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BackgroundAdverse childhood experiences (ACEs) are prevalent, impact long-term physical and mental health, and are associated with eating disorders (EDs) in adulthood. The primary objectives of the current study were: (1) to examine and compare ACEs between two samples: treatment-seeking adults, and a nationally representative sample of adults, (2) to characterize ACEs items and total scores across demographic and diagnostic information in adults seeking treatment for an ED, (3) to statistically classify ACEs profiles using latent class analysis, and (4) to examine associations between ACEs profiles and diagnosis.MethodsThis cross-sectional study assessed patients with a DSM-5 ED receiving treatment between October 2018 and April 2020 at the inpatient, residential, or partial hospitalization levels of care at one of two private ED treatment facilities. ACEs were assessed with the Adverse Childhood Experiences Survey at admission. Generalized linear models and Welch's t-tests were used to compare ACEs in the current sample with national estimates. A latent class analysis was conducted to examine subgroups of ACEs responses, and differences in these classes by ED diagnoses were examined with multinomial logistic regression.ResultsPatients with EDs had significantly higher ACEs scores (M = 1.95, SD = 1.90) than the nationally representative sample (M = 1.57, SD = 4.72; t = 6.42, p

Sasha Gorrell,1 Erin E Reilly,1,2 Leigh Brosof,1 Daniel Le Grange1,3 1Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA; 2Department of Psychology, Hofstra University, Hempstead, NY, USA; 3Department of Psychiatry and Behavioral Neurosciences, The University of Chicago (Emeritus), Chicago, IL, USACorrespondence: Daniel Le Grange, Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA, 94143, USA, Email Daniel.LeGrange@ucsf.eduAbstract: Efforts to increase accessibility of eating disorder (ED) treatment via telemedicine have been ongoing for the past decades. However, there has been a recent surge in research focused on remote delivery of interventions since the onset of the novel coronavirus pandemic (COVID-19) in 2020, the related lockdowns, and an exponential increase in ED symptoms in youth secondary to the pandemic worldwide. In the current review, we provide a focused summary of existing literature regarding telehealth for the treatment of EDs in adolescents using a frame of past, present, and future work. Specifically, we begin with a brief overview of research in remote delivery for EDs in youth prior to 2020. Then, we detail more recent studies in this domain, with a focus on research conducted during the COVID-19 pandemic. We close by outlining limitations of the existing data and future steps necessary to expand the rigor and impact of this work. Overall, there are considerable limitations associated with research conducted during the pandemic, but an increase in the acceptability of remote delivery methods and interest in hybrid care appears to be feasible, and likely to be lasting. Future work must replicate more recent research in non-pandemic contexts and prioritize evaluation of factors that will aid in matching patients to the most efficient and effective modalities of care moving forward.Keywords: telehealth, COVID-19, eating disorders, adolescents, family-based treatment, remote delivery

ObjectiveEcological momentary assessment (EMA) studies suggest that among individuals who binge eat, emotional states and binge eating are functionally related. However, it is unclear whether the trajectory of negative affect (NA) is the same across diagnostic groups or if specific changes in affect are unique to each diagnostic category. This study examined the moderating effect of diagnosis on the trajectory of negative affect before and after binge eating.MethodAdults with eating disorder diagnoses (anorexia nervosa [AN]=118, bulimia nervosa [BN]=133, binge-eating disorder [BED]=112) completed an EMA where they reported binge eating and negative affect throughout the day. Generalized estimating equation analyses were used to model the trajectories of NA before and after binge eating.ResultsFor all individuals, the linear trajectory of NA significantly increased before (B=0.044, p

Additional file1: Table S1 ED Female Sample Compared to Nationally Representative Female Sample. Table S2 ED White Sample Compared to Nationally Representative White Sample. Table S3 Latent Class Solution Fit Indices.

Additional file 1: Systematic Review Search Strategy.

Objective: Various approaches exist to treat youth with anorexia nervosa (AN). Family-based treatment (FBT) has never been compared to long inpatient, multimodal treatment (IMT) in a randomized controlled trial (RCT). The aim of this study was to compare data on body weight trajectories, change in eating disorder psychopathology, hospital days and treatment costs in RCTs delivering FBT or IMT. Method: Review of RCTs published between 2010 and 2020 in youth with AN, delivering FBT or IMT. Results: Four RCTs delivering FBT (United States, n = 2; Australia, n = 2), one RCT delivering Family Therapy for AN (United Kingdom) and two RCTs delivering IMT (France, n = 1; Germany, n = 1) were identified from previous meta-analyses. The comparison of studies was limited by (1) significant differences in patient baseline characteristics including pretreated versus non-pretreated patients, (2) use of different psychometric and weight measures and (3) different initial velocity of weight recovery. Minimal baseline and outcome reporting standards for body weight metrics and nature/dose of interventions allowing international comparison are needed and suggestions to developing these standards are presented. Discussion: An RCT should investigate, whether FBT is a viable alternative to IMT, leading to comparable weight and psychopathology improvement with less inpatient time and costs.

The COVID-19 lockdown has had a significant impact on mental health. Patients with eating disorders (ED) have been particularly vulnerable. (1) To explore changes in eating-related symptoms and general psychopathology during lockdown in patients with an ED from various European and Asian countries; and (2) to assess differences related to diagnostic ED subtypes, age, and geography. The sample comprised 829 participants, diagnosed with an ED according to DSM-5 criteria from specialized ED units in Europe and Asia. Participants were assessed using the COVID-19 Isolation Scale (CIES). Patients with binge eating disorder (BED) experienced the highest impact on weight and ED symptoms in comparison with other ED subtypes during lockdown, whereas individuals with other specified feeding and eating disorders (OFSED) had greater deterioration in general psychological functioning than subjects with other ED subtypes. Finally, Asian and younger individuals appeared to be more resilient. The psychopathological changes in ED patients during the COVID-19 lockdown varied by cultural context and individual variation in age and ED diagnosis. Clinical services may need to target preventive measures and adapt therapeutic approaches for the most vulnerable patients.

Although eating disorders pose a significant threat to the health and well-being of children and adolescents, due to a profound scarcity of specialty providers, only a small percentage of patients receives evidence-based treatment. To improve access to care for restrictive eating disorders, we developed a modified version of Family-Based Treatment to be delivered by primary care providers (PCPs) and conducted a pilot study to evaluate the feasibility and preliminary outcomes of this intervention. Fifteen adolescents (mean age = 15.5 years) with restrictive eating disorders and their caregiver(s) were enrolled in Family-Based Treatment for Primary Care (FBT-PC), delivered by three trained PCPs. Retention for the intervention was high (n = 13, 86.7%). Over the course of 3 months, participants attended an average of 9.2 (SD = 2.8) sessions and experienced a significant increase in BMI percentile from 39.1 to 54.8 (t (13) = -6.71, p < .001; d = .61). FBT-PC appears to be feasible for implementation in the primary care setting and has the potential to improve access to treatment and yield positive outcomes for young patients with restrictive eating disorders.

ObjectiveThe purpose of the current study was to examine the prevalence and trajectory of posttraumatic stress disorder (PTSD) symptoms among patients with eating disorders (EDs) in higher level of ED care with trauma-informed components, but without a formal evidence-based trauma intervention.MethodParticipants were 613 adults diagnosed with EDs receiving treatment at inpatient, residential, or partial hospitalization levels of care. Participants completed the PTSD Checklist-5 (PCL-5) at admission and discharge.ResultsOver half of patients scored above the cutoff of 33 on the PCL-5 at admission, suggestive of PTSD symptoms characteristic of a formal PTSD diagnosis. The average PCL-5 score significantly decreased for every ED diagnostic category, and there was a significant reduction in the proportion of patients above the PCL-5 cutoff score at discharge. PCL-5 subscales measuring PTSD criteria B (intrusions) and C (avoidance) improved with modest effect sizes, whereas PCL-5 subscales D (negative alterations in cognitions and mood) and E (alterations in arousal and reactivity) improved with larger effect sizes.DiscussionPTSD symptoms are prevalent among patients with EDs seeking higher levels of care. Despite not offering evidence-based trauma-specific interventions, PTSD symptoms decreased over the course of treatment. However, improvements cannot definitely be attributed to trauma-informed care.

ObjectiveAnorexia nervosa (AN) is a disorder characterized by a profound fear of weight gain, resulting in significant weight loss, as well as behavioral symptoms that interfere with weight normalization. In concert, weight gain remains a proximal goal of treatment, and patient weighing is a critical component of treatment. However, divergent approaches exist in how patient weighing is undertaken in clinical practice. The aim of this study is to investigate the impact of a brief course of open weighing (sharing weight data with patients) versus blind weighing (not sharing weight data with patients) on distress around being weighed and AN symptom severity.Method216 patients with AN and atypical AN will be randomized to receive 4 weeks of open or blind weighing practices across residential, intensive outpatient, and outpatient treatment settings, within the context of manualized empirically supported treatment. Following 4 weeks of open or blind weighing, all patients will be enrolled into open weighing practices. Primary outcomes of interest will be patient-reported distress around being weighed at week 5 and eating disorder symptom severity at week 5. Secondary outcomes will assess weight prediction error, intolerance of uncertainty, and the fear of food.DiscussionNo best practice guidelines exist in determining optimal practices around weighing patients with AN. This multisite randomized controlled trial will provide the first known data on the impact of open versus blind weighing practices upon weight-related distress and AN symptom severity.

Access to evidence-based treatment for eating disorders is severely limited by patient barriers and available clinician training. While clinical parameters often point to the need for a high level of care, patients may resist pursuing higher levels of care due to these barriers. One option that might mitigate such obstacles is the provision of a higher level of care via internet-based treatment for eating disorders. We sought to determine the feasibility, acceptability, and preliminary clinical outcomes associated with treatment of eating disorders through virtual intensive outpatient programming (VIOP). Fifty-seven patients meeting DSM-5 criteria for an eating disorder participated in VIOP. Of the 57 patients in VIOP treatment, 3 did not complete voluntary measures at admission or discharge, and 9 additional patients did not complete voluntary measures at discharge. Overall, 45 VIOP patients completed admission and discharge assessments, including a net promoter score (NPS) question assessing patient acceptability. Recruitment, treatment adherence, and completion of assessments in VIOP were feasible and acceptable. VIOP patients showed significant and clinically meaningful improvements in all outcomes measured, including self-reported eating disorder symptoms, depression, self-esteem, quality of life, and overall satisfaction. VIOP appears feasible, acceptable, and evidences clinically meaningful changes in eating and mood disorder symptoms.

Emotion regulation theories suggest that affect intensity is crucial in the development and maintenance of eating disorders. However, other aspects of emotional experience, such as lability, differentiation, and inertia, are not as well understood. This study is the first to use ecological momentary assessment (EMA) to examine differences in several daily negative affect (NA) indicators among adults diagnosed with anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED). Using EMA data from three large studies, a series of linear mixed models showed that participants in the AN and BN groups experienced significantly greater NA intensity and better emotion differentiation than participants in the BED group. Alternatively, the BN group demonstrated significantly greater NA lability than the AN group and greater NA inertia than the BED group. These results suggest that several daily affective experiences differ among eating disorders diagnostic groups and have implications towards distinct conceptualizations and treatments.

While facets of both anxiety and impulsivity appear central to the development and maintenance of bulimia nervosa (BN), specific BN behaviors may be propagated by differing profiles of risk. The current study examined associations between dimensions of anxiety and impulsivity and BN symptoms (binge eating, vomiting, laxative misuse, driven exercise), both in terms of the presence of such behaviors and their frequency. Two hundred and four women (Mage=25.7years) who met DSM-IV criteria for full or subthreshold BN completed self-report measures of perfectionism (Frost Multidimensional Perfectionism Scale), anxiety (Spielberger Trait Anxiety Inventory), impulsivity (Barratt Impulsiveness Scale-11; Impulsive Behavior Scale), eating disordered behaviors (Eating Disorder Examination - Questionnaire), and associated psychiatric symptoms (Michigan Assessment Screening Test/Alcohol-Drug; Maudsley Obsessive-Compulsive Inventory). Factor analysis revealed multidimensional impulsive and anxiety-related traits (5 anxiety-related factors; 7 impulsivity-related factors). In zero-sensitive regression models, different facets of impulsivity evidenced association with the presence of binge eating (risk taking), laxative misuse (impulsive spending), and fasting (difficulty concentrating), along with the frequency of vomiting (long-term planning difficulties). In contrast, anxiety-related dimensions were only associated with driven exercise (high standards) and fasting (concern over mistakes, high standards, parental expectations). Overall, impulsive and anxiety-related factors and symptoms showed distinct associations with specific eating disorder behaviors, even among those with the same diagnosis.

There are few systematic studies of treatment of bulimia nervosa (BN) in adolescents. Although family-based treatment has demonstrated preliminary evidence to support involvement of caregivers in treatment, there is significant opportunity for improvement in mitigating binge-eating and purging symptoms among adolescents afflicted with BN. When caregivers are unable to participate in treatment, there is evidence that BN-specific cognitive behavioral therapy approaches are helpful for some adolescents. Further research is needed to determine for whom, and under what conditions certain types of family involvement might be most effective in adolescent treatment of BN.

ObjectiveThis pilot study aimed to refine and test an adaption of family-based treatment (FBT) for eating disorders that addressed the distinct clinical needs of adolescents with overweight or obesity in the absence of eating disorder pathology. Our hypothesis was that FBT for paediatric obesity (FBT-PO) would be feasible to implement and superior to a nutrition education counselling (NEC) condition delivered to both parents and patients, thereby controlling for key information dissemination across groups while manipulating active therapeutic content and strategy.MethodSeventy-seven adolescents were randomized to FBT-PO or NEC across two sites.ResultsResults supported our core prediction, in that weight status among adolescent study participants receiving FBT-PO remained stable while increasing among participants randomized to NEC. Attrition was high in both conditions.ConclusionsFBT-PO, while not seeming to yield a marked decrease in body mass index z-score, may arrest an otherwise-occurring weight-gain trajectory for these adolescents. This efficacy finding is consistent with the overall PO literature supporting parental involvement in the treatment of PO. Future research efforts should address retention in FBT-PO.

ObjectiveThe evolution toward more stringent conceptualizations of remission in family therapy for adolescent anorexia nervosa (AN) has, with time, introduced variability in outcomes across randomized controlled trials (RCTs). An examination of remission across the history of research on family therapy for AN shows that earlier studies adopted lenient definitions and generally yielded higher rates of remission than studies of the past decade that have used stricter definitions of remission. In this study, we investigate the reactivity of remission rates to the application of different definitions of remission used within the family therapy for AN literature, within a single RCT data set.MethodWe conducted a secondary analysis of data from a single-site RCT which compared the relative efficacy of two formats of family therapy in a sample of 106 Australian adolescents with AN. Using end-of-treatment data, we compared remission rates using 11 definitions of remission that have been used in studies of family therapy for AN spanning more than three decades.ResultsWe found wide variability in remission rates (21.7-87.7%; Cochran's Q χ2 (10, N = 106) = 303.55, p = .000], depending on which definition of remission was applied. As expected, more lenient criteria produced higher remission rates than more stringent definitions.DiscussionApplying different criteria of remission to a single data set illustrates the impact of changing how remission is defined. Failure to consider the greater stringency of remission criteria in recent studies could result in false inferences concerning the efficacy of family therapy for AN over time.

ObjectiveDespite known associations between eating disorders and obesity, little is known about the current prevalence of symptoms of eating disorders across the weight spectrum. This study therefore aimed to estimate the population prevalence of eating disorder symptoms in relation to weight status in adolescents.MethodThe sample comprised 3,270 participants (14-15 years; 52% boys) drawn from Wave 6 of the Longitudinal Study of Australian Children. Symptoms of anorexia nervosa (AN) and bulimia nervosa (BN) were assessed using self-report on the Branched Eating Disorder Test. This measure identifies clinically significant symptoms in the past 3 months according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Using study-derived cross-sectional population weights, the prevalence of each symptom was estimated for the total population and by sex and weight status.ResultsThe estimated population prevalence was high (14.3-25.7%) for body image symptoms such as fear of weight gain and overvaluation of body weight but lower (0.5-3.7%) for behavioral symptoms such as binge eating and compensatory behaviors. Symptoms were more prevalent among adolescents with overweight or obesity. Although most symptoms tended to have higher prevalence among girls than boys, boys with obesity had higher prevalence of binge eating and excessive exercise than girls with obesity. The overall estimated population prevalence for AN and BN was 0.20% and 0.10%, respectively.DiscussionThe study highlights a need for clinicians to be cognizant of disordered eating behaviors regardless of weight status and has implications for both eating disorder and obesity prevention and intervention.

OBJECTIVE:This study tested clinical utility of the DSM-5 severity specifier for bulimia nervosa (BN) in predicting treatment response among adolescents (N = 110) within a randomized clinical trial of two psychosocial treatments. METHOD:Analyses grouped individuals meeting criteria for BN diagnosis by baseline severity, per DSM-5. Associations among baseline severity classification and BN behavior (i.e., binge eating and compensatory behavior) and eating disorder examination (EDE) Global scores at end-of-treatment (EOT), 6- and 12-month follow-up were examined. RESULTS:Associations between severity categories with BN symptoms were not significant at EOT, or follow-up. Test for linear trend in BN behavior was significant at EOT, F = 5.23, p = 0.02, without demonstrating a linear pattern. Relation between severity categories with EDE Global scores was significant at 6-month follow-up, F = 3.76, p = 0.01. Tests for linear trend in EDE Global scores were significant at EOT, F = 5.40, p = 0.02, and at 6 months, F = 10.73, p = 0.002, with the expected linear pattern. DISCUSSION:Findings suggest the DSM-5 BN severity specifier holds questionable utility in anticipating outpatient treatment response in adolescents with BN. The specifier may have improved ability to predict attitudinal rather than behavioral treatment outcomes.

PURPOSE OF REVIEW:Urbanization has broadly been implicated in negatively impacting mental health, including risk for disordered eating and eating disorders. Understanding the specific mechanisms that contribute to risk for maladaptive eating behavior in the context of urbanization is essential to improving public health policy and guiding future clinical, research, and prevention efforts. RECENT FINDINGS:This review of recent investigation related to the impact of urbanization on eating disease highlights specific risk factors for eating disorders, including acculturation to Western standards of beauty and food resources with associated body weight and body image concern. SUMMARY:Recommendations for clinical and research endeavors include improved specificity in defining urbanization, as well as increased sensitivity within community-based assessment of cultural and demographic variables that may impact eating behavior and risk for eating disorders.

This study examined the effect of family-based treatment for bulimia nervosa (FBT-BN) and cognitive behavioral therapy for adolescents (CBT-A) on depressive symptoms and self-esteem in adolescents with BN. Data were collected from 110 adolescents, ages 12-18, who met Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, text revision criteria for BN or partial BN. Participants were randomly assigned to FBT-BN or CBT-A and completed measures of depressive symptoms and self-esteem before and after treatment and at 6- and 12-month follow-up assessments. Depressive symptoms and self-esteem significantly improved in both treatments, and neither treatment appeared superior on these clinical outcomes. Parents often worry whether FBT-BN addresses comorbid depressive symptoms and low self-esteem. Our findings address this concern, as they demonstrate that FBT-BN does not differ from CBT-A in improving depressive symptoms and self-esteem, and both treatments result in symptom improvement. These findings can help clinicians guide families to choose a treatment that addresses BN and depressive symptoms and low self-esteem.

Lisa Hail,Daniel Le Grange Department of Psychiatry, University of California, San Francisco, CA, USA Abstract: Bulimia nervosa (BN) is a serious psychiatric illness that typically develops during adolescence or young adulthood, rendering adolescents a target for early intervention. Despite the increasing research devoted to the treatment of youth with anorexia nervosa (AN) and adults with BN, there remains a dearth of evidence for treating younger individuals with BN. To date, there have been four published randomized controlled trials comparing psychosocial treatments, leaving significant room to improve treatment outcomes. Family-based treatment is the leading treatment for youth with AN, while cognitive-behavioral therapy is the leading intervention for adults with BN. Involving caregivers in treatment shows promising results, however, additional research is needed to investigate ways in which this treatment can be adapted further to achieve higher rates of recovery. Keywords: eating disorders, youth, family-based treatment, cognitive behavioral therapy, psychodynamic therapy, psychopharmacological treatment, evidence based treatment

ObjectiveThis pilot study conducted an open trial of a manualized adaptation to Family-Based Treatment for Transition Age Youth (FBT-TAY) for Anorexia Nervosa (AN). The aims were: (1) determine the acceptability of FBT for TAY; and, (2) establish preliminary effect sizes for the impact of FBT-TAY on eating disorder behaviour and weight restoration.MethodTwenty-six participants across two paediatric and one adult hospital site were recruited to participate. Participants completed the Eating Disorder Examination Questionnaire (EDE-Q) at the start of treatment, the end-of-treatment, and three-month follow-up.ResultsFBT-TAY is an acceptable and feasible treatment to all study therapists as evidenced by their fidelity to the model. FBT-TAY is a feasible and acceptable intervention to transition age youth, given only 27.27% chose treatment as usual over FBT-TAY. Participants presented significant improvement at end-of-treatment and three-months post-treatment (p < .001; ES = 0.34) from baseline on the EDE-Q Global Score. Participants also achieved and maintained weight restoration at the end-of-treatment and three-months post-treatment when compared to baseline (p < .0001, ES = 0.54).ConclusionsFBT-TAY, the first manualized AN treatment for TAY, demonstrated feasibility and acceptability with therapists and participants as well as improvement for participants in EDE-Q global score and weight. Given the current dearth of effective treatments for TAY with AN, FBT-TAY is a promising adaptation of FBT. A larger clinical trial with a 12-month follow-up is recommended.

ObjectiveEcological momentary assessment (EMA) research has produced contradictory findings regarding the trajectory of negative affect after binge-eating episodes. Given the clinical implications, the objective of the current study was to reconcile these inconsistencies by comparing the two most commonly employed statistical approaches used to analyze these data.MethodData from two EMA studies were analyzed separately. Study 1 included 118 adult females with full- or subthreshold DSM-IV anorexia nervosa. Study 2 included 131 adult females with full-threshold DSM-IV bulimia nervosa. For each dataset, the single most proximal negative affect ratings preceding and following a binge-eating episode were compared. The times at which these ratings were made, relative to binge-eating episodes, were also compared.ResultsThe results indicate that the average proximal pre-binge ratings of negative affect were significantly higher than the average proximal post-binge ratings of negative affect. However, results also indicate that the average proximal post-binge ratings of negative affect were made significantly closer in time to the binge-eating episodes (∼20 min post-binge) than the average proximal pre-binge ratings of negative affect (∼2.5 hr pre-binge). A graphical representation of the results demonstrates that the average proximal pre-binge and post-binge ratings map closely onto the results of previous studies.DiscussionThese data provide one possible explanation for the inconsistent findings regarding the trajectory of negative affect after binge eating. Moreover, they suggest that the findings from previous studies are not necessarily contradictory, but may be complementary, and appear to bolster support for the affect regulation model of binge eating.

While many studies have explored the relationship between different eating disorder diagnoses and the familial social environment, current evidence does not support associations between distinct family interaction patterns (e.g. high enmeshment) and particular diagnoses (e.g. anorexia nervosa). The current study seeks to move beyond the current literature to explore whether empirically derived subtypes of family environment are associated with clinical features within a transdiagnostic sample of youth seeking treatment for eating disorders (n = 123). Latent class modelling of the Family Environment Scale identified three classes (i.e. different Family Environment Scale profiles): (1) Control-Oriented; (2) System Maintenance-Oriented; and (3) Conflict-Oriented. Data are presented to characterize the classes (e.g. age, gender, rates of different eating disorders, severity of eating disorder pathology and rates of comorbid disorders). These preliminary results suggest that family interaction types may help personalize treatment for eating disorders and encourage future research to guide such efforts. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

ObjectiveOur research focuses on laxative misuse, which has been understudied in previous eating disorders (ED) research, to understand its prevalence and correlates among individuals seeking ED treatment. We also test the association between laxative misuse and binge eating to examine the assumption that laxative misuse is intended to compensate for binge eating.MethodParticipants were 2,295 ED treatment-seeking adults (29.5 ± 10.5) who self-reported their disordered eating behaviors on the Eating Disorder Questionnaire. Participants met DSM-5 diagnostic criteria for anorexia nervosa (AN: 11.5%, n = 264), bulimia nervosa (BN: 39.0%, n = 896), binge-eating disorder (14.9%, n = 343), or other specified feeding or eating disorder (34.5%, n = 792).ResultsNearly 25% of participants (n = 571) reported misusing laxatives during the last month. Laxative misusers with AN reported significantly higher frequency of laxative misuse relative to misusers with BN (F(1,440) = 5.226, p = .023, ηp2= .012). Among laxative misusers, there was no association between frequency of binge eating and frequency of laxative misuse.DiscussionLaxative misusers with AN tend to misuse laxatives more frequently than those with BN. Binge eating was not related to laxative misuse in our sample. Future research may use real-time data collection to understand the function of laxative misuse and to validate our cross-sectional findings.

ObjectiveIndividuals with eating disorders (ED), particularly anorexia nervosa (AN), and bulimia nervosa (BN), often wish to reduce their body weight in pursuit of a thin ideal, but no study has examined the relation between desired weight and ED pathology in a clinical population of youth. Given the potential impact of desired weight on normalization of eating patterns and weight restoration, we examined the relation between desired weight and ED pathology in youth with AN or BN.MethodsParticipants were 340 youth presenting to an outpatient ED clinical research program. Height and weight were measured, and youth completed the Eating Disorder Examination. Desired weight was operationalized as "desired weight percentage" (calculated as a percentage of expected body weight [EBW]) and "weight difference percentage" (actual weight minus desired weight, divided by actual weight and multiplied by 100).ResultsYouth with AN desired to be a lower percentage of their EBW than youth with BN (p

ObjectiveThe DSM-5 includes severity specifiers (i.e., mild, moderate, severe, extreme) for anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED), which are determined by weight status (AN) and frequencies of binge-eating episodes (BED) or inappropriate compensatory behaviors (BN). Given limited data regarding the validity of eating disorder (ED) severity specifiers, this study examined the concurrent and predictive validity of severity specifiers in AN, BN, and BED.MethodAdults with AN (n = 109), BN (n = 76), and BED (n = 216) were identified from previous datasets. Concurrent validity was assessed by measures of ED psychopathology, depression, anxiety, quality of life, and physical health. Predictive validity was assessed by ED symptoms at the end of the treatment in BN and BED.ResultsSeverity categories did not differ in baseline validators, though the mild AN group evidenced greater ED symptoms compared to the severe group. In BN, greater severity was related to greater end of treatment binge-eating and compensatory behaviors, and lower likelihood of abstinence; however, in BED, greater severity was related to lower ED symptoms at the end of the treatment.DiscussionResults demonstrated limited support for the validity of DSM-5 severity specifiers. Future research is warranted to explore additional validators and possible alternative indicators of severity in EDs.

This study examined the prevalence of reported suicide attempts among family members of individuals with an eating disorder (ED). 1870 individuals presenting for ED treatment reported whether their family members ever made a suicide attempt using the Eating Disorders Questionnaire. A lifetime suicide attempt by any family member was reported by 10.8% (n = 202) of the sample and ranged from 7.0% of those with eating disorder not otherwise specified to 16.1% of those with purging disorder. Controlling for age and gender, individuals with bulimia nervosa had a higher prevalence of any familial suicide attempt and mother suicide attempt than individuals with EDNOS; no other differences were observed across ED diagnoses. There were no differences in prevalence of reported suicide attempts made by fathers, brothers, sisters, uncles, or aunts by ED diagnosis. Findings support a growing literature indicating a familial association between EDs and suicide risk.

This study sought to investigate independent associations of impulsivity and compulsivity with eating disorder (ED) symptoms. Women (N = 81) with full or subthreshold Diagnostic and Statistical Manual of Mental Disorders IV anorexia nervosa (AN) completed a semi-structured interview and self-report questionnaires. Multiple regression analyses were conducted using ED symptoms as dependent variables and facets of impulsivity and compulsivity as predictor variables (controlling for body mass index and AN diagnostic subtype). For impulsivity facets, lack of perseverance was uniquely associated with eating concern, shape concern and restraint, whereas negative urgency was uniquely associated with eating concern and frequency of loss of control eating; neither sensation seeking nor lack of premeditation was uniquely associated with any ED variables. Compulsivity was uniquely associated with restraint, eating concern and weight concern. Results support independent associations of impulsivity and compulsivity with ED symptoms in adults with AN, suggesting potential utility in addressing both impulsive and compulsive processes in treatment. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

The aim of this case series was to examine engagement in and outcomes of family-based treatment (FBT) for adolescents with DSM-5 atypical AN, that is, adolescents who were not underweight at presentation. Consecutive referrals for FBT of adolescents with atypical AN to a specialist child and adolescent eating disorder program were examined. Engagement in treatment (i.e., dose of treatment, completion rate), and changes in psychological symptomatology (i.e., eating disorder symptoms, depressive symptoms, self-esteem, obsessive compulsiveness), weight, and menstrual function were examined. The need for additional interventions (i.e., hospitalization and medication), and estimated remission rates were also examined. The sample comprised 42 adolescents aged 12-18years (88% female). Engagement in FBT was high, with 83% completing at least half the treatment dose. There were significant decreases in eating disorder and depressive symptoms during FBT (p&nbsp

BackgroundThis goal of this study was to understand the patterns of expressed emotions (EEs) in adolescent eating disorders. As such, this study compared EE among families of adolescents with anorexia nervosa (AN), bulimia nervosa (BN), and a psychiatric control group, major depressive disorder (MDD). This study also examined the influence of family status (intact vs. nonintact) and the presence of siblings on EE.MethodsTwo-hundred and fifteen adolescents (ages 12-19) and their families were recruited for this study including 121 adolescents with AN, 54 adolescents with BN, and 40 adolescents with MDD. Adolescents with at least one parent completed the Standardized Clinical Family Interview. Adolescents completed structured diagnostic interviews to assess eligibility for the study, as well as a standardized questionnaire to assess depression.ResultsAnalyses revealed that fathers showed higher levels of critical comments to adolescents with BN or MDD than those with AN, whereas mothers made more critical comments toward patients with BN. Mothers made the least number of positive remarks toward patients with MDD. In terms of the influence of family status, fathers from intact families showed more expressions of warmth and were less critical than fathers from nonintact families, whereas mothers from intact families were less critical but also made fewer positive remarks than mothers from nonintact families. The presence of siblings appeared to reduce mothers' expression of warmth and emotional overinvolvement.ConclusionsUnique patterns of EE were found to characterize AN, BN, and MDD. Family status and the presence of siblings exert an influence on EE that should be taken into consideration in future research.

This study examined self-discrepancy, a construct of theoretical relevance to eating disorder (ED) psychopathology, across different types of EDs. Individuals with anorexia nervosa (AN; n = 112), bulimia nervosa (BN; n = 72), and binge eating disorder (BED; n = 199) completed semi-structured interviews assessing specific types of self-discrepancies. Results revealed that actual:ideal (A:I) discrepancy was positively associated with AN, actual:ought (A:O) discrepancy was positively associated with BN and BED, and self-discrepancies did not differentiate BN from BED. Across diagnoses, A:O discrepancy was positively associated with severity of purging, binge eating, and global ED psychopathology. Further, there were significant interactions between diagnosis and A:O discrepancy for global ED psychopathology and between diagnosis and A:I discrepancy for binge eating and driven exercise. These results support the importance of self-discrepancy as a potential causal and maintenance variable in EDs that differentiates among different types of EDs and symptom severity. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

ObjectiveAlthough many individuals with purging disorder (PD) report loss of control (LOC) eating, it is unclear whether they differ from those who do not, or from other eating disorders involving purging and/or LOC.MethodWe compared PD with LOC (PD-LOC), PD without LOC (PD-noLOC), bulimia nervosa (BN), and anorexia nervosa-binge/purge subtype (AN-B/P) on measures of eating-related and general psychopathology in treatment-seeking adolescents.ResultsPD-LOC comprised ∼30% of PD diagnoses. PD-LOC and PD-noLOC did not differ from one another, or from BN and AN-B/P, on most measures of psychopathology, with some exceptions. PD-noLOC was similar to AN-B/P (p = 0.99) and significantly different from BN on eating concerns (p

© 2016 by the American Academy of Pediatrics. Background and Objective: Adolescents with atypical anorexia nervosa (AN) have lost significant weight but are not underweight. This study aimed to describe the physical and psychological morbidity of adolescents diagnosed with atypical AN, and to compare them with underweight adolescents with AN. Methods: All first presentations of atypical AN (n = 42) and full-threshold AN (n = 118) to a specialist pediatric eating disorder program between July 2010 and June 2014 were examined. Diagnosis was assessed by using the Eating Disorder Examination and anthropometric measurement. Psychological morbidity measures included eating and weight concerns, bingeing, purging, compulsive exercise, and psychiatric comorbidity. Results: Compared with AN, more adolescents with atypical AN were premorbidly overweight or obese (71% vs 12%). They had lost more weight (17.6 kg vs 11.0 kg) over a longer period (13.3 vs 10.2 months). There was no significant difference in the frequency of bradycardia (24% vs 33%;) or orthostatic instability (43% vs 38%). We found no evidence of a difference in frequency of psychiatric comorbidities (38% vs 45%) or suicidal ideation (43% vs 39%). Distress related to eating and body image was more severe in atypical AN. Conclusions: Atypical AN considerably affects physical and psychological functioning, despite adolescents presenting within or above the normal weight range. There was little evidence that the morbidity of adolescents with atypical AN was any less severe than that of adolescents with full-threshold AN. The findings support the need for vigilance around weight loss in adolescents, regardless of body size.

© 2015 Wiley Periodicals, Inc. Objective Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings. Methods Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic. Results Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (≥1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown; Discussion Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings.

Eating disorders (EDs) impact both males and females, but little is known about sex differences in ED psychopathology and overall clinical presentation. This study compared demographic and clinical characteristics of child and adolescent males and females who presented for ED treatment.Participants included 619 youth (59 males and 560 females) ages 6-18 years who presented for treatment between 1999 and 2011.Males presented for ED treatment at a significantly younger age (p.001), earlier age of onset (p = .004), and were more likely to be nonwhite (p = .023). Females showed more severe ED pathology across the Eating Disorder Examination subscales (weight concern: p.001; eating concern: p.001; restraint: p = .001; and shape concern: p = .019) and global score (p.001). Males were more likely to present with an ED other than anorexia nervosa or bulimia nervosa (p = .002). Females presented with significantly higher rates of mood disorders (p = .027) and had a lower average percent of expected body weight (p = .020). Males and females did not differ in duration of illness, prior hospitalization or treatment, binging and purging episodes, anxiety disorders, behavioral disorders, or self-esteem. All analyses were controlled for age.Results indicate that further exploration into why the sexes present differently may be warranted. Developing ED psychopathology assessments that better capture nuances particular to males and reevaluating criteria to better categorize male ED diagnoses may allow for more targeted treatment.

The current study examined the relation between parental expressed emotion (EE) and treatment outcome among adolescents participating in a treatment study for adolescent anorexia nervosa, as well as its impact on family functioning. One hundred and twenty-one families were assigned to family-based treatment or adolescent-focused therapy. Paternal criticism predicted lesser improvement in eating disorder psychopathology at end of treatment. There was also a significant interaction between maternal hostility and treatment, indicating that adolescents whose mothers displayed hostility had greater increases in percent of expected body weight in adolescent-focused therapy than family-based treatment. In addition, maternal hostility predicted less improvement in general family functioning and family communication at the end of treatment. Findings suggest that maternal and paternal EE may differentially impact treatment outcome and should be directly attended to in clinical settings. Future research is needed to further explore ways in which parental EE can be effectively modified in treatment.

ObjectiveEvidence supports the presence of significant variability in the timing of affective experiences and eating disorder (ED) behaviors across ED populations. This study examined the naturalistic timing of affective states and ED behaviors in anorexia nervosa (AN).MethodsWomen (N = 118) with full or subthreshold DSM-IV AN completed 2 weeks of ecological momentary assessment (EMA) involving self-reports of affect and ED behaviors. Patterns of positive affect, negative affect, and tension/anxiety across hours of the day and days of the week were examined using linear mixed models. Variation in ED behavior occurrence (i.e., binge eating, vomiting, exercise, meal skipping, and self-weighing) across hours of the day and days of the week was examined using general estimating equations.ResultsResults revealed significant variation in tension/anxiety across hours of the day; there were no significant associations between time of day and negative or positive affect. All affective variables significantly varied across days of the week, with both negative affect and tension/anxiety highest in the middle of the week and lowest on the weekends. The ED behaviors all significantly varied across hours of the day, with binge eating and vomiting most common in later hours, exercise and self-weighing most common in earlier hours, and meal skipping most common at times corresponding to breakfast and lunch. ED behaviors did not significantly vary across days of the week.ConclusionThe significant patterns of variation in the timing of affective experiences and ED behaviors may have utility in informing theories and interventions for AN.

ObjectiveWe examined whether media exposure and media-induced stress contributed to eating disorder behaviors immediately and over the course of a day in women with anorexia nervosa (AN).MethodWomen with AN (N = 118) completed a 2-week ecological momentary assessment protocol during which they reported on exposure to food, shape, or weight-related media, associated stress, and eating behaviors.ResultsFood, weight, or shape-related media exposure alone did not predict more frequent daily eating disorder behaviors. However, stress associated with media exposure was prospectively associated with a greater likelihood of binge eating and vomiting at the next assessment point. In addition, media-induced stress increased the probability of restrictive eating and fluid intake, vomiting, and laxative abuse across the day.DiscussionMedia-induced stress may contribute to increased eating disorder behaviors in women with AN, as women who saw a media image and reported this experience as stressful were more likely to engage in momentary binge eating or vomiting. Reducing stress associated with viewing media images could be a potential target for therapeutic intervention with disordered eating. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:617-621).

ObjectivePicking and nibbling (P&N), defined as eating in an unplanned and repetitious way between meals and snacks, is prevalent among adults with eating disorders (EDs), but unexamined among youth with EDs. This study sought to assess the prevalence of P&N in youth with EDs and its association with ED and comorbid pathology.MethodYouth (N = 515; ages 7-18) who presented to one outpatient ED research-clinical program were assessed for ED and comorbid pathology.ResultsTwo-fifths (n = 214, 41.6%) of youth endorsed P&N. These individuals were older (p .05).DiscussionConsistent with research in adults, P&N is prevalent but not significantly associated with ED pathology, except for global ED pathology in youth with AN/atypical AN, or comorbid disorders.

ObjectiveThe major aim of this study was to investigate any association between binge eating and purging and alcohol and substance use.MethodThe Eating Disorder Questionnaire was completed by 2966 patients. Each patient was assigned to an approximate diagnostic group based on a DSM-5-based algorithm.ResultsPatients with bulimia nervosa (BN) used alcohol/other substances with higher frequencies compared to patients with anorexia nervosa-restricting type (AN-R), binge eating disorder (BED), and eating disorder not otherwise specified (EDNOS; p

ObjectiveTo determine whether increases in adolescent or parental self-efficacy predicted subsequent weight gain in two different therapies for adolescent anorexia nervosa (AN).MethodParticipants were 121 adolescents with AN (M = 14.4 years, SD = 1.6), from a two-site randomized clinical trial for family-based treatment (FBT) and individual adolescent focused therapy (AFT). Both adolescent and parental self-efficacy were assessed at baseline and sessions 2, 4, 6, and 8. Adolescent self-efficacy was assessed using a generic measure of self-efficacy, while parental self-efficacy was assessed using a measure specific to the recovery of an eating disorder. Weight was assessed at baseline, sessions 1 through 8, and end of treatment. Mixed-effects models were used to evaluate the relation between patient and parent self-efficacy and subsequent weight gain, controlling for weight at the previous time point.ResultsFor families who received FBT, greater within-treatment increases in parental self-efficacy predicted greater subsequent adolescent weight gain compared to those who received FBT with lesser change in parental self-efficacy and those who received AFT. Interestingly, adolescent self-efficacy did not significantly predict subsequent weight gain.DiscussionGreater increases in parental self-efficacy predicted significantly greater subsequent weight gain for adolescents who received FBT, but the same was not true for adolescents who received AFT. Neither overall level nor change in adolescent self-efficacy significantly predicted subsequent weight gain in either treatment group. These findings emphasize the importance of increasing parental self-efficacy in FBT in order to impact adolescent weight outcomes.

ObjectiveThis study examined negative and positive affect in relation to restrictive eating episodes (i.e., meals/snacks perceived as restrictive) and whether restrictive eating was associated with likelihood of subsequent eating disorder behaviors (i.e., additional restrictive eating, binge eating, vomiting, laxative use, weighing, exercising, meal skipping, drinking fluids to curb appetite, body checking).MethodWomen with anorexia nervosa (N = 118) completed a 2-week ecological momentary assessment protocol.ResultsFor both restrictive and nonrestrictive eating, negative affect significantly increased from prebehavior to the time of the behavior but remained stable thereafter, while positive affect remained stable from prebehavior to the time of the behavior but decreased significantly thereafter. Across time, negative affect was significantly lower and positive affect was significantly greater in restrictive than nonrestrictive episodes. Engagement in restrictive eating was associated with an increased likelihood of subsequent restrictive eating, laxative use, and body checking, but not other behaviors. Engagement in nonrestrictive eating was associated with a decreased likelihood of subsequent restrictive eating, binge eating, vomiting, laxative use, weighing, meal skipping, drinking fluids to curb appetite, and body checking.DiscussionDespite similar patterns of affect across eating episodes over time, results suggest affect may be involved in the maintenance of restrictive eating in anorexia nervosa since restrictive episodes were associated with lower negative and greater positive affect across time compared to nonrestrictive episodes. Further, while restrictive episodes increased the likelihood of only three subsequent eating disorder behaviors, nonrestrictive episodes were protective since they decreased likelihood of all but one behavior.

Family therapy is often assumed to involve the whole family; that is both parents and children attending the therapist's office together. In practice, however, which family members are included in family therapy, how often, and in what ways, is much more variable. In this article we provide an overview of the recent history of family therapy in regard to who is directly involved in therapy, and contrast changing practices in the eating disorders field with those in the family therapy field more widely. This overview leads into a discussion of current practices in family-based treatment for adolescent anorexia nervosa and the development of a new form of family therapy that is parent-focused.

BackgroundWeak central coherence-a tendency to process details at the expense of the gestalt-has been observed among adults with bulimia nervosa (BN) and is a potential candidate endophenotype for eating disorders (EDs). However, as BN behaviors typically onset during adolescence it is important to assess central coherence in this younger age group to determine whether the findings in adults are likely a result of BN or present earlier in the evolution of the disorder. This study examines whether the detail-oriented and fragmented cognitive inefficiency observed among adults with BN is observable among adolescents with shorter illness duration, relative to healthy controls.MethodThe Rey-Osterrieth Complex Figure Test (RCFT) was administered to a total of 47 adolescents with DSM5 BN, 42 with purging disorder (PD), and 25 healthy controls (HC). Performance on this measure was compared across the three groups.ResultsThose with BN and PD demonstrated significantly worse accuracy scores compared to controls in the copy and delayed recall condition with a moderate effect size. These findings were exacerbated when symptoms of BN increased.DiscussionPoorer accuracy scores reflect a fragmented and piecemeal strategy that interferes with visual-spatial integration in BN spectrum disorders. This cognitive inefficiency likely contributes to broad difficulties in executive functioning in this population especially in the context of worsening bulimic symptoms. The findings of this study support the hypothesis that poor global integration may constitute a cognitive endophenotype for BN.

This study examined predictors of psychological change among 80 adolescents with bulimia nervosa (BN) participating in a randomized-controlled trial comparing family-based treatment (FBT) to supportive psychotherapy (SPT). Psychological outcomes (cognitive eating disorder pathology, depression, and self-esteem) were explored at baseline, post-treatment, and 6-month follow-up. Multi-level growth models examined predictors of rate of change in psychological outcomes and moderators of treatment effects. All psychological outcomes improved through 6-month follow-up (moderate to large effect sizes) across both treatments. Overall, few significant predictors were identified. Older adolescents had faster change in self-esteem relative to younger adolescents (p = 0.03). Adolescents taking psychotropic medication at baseline had faster change in eating concerns relative to adolescents not taking medication (p = 0.02). Age (p = 0.02) and baseline purging severity (p = 0.03) moderated the relationship between treatment condition and change in eating concerns, where younger adolescents and individuals with high baseline purging had greater change when treated with FBT relative to SPT. Age and purging did not significantly moderate change in other psychological outcomes. Bulimic symptom improvement did not predict change in psychological symptoms. Generally, FBT and SPT were equally efficacious with respect to psychological improvement, although FBT may be more efficacious in younger adolescents and those with more frequent purging.

Understanding nutrient intake of anorexia nervosa (AN) patients is essential for the treatment. Therefore, estimates of total energy and nutrient consumption were made in a group of young women (19 to 30 years) with restricting and binge purge subtypes of

ObjectiveThis study investigated the prevalence of driven exercise (DE) and its role in treatment outcome for adolescents with bulimia nervosa (BN) and anorexia nervosa (AN).MethodParticipants were 201 adolescents with an eating disorder (ED) (80 with BN and 121 with AN) presenting for outpatient treatment at two specialist clinics. All adolescents participated in one of two randomized controlled trials. Descriptive statistics were conducted to evaluate the presence and frequency of baseline DE. Exploratory hierarchical regressions were used to evaluate the effect of baseline DE on treatment outcomes.ResultsAbout 66.3% of adolescents with BN and 23.1% of adolescents with AN presented with baseline DE. The presence of baseline DE predicted significantly worse outcomes for adolescents with AN in terms of ED symptom severity (ps

ObjectiveThe objective of this study was to investigate diagnostic differences in weight suppression (e.g., the difference between one's current body weight and highest non-pregnancy adult body weight) and exercise among Bulimia Nervosa (BN) and Binge Eating Disorder (BED). Because exercise may be a key contributor to weight suppression in BN, we were interested in examining the potential moderating effect of exercise on weight suppression in BN or BED.MethodParticipants with BN (n = 774) and BED (n = 285) completed self-report surveys of weight history, exercise and eating disorder symptoms. Generalised linear model analyses were used to examine the associations among diagnosis, exercise frequency and their interaction on weight suppression.ResultsExercise frequency and BN/BED diagnosis were both associated with weight suppression. Additionally, exercise frequency moderated the relationship between diagnosis and weight suppression. Specifically, weight suppression was higher in BN than in BED among those with low exercise frequency but comparable in BN and BED among those with high exercise frequency.DiscussionOur results suggest that exercise frequency may contribute to different weight suppression outcomes among BN and BED. This may inform clinical implications of exercise in these disorders. Specifically, much understanding of the differences among exercise frequency and the compensatory use of exercise in BN and BED is needed.

ObjectiveThe purpose of this paper was to examine expressed emotion (EE) measured from adolescents with bulimia nervosa (BN) toward their parents, in addition to measuring EE from parents toward patients.MethodFifty-four adolescents and their parents who were receiving treatment for BN participated in a videotaped family interview, from which ratings of EE were made.ResultsParent and patient scores were highly correlated. Four family profiles were created (Low Patient EE/Low Parent EE; High Patient EE/High Parent EE; Low Patient EE/High Parent EE; High Patient EE/Low Parent EE) to determine whether the match between parent and patient EE was related to treatment outcome. The Low Patient EE/Low Parent EE group demonstrated the greatest reduction in purging from baseline to end-of-treatment; the High Patient EE/Low Parent EE group showed the smallest reduction in purging.DiscussionEE has historically been rated from relatives toward patients, but patients' own EE may also be related to treatment outcome.