Search

Drawing from literature on measurement-based care and prognostic indices in eating disorder (ED) treatment, Wade et al. offer an algorithm for treating co-occurring mental-health conditions (i.e., psychiatric comorbidity) in people with EDs, and for studying effects of comorbidity-oriented treatments. Advocating session-by-session measurement to inform adaptive treatment, their proposal outlines a process for adjusting conventional ED treatment to situations in which comorbidity impedes treatment progress. The plan is methodical and responsive to evidence suggesting that peoples' early in-treatment change has more power, prognostically, than do indices of comorbidity. In the absence of data to inform practices in some areas, the authors intentionally leave key questions unanswered until future results are in. But this means that they reserve comment on how to determine that comorbidity is interfering with treatment response, or to select the best-fitting of available comorbidity-oriented options. Likewise, the proposal draws most of its inspiration from literature on individual (mainly cognitive-behavioral) psychotherapy and, as a result, does not fully represent biopsychosocial perspectives, or elaborate upon the place in comorbidity management of biological treatments, family, and carer involvement, or more complex integrated approaches. Considerations on how to apply the latter methods would broaden the plan's scope., (© 2023 Wiley Periodicals LLC.)

The effectiveness of mental health care can be improved through coordinated and wide-scale outcome measurement. The International Consortium for Health Outcomes Measurement has produced collaborative sets of outcome measures for various mental health conditions, but no universal guideline exists for eating disorders. This Position Paper presents a set of outcomes and measures for eating disorders as determined by 24 international experts from professional and lived experience backgrounds. An adapted Delphi technique was used, and results were assessed through an open review survey. Final recommendations suggest outcomes should be tracked across four domains: eating disorder behaviours and cognitions, physical health, co-occurring mental health conditions, and quality of life and social functioning. Outcomes are collected using three to five patient-reported measures. For children aged between 6 years and 12 years, the measures include the Children's Eating Attitude Test (or, for those with avoidant restrictive food intake disorder, the Eating Disorder in Youth Questionnaire), the KIDSCREEN-10, and the Revised Children's Anxiety and Depression Screener-25. For adolescents aged between 13 years and 17 years, the measures include the Eating Disorder Examination Questionnaire (EDE-Q; or, for avoidant restrictive food intake disorder, the Nine-Item Avoidant Restrictive Food Intake Disorder Screener [NIAS]), the two-item Patient Health Questionnaire (PHQ-2), the nine-item Patient Health Questionnaire (PHQ-9), the two-item Generalised Anxiety Disorder (GAD-2), the seven-item Generalised Anxiety Disorder (GAD-7), and the KIDSCREEN-10. For adults older than 18 years, measures include the EDE-Q (or, for avoidant restrictive food intake disorder, the NIAS), the PHQ-2, the PHQ-9, the GAD-2, the GAD-7, the Clinical Impairment Assessment, and the 12-item WHO Disability Assessment Schedule 2.0. These questionnaires should be supplemented by information on patient characteristics and circumstances (ie, demographic, historical, and clinical factors). International adoption of these guidelines will allow comparison of research and clinical interventions to determine which settings and interventions work best, and for whom., Competing Interests: Declaration of interests TKR is on the Clinical Advisory Board of Arise. CP is a member of the Clinical Advisory Board for Equip Health. UDS, CI, TL, IM, and MdLSF were employed by the International Consortium for Health Outcomes Measurement (ICHOM) at the time this work was conducted. AA received personal fees from ICHOM during the study. EM is the former chief executive officer of the Academy for Eating Disorders and has unpaid positions on the Board of the European Chapter of the Academy for Eating Disorders and on the Canadian National Initiative for Eating Disorders Board of Directors. LS is the vice president of Mission and Education at the National Eating Disorders Association, who supported the ICHOM project with funding. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: To determine the association between adolescent hospitalization for suicide attempts and the subsequent risk of eating disorder hospitalization., Method: This was a cohort study of 162,398 adolescent girls in Quebec, Canada, including 7741 with suicide attempts before 20 years of age, matched to 154,657 adolescents with no attempt between 1989 and 2019. The main exposure measure was suicide attempt hospitalization. The main outcome measure was hospitalization for an eating disorder up to 31 years later, including anorexia nervosa, bulimia nervosa, and other eating disorders. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between adolescent suicide attempts and eating disorder hospitalization., Results: Adolescent girls admitted for a suicide attempt had 5.55 times the risk of eating disorder hospitalization over time (95% CI 3.74-8.23), compared with matched controls. Suicide attempt was associated with anorexia nervosa (HR 3.57, 95% CI 1.78-7.17) and bulimia nervosa and other eating disorders (HR 8.55, 95% CI 5.48-13.32). Associations were pronounced in girls with repeated suicide attempts. Girls who attempted suicide through self-poisoning had an elevated risk of anorexia nervosa, whereas girls who used violent methods such as cutting or piercing had a greater risk of bulimia nervosa and other eating disorders. Suicide attempt was strongly associated with eating disorder hospitalization in the year following the attempt, but associations persisted throughout follow-up., Discussion: Suicide attempt admission is associated with the long-term risk of eating disorder hospitalization in adolescent girls., Public Significance: This study of adolescent girls suggests that suicide attempt admission is associated with the long-term risk of hospitalization for eating disorders. The risk is greatest in the year after the attempt, but persists over time. Adolescents who present with a suicide attempt may benefit from screening for eating disorders and long-term follow-up to help prevent the exacerbation or development of eating disorders., (© 2023 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Background: We studied the effect of the Covid-19 pandemic on child eating disorder hospitalizations in Quebec, Canada. Quebec had one of the strictest lockdown measures targeting young people in North America., Methods: We analyzed eating disorder hospitalizations in children aged 10-19 years before and during the pandemic. We used interrupted time series regression to assess trends in the monthly number of hospitalizations for anorexia nervosa, bulimia nervosa, and other eating disorders before the pandemic (April 2006 to February 2020), and during the first (March to August 2020) and second waves (September 2020 to March 2021). We determined the types of eating disorders requiring hospital treatment and identified the age, sex and socioeconomic subgroups that were most affected., Results: Hospitalization rates for eating disorders increased during the first (6.5 per 10,000) and second waves (12.8 per 10,000) compared with the period before the pandemic (5.8 per 10,000). The increase occurred for anorexia nervosa as well as other types of eating disorders. The number of girls and boys aged 10-14 years admitted for eating disorders increased during wave 1. Wave 2 triggered an increase in eating disorder admissions among girls aged 15-19 years. Hospitalization rates increased earlier for advantaged than disadvantaged youth., Conclusions: The Covid-19 pandemic affected hospitalizations for anorexia nervosa as well as other eating disorders, beginning with girls aged 10-14 years during wave 1, followed by girls aged 15-19 years during wave 2. Boys aged 10-14 years were also affected, as well as both advantaged and disadvantaged youth., (© 2023 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.)

Despite availability of evidence-based treatments for eating disorders (EDs), individuals with EDs often do not receive informed treatment. Training of non-specialized clinicians by experienced professionals through knowledge exchange (KE) programs is an effective way to enhance accessibility to evidence-based treatments for EDs. The authors conducted a qualitative analysis of factors that facilitated or impeded the uptake of an ED-focused KE program. Semi-structured interviews were conducted with mental health professionals (n = 43) and managers (n = 11) at 13 community mental-health sites at which the KE program was offered. Data were analyzed using a qualitative content analysis. Key facilitators identified were management support for the program and building competence through ongoing supervision of clinicians. Main barriers were limited access to ED patients to treat and having insufficient time to apply ED interventions in front-line settings. The results provide insights into the practical imperatives involved in implementing a KE initiative for ED treatment., (© 2022. National Council for Mental Wellbeing.)

Objectives: Recent studies have reported altered methylation levels at disorder-relevant DNA sites in people who are ill with Anorexia Nervosa (AN) compared to findings in people with no eating disorder (ED) or in whom AN has remitted. The preceding implies state-related influences upon gene expression in people with AN. This study further examined this notion., Methods: We measured genome-wide DNA methylation in 145 women with active AN, 49 showing stable one-year remission of AN, and 64 with no ED., Results: Comparisons revealed 205 differentially methylated sites between active and no ED groups, and 162 differentially methylated sites between active and remitted groups ( Q  < 0.01). Probes tended to map onto genes relevant to psychiatric, metabolic and immune functions. Notably, several of the genes identified here as being differentially methylated in people with AN (e.g. SYNJ2, PRKAG2, STAT3 , CSGALNACT1, NEGR1 , NR1H3 ) have figured in previous studies on AN. Effects also associated illness chronicity and lower BMI with more pronounced DNA methylation alterations, and remission of AN with normalisation of DNA methylation., Conclusions: Findings corroborate earlier results suggesting reversible DNA methylation alterations in AN, and point to particular genes at which epigenetic mechanisms may act to shape AN phenomenology.

Purpose: Self-determination theory suggests that autonomous motivation for change (i.e., motivation that is internal and self-endorsed) can be enhanced in therapeutic contexts by clinicians acting in an autonomy supportive manner. While previous research has established a link between autonomy support (AS) and autonomous motivation in enhancing outcomes in eating disorder (ED) treatment, few studies have examined factors that support or hinder therapists' ability to be autonomy supportive in the context of an ED therapeutic encounter. The goal of the present study was to conduct a qualitative analysis of personal and contextual factors that facilitated or hindered therapists' ability to provide autonomy supportive interventions., Methods: Semi-structured interviews were conducted with 10 therapists conducting outpatient psychotherapy at a specialized eating disorders treatment program. Data were analyzed using thematic analysis., Results: The most frequently noted facilitators were organizational support of AS interventions and patients' engagement and motivation for treatment. The most frequently noted barriers were patients' personality variables such as patients that exhibit passive and help-rejecting behaviours, as well as therapists feeling overwhelmed due to a high workload., Conclusion: Our results provide insight into the factors that facilitate and impede the utilization of an autonomy supportive approach in specialized ED treatment and can be used to inform future quantitative research on such factors., Level of Evidence: Level V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Although treatment dropout is common among patients with eating disorders, very few studies have examined predictors of non-completion in day treatment. We investigated various potential predictors of dropout from adult day treatment. Participants were 295 adult patients with a diagnosis of Anorexia Nervosa (restricting or binge-eating/purging subtype), Bulimia Nervosa (BN), Other Specified Feeding or Eating Disorder, or Avoidant Restrictive Food Intake Disorder. Predictors included eating-disorder characteristics, motivation at the commencement of treatment, Body Mass Index (BMI), time spent in treatment and personality dimensions. Logistic regression analyses showed that for patients with a BMI of less than 20 at the start of treatment, low BMI was a significant predictor of staff-initiated termination due to not meeting weight gain goals. Furthermore, completing less than 6 weeks of treatment was associated with staff-initiated termination. For the whole sample, those with higher changes in weight over the course of treatment were less likely to terminate prematurely. None of the other predictor variables yielded significant results. Results of the current study highlight characteristics of patients who are more likely not to complete day treatment and can help identify patients who may be at risk for not succeeding in multi-diagnostic day treatment programs., (© 2021 Eating Disorders Association and John Wiley & Sons Ltd.)

Objective: Findings show virtual therapy (conducted using internet-based videoconferencing techniques) to be a viable alternative to in-person therapy for a variety of mental-health problems. COVID-19 social-distancing imperatives required us to substitute virtual interventions for in-person sessions routinely offered in our outpatient eating disorder (ED) program-and afforded us an opportunity to compare the two treatment formats for clinical efficacy., Methods: Using self-report assessments, we compared outcomes in a historical sample of 49 adults with heterogeneous EDs (treated in-person over 10-14 weeks in individual and group therapies) to those of 76 patients receiving comparable virtual treatments, at distance, during the COVID-19 outbreak. Linear mixed models were used to study symptom changes over time and to test for differential effects of treatment modality., Results: Participants in both groups showed similar improvements on eating symptoms, levels of weight gain (in individuals in whom gain was indicated), and satisfaction with services., Discussion: Our results suggest that short-term clinical outcomes with virtual and in-person ED therapies are comparable, and point to potentials of virtual therapy for situations in which geographical distance or other barriers impede physical access to trained therapists or specialized treatments., (© 2021 Wiley Periodicals LLC.)

Objective: Identifying modifiable predictors of outcomes following treatment for eating disorders may help to tailor interventions to patients' individual needs, improve treatment efficacy, and develop new interventions. The goal of this meta-analysis was to quantify the association between pretreatment motivation and posttreatment changes in eating disorder symptomology., Method: We reviewed 196 longitudinal studies reporting on change on indices of overall eating-disorder symptomatology, weight gain, binge-eating, vomiting, anxiety/depression, and treatment adherence. Meta-analyses were performed using two complementary approaches: (a) combined probability analysis using the added Z's method; (b) effect size analyses. Using random-effect models, effect sizes were pooled when there were at least three studies with the same type of statistical design and reporting statistics on the same outcome. Heterogeneity in study outcome was evaluated using Q and I 2 statistics. Studies were reviewed qualitatively when the number of studies or reported data were insufficient to perform a meta-analysis., Results: Forty-two articles were included. Although samples and treatments differed substantially across studies, results across studies were remarkably consistent. Both combined-probability and effect-size analyses indicated positive effects of pretreatment motivation on improvement in general eating-disorder symptoms (Cohen's r = .17), and an absence of effects on anxiety/depression symptoms. Remaining outcome indices were subject to selective reporting and/or small sample size bias., Discussion: Our findings underscore the importance of incorporating treatment engagement approaches in the treatment of eating disorders. Optimal reporting of study findings and improving study quality would improve future efforts to obtain an in-depth understanding of the relationship between motivation and eating disorder symptoms., (© 2020 Wiley Periodicals LLC.)

Purpose of Review: Studies indicate that environmental factors, acting at various moments throughout the life cycle, can result in epigenetically mediated alterations in gene expression. In this article, we review recent findings on the role of epigenetic factors in eating disorders, address methodological issues that need to be considered when interpreting research findings, and comment on possible clinical applications., Recent Findings: Evidence suggests that eating disorders implicate alterations of methylation in genes involved in the mental status, metabolism, anthropometric features and immunity. Furthermore, some research in individuals with anorexia nervosa suggests the presence of reversible, malnutrition-induced epigenetic alterations that 'reset' as patients recover., Summary: Epigenetic studies in the eating disorders corroborate the idea that eating disorder cause is multifactorial, and identify markers that could help inform our understanding of illness staging and subtyping that may explain the commonly progressive course of these disorders, and that may provide insights towards the development of novel interventions. Already, there is evidence to suggest that, in people with eating disorders, epigenetically informed interventions help reduce stigma and shame, and increase self-acceptance and hopes of recovery. Although findings are intriguing, further research is required as, to date, studies apply modest sample sizes and disparate methodologies.

Background: Sleep problems are common in eating disorders (EDs)., Purpose: We evaluated whether sleep-phasing regularity associates with the regularity of daily eating events., Methods: ED patients (n = 29) completed hourly charts of mood and eating occasions for 2 weeks. Locomotor activity was recorded continuously by wrist actigraphy for a minimum of 10 days, and sleep was calculated based on periods of inactivity. We computed the center of daily inactivity (CenDI) as a measure of sleep phasing and consolidation of the daily inactivity (ConDI) as a measure of daily sleep rhythm strength. We assessed interday irregularities in the temporal structure of food intake using the standard deviation (SD) of frequency (IFRQ), timing (ITIM), and interval (IINT) of food intake. A self-evaluation of other characteristics included mood, anxiety, and early trauma., Results: A later phasing of sleep associated with a lower frequency of eating (eating frequency with the CenDI rho = -0.49, p = .007). The phasing and rhythmic strength of sleep correlated with the degree of eating irregularity (CenDI with ITIM rho = 0.48, p = .008 and with IINT rho = 0.56, p = .002; SD of CenDI with ITIM rho = 0.47, p = .010, and SD of ConDI with IINT rho = 0.37, p = .048). Childhood Trauma Questionnaire showed associations with variation of sleep onset (rho = -0.51, p = .005) and with IFRQ (rho = 0.43, p = .023)., Conclusions: Late and variable phasing of sleep associated robustly with irregular pattern of eating. Larger data sets are warranted to enable the analysis of diagnostic subgroups, current medication, and current symptomatology and to confirm the likely bidirectional association between eating pattern stability and the timing of sleep., (© Society of Behavioral Medicine 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To validate the Autonomous and Controlled Motivation for Treatment Questionnaire (ACMTQ) for use in women with an eating disorder (ED)., Method: Data were available for 463 individuals. We assessed factor structure, internal reliability, test-retest reliability, convergent/divergent validity, and incremental predictive validity., Results: Our data showed acceptable fit to our hypothesized model (comparative fit index = 0.92, root mean square error of approximation = 0.09, standardized root mean square residual = 0.09). We found test-retest reliability of 0.73 for both the autonomous (α = 0.85) and controlled (α = 0.80) subscales. Autonomous scores were more strongly associated with motivation measures (β = 0.37; 0.46) than with ED severity measures (β = -0.10; -0.18). Associations between autonomous motivation and symptom improvement over time supported predictive validity. Controlled motivation was associated with lower motivation (β = 0.02; -0.31) and with higher ED severity (β = 0.12; 0.47)., Conclusion: Our results suggest that the ACMTQ is valid for use in women with EDs and lend support to the validity of findings from previous ED studies that have used the ACMTQ., (© 2018 John Wiley & Sons, Ltd and Eating Disorders Association.)

We describe the implementation and impact of a province-wide program of knowledge exchange (KE), aimed at developing capacity for the treatment of people with eating disorders (EDs). The program is designed to equip clinicians working in nonspecialized health-care installations with skills to evaluate and treat people with EDs. Trainings were conducted at 21 institutions. The majority of clinicians reported satisfaction with the KE program and indicated that the trainings enhanced their confidence and ability to treat patients with EDs. A subset of clinicians received case supervision with a specialist ED therapist and followed patients with EDs (n = 119). Treated patients showed significant improvements on eating and depressive symptoms, and reported satisfaction with the treatments they received.

According to Self-Determination Theory, when motivation to reach an objective is fully internal, it is said to be "autonomous"; when driven by external incentives, it is said to be "controlled". Previous research has indicated that autonomously motivated individuals show better response to treatments for eating disorders., Objective: In individuals undergoing different intensities of outpatient treatment for an eating disorder, we sought to assess associations between autonomous and controlled motivations and response to treatment on the one hand, and likelihood of dropping out of treatment, on the other., Method: Seven hundred seventy adults meeting DSM-5 criteria for an eating disorder (216 with Anorexia Nervosa, 282 with Bulimia Nervosa, and 272 with Other Specified Feeding or Eating Disorder) were included in this study. Before an interval of outpatient treatment, individuals completed the Eating Disorder Examination Questionnaire and the Autonomous and Controlled Motivations for Treatment Questionnaire. Participants completed the Eating Disorder Examination Questionnaire again at one or two subsequent timepoints., Results: After controlling for diagnosis, treatment intensity, and number of previous treatments, analyses showed that higher autonomous motivation was associated with better response on eating-disorder overall symptoms and lower likelihood of dropping out of treatment. In contrast, controlled motivation was not associated with response to treatment., Discussion: Our results suggest that autonomous motivation has trans-diagnostic influence upon response to various intensities of treatment for an eating disorder. In support of an autonomy supportive approach to treatment, findings link autonomous motivation with more favorable outcome., (© 2018 Wiley Periodicals, Inc.)

Objective: We examined the psychometric properties of the Eating Disorder Readiness Ruler a simple self-report instrument designed to enable rapid assessment of readiness to change problematic eating behaviours in people with clinical eating disorders., Method: We administered the ED-RR, the Eating Disorders Examination Questionnaire and a measure of autonomous and controlled motivation for change to 206 individuals receiving outpatient treatment for an eating disorder., Results: A principal axis factoring analysis of the ED-RR yielded a significant two-factor solution (explaining 59% of variance)-one factor pertaining to restriction and body image preoccupation (four items), the other to binge-eating and vomiting symptoms (two items). The ED-RR showed good internal consistency (alpha coefficients for the two factors being .77 and .84 respectively). Furthermore, individuals reporting higher readiness showed higher scores on independent measures of autonomous motivation and greater symptom reductions over time., Discussion: Results suggest that the ED-RR is a psychometrically sound tool with potential clinical utility. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association., (Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.)

Objective: Across diverse clinical problems, therapists' autonomy support has been found to increase patients' autonomous motivation for change. Being self-motivated has, in turn, been linked to superior treatment response. In people undergoing outpatient eating disorder (ED) treatment, we examined associations among ratings of autonomy support received from therapists and other carers, self-reported engagement in therapy, and clinical outcomes., Method: Ninety-seven women with anorexia nervosa, bulimia nervosa, or a related ED provided measures of motivational status and clinical symptoms at the beginning and end of time-limited (12-16 weeks) segments of specialized treatment. At mid-treatment, patients also rated the extent to which they perceived their individual therapists, group therapists, group-therapy peers, family members, friends, and romantic partners as being autonomy supportive., Results: Overall, multiple regression analyses indicated autonomy support to moderate (rather than mediate) the link between initial autonomous motivation and later change in autonomous motivation-with results indicating that, independently of ED diagnosis or treatment intensity, greater perceived autonomy support (from therapists and nontherapists alike) coincided with larger increases in autonomous motivation over the course of therapy. In turn, higher autonomous motivation at end-of-therapy coincided with larger reductions in eating symptoms., Discussion: Findings suggest that the experience of autonomy support (from therapists and nontherapists) is associated with increasing motivation in people undergoing ED treatment, and that becoming self-motivated is linked to better outcomes. Such results indicate that support from therapists, relatives, and peers can favorably influence personal engagement in individuals undergoing ED treatment., (© 2017 Wiley Periodicals, Inc.)

Eating disorders (EDs) are characterized by intense preoccupation with shape and weight and maladaptive eating practices. The complex of symptoms that characterize EDs often arise through the activation of latent genetic potentials by environmental exposures, and epigenetic mechanisms are believed to link environmental exposures to gene expression. This chapter provides an overview of genetic factors acting in the etiology of EDs. It then provides a background to the hypothesis that epigenetic mechanisms link stresses such as obstetric complications and childhood abuse as well as effects of malnutrition to eating disorders (EDs). The chapter then summarizes the emerging body of literature on epigenetics and EDs-mainly studies on DNA methylation in samples of anorexia and bulimia. The available evidence base suggests that an epigenetically informed perspective contributes in valuable ways to the understanding of why people develop EDs.

Objectives: To summarize and synthesize the growing gene x environment (GxE) research investigating the promoter region of the serotonin transporter gene (5-HTTLPR) in the eating disorders (ED) field, and overcome the common limitation of low sample size, by undertaking a systematic review followed by a secondary data meta-analysis of studies identified by the review., Method: A systematic review of articles using PsycINFO, PubMed, and EMBASE was undertaken to identify studies investigating the interaction between 5-HTTLPR and an environmental or psychological factor, with an ED-related outcome variable. Seven studies were identified by the systematic review, with complete data sets of five community (n = 1750, 64.5% female) and two clinical (n = 426, 100% female) samples combined to perform four secondary-data analyses: 5-HTTLPR x Traumatic Life Events to predict ED status (n = 909), 5-HTTLPR x Sexual and Physical Abuse to predict bulimic symptoms (n = 1097), 5-HTTLPR x Depression to predict bulimic symptoms (n = 1256), and 5-HTTLPR x Impulsiveness to predict disordered eating (n = 1149)., Results: Under a multiplicative model, the low function (s) allele of 5-HTTLPR interacted with traumatic life events and experiencing both sexual and physical abuse (but not only one) to predict increased likelihood of an ED and bulimic symptoms, respectively. However, under an additive model there was also an interaction between sexual and physical abuse considered independently and 5-HTTLPR, and no interaction with traumatic life events. No other GxE interactions were significant., Conclusion: Early promising results should be followed-up with continued cross-institutional collaboration in order to achieve the large sample sizes necessary for genetic research., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Epigenetic mechanisms are believed to link environmental exposures to gene expression, and in so doing, to provide a physical basis for the activation, by life experiences, of mental-health problems. This paper provides a background to the hypothesis that epigenetic mechanisms link life stresses (perinatal, childhood and adult) and effects of malnutrition to the eating disorders (EDs). The paper reviews literature bearing upon the putative link between epigenetic factors and ED development, and examines ways in which epigenetic alterations could account for risk of eating disturbances and commonly associated behavioral and emotional problems. Ultimately, we propose that epigenetic processes provide an intriguing (although hypothetical) biological "platform" upon which ED-relevant effects of perinatal insults, life stresses, and consequences of malnutrition may be registered, and argue that an epigenetically informed understanding may explain why EDs are triggered and maintained by excessive caloric restraint, why they coincide so frequently with mood- and impulse-regulation problems, and why they tend to become increasingly entrenched over time. Finally, we comment on the clinical relevance and implications of an epigenetically informed model of ED etiology., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Inspired by an article on 50 terms that, in the interest of clarity in scientific reasoning and communication in psychology, psychiatry, and allied fields, "should be avoided or at most be used sparingly and only with explicit caveats,"(1) we propose a list of terms to avoid or think twice about before using when writing for the International Journal of Eating Disorders (IJED). Drawing upon our experience as reviewers or editors for the IJED, we generated an abridged list of such terms. For each term, we explain why it made our list and what alternatives we recommend. We hope that our list will contribute to improved clarity in scientific thinking about eating disorders, and that it will stimulate discussion of terms that may need to be reconsidered in our field's vocabulary to ensure the use of language that is respectful and sensitive to individuals who experience an eating disorder., (© 2016 Wiley Periodicals, Inc.)

The study explored lifetime prevalence of non-suicidal self-injury (NSSI) in female and male individuals with eating disorders (ED) and compared ED symptoms, general psychopathology and personality traits across individuals with and without a history of NSSI. The incremental discriminative capacity of gender on the manifestation of lifetime NSSI was also studied. A total sample of 1649 consecutively admitted ED patients (1515 women and 134 men) participated in the current study [339 ED + NSSI (ED with NSSI) and 1310 ED - NSSI (ED without NSSI)]. Specific self-report measures were included and other clinical and psychopathological indices. The observed lifetime prevalence of NSSI was 20.6% (20.9% in women and 17.2% in men). NSSI was not associated with ED type or gender. However, ED + NSSI patients exhibited more impulsive behaviour, substance-abuse disorders and additional impulse-control disorders, were younger and had more previous treatments. Age was shown to affect the presentation of NSSI. Additionally, ED + NSSI patients exhibited more severe ED and general psychopathological symptoms and had more dysfunctional personality traits when compared with ED - NSSI. ED + NSSI was found to be positively associated with harm avoidance and self-transcendence but negatively with reward dependence, self-directedness and cooperativeness. Thus, the variables with stronger capacity to identify the presence of ED + NSSI were younger age, harm avoidance, self-directedness and self-transcendence. A lack of association between sex and ED subtype with the presence of NSSI was observed., (Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.)

Background: Research associates maternal stress exposures (especially when occurring late in gestation) with heightened risk of subsequent emotional and behavioral problems in affected offspring. However, as yet, no study has examined the association between prenatal maternal stress (PNMS) and affected children's risk of anorexia- or bulimia-type eating disturbances., Objective: To study the influences of PNMS on later disordered eating in exposed offspring., Method: We used the Eating Attitudes Test (EAT)-26 to measure eating attitudes and behaviors in 54 thirteen-year olds whose mothers had been exposed, while pregnant with these children, to the 1998 Quebec Ice Storm-a natural disaster regarded as a model of exposure to severe environmental stress. Mothers' stress was measured shortly after exposure to the storm using established indices of objective and subjective stress., Results: Hierarchical multiple linear regression analyses indicated that once variance owing to children's body mass index and sex was accounted for, stress exposures during the third trimester of pregnancy predicted elevated EAT-26 scores in affected children-perhaps even more so when levels of objective stress were high., Discussion: Third trimester exposure to PNMS, especially when objectively severe, seems to be associated with increased eating-disorder-linked manifestations in affected early adolescents., (© 2015 Wiley Periodicals, Inc.)

Eating disorder (ED) variants characterized by "binge-eating/purging" symptoms differ from "restricting-only" variants along diverse clinical dimensions, but few studies have compared people with these different eating-disorder phenotypes on measures of neurocognitive function and brain activation. We tested the performances of 19 women with "restricting-only" eating syndromes and 27 with "binge-eating/purging" variants on a modified n-back task, and used functional magnetic resonance imaging (fMRI) to examine task-induced brain activations in frontal regions of interest. When compared with "binge-eating/purging" participants, "restricting-only" participants showed superior performance. Furthermore, in an intermediate-demand condition, "binge-eating/purging" participants showed significantly less event-related activation than did "restricting-only" participants in a right posterior prefrontal region spanning Brodmann areas 6-8-a region that has been linked to planning of motor responses, working memory for sequential information, and management of uncertainty. Our findings suggest that working memory is poorer in eating-disordered individuals with binge-eating/purging behaviors than in those who solely restrict food intake, and that observed performance differences coincide with interpretable group-based activation differences in a frontal region thought to subserve planning and decision making., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: To depict the processes through which animals and human beings engage their environment in continuously evolving states of conflict and cooperation., Method: Descriptive literature review., Results: Life history outcomes are more relative than they are absolute. Genetic variations play a crucial role, but heavily influencing behavioral outcomes, psychopathology included, are external cues that epigenetically remodel DNA along experience-dependent signaling pathways. The result is phenotypes that either optimize adjustment, or constrain it., Discussion: Knowledge of epigenetic mechanisms may help shed new light on the origin of maturational phenotypes underlying eating disorders and why adjusting treatments to these realities warrants our attention., (© 2014 Wiley Periodicals, Inc.)

Objective: We examined differences in treatment outcome associated with a "self-directed"- versus "external-incentive"-based day treatment protocol for individuals with eating disorders (EDs) with below normal body mass index. The self-directed protocol recommended a weekly 500 g weight gain, but allowed participants freedom to gain weight at their own rate; the "external-incentive" protocol required a minimum weight gain of 500 g/week as a requirement for staying in the program., Method: Weight outcome was available for 49 individuals who were treated with the recommended weight gain protocol, and 40 individuals who were treated with the required weight gain protocol., Results: Post-treatment weight was significantly higher in patients treated in the required weight gain protocol compared to those treated in the recommended weight gain protocol. All patients, regardless of which program they completed, showed improvements in the measures of eating-disorder and comorbid-psychiatric symptoms., Discussion: This study demonstrated the benefits of an alteration in protocol that required no additional financial or human resources. Further studies are needed to validate the effectiveness of various day treatment protocol parameters., (© 2014 Wiley Periodicals, Inc.)

Objective: Previous findings indicate that women with Bulimia Nervosa (BN), when compared to women with no eating disorder (NED), tend to display elevated methylation in the promoter region of the DRD2 gene. The preceding would be compatible with evidence of generally reduced dopamine activity in people with BN. However, altered DNA methylation has also been associated with adverse environmental exposures (such as to childhood abuse) and with psychiatric disturbances (such as Borderline Personality Disorder: BPD). In this study, we examined the extent to which DRD2 methylation was associated with the presence or absence of a bulimic eating disorder, to childhood abuse exposure, or to comorbid BPD., Method: Women with a bulimia-spectrum disorder (BSD) and women with NED were assessed for childhood traumata, eating-disorder symptoms and BPD, and provided blood samples for methylation analyzes., Results: BSD and NED groups did not differ as to mean percent DRD2 promoter methylation. However, among the women with a BSD, those with BPD showed small, but significant increases in DRD2 methylation levels compared to women with NED (as indicated by Hochberg's post-hoc tests). Similarly, women with a BSD who reported a history of childhood sexual abuse showed a trend-level elevation of DRD2 methylation compared to our NED group., Discussion: Our findings imply that, in people with a BSD, increased methylation of the DRD2 gene promoter may be more strongly characteristic of comorbid psychopathology than it is a global correlate of the eating disorder per se. We discuss theoretical implications of our findings., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Pathological gambling (PG) and eating disorders (ED) rarely co-occur. We explored the prevalence of lifetime PG in ED, compared severity of ED symptoms, personality traits, and psychopathological profiles across individuals with ED and PG (ED+PG) and without PG (ED-PG). Finally, we assessed the incremental predictive value of gender on the presentation of a comorbid PG., Method: A total sample of 1681 consecutively admitted ED patients (1576 females and 105 males), participated in the current study (25 ED+PG and 1656 ED-PG). All participants were diagnosed according to DSM-IV criteria. Assessment measures included the Symptom Checklist and the Temperament and Character Inventory-Revised, as well as other clinical and psychopathological indices., Results: The observed lifetime prevalence of PG was 1.49%. ED subtype was associated with lifetime PG (p=.003), with PG being more frequent in binge eating disorder (5.7%). ED+PG was more prevalent in males than in females (16% vs. 1.26%, respectively). Additionally, ED+PG patients exhibited more impulsive behaviours, lower impulse regulation and higher novelty seeking. Best predictors of ED+PG were novelty seeking (OR 1.030, p=.035), sex (OR 3.295, p=.048) and BMI (OR 1.081, p=.005)., Conclusions: Some personality traits (novelty seeking), being male and higher BMI are strongly related to the presence of lifetime PG in specific ED subtypes (namely binge eating disorder)., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: We explored interaction effects involving polymorphisms of targeted dopamine system genes and selected forms of childhood abuse (sexual, physical and emotional) acting upon severity of binge-eating and psychopathological symptoms in women with Bulimia-Spectrum Disorders (BSDs)., Methods: Women diagnosed with a BSD (n = 216) were assessed for childhood traumata, eating-disorder (ED) symptoms, and selected psychopathological features (sensation seeking, impulsivity, compulsivity and affective instability), and then provided blood samples for genotyping of main polymorphisms of dopamine-2 receptor (DRD2), dopamine transporter (DAT1) and catechol o-methyltransferase (COMT) genes., Results: Sensation Seeking was elevated in carriers of the low-function allele of the DRD2 Taq1A polymorphism who also reported childhood sexual abuse, relative to that in individuals showing other combinations of alleles and abuse exposures. In addition, carriers of a low-function allele of COMT scored higher on compulsivity, lower on impulsivity, and marginally lower on frequency of binge-eating than did individuals in whom the allele was absent., Discussion: Our results suggest that genes acting within the dopamine system may contribute, either directly or indirectly (i.e., in interaction with traumatic childhood experiences), to variations in the presentation of comorbid traits and, possibly, of bulimic symptoms., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: Evidence associates Bulimia Nervosa (BN) with altered functioning of the hypothalamic-pituitary-adrenal (HPA) axis, but the clinical implications of such alterations need to be better understood. We contrasted cortisol responses to the dexamethasone suppression test (DST) in bulimic and non-eating disordered women and examined relationships among DST cortisol responses, eating symptoms and co-morbid disturbances., Method: Sixty women with Bulimia Spectrum (BS) Disorders (either BN or normal weight Eating Disorder NOS with regular binge eating or purging) and 54 non-eating disordered women of similar age and body mass index participated in a 0.5 mg DST, and completed interviews and questionnaires assessing eating symptoms and co-morbid psychopathology., Results: Compared with the normal-eater group, the BS women demonstrated significantly less DST suppression. Among BS women, DST non-suppression was associated with more severe depression, anxiety and eating preoccupations., Conclusions: Our findings show BS women to show less DST suppression compared to normal eater women, and results link extent of non-suppression, in BS individuals, to severity of depression, anxiety and eating preoccupations., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: We examined the population reach, acceptability, and perceived potential of an initiative that developed a promotional tool for a healthy body image, the Québec Charter for a Healthy and Diverse Body Image. The Charter, developed through consensus building by a multisectoral, government-led task force, outlined actions to be undertaken by organizations or citizens to reduce media pressures favoring thinness., Methods: Six months after the Charter's launch, we surveyed 1003 Québec residents aged 18 years or older about their knowledge of the Charter, their willingness to adhere to it, and their perceptions of its potential., Results: After minimal prompting, more than 35% of respondents recognized the Charter. About 33.7% were very favorable toward personally adhering to the Charter and 32.7% perceived the Charter as having high potential to sensitize people to negative consequences of disordered eating. Women showed greater likelihood and people with lesser education showed lower likelihood of spontaneous recognition., Conclusions: An initiative involving the creation of a body image Charter reaches a substantial portion of adults and is viewed as acceptable and potentially influential.

This systematic review summarises and critically appraises the literature on structural magnetic resonance imaging in people with a current or past eating disorder. Studies using voxel-based morphometry image analysis were included. Ten studies reported on a total of 236 people with a current or past eating disorder and 257 healthy controls. Sample heterogeneity prohibited a meta-analytic approach. The findings do not unequivocally indicate grey or white matter volume abnormalities in people with an eating disorder. Nevertheless, these preliminary data suggest that, compared with healthy controls, people with anorexia nervosa have decreased grey matter in a range of brain regions and that those with bulimia nervosa have increased grey matter volumes in frontal and ventral striatal areas. Research in the recovery phase and longitudinal studies suggest that potential brain tissue abnormalities may recover with clinical improvement. Overall, as the available data are inconclusive, further efforts in this field are warranted., (Copyright © 2011 John Wiley & Sons, Ltd and Eating Disorders Association.)

Across populations, findings suggest that rates of self-mutilation, suicidal acts, and other self-harming behaviors (SHBs) may be influenced by polymorphisms that code for activity of the serotonin transporter (e.g., 5HTTLPR) and the enzyme, monoamine oxidase A (e.g., MAOAuVNTR). SHBs being common in patients with Eating Disorders (EDs), we evaluated (in a large sample of eating-disordered women) relationships between triallelic 5HTTLPR and MAOAuVNTR variants, on the one hand, and SHBs, on the other. We had 399 eating-disordered women report on eating symptoms and lifetime history of SHBs, and provide blood samples for genotyping. Individuals carrying high-function MAOAuVNTR alleles reported a history of SHBs about twice as often as did carriers of low-function alleles. We obtained no comparable main effect of 5HTTLPR, or MAOAuVNTR×5HTTLPR interaction effect. Genetic variations did not predict severity of eating symptoms. As in other populations, our findings link the MAOAuVNTR high-function alleles with increased risk of self-directed harm in bulimic females. We discuss theoretical and clinical ramifications of our results., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objective: In participants with eating disorders (EDs), prior physical or sexual abuse has been associated with increased likelihood of impulsivity and affective instability. However, previous studies among participants with eating disorders have not systematically explored relationships between empirically derived, personality-trait-based classes, on the one hand, and likelihood of exposure to either childhood sexual or physical abuse, on the other., Method: We assessed multiple psychopathological traits, eating symptoms, and history of abuse in 185 women with an ED and 93 with no ED., Results: A latent class analysis, conducted using psychopathological-trait measures, yielded latent classes of participants with eating disorders fitting the descriptors "dissocial/impulsive," "inhibited/compulsive," and "low psychopathology." ED was generally associated with increased risk of childhood sexual abuse, but the dissocial/impulsive characteristic corresponded with a unique likelihood of physical abuse and especially high rates of sexual abuse., Discussion: Observed associations between different forms of childhood abuse and trait-defined ED variants help inform models on the development of eating disorders and of psychopathological traits that often accompany them., (2009 by Wiley Periodicals, Inc.)

Context: Efforts to classify eating-disordered individuals based on concurrent personality traits have consistently converged on a typology encompassing "over-regulated", "dysregulated", and "low psychopathology" subgroups. In various populations, evidence has associated personality variations of an "over-regulated/dysregulated" type with differences on serotonin-system indices, and specifically, with different loadings of serotonin transporter promoter regulatory region polymorphism (5HTTLPR) genotypes and alleles. We explored the extent to which an empirical, trait-defined typology of eating-disordered individuals coincided systematically with variations in 5HTTLPR, assayed using biallelic and triallelic models., Method: We tested 185 women with a DSM-IV eating disorder (108 with Bulimia Nervosa, 17 Anorexia Nervosa, and 60 an Eating Disorder Not Otherwise Specified) and 93 with no eating disorder on measures reflecting psychopathological traits and 5HTTLPR (biallelic and triallelic) genotypes and alleles., Results: The highest-function, triallelic (L(A)/L(A)) genotype occurred significantly more frequently among eating-disordered individuals than among controls. However, a more fine-grained analysis suggested that this association was attributable to the fact that, among eating-disordered participants, those displaying an "Inhibited/Compulsive" profile (derived using latent class analysis) were more likely than those of a "Dissocial/Impulsive" or a "Low Psychopathology" group to carry the triallelic 5HTTLPR gain-of-function L(A) allele and to be L(A)/L(A) homozygotes., Discussion: This study's empirically derived classes coincide with interpretable differences on genetic indices-associating an "Inhibited/Compulsive" group with 5HTTLPR gain-of-function genotypes (and alleles) that have elsewhere been linked to trait compulsivity. The findings, furthermore, suggest that 5HTTLPR, by influencing personality-trait manifestations may, in turn, influence eating-disorder risk and symptom expression.

Objective: We estimated the prevalence of eating disorders and maladaptive eating behaviors in a population-based sample and examined the association of maladaptive eating with self-rated physical and mental health., Method: A sample of 1,501 women (mean age = 31.2 years, SD = 6.2) were recruited using random-digit dialing to participate in a 20-min telephone interview about eating behaviors., Results: Weighted frequency analysis showed the prevalence of frequent binge-eating to be 4.1%, that of regular purging to be 1.1%, and that of frequent compensation to be 8.7%. Although we found none of the women to meet full criteria for anorexia nervosa, 0.6% met criteria for bulimia nervosa, 3.8% provisional criteria for binge eating disorder, and 0.6% criteria for a newly proposed entity, purging disorder. As many as 14.9% fell into a residual category representing subthreshold, but potentially problematic variants of eating disturbances. Logistic regression analyses showed that clinical-level maladaptive eating attitudes and behaviors predicted self-rated physical- and mental-health problems after sociodemographic factors were controlled., Discussion: This population-based survey provides prevalence estimates of BN, BED, and purging disorder that are compatible with those of recent epidemiological studies and shows that maladaptive eating attitudes and behaviors represent a substantial population burden.

Alterations in brain serotonin (5-hydroxytryptamine [5-HT]) function are thought to contribute to diverse aspects of eating disorders, including binge eating, perfectionism, impulsivity and mood-regulation problems. In addition, 5-HT anomalies in individuals with eating disorders are believed to have multiple determinants associated with secondary (state-related) effects of their nutritional status, hereditary effects (related to such trait variations as impulsivity or perfectionism) and, possibly, long-term neurobiologic sequelae of developmental stressors (such as childhood abuse). On the strength of the available neurobiologic and genetic data, this paper presents the idea that 5-HT variations in those with eating disorders represent (1) a structured coaggregation of biologic, psychologic and social influences and (2) converging state, trait and developmental effects. Data are taken to support a multidimensional model of 5-HT function in eating disorders that, it is argued, can serve as a prototype for etiologic modelling, diagnostic classification and clinical decision-making bearing not only upon eating disorders but also upon other psychiatric disturbances.

Objective: We investigated the predictive utility of three dimensions of body esteem in explaining self-esteem in samples of eating-disordered (ED) and nonclinical women., Method: Participants comprised 74 ED women and 103 female university students. All women completed questionnaires measuring body esteem and self-esteem and all provided information on height and weight. We ran hierarchical multiple regression analyses with self-esteem as the outcome variable and participant status (clinical or non), body mass index (BMI), body esteem, and interaction terms as predictors., Results: The main finding was a Body Esteem x Participant Status interaction involving the attribution dimension of body esteem. Specifically, among ED women, the higher their body esteem attribution (i.e., the more they endorsed items such as "I think my appearance would help me get dates"), the higher their self-esteem; whereas this relationship was not found among the students., Discussion: Our results contribute to an emerging profile of ED patients as highly socially sensitive., (Copyright 2002 by Wiley Periodicals, Inc.)