitment, retention, and adherence were met, with 100% of the targeted sample size (n = 80) recruited within 12 months, 85% of participants retained at 4 weeks, and 80% of the FoodT + TAU group completing ≤8 sessions. The reduction in binge eating did not differ between groups. However, moderate reductions in secondary outcomes (eating disorder psychopathology: SES = -0.57, 95% CI [-1.12, -0.03]; valuation of high energy-dense foods: SES = -0.61, 95% CI [-0.87, -0.05]) were found in the FoodT group compared to TAU. Furthermore, small greater reductions in food addiction (SES = -0.46, 95% CI [-1.14, 0.22]) and lack of premeditation (SES = -0.42, 95% CI [-0.77, -0.07]) were found in the FoodT group when compared to TAU. The focus groups revealed acceptability of FoodT. Participants discussed personal barriers (e.g. distractions) and suggested changes to the app (e.g. adding a meditation exercise). Augmenting treatment for BED/BN with a food-specific ICT app is feasible, acceptable, and may reduce clinical symptomatology with high reach and wide dissemination.

A proof-of-concept study for the use of a computerised avatar to embody the eating disorder voice in anorexia nervosa.

PURPOSE: This study assessed (1) the experience of the eating disorder voice in people with anorexia nervosa or in remission, and (2) the feasibility of creating and interacting with a computerised representation (i.e., avatar) of this voice. METHODS: Twenty-one individuals with anorexia nervosa and 18 individuals who were in remission participated in the study. They reported on the characteristics of their eating disorder voice and created a personalised avatar (a visual and auditory representation of the eating disorder voice), using a computerised software. Participants assessed closeness of match between the voice and the avatar, perceived distress and acceptability of re-exposure to the avatar. RESULTS: Patients felt less powerful than their eating disorder voice and unable to disregard the voice's commands. The experience of the voice was associated with negative, as well as some positive emotions, reflecting the prototypical ambivalence towards the illness. Individuals in remission had an opposite pattern of responses. They attributed only negative emotions to the voice, felt more powerful than the voice, and able to disregard its commands. Overall participants reported that there was a good match between the voice and the sound of the avatar. Patients expressed willingness to repeat exposure to the avatar. CONCLUSION: Individuals with anorexia can create personalised digital avatars representing the eating disorder voice and are willing to engage therapeutically with the avatar. The next step is to test the feasibility of repeated exposure to the avatar to address the power and distress associated with the eating disorder voice. LEVEL OF EVIDENCE: Level III.

A community-based feasibility randomized controlled study to test food-specific inhibitory control training in people with disinhibited eating during COVID-19 in Italy.

PURPOSE: The aim of this study was to expand the evidence on the feasibility and impact of food-specific inhibitory control training in a community sample of people with disinhibited eating. METHODS: Recruitment and data collection were conducted during the COVID-19 outbreak, in Italy. Ninety-four adult individuals with disinhibited eating were randomised to one of two conditions: App-based food-specific inhibitory control training or waiting list. Participants were assessed at baseline, end of intervention (2 weeks following baseline) and follow-up (one week later). The assessment measures included questionnaires about eating behaviour and mood. RESULTS: Seventy-three percent of the sample reported a diagnosis of binge eating disorder, and 20.4% a diagnosis of bulimia nervosa. Retention rates were 77% and 86% for the food-specific inhibitory control training and the waiting list conditions, respectively. Almost half of the participants allocated to the training condition completed the "recommended" dose of training (i.e., 10 or more sessions). Those in the training condition reported lower levels of wanting for high-energy dense foods (p < 0.05), a trend for lower levels of perceived hunger (p = 0.07), and lower levels of depression (p < 0.05). Binge eating symptoms, disinhibition, wanting for high-energy dense foods, stress and anxiety were significantly lower at end of intervention, compared to baseline (p < .05). CONCLUSION: Findings corroborated the feasibility of food-specific inhibitory control training, and its impact on high-energy dense foods liking. The study expands the evidence base for food-specific inhibitory control training by highlighting its impact on perceived hunger and depression. The mechanisms underlying these effects remain to be clarified. LEVEL OF EVIDENCE: Level I, Evidence obtained from at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies.

Outcomes for adults with anorexia nervosa who do not respond early to outpatient treatment.

OBJECTIVE: To better understand those patients with anorexia nervosa who do not show early response to treatment and are likely to have poorer outcome. METHOD: From an existing data set of 187 patients with anorexia nervosa across 22 eating disorder outpatient services in the United Kingdom, participants who had started treatment and had at least one body mass index (BMI) observation in the first 6 weeks of treatment were eligible for these secondary analyses (N = 65), a latent class analysis of BMI change over the first 6 weeks of treatment. Fifty-six patients showed no early change in BMI. We used logistic regression to examine predictors of good outcome in the 40 participants who had 12-month follow-up data. Predictors included global EDE-Q, negative affect (Depression, Anxiety, and Stress Scales) and functional impairment (Work and Social Adjustment Scale). RESULTS: Good outcome was achieved by 23% of patients and remission by 15%. Good outcome was predicted by less functional impairment at baseline. DISCUSSION: Further work that can identify sub-groups of patients with anorexia nervosa who do not achieve good outcome after treatment will inform the development of targeted engagement approaches.

The relationship between working alliance with peer mentors and eating psychopathology in a digital 6-week guided self-help intervention for anorexia nervosa.

OBJECTIVE: The quality of working alliance (WA) is associated with treatment outcomes across several types of psychiatric disorders and psychological interventions. This study examined the role of WA with peer mentors (people with lived experience of illness) and student mentors (graduated psychology students) in a 6-week, digital, guided self-help (GSH) intervention for anorexia nervosa. METHOD: Ninety-nine patients rated weekly, for 6 weeks: (a) eating psychopathology using the short version of the Eating Disorder Examination Questionnaire (EDE-QS) and (b) WA with a student mentor (n = 14) or a peer mentor (n = 10). WA was assessed by asking patients the extent to which they felt comfortable working with their mentor and the extent to which they agreed with them on the goals for support. WA with mentors and the association with eating psychopathology change were measured on a session-by-session basis. The analysis involved a random intercepts cross-lagged panel model. RESULTS: WA with peer mentors was slightly higher than WA with students (ES = 0.3). Peer mentors' WA in the previous session was significantly associated with eating psychopathology ratings in the next session. No significant relationship was found between the previous session's EDE-QS scores and peer mentor alliance in the following session. In the student mentor group, there were no session-by-session associations between WA and eating psychopathology. However, greater WA with the student mentor across sessions was associated with less eating psychopathology. DISCUSSION: These findings suggest that clinical outcomes are in part associated with the characteristics of the mentor delivering guidance in an online GSH for eating disorders.