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Cognitive inflexibility and compulsive behaviours are commonly observed in patients with anorexia nervosa (AN) and are often considered to be caused by impairments in executive functioning and visuospatial processing. Despite an increasing number of young individuals presenting with AN, there is a lack of meta-analytic evidence on the neuropsychological functioning in this population. Our primary aim was to review and synthesize the differences in neuropsychological test performance between young people with AN and healthy controls, and to explore potential moderators.A database search following PRISMA guidelines of MEDLINE, PsycINFO, ISI Web of Science and Epistemonikos was conducted. Hedges' g served as an effect size indicating the standardized mean differences. We utilized mixed-effects meta-regression and machine learning meta-analyses to identify relevant moderators.Sixteen studies met the inclusion criteria with a total of 1333 participants (665 with AN) and 59 effect sizes. Random-effects meta-analyses demonstrated a small and insignificant difference between young individuals with AN and controls (Our findings highlight the significant impact of age on neuropsychological test performance in patients with AN. There is a need for a more widespread inclusion of potentially confounding variables in primary studies as well as instruments specifically targeted at younger populations.

Objective This study aimed to provide updated lifetime prevalence estimates of eating disorders, specifically bulimia nervosa (BN) and binge eating disorder (BED) and investigate changes over time in lifetime prevalence by age. Method Two thousand nine hundred seventy-seven participants from South Australia were interviewed in the Health Omnibus Survey. DSM-5 criteria were used for current and broad (in accord with the International Statistical Classification of Diseases and Related Health Problems-11 [ICD-11]) criteria for lifetime prevalence of BED. Results This study found that the lifetime prevalence of BN was 1.21% (95% CI [0.87, 1.67]) and 2.59% (95% CI [2.07, 3.22]) for males and females, respectively, and that lifetime prevalence for BED-broad was 0.74% (95% CI [0.49, 1.11]) and 1.85% (95% CI [1.42, 2.40]) for males and females, respectively, which is higher than reported in previous research. Current prevalence (past 3 months) of BN was 0.40% (95% CI [0.23, 0.70]) and 0.81% (95% CI [0.54, 1.20]) for males and females, respectively, and current prevalence for BED was found to be 0.03 (95% CI [0.01, 0.04]) and 0.20% (95% CI [0.09, 0.44]) for males and females, respectively. Conclusions The current study confirmed the moderate community prevalence of BN and BED. BED was found to be less prevalent than BN in the present study, and a significant lifetime prevalence by age effect was found for both. Lifetime prevalence by age indicated that past increases in prevalence may be waning in this century and that overall BN and BED are not increasing in Australia.

Despite the existence of reviews which document the effectiveness of online therapies, there is little consensus regarding the exact components of online treatment delivery that are most effective in maintaining user engagement and reducing eating disorder (ED) symptomology. The current review and meta-analysis aimed to determine which components of web-based, ED self-help interventions are associated with lower attrition and improved therapeutic outcome.A systematic search of electronic databases (PsycINFO, Medline, Web of Science, Scopus) was conducted for published studies of web-based interventions for EDs and a meta-analysis of the final included studies was performed. Each intervention was coded across four dimensions, including the multimedia channels employed (e.g., text, audio, videos), degree of user interactivity (e.g., online self-monitoring, skills exercises), level of automated feedback (e.g., reminders, personalized feedback), and technological device through which the program was accessed (e.g., smartphone, computer).A final 23 papers were included. The results of meta-regressions indicated that higher scores on the multimedia subscale were associated with greater ED symptom improvement in treatment groups. Conversely, a higher degree of feedback in the treatment group was associated with a group difference in ED psychopathology favoring the control group. Other intervention components were not associated with treatment outcome or dropout.The results are discussed in relation to limitations of the scale used to quantify digital intervention features, as well as the limited diversity and technological sophistication of available ED digital interventions. Such findings indicate the importance of understanding the digital components, which differentiate online therapeutic programs.Objetivo: A pesar de las existencia de revisiones que documentan la efectividad de las terapias en línea, hay poco consenso acerca de los componentes exactos de los tratamientos llevados a cabo en línea que son más efectivos en mantener involucrado al usuario y reducir la sintomatología de trastorno de la conducta alimentaria (TCA). La presente revisión y meta-análisis pretende determinar qué componentes de las intervenciones de autoayuda para TCA basadas en la web, están asociadas con menor deserción y resultados terapéuticos mejorados. Método: Una revisión sistemática de las bases de datos electrónicas (PsycINFO, Medline, Web of Science, Scopus) fueron revisadas buscando estudios de intervenciones para TCAs basadas en la web y se realizó un meta-análisis de los estudios finalmente incluidos. Cada intervención fue codificada en cuatro dimensiones, incluyendo los canales multimedia (por ejemplo, texto, audio, videos), grado de interacción con el usuario (por ejemplo, auto monitoreo en línea, ejercicios de habilidades), nivel de retroalimentación automatizada (por ejemplo, recordatorios, retroalimentación personalizada), y aparatos tecnológicos a través de los cuáles se accesó al programa (por ejemplo, teléfonos inteligentes, computadora). Resultados: Al final fueron incluidos 23 estudios. Los resultados de las meta-regresiones indicaron que puntuaciones más elevadas en la subescala de multimedia estaba asociado con mayor mejoría de los síntomas de TCA en los grupos de tratamiento. Por lo contrario, un mayor grado de retroalimentación en el grupo de tratamiento fue asociado con una diferencia grupal en la psicopatología de TCA favoreciendo el grupo control. Otros componentes de la intervención no fueron asociados con resultados o abandonos de tratamiento. Discusión: Los resultados fueron discutidos en relación a las limitaciones de la escala utilizada para cuantificar las características de la intervención digital, así como la limitada diversidad y sofisticación tecnológica de las intervenciones digitales para TCA disponibles. Estos hallazgos indican la importancia de entender los componentes digitales que diferencían los programas terapéuticos en línea.

Objective: To compare the efficacy of the compuLsive Exercise Activity theraPy (LEAP) programme integrated with manualised cognitive behavioural therapy for anorexia nervosa (CBT-AN) compared to CBT-AN alone. Method: Seventy-eight adults were randomised to CBT-AN, delivered with or without 8 embedded sessions of LEAP, for a total of 34 individual outpatient sessions. Participants were assessed at baseline, the end of the first phase of CBT-AN (which included LEAP), mid-therapy, end of therapy, and at 3 and 6-months follow-up. Linear mixed effects modelling was used for comparing trajectories over time by group in primary outcomes of pathological exercise cognitions and secondary outcomes of exercise frequency, BMI, eating disorder (ED) symptoms, AN stage of change, anxiety/depression, and health related quality of life. Results: There were significant improvements over time in all outcomes. There were no significant differences between treatment groups in primary outcome measures. Fidelity and end-of- treatment participant satisfaction were satisfactory across both conditions. Discussion: CBT-AN and LEAP added to CBT-AN resulted in improved attitudes and beliefs towards exercise and general improvements in BMI and eating disorder psychopathology in people with AN.

Background Until recently, research into Chew and Spit (CHSP) behavior has predominantly focused on clinical samples, and little is known of its prevalence in the community. The current study aimed to bridge this gap by exploring CHSP features in a representative sample of the general population. We hypothesized that the point-prevalence of CHSP would be less than 1%; concurrent with other eating disorder symptomology, and associated with poorer health related quality of life (HRQoL). Methodology Using the 2016, respondent-based, South Australian Health Omnibus Survey (HOS), data were collected on 3047 participants aged ≥15 years old. HRQoL was assessed with the Short-Form health-questionnaire-v1 (SF-12). Results CHSP point prevalence was 0.4% (95% CI .23 to .69%; n = 13), and was more prevalent in people with compensatory disordered eating behaviors. The median age of those with CHSP was 39, and both mental and physical HRQoL were reduced compared with the general population (Mdn: MHQoL = 49; HRQoL = 50), with MHQoL being significantly lower in those with symptoms of a clinically diagnosable ED and concurrently engaged in CHSP (z = -2.33, p = .020). Conclusions Due to the low prevalence of CHSP, the reliability of inferential statistics may increase the chance of Type II errors, therefore, future studies should use larger samples. Although CHSP is not "common" in a wider community sample, its prevalence appears to be similar to other ED associated symptoms.

Objective The current study examined a theoretical model (the identity disruption model) linking negative early life experiences to body dissatisfaction and disordered eating via self-concept clarity and sociocultural factors (internalization of beauty ideals and appearance comparison tendencies). Method 1,023 participants (52% women) completed a series of questionnaires online, including measures of negative early life experiences and childhood abuse, self-concept clarity, internalization of beauty ideals, appearance comparison tendencies, sociocultural pressure to improve one's appearance, body dissatisfaction, and disordered eating. Results Structural equation modeling indicated that self-reported early adversity was associated with lower self-concept clarity, which in turn was associated with greater internalization of beauty ideals and more frequent appearance comparisons. Internalization and appearance comparisons were associated with body image concerns, which in turn were associated with disordered eating and exercise behaviors. There were few sex differences in these paths. Discussion These findings provide initial conceptual support for the identity disruption model and extend previous models of body dissatisfaction and disordered eating to include processes that occur earlier in life. This model opens up the possibility for new interventions that are targeted toward those who are most vulnerable to developing body dissatisfaction and disordered eating.

Objective To systematically review the literature reporting outcomes of augmentative family-based treatment (FBT) interventions for adolescents with restrictive eating disorders (EDs). Method Articles were identified through a systematic search of five electronic databases (PsycINFO, MEDLINE, EMBASE, CINAHL, Cochrane Database). Results Thirty articles were included, reporting on FBT augmentations featuring adjunctive treatment components, modified treatment structure and/or content with adherence to FBT principles, and adaptations allowing FBT delivery in different settings. All reported significant improvements in weight and/or ED symptoms at end-of-treatment, although few compared augmentative and standard FBT interventions and good quality follow-up data was generally lacking. Conclusions There is early evidence for the effectiveness of augmentative FBT-based approaches in facilitating weight and/or ED symptom improvements for adolescents with restrictive EDs. There remains a lack of robust evidence demonstrating superior effects of such approaches over standard FBT, and further controlled studies are required to expand on the current evidence. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

This longitudinal study explored family functioning and relationship quality for adolescents with severe anorexia nervosa (AN). An important outcome given healthy family functioning supports effective adolescent development. Fifty-four female adolescents and their parents, treated with family-based treatment after inpatient admission, and 49 non-clinical age-matched adolescents and their parents were compared at assessment and 6 months after session 20. At baseline, AN group mothers and fathers reported poorer family function. AN adolescents were notably similar to controls, reporting poorer function in only one domain. There were no changes for adolescents, an improvement for mothers in the AN group, but an increase in perceived impairment for fathers in both groups, with AN fathers more affected. The similarity in adolescent reports and the increase for fathers over time may indicate that normal adolescent family processes occur even in the midst of serious illness. There is a need to provide intervention to ameliorate the impact of treatment on parents. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Objective This study was to model the cost-effectiveness of specialist-delivered cognitive behavioral therapy for bulimia nervosa (CBT-BN) compared to no intervention within the Australian context. Method An illness-death model was developed to estimate the cost per disability-adjusted life-year (DALY) averted of CBT-BN over 2 years from the healthcare perspective. Target population was adults aged 18–65 years with BN. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted. Uncertainty and sensitivity analyses were conducted to test the robustness of results. Results Primary analysis indicated that CBT-BN was associated with greater DALY averted (0.10 DALY per person) and higher costs ($1,435 per person) than no intervention, resulting the mean ICER of $14,451 per DALY averted (95% uncertainty interval [UI]: $8,762 to $35,650). Uncertainty analysis indicated CBT-BN is 99% likely to be cost-effective at a threshold of $50,000 per DALY averted. Including the patients' time and travel costs resulted in the mean ICER of $18,858 per DALY averted (95% UI: $11,235 to $46,026). Sensitivity analysis indicated the intervention was not cost-effective if over 80% people discontinued treatment. Other analyses including a reduced time horizon, increased remission rates, and 4-month effect size of CBT-BN increases the ICERs but these ICERs remained well below under a threshold of $50,000 per DALY averted. Conclusion This study has demonstrated that CBT-BN for adults with BN is a cost-effective treatment intervention. Further research is required to investigate the practicability of CBT-ED and the cost-effectiveness of other formats of CBT-BN delivery.

Objective With anorexia nervosa (AN) having various presentations, attention has been directed towards particularly durable forms of the condition in both research and clinical contexts. A major hindrance in terms of advancing the field is the inconsistent labeling and defining of this subgroup. This has two implications; first, the inconsistent recruitment of participants when researching this sample, and second, the misdiagnosing of patients who may or may not have a durable course of the disease. The current research had the purpose of providing an overview of the current labels and criteria used for defining cases of severe and enduring AN, and critically analysing the implications of these findings. Method In accordance with PRISMA guidelines, a literature search was conducted using four electronic databases (PsycINFO, MEDLINE, Web of Science and Scopus) in order to identify 32 records that met the standards stipulated by the criteria. Data extraction included explicit labeling, the definition or criteria used to describe the subgroup, along with participant age and study design. Results It was found that the terms chronic and severe and enduring were the most commonly used adjectives when referring to this subgroup. In terms of criteria, illness duration and the number of previously failed treatment attempts were the most common defining features within the literature. Discussion It is the aim of the authors to inspire further research into what is the most appropriate label and defining features for the subgroup in order to facilitate a better approach and outcome for the individuals affected. ResumenObjetivo Con la Anorexia Nervosa (AN) teniendo varias presentaciones, tanto en la investigacion como en los contextos clinicos, la atencion se ha dirigido particularmente hacia las formas duraderas de esta condicion. Un obstaculo importante en terminos de avanzar en el campo es la inconsistencia en el etiquetado y definicion de este subgrupo. Esto tiene dos implicaciones; Primero, el inconsistente reclutamiento de participantes cuando se investiga esta muestra, y segundo, el diagnostico equivocado de pacientes que pueden o no tener un curso duradero de la enfermedad. La presente investigacion tiene el proposito de proporcionar una vision general de las etiquetas actuales y los criterios utilizados para definir los casos de AN severa y duradera, y analizar criticamente las implicaciones de estos hallazgos. Metodo: De acuerdo con las guias PRISMA, se realizo una busqueda en la literatura utilizando cuatro bases de datos electronicas (PsycINFO, MEDLINE, Web of Science y Scopus) para identificar 32 articulos que cumplian con los estandares estipulados por los criterios. La extraccion de datos incluyo el etiquetado explicito, la definicion o criterio utilizado para describir este subgrupo, junto con la edad del participante y el diseno del estudio. Resultados: Se encontro que los terminos cronico, severo y duradero eran los adjetivos mas comunmente utilizados cuando se referian a este subgrupo. En terminos de criterios, la duracion de la enfermedad y el numero de intentos de tratamiento previamente fallidos fueron las caracteristicas definitorias mas comunes dentro de la literatura. Discusion: Uno de los objetivos de los autores es inspirar a que se realice mas investigacion en torno a cual seria el etiquetado y la definicion mas apropiados para este subgrupo y asi facilitar un mejor abordaje y resultados para los individuos afectados.

Objective Although findings suggest that binge eating is becoming increasingly normative, the ‘clinical significance’ of this behaviour at a population level remains uncertain. We aimed to assess the time trends in binge-eating prevalence and burden over 18 years. Method Six cross-sectional face-to-face surveys of the Australian adult population were conducted in 1998, 2005, 2008, 2009, 2014, and 2015 (Ntotal = 15 126). Data were collected on demographics, 3-month prevalence of objective binge eating (OBE), health-related quality of life, days out of role, and distress related to OBE. Results The prevalence of OBE increased six-fold from 1998 (2.7%) to 2015 (13.0%). Health-related quality of life associated with OBE improved from 1998 to 2015, where it more closely approximated population norms. Days out of role remained higher among participants who reported OBE, although decreased over time. Half of participants who reported weekly (56.6%) and twice-weekly (47.1%) OBE reported that they were not distressed by this behaviour. However, the presence of distress related to OBE in 2015 was associated with greater health-related quality-of-life impairment. Conclusion As the prevalence of binge eating increases over time, associated disability has been decreasing. Implications for the diagnosis of disorders associated with binge eating are discussed.

OBJECTIVE: To investigate the relationships between weight/shape overvaluation, health-related quality of life (HRQoL) and functional role impairment (days out of role [DOR]) in the general population over 11 years. METHOD: Five cross-sectional surveys of men and women representative of the South Australian population were conducted in 2005, 2008, 2009, 2015, and 2016 (ntotal = 15,140). Data were collected on demographics, overvaluation, HRQoL, DOR, and eating disorder behaviours. RESULTS: Between 2005 and 2016, the prevalence of moderate overvaluation increased from 18.1% to 40.0%, marked overvaluation from 7.5% to 23.7%, and extreme overvaluation from 3.1% to 9.2% (all p

BACKGROUND: Clinical guidelines recommend outpatient care for the majority of people with an eating disorder. The optimal use of inpatient treatment or combination of inpatient and partial hospital care is disputed and practice varies widely. OBJECTIVES: To assess the effects of treatment setting (inpatient, partial hospitalisation, or outpatient) on the reduction of symptoms and increase in remission rates in people with: 1. Anorexia nervosa and atypical anorexia nervosa; 2. Bulimia nervosa and other eating disorders. SEARCH METHODS: We searched Ovid MEDLINE (1950‐ ), Embase (1974‐ ), PsycINFO (1967‐ ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 2 July 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD‐CTR) (all years to 20 November 2015). We also searched the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (6 July 2018). We ran a forward citation search on the Web of Science to identify additional reports citing any of the included studies, and screened reference lists of included studies and relevant reviews identified during our searches. SELECTION CRITERIA: We included randomised controlled trials that tested the efficacy of inpatient, outpatient, or partial hospital settings for treatment of eating disorder in adults, adolescents, and children, whose diagnoses were determined according to the DSM‐5, or other internationally accepted diagnostic criteria. We excluded trials of treatment setting for medical or psychiatric complications or comorbidities (e.g. hypokalaemia, depression) of an eating disorder. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane procedures to select studies, extract and analyse data, and interpret and present results. We extracted data according to the DSM‐5 criteria. We used the Cochrane tool to assess risk of bias. We used the mean (MD) or standardised mean difference (SMD) for continuous data outcomes, and the risk ratio (RR) for binary outcomes. We included the 95% confidence interval (CI) with each result. We presented the quality of the evidence and estimate of effect for weight or body mass index (BMI) and acceptability (number who completed treatment), in a 'Summary of findings' table for the comparison for which we had sufficient data to conduct a meta‐analysis. MAIN RESULTS: We included five trials in our review. Four trials included a total of 511 participants with anorexia nervosa, and one trial had 55 participants with bulimia nervosa. Three trials are awaiting classification, and may be included in future versions of this review. We assessed a risk of bias from lack of blinding of participants and therapists in all trials, and unclear risk for allocation concealment and randomisation in one study. We had planned four comparisons, and had data for meta‐analyses for one. For anorexia nervosa, there may be little or no difference between specialist inpatient care and active outpatient or combined brief hospital and outpatient care in weight gain at 12 months after the start of treatment (standardised mean difference (SMD) ‐0.22, 95% CI ‐0.49 to 0.05; 2 trials, 232 participants; low‐quality evidence). People may be more likely to complete treatment when randomised to outpatient care settings, but this finding is very uncertain (risk ratio (RR) 0.75, 95% CI 0.64 to 0.88; 3 trials, 319 participants; very low‐quality evidence). We downgraded the quality of the evidence for these outcomes because of risks of bias, small numbers of participants and events, and variable level of specialist expertise and intensity of treatment. We had no data, or data from only one trial for the primary outcomes for each of the other three comparisons. No trials measured weight or acceptance of treatment for anorexia nervosa, when comparing inpatient care provided by a specialist eating disorder service and health professionals and a waiting list, no active treatment, or treatment as usual. There was no clear difference in weight gain between settings, and only slightly more acceptance for the partial hospital setting over specialist inpatient care for weight restoration in anorexia nervosa. There was no clear difference in weight gain or acceptability of treatment between specialist inpatient care and partial hospital care for bulimia nervosa, and other binge eating disorders. AUTHORS' CONCLUSIONS: There was insufficient evidence to conclude whether any treatment setting was superior for treating people with moderately severe (or less) anorexia nervosa, or other eating disorders. More research is needed for all comparisons of inpatient care versus alternate care.

Objectives Unfulfilled basic psychological needs have been associated with disordered eating behaviours, but the mechanisms underlying that associations are not well understood. This study examined a two-stage path model linking basic psychological need satisfaction to disordered eating behaviours via issues of control. Methods Female university students (N = 323; Mage = 19.61), community participants (N = 371; Mage = 29.75), and women who self-reported having been diagnosed with an eating disorder (ED; N = 41; Mage = 23.88) completed measures of psychological need satisfaction (i.e., autonomy and competence), issues of control (i.e., feelings of ineffectiveness and fear of losing self-control [FLC]), and ED pathology. Results Path analysis revealed that unsatisfied needs of autonomy and competence were indirectly related to disordered eating behaviours through feelings of ineffectiveness and FLC. Conclusions The results indicate that issues of control might be one of the mechanisms through which lack of psychological need satisfaction is associated with disordered eating. Although the model was constructed using cross-sectional data, these findings suggest potential targets for prevention and treatment efforts aimed at reducing disordered eating in young females. Practitioner points Our results indicate that young women with chronically unfulfilled basic psychological needs might be vulnerable to developing disordered eating behaviours. The observed patterns suggest that persistent experience of need frustration may engender an internal sense of ineffectiveness and lack of control, which then compels individuals to engage in disordered eating behaviours in an attempt to regain autonomy and competence. Interventions for eating disorders may be most effective when emphasizing the promotion of people's needs for autonomy and competence. Limitations The model was constructed using cross-sectional data. Future experimental and longitudinal studies are needed to confirm the temporal sequence from basic psychological needs to issues of control. The sample only consisted of young women. Further research should explore how thwarting of psychological need satisfaction functions in men. Our clinical sample was small and diagnosis was not confirmed through clinical interview; therefore, those data should be interpreted with caution.

Objective Compulsive exercise is a prominent feature for the majority of patients with Anorexia Nervosa (AN), but there is a dearth of research evaluating assessment instruments. This study assessed the concurrent validity of the exercise items of the Eating Disorder Examination (EDE) and Eating Disorder Examination-Questionnaire (EDE-Q), with the Compulsive Exercise Test (CET) and other self-report exercise measures in patients with AN. We also aimed to perform validation of the CET in an adult clinical sample. Methods The sample consisted of 78 adults with AN, recruited for the randomized controlled trial “Taking a LEAP forward in the treatment of anorexia nervosa.” At baseline, participants completed the EDE, EDE-Q, CET, Reasons for Exercise Inventory (REI), Commitment to Exercise Scale (CES) and Exercise Beliefs Questionnaire (EBQ). Correlational and regression analyses were performed. Results EDE exercise days and exercise time per day were positively correlated with each other and with all CET subscales (except Lack of exercise enjoyment), CES mean, EBQ total and REI total. Exercise time per day was associated with a higher EDE global score. The CET demonstrated good concurrent validity with the CES, the REI and the EBQ. Of the self-reports, the CET explained the greatest variance in eating disorder psychopathology and demonstrated good to excellent reliability in this sample. Discussion The EDE and EDE-Q demonstrated good concurrent validity with the CET. Further research is required to evaluate the CET's factor structure in a large clinical sample. However, the CET has demonstrated strong clinical utility in adult patients with AN. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:533–541)

Objective To Identify whether early weight gain in family-based treatment (FBT) predicted greater weight and remission at end of FBT and 12-month follow-up. Method Eighty-two adolescents, with anorexia nervosa, participated in a randomized control trial comparing brief hospitalization for medical stabilization and hospitalization for weight restoration to 90% expected body weight (EBW) (1:1), followed by 20 sessions of FBT. Sixty-nine completed trial protocol. Receiver operating characteristic analyses were conducted investigating whether early weight-gain in FBT predicted outcomes at end of FBT and 12-month follow-up. Participants were analyzed according to their original randomization and as a combined set. Binary logistic regression was used to control for randomization arm effect in combined set analysis. Results Weight gain greater than 1.8 kg at FBT Session 4 predicted greater %EBW (99.18 SD = 6.93 vs. 92.79 SD = 7.74, p

Severe dietary energy restriction is often used for overweight or obese individuals to achieve rapid weight loss and related health improvements. However, the extent of putative adverse effects on eating behaviour is unknown. We thus systematically searched seven databases for studies that assessed binge eating before and after severe dietary energy restriction (low or very low energy diets) in overweight or obese individuals. Fifteen clinically supervised interventions from 10 publications (nine of which involved only women) were included. Among individuals with clinically relevant pre-treatment binge eating disorder, severe dietary energy restriction significantly decreased binge eating in all four interventions involving this population, at least during the weight loss programme. In contrast, no consistent association between severe dietary energy restriction and the onset of bingeing was found in 11 interventions involving individuals without pre-treatment binge eating disorder, with four such interventions showing significant increases, two showing no change, and five showing significant decreases in binge eating. We conclude that clinically supervised severe dietary energy restriction appears safe and beneficial for overweight or obese individuals with pre-treatment binge eating disorder, and does not necessarily trigger binge eating in those without binge eating disorder.

To examine whether self-stigma of seeking psychological help and being male would be associated with an increased likelihood of having an undiagnosed eating disorder. A multi-national sample of 360 individuals with diagnosed eating disorders and 125 individuals with undiagnosed eating disorders were recruited. Logistic regression was used to identify variables affecting the likelihood of having an undiagnosed eating disorder, including sex, self-stigma of seeking psychological help, and perceived stigma of having a mental illness, controlling for a broad range of covariates. Being male and reporting greater self-stigma of seeking psychological help was independently associated with an increased likelihood of being undiagnosed. Further, the association between self-stigma of seeking psychological help and increased likelihood of being undiagnosed was significantly stronger for males than for females. Perceived stigma associated with help-seeking may be a salient barrier to treatment for eating disorders-particularly among male sufferers.

Objective The family meal is an integral component of Maudsley family-based treatment for anorexia nervosa. The aim of this study was to determine whether there are different types of family meal, as suggested in the treatment manual, and whether within session processes differ according to meal type. Method Thirty video-recorded family meal sessions from a randomised controlled trial were transcribed and analysed using thematic analysis. Results Analyses revealed two types of family meal. In the first, the patient ate one mouthful more than they were willing to eat. This meal type was characterised by processes that were consistent with the Maudsley model. In the second, the patient ate what was asked of them with little to no difficulty. Therapist and family avoidance differentiated this meal type from the first. Discussion The current findings, along with the existing theory, suggest that avoidance may have reduced the therapeutic impact of the meal for many families. Strategies to challenge therapist and family avoidance are suggested. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.

Objective To date, studies of stigma relating to eating disorders have been largely confined to surveys of the public. We sought to examine the prevalence and correlates of stigma as reported by individuals with eating disorders. Method An online survey designed to assess frequency of exposure to potentially stigmatizing attitudes and beliefs as well as the perceived impact of this on health and well-being was completed by a cross-national sample of 317 individuals with anorexia nervosa (n = 165), bulimia nervosa (n = 66), or Eating Disorder Not Otherwise Specified (EDNOS; n = 86). Results Participants rated two beliefs as both particularly common and particularly damaging, namely “I should be able to just pull myself together” and “I am personally responsible for my condition”. Participants with bulimia nervosa more commonly experienced the belief that they had “no self-control” and male participants more commonly experienced the belief that they were “less of a man”. More frequent stigmatization was associated with higher levels of eating disorder psychopathology, a longer duration of disorder, lower self-esteem, and more self-stigma of seeking psychological help. Discussion Stigma towards individuals with eating disorders, as experienced by sufferers, is common and associated with numerous adverse outcomes. The perceptions that eating disorders are trivial and self-inflicted should be a focus of destigmatization interventions. Efforts to reduce stigma towards individuals with bulimia nervosa may need to focus on perceptions of self-control, whereas efforts to reduce stigma towards males with eating disorders may need to focus on perceptions of masculinity/manhood. © 2014 Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:767–774)

Objective To investigate whether impaired set shifting and weak central coherence represent state or trait characteristics and, therefore, candidate endophenotypes of anorexia nervosa (AN). Method Forty-nine individuals with lifetime AN (24 acutely unwell, 10 weight recovered, and 15 fully recovered) and 43 healthy controls completed the Wisconsin Card Sorting Test (WCST), the Matching Familiar Figures Test, and the Rey Complex Figure Task measuring cognitive flexibility, local processing, and global processing, respectively. Participants also completed questionnaires assessing eating disorder, anxiety and depressive symptoms, obsessional traits, interpersonal functioning, and quality of life. Body mass index was calculated from height and weight measurements. Results Participants with lifetime AN demonstrated poorer set shifting ability than healthy controls as evidenced by a greater number of perseverative errors on the WCST. When participants were grouped according to illness status, only those in the two recovered groups demonstrated poorer set shifting ability than healthy controls while patients with acute AN performed comparably to all other groups. There were no significant differences between groups on measures of local and global processing. No relationship was found between specific clinical features of AN and cognitive performance. Discussion The results of this study are consistent with a global trend toward set shifting difficulties in patients with AN but do not support weak central coherence as a candidate endophenotype for AN. These findings have clinical implications in terms of treatment selection and planning, particularly in relation to the use of cognitive remediation therapy with patients with AN. © 2014 Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:15–25)

The aim of this pilot study was to investigate the impact of the direct treatment of perfectionism on the outcome of perfectionism and eating disorder pathology. Sixty-one participants, attending day hospital treatment, participated in a randomised controlled study, in which treatment as usual (TAU) was compared with TAU combined with a clinician-lead cognitive behavioural treatment for perfectionism (TAU+P). Linear mixed model analysis revealed no significant interaction effects but significant main effects for time on variables measuring eating pathology and perfectionism. Outcomes supported the effectiveness of overall treatment but suggested that adding direct treatment of perfectionism did not enhance treatment. The results are discussed in relation to the existing literature on the treatment of perfectionism.

Objective: The nature and extent of stigma toward individuals with anorexia nervosa and muscle dysmorphia remains underexplored. This study investigated attitudes and beliefs likely to be conducive to stigmatization of individuals with these conditions. Method: Male and female undergraduate students (n 5 361) read one of four vignettes describing a fictional male or female character with anorexia nervosa or muscle dysmorphia, after which they responded to a series of questions addressing potentially stigmatizing attitudes and beliefs toward each character. Results: Characters with anorexia nervosa were more stigmatized than characters with muscle dysmorphia, female characters were more stigmatized than male characters, and male participants were more stigmatizing than female participants. A large effect of character diagnosis on masculinity was observed, such that characters with anorexia nervosa were perceived as less masculine than characters with muscle dysmorphia, and this effect was more pronounced among male participants. However, no significant corresponding effects were observed for femininity. Discussion: Females with anorexia nervosa may be particularly susceptible to stigmatization, especially by males. Anorexia nervosa and muscle dysmorphia are perceived as “female” and “male” disorders respectively, in line with societal gender role expectations, and this stigmatization is tied more strongly to perceptions of sufferers’ masculinity than

Objective: The aim of this study was to investigate the strength and role of therapeutic alliance in a trial comparing Cognitive Behavioral Therapy for anorexia nervosa (CBT-AN) and Specialist Supportive Clinical Management for the treatment of severe and enduring AN (SE-AN). Method: Participants were 63 adult females with SE-AN presenting to an outpatient, multisite randomized controlled trial conducted at two clinical sites. Participants completed measures assessing their perception of the quality of the therapeutic relationship, eating disorder (ED) symptomatology, and depressive symptomatology. Results: Beyond the effect of early treatment change and treatment assignment, early therapeutic alliance was a significant predictor of Restraint and Shape Concern at follow-up (ps < .02). Late therapeutic alliance was a significant predictor of weight change, depressive symptomatology, and ED symptomatology at end of treatment and follow-up (ps < .008), with the exception of Shape Concern at follow-up (p = .07). Discussion: The results suggest that therapeutic alliance can be effectively established in the treatment of SE-AN and may be relevant for treatment response, particularly in late treatment, on some aspects of ED and depressive symptomatology..

Aim Muscle dysmorphia is a psychiatric disorder that has been conceptually linked to eating disorders, although its precise nosology remains unclear. To further investigate this notion, the present study examined the applicability of the transdiagnostic model of eating disorders to muscle dysmorphia. Method One hundred and nineteen male undergraduate students completed self-report measures of multidimensional perfectionism, mood intolerance, self-esteem, interpersonal problems, and muscle dysmorphia symptomatology. Results Self-oriented perfectionism, socially prescribed perfectionism, mood intolerance, and low self-esteem significantly predicted muscle dysmorphia symptomatology, whereas other-oriented perfectionism and interpersonal problems did not demonstrate significant predictive value when accounting for the other transdiagnostic constructs. Discussion The transdiagnostic model of eating disorders may potentially be applied to enhance our understanding of the maintenance of muscle dysmorphic features in addition to eating disorder symptomatology. Copyright © 2012 John Wiley & Sons, Ltd and Eating Disorders Association.

Aim: To investigate and compare the level of nutrition knowledge of health professionals, patients with eating disorders and individuals without an eating disorder as controls. Methods: Participants were recruited online through an Australian and New Zealand professional eating disorder organisation and community eating disorder organisations and a university in Australia. Assessment was conducted online using the General Nutrition Knowledge Questionnaire and SCOFF. Demographic data were also collected. Results: Dietitians had greater nutrition knowledge than all other health professionals, except medical doctors. Psychologists and dietitians had similar knowledge for choosing everyday foods. Dietitians had greater nutrition knowledge than eating disorder patients and controls in all areas of nutrition knowledge, while other health professionals had similar knowledge to patients. Patients with eating disorders had greater knowledge of sources of nutrients than controls. Conclusions: Australian health professionals exhibited higher levels of nutrition knowledge than health professionals in previous studies in other countries. However, non-dietitian health professionals had similar levels of knowledge to individuals with eating disorders. Training and continuing education in nutrition is needed so health professionals can confidently identify when a patient has misleading information about nutrition and either correct the misinformation or refer the patient on to a qualified dietitian.

Objective: To develop and evaluate an instrument to assess severity in anorexia nervosa (AN), the Clinician Administered Staging Instrument for Anorexia Nervosa (CASIAN). Method: Candidate items for the CASIAN were developed in three phases (domain, content, and item generation) followed by a pilot study. The psychometric properties of the resultant 34-item questionnaire were investigated in cross-sectional and longitudinal samples (N = 171) with DSM-IV AN and subthreshold AN. Results: Item and factor analysis procedures resulted in a refined 23-item CASIAN comprising of six factors (“Motivation,” “Weight,” “Illness Duration,” “Obsessionality,” “Bulimic Behaviors,” and “Acute Issues”). The CASIAN had high internal consistency (.811), test–retest (.957), and interrater reliability (.973). Preliminary support for the convergent, discriminant, concurrent, and predictive validity of the CASIAN was found. Discussion: The CASIAN is a psychometrically sound instrument. Further studies are needed to confirm the factor structure and assess its clinical and research utility. © 2011 by Wiley Periodicals, Inc. (Int J Eat Disord 2012)

Objective The Compulsive Exercise Test (CET) was developed to assess the primary factors operating in the maintenance of excessive exercise. Methods A total of 367 young female exercisers were recruited from University campuses. Across three separate studies, the participants completed either the CET alone, or the CET and other standard self-report measures of excessive exercise and eating psychopathology. Results Factor analyses yielded five factors from which a final 24-item, five subscale measure was constructed. The CET demonstrated high internal consistency across the three samples. Supporting the concurrent and convergent validity of the scale, the CET correlated in the expected direction with existing measures of excessive exercise and eating pathology. As expected, the CET explained greater variance in eating pathology than existing measures of excessive exercise. Discussion The resulting subscales of the CET are consistent with a cognitive-behavioural maintenance model of excessive exercise and support the multidimensionality of the excessive exercise construct. Further research is required to validate the instrument within a sample of eating disordered women. Copyright © 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

There is a dearth of literature evaluating day patient treatment for eating disorders based upon the targeted goals of treatment, to conclude that day patient programmes are effective. This study aimed to explore the effectiveness of an innovative day patient programme by examining whether the seven key treatment goals improved across treatment and were maintained 3 months after discharge. Of the 58 participants who completed measures assessing BMI, eating disorder cognitions, behaviours, core beliefs, readiness to change, quality of life and perpetuating factors at admission, discharge and follow-up, 44 completed the day programme with 14 non-completers. The results demonstrated that all seven treatment goals improved across treatment and the improvements were maintained or further improved at 3 month follow-up. The results are discussed in context of the published day patient programme literature with implications for future research to maximise optimal treatment outcomes from day patient treatment. Copyright © 2010 John Wiley & Sons, Ltd and Eating Disorders Association.

Difficulties in fostering eating disorder (ED) patients' motivations to overcome their illness are widely considered to be a major hurdle in the course of successful treatment. However, no previous study has assessed the use of interventions specifically designed to target poor motivation amongst patients with illnesses that are severe enough to warrant hospitalisation. Objective A brief Motivational Enhancement Therapy (MET) group programme for inpatient ED sufferers was developed and evaluated. Method Forty two consecutive inpatients were sequentially allocated to treatment groups. Twenty three inpatients completed a four session MET group programme in addition to routine hospital care. A control group of 19 participants completed treatment as usual (TAU). Results Despite an absence of significant differences between the MET and the TAU groups on the overall formal outcome measures, there were nevertheless differences between the groups. Specifically, the MET groups appeared to foster longer term motivation and engagement, and to promote treatment continuation. Conclusion The results tentatively suggest that MET could be valuable for the treatment of inpatient eating disorder patients and further research is warranted. Copyright © 2007 John Wiley & Sons, Ltd and Eating Disorders Association.

Objective To investigate body image disturbance in young women with and without an eating disorder (ED) across two different ethnic groups in Australia and Singapore. Method The relationship of body image disturbance to cultural orientation and socio-cultural factors was analysed in 154 women with and without an ED. Participants were from the following backgrounds: North European Australian, East Asian Australian, Singaporean Chinese (SC) and North European expatriates in Singapore. Results Irrespective of cultural group, women with an ED had similar body dissatisfaction. Among those without an ED, SC women reported greater body dissatisfaction than all other cultural groups. Finally, within each cultural group, ED participants reported significantly higher body dissatisfaction than their non-ED counterparts with the exception of SC women where there was no difference. Discussion Socio-cultural factors other than body image may play more important roles in SC women's ED psychopathology. Copyright © 2007 John Wiley & Sons, Ltd and Eating Disorders Association.

Self-esteem has been hypothesised to play a pivotal role in the development and treatment, and outcome of anorexia nervosa (AN). Though this relationship is typically investigated by considering self-esteem as a unitary construct, research suggests that this comprises of two related but distinct components of self-liking and self-competence. This study investigates the association between self-liking, self-competence, and symptomatology of AN through the course of a defined treatment episode in 77 women. Self-liking was significantly associated with laxative abuse. Self-competence was significantly associated with elevated ineffectiveness, perfectionism and interpersonal distrust. Although self-competence and eating disturbance severity significantly improved over the treatment episode, one in three participants reported a reduced self-like or self-competence. Changes in both self-competence and self-liking at the end of treatment was associated with changes in drive for thinness. Such findings have implications for treatment models concerned with improving self-esteem.

Background: Anorexia nervosa is a disorder with high morbidity and significant mortality. It is most common in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting, and a number of differing psychological therapies are presently used in treatment. This is an update of a Cochrane review which was last published in 2008. Objectives: To assess the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents treated in an outpatient setting. Search methods: We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) (16 July 2014). This register includes relevant randomised controlled trials from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We screened reference lists of all included studies and sent letters to identified, notable researchers requesting information on unpublished or ongoing studies. Selection criteria: All randomised controlled trials of one or more individual outpatient psychological therapies for adults with anorexia nervosa, as defined by DSM-5 or similar international criteria. Data collection and analysis: We selected a range of outcome variables, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons used the mean or standardised mean difference (MD or SMD), and binary outcome comparisons used the risk ratio (RR). Two review authors (PH and AC or ST) extracted data independently. Main results: We identified 10 trials from the search, with a total of 599 anorexia nervosa participants, and included them in the review. Seven had been identified in the previous versions of this review and we now include three new trials. We now deem one previously identified ongoing trial to be ineligible, and six ongoing trials are new for this update. Two of the 10 trials included children. Trials tested diverse psychological therapies and comparability was poor. Risks of bias were mostly evident through lack of blinded outcome assessments (in 60% of studies) and incomplete data reporting (attrition bias). The results suggest that treatment as usual (TAU) when delivered by a non-eating-disorder specialist or similar may be less efficacious than focal psychodynamic therapy. This was suggested for a primary outcome of recovery by achievement of a good or intermediate outcome on the Morgan and Russell Scale (RR 0.70, 95% confidence interval (CI) 0.51 to 0.97; 1 RCT, 40 participants; very low-quality evidence). However there were no differences between cognitive analytic therapy and TAU for this outcome (RR 0.78, 95% CI 0.61 to 1.00; 2 RCTs, 71 participants; very low-quality evidence), nor for body mass index (BMI). There were no differences in overall dropout rates between individual psychological therapies and TAU. Two trials found a non-specific specialist therapy (Specialist Supportive Clinical Management) or an Optimised TAU delivered by therapists with eating disorder expertise was similar in outcomes to cognitive behaviour therapy (BMIMD-0.00, 95% CI -0.91 to 0.91; 197 participants, low-quality evidence). When comparing individual psychological therapies with each other, no specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non-completion rate in one trial (35 participants). None of the trials identified any adverse effects. Insufficient power was problematic for the majority of trials. Authors' conclusions: There was a suggestion in one trial that focal psychodynamic therapy might be superior to TAU, but this is in the context of TAU performing poorly. An alternative control condition of dietary advice alone appeared to be unacceptable, but again this is based on just one trial. Owing to the risk of bias and limitations of studies, notably small sample sizes, we can draw no specific conclusions about the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents. Larger RCTs of longer treatment duration and follow-up are needed.

Objective To investigate the factorial structure of motivation to change anorexic symptomatology. Method One hundred and fifteen inpatients with anorexia nervosa completed the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) at the time of admission. Results Factor analysis yielded three factors: the Weight Gain factor was comprised of items pertaining to readiness to gain weight; the Eating, Shape and Weight Concerns factor was made up of items referring to the cognitive, affective and behavioural aspects of eating and body image; and the Ego-Alien Aspects factor was comprised of items which are subjectively distressing. In addition, the results supported the existence of a higher-order factor of general motivation to recover. Discussion The three-factor solution indicates a somewhat more complex factorial structure of motivation to change in anorexia nervosa than has been previously theorised and generally corresponds to symptoms that are experienced as egosyntonic, ambivalent or distressing. Nevertheless, motivational level was generally low across each of the factors, suggesting that high levels of motivation to change may not even characterise those symptoms regarded by clinicians as subjectively aversive. Copyright © 2006 John Wiley & Sons, Ltd and Eating Disorders Association.

Objective To critically review the literature examining the impact of acculturation, socio-economic status, family functioning and psychological control in relation to eating and body image disturbances across cultures. Method A review of the literature on eating disorders, eating and body image disturbances, psychological control, body composition, socio-economic status and family functioning on different cultural groups. Results Of the empirical studies undertaken, few investigated a cultural group's eating pathology in both its country of origin and a Western country using the same methodology. To date, the research findings are mixed and it is still unclear if the presentation of an eating disorder differs across cultures. Acculturation has not been consistently taken into consideration and psychological control has not been examined in relation to eating disturbances in non-Western groups. Discussion This review focuses on some of the methodological limitations of previous research and attempts to delineate the salient issues which warrant further scientific enquiry. Copyright © 2006 John Wiley & Sons, Ltd and Eating Disorders Association.

Objective: This study investigated males' and females' judgments of the actual size of thin female celebrities and their attitudes toward size for a female, depending on their current body satisfaction or body dissatisfaction. Method: In this study, 118 undergraduate Sydney University students (64 female, 54 male) were separated into body-satisfied and body-dissatisfied groups as a result of their scores on the Body Esteem Scale. Participants were presented with one accurate and six distorted photographs of five thin female celebrities, making the celebrity appear thinner or heavier than actuality. Participants chose what image they thought was the actual size of each female celebrity and which they thought was the ideal size for a female. Results: Body-dissatisfied individuals judged the actual size of thin female celebrities thinner than actuality and chose an ideal size that was thinner than the celebrity's real size. Body-satisfied individuals were accurate in their judgments of the actual size of female celebrities and chose ideals that were larger than the celebrity's real size. Conclusion: Misperceptions of media images appear to result from prior body dissatisfaction. Importantly, body-dissatisfied males misperceive female bodies and view a thin body size as ideal for females, implicating the need to target both body-dissatisfied males and females in future interventions. © 2006 by Wiley Periodicals, Inc. Int J Eat Disord 2006

Objective The clinical effectiveness of group and individual cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) was compared. Method Sixty BN patients from hospitals and general practitioners in Sydney, Australia, were allocated randomly to group or individual CBT. Forty-four completed treatment (n = 22 in group CBT and n = 22 in individual CBT). Patients were assessed at pretreatment, posttreatment, and at 3 and 6 months follow-up with the Eating Disorder Examination-12 and self-report questionnaires examining weight and shape attitudes (Eating Disorder Inventory-2), social adjustment (Socail Adjustment Scale-Modified), self-esteem (Rosenberg Self-Esteem Scale), and general psychopathology (Symptom Checklist 90R). Results The effects of group and individual CBT were equivalent on most measures. However, a significantly greater proportion of individual CBT patients than group CBT patients were abstinent from bulimic behaviors at posttreatment, but not at follow-up. Discussion This has implications for the delivery of cost-effective and clinically effective treatment for BN. © 2003 by Wiley Periodicals, Inc. Int J Eat Disord 33: 241–254, 2003.

Objective The Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) was developed to assess patients' readiness to recover from anorexia nervosa. In this article we present additional findings supporting the psychometric properties of the ANSOCQ. Method Forty-four inpatients with anorexia nervosa participated in the study. At the time of admission, patients were requested to complete the ANSOCQ as well as several other self-report questionnaires assessing constructs related to readiness to change. Results The ANSOCQ demonstrated good construct-related validity in that significant correlations emerged between the ANSOCQ and instruments assessing the theoretically related constructs of decisional balance and self-efficacy. Discussion Having developed a reliable and valid self-report questionnaire for the assessment of readiness to change in anorexia nervosa, the ANSOCQ provides a means of addressing motivational hypotheses which have been advanced in the context of eating disorders. © 2002 by Wiley Periodicals, Inc. Int J Eat Disord 32: 24–38, 2002.

Objective To critically examine two assumptions guiding cross-cultural research on the weight concerns of anorexia nervosa: (1) that weight concerns are specific to contemporary, Western manifestations of the disorder and (2) that the dissemination of Western values regarding thinness is primarily responsible for the development of anorexia nervosa in non-Western contexts. Method A review of theoretical and empirical literature on cross-cultural aspects of anorexia nervosa and the medical records of 14 Asian patients treated for eating disorders in Sydney, Australia. Results and Discussion Regarding the first assumption: It is argued that weight concerns when defined as weight loss that is positively valued (rather than a fat phobia) is a defininig characteristic of anorexia nervosa and is not limited to contemporary, Western cases of the disorder. Regarding the second assumption: It is argued that the occurrence of anorexia nervosa in non-Western contexts cannot be solely attributed to the acceptance of Western thinness ideals because values and practices intrinsic to non-Western cultures are also likely to be etiologically relevant. © 2001 by John Wiley & Sons, Inc. Int J Eat Disord 29: 205-215, 2001.

Objective The present study investigated the relationship between the level of perceived Expressed Emotion (EE) of the siblings and parents of patients hospitalized with anorexia nervosa and its effect on weight gain and psychological functioning. Method The Level of Expressed Emotion (LEE) Scale was administered on admission to 19 patients with anorexia nervosa who completed the LEE three times so as to identify their perceptions of their relationship with their closest age sibling, mother, and father. They were also required to complete the Eating Disorder Inventory 2 (EDI-2). Patients' closest age sibling completed the Family Attitude Scale (FAS). The patients' body mass index (BMI) was calculated 6 weeks later, and the EDI-2 readministered. Results Perceived EE was not predictive of BMI change after 6 weeks of hospitalization. A composite perceived family EE score was a significant predictor of change on the Interpersonal Distrust, Maturity Fears, and Perfectionism subscales of the EDI-2. Discussion These findings suggest that patients' perceptions of their relationships with their closest aged sibling, mother, and father are poor predictors of weight gain and improvement in psychological functioning following 6 weeks of inpatient treatment. © 2000 by John Wiley & Sons, Inc. Int J Eat Disord 27: 288–296, 2000.

Objective The deliberate restriction of fluids to control weight is even more dangerous than food restriction since it results in several serious medical complications. However, there has been scant attention given to the anorexia nervosa patient's manipulation of fluids. It is our clinical impression that fluid restriction in this illness is more common than previously thought. Method We summarize the demographic and clinical features of six cases of anorexia nervosa and one case of eating disorder not otherwise specified (ED-NOS) (subthreshold anorexia nervosa), where fluid restriction was a major behavioral problem. We then decribe two of the anorexia nervosa cases in more detail. All were treated at a dieting disorders unit affiliated with the University of Sydney. Their preadmission history, psychological and physical status on admission, results of physical investigations, the beginning of the fluid restriction, fluid and food intake throughout treatment, and the resolution of the fluid restriction were assessed. Results Patterns emerged in the relationship between eating and drinking. In all cases, food restriction was severe prior to the onset of fluid restriction but, notably, fluid intake recommenced prior to food intake. The reasons given by patients for restricting fluid were that it contained calories and that it made them feel full. Most anorexic patients equate feeling full with “feeling fat.” Furthermore, they feel fully in control when they restrict fluid as well as food and this produces a strong motivation to maintain the behavior. Discussion The cases illustrate the insidious nature and serious consequences of fluid restriction and the difficulties managing dieting-disordered patients who undertake it. Careful attention must be given to assessment and clinicians should be aware of fluid restriction as an important aspect of anorexic behavior. © 1999 by John Wiley & Sons, Inc. Int J Eat Disord 26: 392–396, 1999.

Objective In order to ascertain the most appropriate measure of self-esteem for dieting disordered patients, this study contrasted the construct and convergent validities of two widely used measures. In addition, dieting disordered subgroups were compared on levels of self-esteem. Method One hundred and seventeen male and female patients diagnosed with anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified completed the Rosenberg Self-Esteem Scale (SES), the Coopersmith Self-Esteem Inventory (SEI), and measures of dieting disorder pathology and depression. Results No significant differences among the three dieting disorder subgroups were found. In determining convergent validity, regression analyses indicated that the SES was a significant predictor of dieting disorder psychopathology whereas the SEI was not. Of the two self-esteem measures, only the SES showed evidence of convergent validity. Discussion The results suggest that the SES has sounder construct and convergent validity than the SEI. Hence, the SES may be more appropriate for use with dieting disordered populations. © 1999 by John Wiley & Sons, Inc. Int J Eat Disord 25: 227–231, 1999.

Objective This study investigated non-binge eating behavior in bulimia nervosa, restrained and unrestrained eaters. Method: Nine females with bulimia nervosa, 12 female restrained eaters, and 13 female unrestrained eaters were administered the Eating Disorder Inventory-2 (EDI-2), the Body Shape Questionnaire, the Beck Depression Inventory, the Rosenberg Self-Esteem Scale, and the Revised Restraint Scale (RRS). All subjects were videotaped during a midday meal and their eating behavior was subsequently rated using the Eating Behaviour Rating Scale (EBRS). Results: EBRS ratings were higher for bulimic than for unrestrained subjects. Restrained subjects' ratings did not differ from those of either bulimic or unrestrained subjects. EBRS scores were positively correlated with RRS and EDI-2 total scores. Conclusions: Bulimic subjects display aberrant eating behavior, and the extent to which subjects engage in maladaptive eating behavior is related to the degree of eating pathology. These results support the utility of the EBRS as a useful index of eating behaviors in clinical and nonclinical populations. © 1998 by John Wiley & Sons, Inc. Int J Eat Disord 24: 185–192, 1998.

Objective The present study investigates the relationship between hazardous alcohol consumption and bulimia nervosa in a clinical population. Method: The Alcohol Use Disorders Identification Test (AUDIT) was administered to two groups of female subjects: patients with bulimia nervosa (n = 30) and nonbulimic controls (n = 15). These two groups were further subdivided on the basis of personality disorder as assessed by the Personality Disorder Examination (PDE), a comprehensive interview covering all of the criteria for the 13 DSM-III-R Axis II disorders. The bulimic patients were referred to a dieting disorders clinic affiliated with the University of Sydney. All met DSM-III-R criteria for bulimia nervosa and all had Body Mass Indices (BMIs) greater than 19. The nonbulimic control group were recruited from an undergraduate psychology course. All subjects were given the Bulimic Investigatory Test, Edinburgh (BITE) and the Eating Disorders Inventory-2 (EDI-2). Results: 66.7% (8/12) of personality disordered bulimic patients were drinking at hazardous levels whereas 61.1% (11/18) of bulimic patients without a personality disorder were doing likewise. Furthermore, 35.7% (5/14) of the nonbulimic controls without personality disorders were drinking at hazardous levels and the only control subject with a personality disorder was doing likewise. The association between personality disorder diagnosis and hazardous alcohol use in the bulimic sample just failed to reach significance at the 5% level (χ21,upper .05 = 3.84, p = .052). No association between Axis 1 diagnosis of bulimia nervosa and hazardous alcohol use was found (χ21,upper .05 = 3.84, p = .52). Discussion: The results of the present study suggest we may need to rethink the relationship between hazardous alcohol use and bulimia nervosa reported in the literature, as it may be an artifact of the relationship between personality disorder and hazardous alcohol consumption. Further research is necessary to clarify this issue. © 1998 John Wiley & Sons, Inc. Int J Eat Disord 24:95–99, 1998.

Objective Few studies have investigated perceptions of operant conditioning programs by anorexic patients. This study examined patients' perceptions of the Bed Rest (BR) component which is employed in some operant conditioning programs. Methods: A sample of 48 anorexic inpatients was administered a survey to elicit their attitudes towards BR. Results: Results from the survey suggested that most patients perceived BR in a negative way. The main complaint, however, was not punishment or humiliation, as predicted, but isolation and boredom. A number of patients concluded that they wanted more individualization and distraction and less restriction while on BR. Discussion: The findings justify the use of BR within a humane framework in the inpatient treatment of anorexia nervosa, but suggest that patients' perceptions of BR warrant systematic scrutiny. © 1998 John Wiley & Sons, Inc. Int J Eat Disord 23: 443–447, 1998.

Objective To investigate attentional biases for body shape and weight-related stimulus words among subjects with anorexia nervosa, bulimia nervosa, and control subjects classified using a measure of dietary restraint. Methods: A visual probe detection task was used to assess attention toward stimulus words reflecting either a thin or a large physique and positively or negatively valenced emotion words. Results: In comparison to controls, subjects with eating disorders detected target probes more slowly when they appeared in the same location as had stimulus words connoting a thin physique. In addition, there was a trend toward faster detection or target probes that appeared in the same location as had stimulus words connoting a large physique. Neither of these effects were observed among restrained eaters. Discussion: Our results extend prior work suggesting information-processing biases for body shape and weight-related stimuli among persons with eating disorders. © 1998 by John Wiley & Sons, Inc. Int J Eat Disord 23: 199–205, 1998.

Objective The present study was conducted to extend prior research on attention toward food and body weight and shape-related stimuli in women with eating disorders. Method: A modified Stroop color-naming task was completed by women with anorexia nervosa and by control females subdivided on a measure of dietary restraint. Eating disorder-relevant word categories included words connoting fatness, words connoting thinness, low caloric density food words, high caloric density food words, and neutral, control words. Valence effects were controlled for by including positively and negatively valenced emotion words. Stimuli were presented under both unmasked and masked conditions. Results: Using unmasked stimuli, patients with anorexia nervosa, but not unrestrained or restrained eaters, had delayed color-naming latencies for both thin and fat word categories and, to a lesser extent, for high caloric density food words. No differences were observed with masked stimuli. Discussion: Our findings suggest that both thinness and fatness are especially salient to women with anorexia. The lack of effects for emotion words suggests that these findings do not reflect a valence effect. We found no evidence for preconscious attentional biases in the masked condition. © 1998 by John Wiley & Sons, Inc. Int J Eat Disord 23: 77–82, 1998.