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Objective: Fraudulent participation is an escalating concern for online clinical trials and research studies and can have a significant negative impact on findings. We aim to shed light on the risk and to provide practical recommendations for detecting and managing such instances., Methods: The FREED-Mobile (FREED-M) study is an online, randomized controlled feasibility trial to assess a digital early intervention for young people (aged 16-25) in England or Wales with eating problems. The trial involved baseline (week 0), post-intervention (week 4), and follow-up (week 12) surveys, alongside weekly modules provided over 4 weeks on the study website. Study completers were compensated with £20 shopping vouchers. Despite the complexity of the trial design, two instances of fraudulent sign-ups occurred in January and March 2023. To counter this, we developed a "fraudulent participants protocol" following internal investigations and discussions with collaborators., Results: The implementation of prevention measures such as reCAPTCHA updates, IP address review, and changes in reimbursement effectively halted further fraudulent sign-ups. Our protocol facilitated the systematic identification and withdrawal of suspected or clear fraudsters and was demonstrably robust at distinguishing between fraudsters and genuine responders., Discussion: All remote, online trials or studies are at risk of fraudulent participation. Drawing from our experience and existing literature, we offer practical recommendations for researchers considering online recruitment and data collection. Vigilance and the integration of deterrents, and data quality checks into the study design from the outset are advised to safeguard research integrity., Public Significance: Fraudulent participation in digital research can have asignificant impact on research findings, potentially leading to biased resultsand misinformed decisions. We developed an effective protocol for theprevention, identification, and management of fraudulent participants. Bysharing our insights and recommendations, we hope to raise awareness of thisissue and provide other researchers with the knowledge and strategies necessaryto safeguard research integrity moving forward., (© 2023 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Objective: An extensive number of predictors has been examined across the literature to improve knowledge of relapse in anorexia nervosa (AN). These studies provide various recovery and relapse definitions, follow-up durations and relapse rates. The current study summarizes these values and predictors of relapse in AN in a review and meta-analysis., Method: The study was executed according to PRISMA guidelines. Different databases were searched and studies in which participants did not receive an official clinical diagnosis were excluded. A quality analysis was performed using the National Institute of Health's Study Quality Assessment Tool. Random-effects meta-analyses were conducted to summarize data., Results: Definitions of relapse and recovery were diverse. During an average follow-up period of 31 months an average relapse rate of 37% was found. Predictive variables from 28 studies were grouped in six categories: age and sex, symptoms and behaviors, AN subtype and duration, weight or weight change, comorbidity, and personality. The studies were characterized by non-significant and contradictory results. Meta-analyses were performed for the predictors age, AN duration, pre-treatment BMI, post-treatment BMI and depression. These yielded significant effects for post-treatment BMI and depression: higher pre-treatment depression (SMD = .40 CI [.21-.59] and lower post-treatment BMI (SMD = -.35 CI [-.63 to -.07]) increased relapse chances in AN., Discussion: Our results emphasized a lack of sufficiently powered studies, consistent results, and robust findings. Solely post-treatment BMI and pre-treatment depression predicted relapse. Future research should use uniform definitions, larger samples and better designs, to improve our understanding of relapse in AN., Public Significance: Knowledge about predictors is important to understand high relapse rates. Our study performed a review and meta-analysis of relapse predictors in AN. Related to the heterogeneity in studies examining predictors, an overview of relapse and recovery definitions, follow-up durations and relapse rates for AN was provided. Significant effects were found for post-treatment BMI and pre-treatment depression. More studies with uniform definitions are needed to improve clinical implications., (© 2023 Wiley Periodicals LLC.)

Objective: There has been no review on eating disorder-focused psychological interventions in East Asia. The aims of this systematic scoping review were to summarize existing and forthcoming studies and to synthesize the cultural adaptations and effectiveness of the interventions identified., Method: Five databases (PubMed, Embase, Global Health, Medline, PsychInfo) and seven trial registries were searched. Studies examining eating disorder (ED)-focused psychological interventions in East Asia were included. Narrative synthesis was used for the analysis., Results: Eighteen published studies and 14 ongoing/completed but unpublished studies were included. Most published studies were uncontrolled and five were feasibility studies. Among the ongoing studies, 71% are randomized controlled trials. Cognitive therapies were the main approach used, including individual cognitive behavioral therapy (CBT), internet CBT, group CBT, guided self-help, and cognitive remediation therapy. Cultural adaptations were mostly related to language, communication style and tailoring the dietary requirements to local diets. Interventions were shortened to increase acceptability and reduce financial and time burden to patients. Overall, studies showed good acceptability, completion rates and positive effects on ED symptoms (indicated by moderate to large effect sizes or statistical significance)., Discussion: Studies were underpowered and uncontrolled, thus precluding meaningful interpretations of effectiveness to be made. However, the psychological interventions were acceptable and showed promise in delivery. Digital and group interventions seemed to be the most feasible given barriers in the local health systems. More controlled studies, as well as studies on children and adolescents, are needed in future., Public Significance: This is the first systematic scoping review examining psychological interventions for eating disorders in East Asia. Research in eating disorders has largely focused on White people and in Western countries. This review will be helpful for clinicians and researchers to understand the current state of the field through a non-Eurocentric lens, to identify gaps and plan future research., (© 2023 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Objective: The high burden of eating disorders (EDs) and limited availability of treatment speaks of a need to explore new avenues for treatment delivery. To understand if new treatment avenues are helpful and acceptable to patients, we investigated the effectiveness of Physical Exercise and Dietary Therapy (PED-t) in participants with bulimia nervosa or binge-eating disorder, and acceptability when the PED-t was implemented in a Healthy Life Center in a municipal primary healthcare service., Method: Exercise physiologists and one dietitian were trained in ED literacy and to run PED-t, before screening women for eligibility. Effectiveness (n = 16) of PED-t and participants' experiences (n = 8) were evaluated by a mixed methods study design. Results were analyzed by relevant statistics and reflexive thematic analysis., Results: Of 19 eligible participants, 16 completed treatment. At post-treatment, the Eating Disorder Examination Questionnaire global score, binge-eating frequency, and symptoms of depression were lower, and nine (56% of completers) were in remission. Participants' treatment experiences were classified into two overarching themes: "competence" and "emotional support." Participants reported high acceptance for PED-t, the local venue and group format, and felt that PED-t provided them with coping tools and increased mental strength. However, many also spoke of an unmet need to address emotional eating., Discussion: Findings point to a potential for making an effective ED therapy more accessible, and that participants find the local low-threshold delivery within a group-format helpful. With small adjustments, the PED-t could emerge as a promising first-line treatment for bulimic EDs., Public Significance Statement: Limited access to treatment for EDs, patients' high barriers to help-seeking, and the high rates of limited efficacy from psychotherapy speak of a need to explore new therapies and avenues for delivery. In this study, we build on findings from a controlled ED treatment trial and replicate the beneficial effects and find a high patient acceptance of "physical exercise and diet therapy" implemented in a real, non-clinical setting., (© 2023 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Objective: First Episode Rapid Early Intervention for Eating Disorders (FREED) is a service model and care pathway which aims to provide timely, well-coordinated, developmentally informed and evidence-based care for young people with eating disorders (EDs). This article investigates the impact of the COVID-19 pandemic on FREED patient presentations and service provision in England., Method: Data from three services spanning the pre- to post-pandemic period were included (January 2019-September 2021; n = 502 patients). Run charts were created to analyze changes in monthly baseline patient data (e.g., referral numbers, duration of an untreated ED, diagnostic mix, and average body mass index for patients with anorexia nervosa [AN])., Results: Significant increases in referral numbers were found from September 2020 onward, coinciding with the end of the first UK national lockdown. The percentage of AN presentations significantly increased after the onset of the first national lockdown (April 2020-December 2020). No other significant change patterns were identified., Discussion: There have been substantial increases in referral numbers and presentations of AN to FREED services whereas illness severity seems largely unchanged. Together, this suggests that increased referrals cannot be attributed to milder presentations being seen. Implications for the implementation, funding, and sustainability of the model are discussed., Public Significance: Our research suggests that early intervention eating disorder services across England faced significant increases in patient referrals and presentations of anorexia nervosa over the COVID-19 pandemic. This increase in referrals is not due to a rise in milder eating disorder cases, as baseline symptom severity remained stable across the pandemic. Investment in early intervention for eating disorders must therefore match increased referral trends., (© 2022 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Objective: This study reviewed the quantitative and qualitative evidence-base for multi-family therapy (MFT) for eating disorders regarding change in physical and psychological symptoms, broader individual and family factors, and the experience of treatment., Method: A systematic scoping review was conducted. Four databases (PsycInfo, Medline, Embase, CENTRAL) and five grey literature databases were searched on 24th June 2021 for relevant peer-reviewed journal articles, book chapters, and dissertations. No beginning time-point was specified. Only papers that presented quantitative or qualitative data were included. No restrictions on age or diagnosis were imposed. Studies were first mapped by study design, participant age, and treatment setting, then narratively synthesized., Results: Outcomes for 714 people who received MFT across 27 studies (one mixed-method, 17 quantitative and nine qualitative) were synthesized. MFT is associated with improvements in eating disorder symptomatology and weight gain for those who are underweight. It is also associated with improvements in other individual and family factors including comorbidities, self-esteem, quality of life, and some aspects of the experience of caregiving, although these findings are more mixed. MFT is generally experienced as both helpful and challenging due to the content addressed and intensive group process., Discussion: MFT is associated with significant improvements in eating disorder symptoms across the lifespan and improvement in broader individual and family factors. The evidence base is small and studies are generally underpowered. Larger, higher-quality studies are needed, as is research investigating the unique contribution of MFT on outcomes, given it is typically an adjunctive treatment., (© 2021 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Objective: This study aimed to evaluate the effectiveness of evidenced-based psychological treatments (specifically, Cognitive-Behaviour Therapy for Eating Disorders [CBT-ED] and Maudsley Anorexia Nervosa Treatment for Adults [MANTRA]) for a transdiagnostic eating disorder population in a routine clinical setting. In particular, it aimed to determine the extent to which treatment was provided in line with current clinical guidelines (NICE, 2017) and how effective treatment was in improving eating disorder and general psychopathology., Method: Three hundred and seventy-nine participants meeting criteria for DSM-5 anorexia nervosa, bulimia nervosa, binge-eating disorder or other specified feeding or eating disorder completed pre- and posttreatment measures of eating disorder pathology and general distress. Clinicians recorded weight and episodes of bingeing and purging., Results: Ninety seven percent of participants received treatment in line with evidence-based psychotherapies. Treatment was completed by 59.9% of the whole sample. Using stringent criteria and ITT analysis 21.4% met criteria for remission at end of treatment. In the underweight sample, there was a significant increase in BMI, averaging 1.38 kg/m 2 over treatment, with similar outcomes for MANTRA and CBT-ED., Discussion: These findings, in a large transdiagnostic population, add to emerging literature on the translation of evidence-based psychotherapies to real-world clinical settings. Our results converge well with prior similar studies. Findings highlight the need for routine data collection in services and for the ongoing improvement of treatments for the eating disorders., (© 2021 Wiley Periodicals LLC.)

Several objectives underlie the current article. First, to review historical diagnostic issues and clinical strategies for treating SE-AN. Second, to provide an overview of recent evidence informed strategies and clinical innovations for the treatment of SE-AN. Third, based on the authors' collective clinical and research experience, we offer eight observations that we believe capture the current clinical experience of patients with SE-AN. Some of these observations represent empirically testable hypotheses, but all are designed to generate a meaningful discussion about the treatment of this group of individuals with eating disorders. Finally, we hope to call clinicians, scientists, professional organizations, advocates, and policy makers to action to attend to critical issues related to the care of individuals with SE-AN. We believe that an international discussion could clarify areas of need for these patients and identify opportunities for clinical innovation that would enhance the lives of individuals with SE-AN and their families., (© 2020 Wiley Periodicals, Inc.)

Objective: Individuals with anorexia nervosa (AN) pursue low-fat, low-calorie diets even when in a state of emaciation. These maladaptive food choices may involve fronto-limbic circuitry associated with cognitive control, habit, and reward. We assessed whether high-frequency repetitive transcranial magnetic stimulation (rTMS) to the left dorsolateral prefrontal cortex (DLPFC) influenced food-related choice behavior in patients with severe, enduring (SE)-AN., Method: Thirty-four females with SE-AN completed a Food Choice Task before and after 20 sessions of real or sham rTMS treatment and at a 4-month follow-up. During the task, participants rated high- and low-fat food items for healthiness and tastiness and then made a series of choices between a neutral-rated food and high- and low-fat foods. Outcomes included the proportion of high-fat and self-controlled choices made. A comparison group of 30 healthy women completed the task at baseline only., Results: Baseline data were consistent with previous findings: relative to healthy controls, SE-AN participants showed a preference for low-fat foods and exercised self-control on a greater proportion of trials. There was no significant effect of rTMS treatment nor time on food choices related to fat content. However, among SE-AN participants who received real rTMS, there was a decrease in self-controlled food choices at post-treatment, relative to baseline. Specifically, there was an increase in the selection of tasty-unhealthy foods., Discussion: In SE-AN, rTMS may promote more flexibility in relation to food choice. This may result from neuroplastic changes in the DLPFC and/or in associated brain areas., (© 2020 The Authors. International Journal of Eating Disorders published by Wiley Periodicals, Inc.)

Background: We explored the utility of "staging" anorexia nervosa (AN) by duration of illness and psychological wellbeing. We also investigated 12-month symptom trajectories and service usage in a large cohort of patients with AN assessed for outpatient treatment., Method: We conducted secondary analyses on data from a multisite clinical trial of adults with AN (n = 187) recruited from 22 NHS England specialist eating disorder (ED) services into a digital treatment augmentation study. Clinical outcomes and service use were measured at postintervention (six weeks), 6 and 12 months. We grouped patients into two categories: "early stage" (illness duration <3 years; n = 60) and "severe and enduring" stage (SE-AN; n = 41) indicated by distress (Depression Anxiety and Stress Scales, DASS ≥60) and illness duration (≥7 years)., Results: At 12 months, patients reported large improvements in body mass index, small to moderate improvements in ED symptoms, mood, and work/social adjustment, and 23.6% met criteria for recovery. However, patients classified as SE-AN reported higher rates of accessing intensive services, higher ED symptomatology, and poorer work/social adjustment at baseline, and lower rates of improvement in work/social adjustment at 12 months compared to "early stage" respondents., Discussion: Although present findings suggest overall symptomatic improvements, exploratory results highlight marked differences in course and service use between people at different stages of AN, suggesting a need to consider staging for clinical decision-making. Further research differentiating between clinical subtypes of AN and adoption of a more personalized approach may ensure that services and care pathways better fit patient needs., (© 2020 Wiley Periodicals, Inc.)

Objective: Suicide attempts requiring hospitalization are known to be common in patients who are diagnosed with eating disorders. Attempting suicide is a major indicator for those at risk of completed suicide. Both the specific eating disorder diagnosis and the influence of psychiatric comorbidities on suicide attempts requiring hospitalization were investigated, with demographic and socioeconomic variables as confounders, over a 10-year observation period from January 2007 to March 2017., Methods: Anonymized health-record data from the South London and Maudsley NHS Foundation Trust (SLaM) were retrieved through the Clinical Record Interactive Search (CRIS) data resource; this is linked to national Hospital Episode Statistics (HES) data. These data include all diagnoses for inpatient admissions. Hazard ratios, with 95% confidence intervals (CIs), were calculated from cox regression analyses and the effects of a number of confounders were estimated by performing multivariable analyses., Results: In total, 4,895 patients were diagnosed with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder otherwise not specified (EDNOS). Of these, 331 (6.7%) had attempted suicide requiring hospitalization and 21 (0.04%) completed suicide. The eating disorder category associated with the highest risk of a suicide attempt was AN (HR: 1.43, 95%CI: 1.08-1.89, p = .01). The risk was significantly increased further if the patient had a comorbid diagnosis of personality disorder, depression, bipolar affective disorder, and substance misuse., Discussion: Suicide attempts requiring hospitalization have a high incidence rate among patients with eating disorders, and the risk is significantly increased in AN. Comorbid psychiatric illness and suicidal ideation should be carefully assessed in all eating disorder patients., (© 2020 Wiley Periodicals, Inc.)

Objective: Self-help interventions have been demonstrated to be effective in treating bulimic-type eating disorders (EDs). In particular, computer-based interventions have received increasing attention due to their potential to reach a wider population. This systematic review aimed to synthesize findings from qualitative studies on users' experiences of self-help interventions for EDs and to develop an exploratory framework., Method: A systematic review and meta-synthesis on seven peer-reviewed qualitative studies on structured computer and book-based self-help interventions for EDs was conducted using Noblit and Hare's (1988) 7-phase meta-ethnography. Four of the selected studies investigated computer-based self-help programs, and three of the studies investigated book-based guided self-help programs., Results: Six concepts were synthesized. They included intervention-related factors (anonymity and privacy; accessibility and flexibility; guidance) and user-related factors (agency/autonomy; self-motivation; and expectations/attitudes). The study revealed the "machine-like" and relational properties of the computer; the expansion of treatment time and space in psychological interventions, the changing role of the medical health professional from a "therapist" to a "guide," and a change from understanding interventions as a conclusive treatment plan to a starting point or stepping stone toward recovery., Discussion: Computer-based self-help interventions should take advantage of the "machine-like" properties of a computer (neutrality, availability, etc.) as well as its ability to facilitate human interactions. Users should also be facilitated to have a realistic understanding of the purpose of self-help interventions and the place of self-help interventions in their broader treatment plans to moderate expectations and attitudes., (© 2019 Wiley Periodicals, Inc.)

Objective: Attention processing for food may be biased in people with Anorexia Nervosa (AN). However, previous studies have had inconsistent results. This is likely to be due to indirect assessment of attention, which does not inform on the underlying attention processes, and/or the heterogeneity of participants across studies, testing either adults or adolescents with AN, that is, people at very different developmental and illness stages., Method: Eye-tracking was employed as a direct assessment of attention during a visual probe task with food versus non-food pictures. Attention bias for food was measured in 39 adults and 34 adolescents with AN and in 53 adults and 31 adolescents without AN., Results: All participants had a direction bias for food, specifically for high-calorie food. However, adults with AN subsequently avoided maintaining attention on food versus non-food cues, compared to adults without AN. Adolescents with or without AN demonstrated increased attention maintenance on food versus non-food cues, and, contrary to our hypothesis, did not differ in their attention bias for food cues. Accordingly, adults with AN differed significantly from adolescents with AN in attention maintenance for food cues: while adolescents with AN showed significantly increased attention maintenance on food stimuli, adults avoided maintaining attention on food cues., Discussion: Adults with AN may apply attention strategies to facilitate restrictive eating. This strategy is absent in adolescents with AN. This difference in food-related attention bias between adolescents and adults with AN suggests that attention biases develop over time as the illness progresses., (© 2019 Wiley Periodicals, Inc.)

Objective: Bulimia nervosa (BN) and binge-eating disorder (BED) are associated with poorly controlled approach behavior toward food resulting in binge eating. Approach bias modification (ABM) may reduce these automatic action tendencies (i.e., approach bias) toward food and may thus decrease binge eating and related symptoms., Method: A total of 56 patients with BN/BED participated in this double-blind, randomized controlled trial (RCT) comparing real and sham ABM. The real ABM condition adopted an implicit learning paradigm in which participants were trained to show avoidance behavior in response to food cues. Participants in the sham condition used a similar task but were not trained to avoid food cues. Both conditions comprised 10 training sessions within 4 weeks., Results: Participants in both groups experienced significant reductions in binge eating, eating disorder symptoms, trait food craving, and food cue reactivity. Real ABM tended to result in greater reductions in eating disorder symptoms than sham ABM. Food intake, approach bias, and attention bias toward food did not change., Discussion: This is the first RCT on ABM in eating disorders. The findings provide limited support for the efficacy of ABM in BN/BED and pose questions regarding its active ingredients and its usefulness as a stand-alone treatment for eating disorders., (© 2019 Wiley Periodicals, Inc.)

Objectives: To compare the clinical outcomes of adolescents and young adults with anorexia nervosa (AN) comorbid with broad autism spectrum disorder (ASD) or ASD traits., Method: The developmental and well-being assessment and social aptitude scale were used to categorize adolescents and young adults with AN (N = 149) into those with ASD traits (N = 23), and those who also fulfilled diagnostic criteria for a possible/probable ASD (N = 6). We compared both eating disorders specific measures and broader outcome measures at intake and 12 months follow-up., Results: Those with ASD traits had significantly more inpatient/day-patient service use (p = .015), as well as medication use (p < .001) at baseline. Both groups had high social difficulties and poorer global functioning (strengths and difficulties questionnaire) at baseline, which improved over time but remained higher at 12 months in the ASD traits group (p = .002). However, the improvement in eating disorder symptoms at 12 months was similar between groups with or without ASD traits. Treatment completion rates between AN only and ASD traits were similar (80.1 vs. 86.5%)., Discussion: Adolescents with AN and ASD traits show similar reductions in their eating disorder symptoms. Nevertheless, their social difficulties remain high suggesting that these are life-long difficulties rather than starvation effects., (© 2018 Wiley Periodicals, Inc.)

Objective: Sudden gains (SGs), broadly defined as sudden symptom reductions occurring between two consecutive treatment sessions, have been associated with improved treatment outcomes in anxiety and depression. The present study is the first to formally define SGs in anorexia nervosa and explore the characteristics, demographic and baseline clinical predictors, and clinical impact of SGs in anorexia nervosa., Method: This is a secondary analysis of data from 89 outpatients with broadly defined anorexia nervosa who received one of two psychotherapeutic interventions as part of the MOSAIC trial (Schmidt et al., 2015). SGs were defined using session-by-session body mass index (BMI) measures. This study investigated whether SGs were associated with changes in BMI, eating disorder symptomology, general psychopathology, and psychosocial impairment between baseline and 6, 12, and 24 months follow-up., Results: SGs, experienced by 61.8% of patients, mostly occurred during the early and middle phases of treatment. A larger proportion of SGs predicted larger increases in BMI between baseline and 6, 12, and 24 months follow-up. Amongst those experiencing at least one SG, fewer days between baseline and a patient's first SG predicted a larger increase in BMI between baseline and both 6 and 12 months follow-up. The proportion and timing of SGs did not predict changes in other outcome measures., Discussion: SGs in BMI during the outpatient treatment of anorexia nervosa are clinically useful predictors of longer-term weight outcomes., (© 2017 Wiley Periodicals, Inc.)

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

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

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

Objective: The aim of this study was to develop and validate a new questionnaire designed to measure caregiver skills that, in line with the interpersonal component of the cognitive interpersonal maintenance model (Schmidt and Treasure, J Br J Clin Psychol, 45, 343-366, 2006), may be helpful in the support of people with anorexia nervosa (AN). A further aim is to assess whether this scale is sensitive to change following skills-based caregiver interventions., Method: The Caregiver Skills (CASK) scale was developed by a group of clinicians and caregivers. Preliminary versions of the scale devised for both caregivers and parents were given at baseline and at follow-up after two studies of caregiver interventions (a clinical trial of the effectiveness of guided self-help and training workshops). Exploratory and confirmatory factor analyses (CFA) were used to test the factorial structure of the CASK scale. Cronbach's alpha was used to measure internal consistency of the CASK scales., Results: Exploratory Factor Analysis suggested a six component solution (Bigger Picture, Self-Care, Biting-Your-Tongue, Insight and Acceptance, Emotional Intelligence and Frustration Tolerance) and this model was confirmed with CFA. Significant clinically relevant correlations were found between the CASK scales and other standardised measures of caregivers' attitudes and behaviours. Furthermore, greater improvements on abilities measured by the CASK scale were found in caregivers who received skills-training than caregivers assigned to a 'treatment as usual' condition., Discussion: The CASK scale is a measure of the fidelity of interventions based on the cognitive interpersonal maintenance model and is sensitive to the intensity of the intervention provided., (© 2014 Wiley Periodicals, Inc.)

Objective: This study aimed to explore the neuro- and social-cognitive profile of a consecutive series of adult outpatients with anorexia nervosa (AN) when compared with widely available age and gender matched historical control data. The relationship between performance profiles, clinical characteristics, service utilization, and treatment adherence was also investigated., Method: Consecutively recruited outpatients with a broad diagnosis of AN (restricting subtype AN-R: n = 44, binge-purge subtype AN-BP: n = 33 or Eating Disorder Not Otherwise Specified-AN subtype EDNOS-AN: n = 23) completed a comprehensive set of neurocognitive (set-shifting, central coherence) and social-cognitive measures (Emotional Theory of Mind). Data were subjected to hierarchical cluster analysis and a discriminant function analysis., Results: Three separate, meaningful clusters emerged. Cluster 1 (n = 45) showed overall average to high average neuro- and social- cognitive performance, Cluster 2 (n = 38) showed mixed performance characterized by distinct strengths and weaknesses, and Cluster 3 (n = 17) showed poor overall performance (Autism Spectrum disorder (ASD) like cluster). The three clusters did not differ in terms of eating disorder symptoms, comorbid features or service utilization and treatment adherence. A discriminant function analysis confirmed that the clusters were best characterized by performance in perseveration and set-shifting measures., Discussion: The findings suggest that considerable neuro- and social-cognitive heterogeneity exists in patients with AN, with a subset showing ASD-like features. The value of this method of profiling in predicting longer term patient outcomes and in guiding development of etiologically targeted treatments remains to be seen., (© 2014 Wiley Periodicals, Inc.)

Objectives: To investigate physical activity (PA) and drive for exercise in anorexia nervosa (AN) in relation to eating disorder (ED) pathology and anxiety., Method: Female participants were recruited into four groups: AN outpatients (n = 37), AN inpatients (n = 18), an anxiety group (n = 34), and healthy controls (HCs; n = 30). PA was measured by actigraphy and self-report together with drive/reasons for exercise, ED pathology, anxiety, depression, stress, BMI, and body composition., Results: ED psychopathology, general psychopathology, and physiological measures were consistent with diagnosis. All groups showed a wide range in activity, especially on self-report. No significant group differences were observed in objective PA levels, yet AN groups reported 57-92% higher total activity than HCs. Outpatients reported more walking and moderate exercise than HCs, and inpatients reported more walking but less moderate and vigorous activity than all other groups. AN groups had significantly higher drive to exercise and valued "improving tone" as important and health and enjoyment as less important reasons to exercise., Discussion: Self-perceived activity rather than objective data may partly explain the increased activity reported in AN. Drive to exercise in AN appears to be more related to ED pathology than to anxiety., (© 2014 Wiley Periodicals, Inc.)

Objective: Compulsory in-patient refeeding of patients with severe anorexia nervosa (AN) has caused considerable controversy. The effects of such treatment on longer-term outcome are not well known. The objective of this article is to review the evidence on the outcome of compulsory treatment for AN., Method: Three large databases were searched for studies regarding compulsory treatment in AN., Results: Detained patients have more severe symptoms and comorbidity and a longer duration of inpatient stay. In the short term compulsory refeeding in AN appears to be beneficial, but the longer term effects remain uncertain. Clinicians report no worsening of the therapeutic relationship after compulsory treatment., Discussion: In severe cases of AN where the patient refuses life-saving treatment compulsory treatment needs to be considered. Future research should focus on the longer term effects of compulsory treatment and also on questions related to mental capacity in AN., (© 2014 Wiley Periodicals, Inc.)

Objective: To (1) determine whether childhood risk factors for early onset binge eating and purging eating disorders also predict risk for later-onset binge eating and purging disorders, and (2) compare the utility of childhood and early adolescent variables in predicting later-onset disorders., Method: Participants (N = 1,383) were drawn from the Western Australian Pregnancy Cohort (Raine) Study, which has followed children from pre-birth to age 20. Eating disorders were assessed when participants were aged 14, 17, and 20. Risk factors for early onset eating disorders have been reported previously (Allen et al., J Am Acad Child Psychiat, 48, 800-809, 2009). This study used logistic regression to determine whether childhood risk factors for early onset disorders, as previously identified, would also predict risk for later-onset disorders (n = 145). Early adolescent predictors of later-onset disorders were also examined., Results: Consistent with early onset cases, female sex and parent-perceived child overweight at age 10 were significant multivariate predictors of binge eating and purging disorders with onset in later adolescence. Eating, weight, and shape concerns at age 14 were also significant in predicting later-onset disorders. In the final stepwise multivariate model, female sex and eating, weight, and shape concerns at age 14 were significant in predicting later-onset eating disorders, while parent-perceived child overweight at age 10 was not., Discussion: There is overlap between risk factors for binge eating and purging disorders with early and later onset. However, childhood exposures may be more important for early than later onset cases., (© 2014 Wiley Periodicals, Inc.)

Objective: Attentional bias (AB) modification treatment targeting general or social anxiety has been recently highlighted as a potential novel approach for the treatment of anorexia nervosa (AN). The purpose of this study was to examine threat-related AB in patients with ANand healthy control participants (HC) and the relationship between AB and eating disorder and other psychopathology., Method: Forty-nine female outpatients with AN or Eating Disorder Not Otherwise Specified, Anorexia Type (EDNOS-AN), and 44 female HC completed a dot-probe task with threat words and a range of self-report measures assessing eating disorder symptoms and other psychopathology., Results: There was no evidence for a differential threat-related AB in AN patients despite elevated anxiety in this group. The AB-index, a parameter of the magnitude of attention allocation when two competing stimuli are presented, did not correlate with any of the self-report measures. However, patients with AN responded significantly more slowly to the probe as compared to controls, regardless of the valence or position of the stimuli., Discussion: The results suggest that the AB in AN patients may be specific to eating disorder-relevant anxieties., (Copyright © 2013 Wiley Periodicals, Inc.)

Objective: A cognitive interpersonal maintenance model of anorexia nervosa (AN) was first proposed in 2006 and updated in 2013 (Schmidt and Treasure, J Br J Clin Psychol, 45, 343-366, 2006; Treasure and Schmidt, J Eat Disorders, in press.). The aim of this study was to test the interpersonal component of this model in people with AN requiring intensive hospital treatment (inpatient/day patient)., Method: On admission to hospital women with AN or eating disorder not otherwise specified (AN subtype; n = 152; P) and their primary carers (n = 152; C) completed questionnaires on eating symptoms (P), depression and anxiety (P, C), accommodation and enabling (C), and psychological control (C). Structural equation modeling was used to examine relationships among these components., Results: Carers' expressed emotion and level of psychological control were significantly related to carers' distress, which in turn, was related to patients' distress. This pathway significantly predicted eating symptoms in patients., Discussion: The cognitive interpersonal maintenance model of eating disorders (EDs) was confirmed in part and suggests that interventions targeting interpersonal maintaining factors such as carer distress might impact on patient outcomes., (Copyright © 2013 Wiley Periodicals, Inc.)

Objective: Fat talking has been assumed to be a causal risk factor for body dissatisfaction in a number of prevention programs and body confidence campaigns. The aim of this paper was to assess whether fat talking meets three criteria necessary for causal risk factors, namely whether fat talking is: (a) cross-sectionally associated with body dissatisfaction; (b) prospectively associated with changes in body dissatisfaction; and (c) associated with changes in body dissatisfaction in experimental studies., Method: A systematic literature review was conducted using electronic databases and hand searching of relevant journals. Meta-analyses provided pooled effect size estimates, and meta-regressions were used to determine whether age, gender or risk of bias were effect modifiers of the relationship., Results: Searches revealed 24 studies. There was a significant cross-sectional association (r = 0.297, 95% CI = 0.225-0.349), which differed in strength between age groups and genders. There was a prospective association between fat talking and changes in body dissatisfaction in long term (r = 0.144, 95% CI = 0.050-0.234), but not in short-term studies (r = 0.022, 95% CI = -0.131-0.174). One study showed that experimental exposure to fat talking was associated with increases in body dissatisfaction (d = 0.124)., Discussion: As such, there is good evidence that fat talking is a correlate of body dissatisfaction. The few prospective and experimental studies give an initial indication that fat talking is a causal risk factor for body dissatisfaction. Further work is needed to support this position., (Copyright © 2013 Wiley Periodicals, Inc.)

Objective: To investigate the feasibility and usefulness of an online information and skills development intervention for carers of individuals with anorexia nervosa (AN) and individuals with AN., Method: Thirty-seven carers and seventeen individuals with AN were recruited; carers completed the intervention Overcoming Anorexia Online (OAO), with random allocation to receiving additional clinician guidance (OAO-G) or no guidance (OAO-NoG). Level of expressed emotion, distress, depressive symptoms, experience of caregiving, and impact of eating disorder symptoms were assessed in carers and perceptions of changes in their carers' expressed emotion were assessed in individuals with AN. Participants completed questionnaires at pre-intervention, post-intervention and 3-month follow-up., Results: Significant reductions were found for carer intrusiveness, negative experiences of caregiving, and the impact of starvation and guilt. Within group effect sizes suggested mixed findings with respect to whether greater benefits were conferred for carers receiving clinician guidance. Decreases in perceived intrusiveness of the carer by the individual with AN were associated with a large effect size., Discussion: Results demonstrate the feasibility and usefulness of an online intervention for carers. Further examination of the efficacy of the intervention for both carers and individuals with AN is warranted., (Copyright © 2013 Wiley Periodicals, Inc.)

Objective: The aim of the study was to examine how carers cope practically and emotionally with caring for individuals with anorexia nervosa who require intensive hospital care., Method: This study explores objective burden (time spent with caregiving and number of tasks), subjective burden (psychological distress), and social support in a sample of parents (n = 224) and partners (n = 28) from a consecutive series of patients (n = 178) admitted to inpatient units within the United Kingdom., Results: Most time was spent providing emotional support and less with practical tasks. Time spent with caregiving was associated with carer distress and was fully mediated by carer burden. This was ameliorated by social support. Partners received minimal support from others, and we found similar levels of burden and distress for mothers and partners., Discussion: The data indicate that professional and social support alleviates carer distress and may be of particular value for partners who are more isolated than parents. The data also suggest that time spent with practical support may be of more value than emotional support., (Copyright © 2012 Wiley Periodicals, Inc.)

Objective: Exploring social anhedonia in eating disorders (ED) was the main objective of this study. Social anhedonia relates to a reduced feeling of pleasure from social stimulation. Researching the exact nature of problems in interpersonal relationships is an important topic for clinicians and researchers in the field., Method: The revised social anhedonia scale was completed by 148 participants: anorexia nervosa (AN) n = 72; bulimia nervosa (BN) n = 19; recovered AN n = 14; healthy controls (HC) n = 43. Participants also completed mood related measures and the Toronto Alexythimia scale., Results: People with AN and BN had higher self-reported social anhedonia than people without ED. Recovered AN had an intermediate profile in between AN and HC. Clinical severity and alexithymia were strongly associated with social anhedonia scores., Discussion: Difficulty identifying and expressing feelings could be related to this diminished drive for social pleasure. Tackling these interpersonal maintaining factors in treatment is likely to be a worthwhile endeavor., (Copyright © 2012 Wiley Periodicals, Inc.)

Objective: To explore the role of specialist outpatient eating disorders services and investigate how direct access to these affects rates of referral, admissions for inpatient treatment, and continuity of care., Method: Services beyond primary care in Greater London retrospectively identified adolescents who presented with an eating disorder over a 2-year period. Data concerning service use were collected from clinical casenotes., Results: In areas where specialist outpatient services were available, 2-3 times more cases were identified than in areas without such services. Where initial outpatient treatment was in specialist rather than nonspecialist services, there was a significantly lower rate of admission for inpatient treatment and considerably higher consistency of care., Discussion: Developing specialist outpatient services with direct access from primary care is likely to lead to improvements in treatment and reduce overall costs., (Copyright © 2012 Wiley Periodicals, Inc.)

Objective: Dropout from treatment has serious implications for patients, clinicians, and researchers. The aim of this study was to examine rates of dropout from outpatient treatment for anorexia nervosa (AN) and critically examine the various definitions of dropout used., Method: A systematic review was conducted, including pharmacological and psychological interventions. All articles in PubMed, Web of Science, and the Cochrane Library were considered, and screened against a priori inclusion/exclusion criteria. Relationships between treatment outcome and dropout rate were examined across studies., Results: Nineteen relevant studies were identified, with dropout rates ranging from 4.8% (family therapy) to 100% (dietary advice). In most cases, dropout was in the range of 20-40%. Definitions of dropout used varied widely. A significant negative correlation was found between rate of dropout and body mass index (BMI) at 1 year, but this did not remain significant when differences in BMI at baseline were taken into account., Discussion: High rates of dropout from treatment for AN have serious implications for recovery, research, and the development of new treatments. A suggested reporting structure is proposed, with the aim of increasing the consistency of dropout reporting and facilitating greater understanding of this phenomenon., (Copyright © 2011 Wiley Periodicals, Inc.)

Objective: This study aimed to investigate theory of mind (ToM) in individuals with bulimia nervosa (BN), an area neglected by empirical research despite social functioning difficulties in this disorder and evidence of ToM deficits in people with anorexia nervosa (AN)., Method: ToM was assessed in 48 BN and 34 Eating Disorder Not Otherwise Specified BN-type (EDNOS-BN) outpatients and 57 healthy controls (HCs) using the Reading the Mind in the Eyes and the Reading the Mind in the Films (RMF), an ecologically valid task novel to BN research., Results: Overall performance in BN and EDNOS-BN groups was equivalent to HCs on both tasks. Individuals with BN had enhanced negative emotion recognition on the RMF., Discussion: Individuals with AN and BN have distinct socio-cognitive profiles. Further research into social cognition is required to establish the link between interpersonal difficulties and psychopathology in people with BN., (Copyright © 2011 Wiley Periodicals, Inc.)

Objective: To evaluate the feasibility and acceptability of a novel systemic cognitive behavior therapy-based intervention for carers of people with anorexia nervosa (AN). The intervention provides information and promotes skills development in managing the illness. Carers were also offered professional support., Method: Twenty-seven carers were recruited. Outcomes measuring carer distress, experience of care-giving, level of expressed emotion and problem solving were measured pre- and post-intervention and at follow-up. Carers also gave feedback., Results: There was a significant reduction in carers' anxiety and depression, negative experiences of caregiving and expressed emotion and a significant increase in positive experiences in caregiving after the intervention. Most improvements were maintained at follow-up. The intervention was well received., Discussion: The results of this pilot study indicate that the intervention is acceptable to carers and may have a positive impact on carers' mental health and experience of care-giving. Further investigation of the intervention is warranted., (Copyright © 2010 Wiley Periodicals, Inc.)

Objective: This study examined the prevalence of irritable bowel syndrome (IBS) in patients with bulimia nervosa (BN), and the relationship between these disorders., Method: Sixty-four participants with a diagnosis of BN or a related condition were recruited from an outpatient eating disorders service. Questionnaire and interview measures were used to assess bulimic symptoms and attitudes, IBS symptoms, anxiety and depression. Cases of IBS were identified using the Manning criteria., Results: There was a high prevalence of IBS in the patient group (68.8%), but IBS status was not predicted by any of the other variables measured. Patients who met criteria for IBS reported more frequent self-induced vomiting than those who did not (U = 256.0, p = 0.038)., Discussion: There is evidence of an high incidence of IBS in outpatients with BN, but the relationship between these conditions remains unclear. Future research should consider possible common risk factors., (Copyright © 2011 Wiley Periodicals, Inc.)

Objective: To use an experimental paradigm to assess facial expression, subjective experience of emotion and the relationship between them in people with anorexia nervosa (AN)., Method: Film clips are used to elicit emotion and participants' facial expression and subjective experience are recorded. Thirty inpatients with AN and 34 healthy control (HC) women are included in the study., Results: People with AN are less facially expressive than HC while watching positive and negative film clips and report feeling less positive emotion than HC but not less negative emotion. People with AN look away significantly more than HC during the negative film clip. Duration of illness and depression relate to attenuated positive facial expression and eating pathology to attenuated negative facial expression., Discussion: This experimental study supports self report studies showing people with AN attenuate emotional expression and avoid negative affect. Such behavior may affect social interaction and contribute to the maintenance of the disorder., (Copyright © 2010 Wiley Periodicals, Inc.)

Objective: This study aimed to investigate the specific risk factors, correlates, and markers associated with the development of symptomatology of early-onset BN and subclinical BN., Method: Two semi-structured interviews were used to examine symptomatology and antecedent factors of bulimic symptoms in a sample of British adolescents., Results: Adolescents with early-onset eating pathology were significantly more likely to report an earlier age of menarche than those developing the disorder at the typical age, and were found to have a different pathway of symptom development., Discussion: Increased awareness of this may help identify those particularly at risk for developing an early-onset of eating pathology., (Copyright © 2010 Wiley Periodicals, Inc.)

Objective: To perform a United States-United Kingdom cross-national comparison of service users' perspectives on eating disorder (ED) treatments and services., Method: Qualitative, exploratory study. One hundred forty-four US and 150 UK ED service users completed a questionnaire developed by the Academy for Eating Disorders. Data were analyzed using conventional content analysis., Results: Both samples identified the following as essential aspects of care: good therapeutic relationship, holistic approach, individual psychotherapy/counseling, specialized treatment, client-centered care, and support. In the US sample, the main concerns involved lack of financial accessibility to services and problems with insurance coverage. In the UK sample, lack of and inequity of availability of services were highlighted and three main barriers to accessing care were identified., Discussion: US and UK service users' views suggest that neither country provides early intervention and comprehensive care for EDs at present, although due to dissimilar health care systems the barriers to care differ., (© 2009 by Wiley Periodicals, Inc.)

Objective: This study explored the effects on bulimic symptomatology of a writing task intended to reduce emotional avoidance., Method: Eighty individuals reporting symptoms of bulimia completed, by e-mail, a therapeutic or control writing task. Participants completed questionnaires on bulimic symptoms, mood, and potential moderating and mediating factors, and were followed up after 4 and 8 weeks. Writing content was explored using a word count package and qualitative framework analysis., Results: Bulimic symptoms decreased in both groups, although in both groups the number of participants who improved was approximately equal to the number who did not improve. Symptom decreases were associated with increases in perceived mood regulation abilities, and decreases in negative beliefs about emotions. Participants preferred internet delivery to face to face discussion., Discussion: For individuals experiencing symptoms of bulimia, the effects of therapeutic writing did not differ significantly from effects of a control writing task., (2009 by Wiley Periodicals, Inc.)

Objective: This study examined the influence of primary care physicians' knowledge of and attitudes to eating disorders on their treatment decisions., Method: A sample of primary care physicians completed self-report measures on eating disorders and their attitudes towards such patients. They also indicated their diagnosis and treatment decisions in response to case vignettes., Results: Physicians had substantial gaps in knowledge of the eating disorders. Attitudes to anorexia nervosa clustered differently to those toward patients with bulimia nervosa. However, for both disorders, the factor that explained the most variance was illness duration and consequences. There was no association of knowledge and attitudes, and these variables did not predicted the likelihood of diagnosing an eating disorder. However, those with higher knowledge scores were more likely to ensure that a follow-up appointment took place, particularly when they held the attitude that people with anorexia nervosa had personal control over their problem., Discussion: There is a need for greater education of primary care physicians regarding the diagnosis and treatment of the eating disorders, and for that information to be more readily accessible when it is needed. Their clinical actions need to be guided by more objective sources of information and protocols.

Objective: This study considered the impact of ethnicity on the referral process for patients with eating disorders, at the levels of referral rate, diagnosis, and treatment offered., Method: A catchment area cohort of 648 patients was referred and assessed at specialist eating disorders services in a multiethnic urban area (all boroughs in South London, UK). Each patient was diagnosed and offered treatment (or an alternative appropriate end-point to the referral), and self-identified their ethnicity. For comparison purposes, the local ethnic minority population was taken from census data., Results: Ethnic minority patients were substantially less likely to be referred to the services than white patients, relative to the local population. The ethnic minority group were more likely to suffer from bulimia nervosa, and less likely to be found to have no eating disorder. However, the treatments offered did not differ substantially across the ethnic groups., Discussion: Referrals to specialist eating disorder services do not reflect local populations' ethnic composition, though this disparity seems to be less by the time that the patient is offered treatment. It will be important to determine the source of these ethnic differences, and to take steps to reduce them.

Objective: We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ from those with bulimia nervosa (BN) in clinical features, comorbidity, risk factors, treatment outcome or cost., Method: Adolescents with EDNOS (n = 24) or BN (n = 61) took part in a trial of family therapy versus guided self-care. At baseline, eating disorder symptoms, risk factors, and costs were assessed by interview. Patients were reinterviewed at 6 and 12 months., Results: Compared with EDNOS, BN patients binged, vomited and purged significantly more, and were more preoccupied with food. Those with EDNOS had more depression and had more current and childhood obsessive-compulsive disorder. 66.6% of EDNOS versus 27.8% of BN patients were abstinent from bingeing and vomiting at 1 year. Diagnosis did not moderate treatment outcome. Costs did not differ between groups., Conclusion: EDNOS in adolescents is not trivial. It has milder eating disorder symptoms but more comorbidity than BN., ((c) 2008 by Wiley Periodicals, Inc.)

Objective: Caring for a person with anorexia nervosa (AN) has been associated with psychological distress and poor life quality of carers. Addressing carers' needs may impact on prognostic outcome. The aim was to explore and model factors associated with distress in parents of people with AN (N = 151)., Method: A cross-sectional design was used to assess caregiving strains (Pearlin Stress Scales) and psychological distress (Hospital Anxiety and Depression Scale)., Results: Over 70% of carers (N = 107) scored at or above the suggestive threshold (score > or = 8) for anxiety, and 38% (N = 54) for depression. Over 50% of carers (N = 78) scored at or above the clinical threshold (score > or = 11) for anxiety, and 13% (N = 20) for depression. A model of carer distress after multiple regression analyses showed three significant associated variables. In order of significance, self-related strains, carer sex, and interpersonal strains accounted for 41% of the variance, (F(3, 112) = 29.85, p < .001)., Conclusion: Interventions aimed at improving outcome in AN may need to focus on reducing caregiving strains and carers' distress, particularly of mothers., (Copyright 2007 by Wiley Periodicals, Inc.)

Objective: High expressed emotion (EE) has been linked to outcome in anorexia nervosa (AN). Traditional interview measures of EE require considerable resources. The aim was to compare EE, measured with a self report tool, in parents of people with AN (carers; N = 151) with that of parents of healthy people (controls; N = 93), and to explore factors associated with EE., Method: A cross-sectional design was used to assess EE (Family Questionnaire) and psychological distress (Hospital Anxiety and Depression Scale)., Results: Over 60% (96/151) of carers showed high emotional over-involvement (EOI) compared with 3% (3/93) of controls, whereas 47% (71/151) of carers showed high criticism (CC) compared with 15% (14/93) of controls. The most significant variable related to CC was "negative/difficult behaviors," and anxiety, for EOI., Conclusion: The FQ was sensitive both to CC and EOI. Interventions aimed at reducing EE may need to focus on decreasing carers' anxiety and teaching skills to moderate difficult behaviors.

Objective: A number of sets of clinical guidelines have been developed for the treatment of eating-disordered patients. This study aimed to measure adherence to such guidance among family physicians working in primary care settings., Method: In the wake of the publication of national guidelines for "best practice," family physicians in a large but diverse geographical region of the UK (population of 6.4 million) were approached and asked to complete a two-stage survey., Results: Only 4% of these clinicians report using published guidelines or protocols, and none used the national guidelines that were available. Nor were these clinicians using the spirit of the guidelines, as there was little correspondence between recommended and actual treatment behavior., Conclusion: These findings suggest that specialist eating disorders services should not rely on guidelines to ensure the dissemination of best practice for these patients in primary care. Alternative means of dissemination are needed, and suggestions are made., ((c) 2007 by Wiley Periodicals, Inc.)

Objective: This study examined the influence of clinical and nonclinical features of case presentation on the diagnosis and treatment of eating disorders in primary care., Method: Family physicians from a defined region of the UK were provided with two vignettes, characterizing eating disorder presentations in primary care. Case gender, ethnicity, weight status, and diabetes history were experimentally manipulated. Outcome variables included the primary diagnosis and the treatment course selected for each case., Results: Female cases were more likely to receive an eating disorder diagnosis, even when their symptoms were identical to those of males. Nonclinical demographic variables also influenced treatment decisions. Weight status and physical comorbidity had a limited influence on treatment pathways., Conclusion: Nonclinical features of case presentations are used when making eating disorder diagnoses and in selecting treatment. Decision-making in primary care does not reflect recommendations from clinical guidance, and this disparity might increase the risk of complications in the care of sub-groups of eating-disordered patients.

Objective: This exploratory study focuses on the mental health (MH) and caregiving experience of carers of adolescents with Bulimia Nervosa (BN)/Eating Disorder not otherwise specified (EDNOS), aiming to determine: levels of MH problems in carers and if a negative experience of caregiving predicts carer MH status and which factors predict a negative experience of caregiving., Method: Hundred and twelve carers and 68 adolescents with BN/EDNOS completed self-report measures (General Health Questionnaire, Experience of Caregiving Inventory, Level of Expressed Emotion, Self-report Family Inventory, Inventory of Interpersonal Problems)., Results: Over half of the carers reported some MH problems and a minority (5.4%) were experiencing considerable difficulties. A negative experience of caregiving predicted carer MH status. Higher weekly contact hours and patient ratings of expressed emotion (EE) predicted a negative experience of caregiving., Conclusions: Interventions focusing on reducing EE and contact hours could prove beneficial for both patient and caregiver outcomes., (2006 by Wiley Periodicals, Inc.)

Objective: Even with the best available treatment, most bulimia nervosa (BN) sufferers are not symptom free at the end of therapy and, for those who have achieved remission, risk of relapse is high. Thus, there is a need for aftercare or relapse prevention interventions after therapy. It is not yet known what type of intervention should be delivered, and how to suit patient needs while being mindful of cost and time constraints of service providers. This pilot study was conducted to explore the feasibility, acceptability, and efficacy of a text messaging (short messaging service [SMS])-based intervention in the aftercare of BN patients who had received outpatient psychotherapy., Method: A total of 21 patients with BN participated in the 6-month SMS-based intervention as a step-down treatment after outpatient therapy., Results: Levels of use of the program were relatively low and attrition high, indicating limited acceptance of the intervention., Conclusion: This study suggests that the SMS-based intervention would benefit from further adaptation to make it a more useful tool for the aftercare of patients after outpatient treatment for bulimia nervosa., (Copyright 2006 by Wiley Periodicals, Inc.)