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There is a paucity of validated diagnostic interviews for avoidant/restrictive food intake disorder (ARFID) to aid identification and classification of cases for both clinical and research purposes. To evaluate the factor structure, construct validity, and criterion validity of the Pica ARFID and Rumination Disorder Interview (PARDI; ARFID module), we administered the PARDI to 129 children and adolescents ages 9-23 years (M = 16.1) with ARFID (n = 84), subclinical ARFID (n = 11), and healthy controls (n = 34).We used exploratory factor analysis to examine the factor structure of the PARDI in children, adolescents, and young adults with an ARFID diagnosis, the Kruskal-Wallis analysis of variance and Spearman correlations to test the construct validity of the measure, and non-parametric receiver operating characteristic curves to evaluate the criterion validity of the PARDI.Exploratory factor analysis yielded a 3-factor structure: (1) concern about aversive consequences of eating, (2) low appetite/low interest in food, and (3) sensory sensitivity. Participants with ARFID demonstrated significantly higher levels of sensory sensitivity, low appetite/low-food interest, and concern about aversive consequences of eating symptoms relative to control participants. The construct validity for each PARDI subscale was supported and clinical cutoffs for the low appetite/low interest in food (1.1) and sensory sensitivity subscales (0.6) were established.These data present evidence for the factor structure and validity of the PARDI diagnostic interview for diagnosing ARFID in children, adolescents, and young adults, supporting the use of this tool to facilitate ARFID clinical assessment and research.Due to the paucity of validated diagnostic interviews for avoidant/restrictive food intake disorder (ARFID), we evaluated the factor structure and validity of the Pica ARFID and Rumination Disorder Interview (ARFID module). Findings suggest that the interview assesses 3 components of ARFID: concern about aversive consequences of eating, low-appetite, and sensory sensitivity, and that clinical threshold scores on the latter two subscales can be used to advance ARFID assessment.

Research comparing psychiatric comorbidities between individuals with avoidant/restrictive food intake disorder (ARFID) and anorexia nervosa (AN) is limited. ARFID often develops in childhood, whereas AN typically develops in adolescence or young adulthood. Understanding how age may impact differential psychological comorbidity profiles is important to inform etiological conceptualization, differential diagnosis, and treatment planning. We aimed to compare the lifetime frequency of psychiatric comorbidities and suicidality between females with ARFID (n = 51) and AN (n = 40), investigating the role of age as a covariate.We used structured interviews to assess the comparative frequency of psychiatric comorbidities/suicidality.When age was omitted from analyses, females with ARFID had a lower frequency of depressive disorders and suicidality compared to AN. Adjusting for age, only suicidality differed between groups.This is the first study to compare comorbidities in a similar number of individuals with ARFID and AN, and a structured clinical interview to confer ARFID and comorbidities, covarying for age, and the first to compare suicidality. Although suicidality is at least three times less common in ARFID than AN, observed differences in other psychiatric comorbidities may reflect ARFID's relatively younger age of presentation compared to AN.Our results highlight that, with the exception of suicidality, which was three times less common in ARFID than AN irrespective of age, observed differences in psychiatric comorbidities in clinical practice may reflect ARFID's younger age at clinical presentation compared to AN.

Cardiac MyBP-C (cMyBP-C) interacts with actin-myosin to fine-tune cardiac muscle contractility. Phosphorylation of cMyBP-C, which reduces binding of cMyBP-C to actin or myosin, is often decreased in heart failure (HF) patients, and is cardioprotective in model systems for HF. Therefore, cMyBP-C is a potential target for HF drugs that mimic phosphorylation and/or perturb its interactions with actin or myosin. We labeled actin with fluorescein-5-maleimide (FMAL), and the C0-C2 fragment of cMyBP-C (cC0-C2) with tetramethyl rhodamine (TMR). We performed two complementary high-throughput screens (HTS) on an FDA-approved drug library, to discover small molecules that specifically bind to cMyBP-C and affect its interactions with actin or myosin, using fluorescence lifetime (FLT) detection. We first excited FMAL and detected its FLT, to measure changes in fluorescence resonance energy transfer (FRET) from FMAL (donor) to TMR (acceptor), indicating binding and/or structural changes in the protein complex. Using the same samples, we then excited TMR directly, using a longer wavelength laser, to detect the effects of compounds on the environmentally sensitive FLT of TMR, to identify compounds that bind directly to cC0-C2. Secondary assays, performed on selected modulators with the most promising effects in the primary HTS assays, characterized specificity of these compounds for phosphorylated versus unphosphorylated cC0-C2 and for cC0-C2 versus C1-C2 of fast skeletal muscle (fskC1-C2). A subset of identified compounds modulated ATPase activity in cardiac and/or skeletal myofibrils. These assays establish feasibility for discovery of small-molecule modulators of the cMyBP-C-actin/myosin interaction, with the ultimate goal of developing therapies for HF.

Background Anorexia nervosa (AN) is associated with structural brain abnormalities. Studies have reported less cerebral tissue and more cerebrospinal fluid (CSF) in individuals with AN relative to healthy controls, although findings are variable and inconsistent due to variations in sample size, age, and disease state (e.g., active AN, weight-recovered AN). Further, it remains unclear if structural brain abnormalities observed in AN are a consequence of specific brain pathologies or malnutrition, as very few longitudinal neuroimaging studies in AN have been completed. Methods To overcome this issue, this comprehensive meta-analysis will combine region-of-interest (ROI) and voxel-based morphometry (VBM) approaches to understand how regional and global structural brain abnormalities differ among individuals with AN and healthy controls (HCs). Additionally, we aim to understand how clinical characteristics and physiological changes during the course of illness, including acute illness vs. weight recovery, may moderate these structural abnormalities. We will create an online database of studies that have investigated structural brain abnormalities in AN. Data will be reviewed independently by two members of our team using MEDLINE databases, Web of Science, PsycINFO, EMBASE, and CINAHL. We will conduct ROI and VBM meta-analysis using seed-based d mapping in AN and HCs. We will include all studies that include structural neuroimaging of individuals with AN (both acute and weight-recovered) and HCs between January 1997 and 2020. Discussion This systematic review will assess the effects of AN compared to HC on brain structure. Futhermore, it will explore the role of acute AN and weight-recovered AN on brain structure. Findings will help researchers and clinicians to better understand the course of illness in AN and the nature of recovery, in terms of weight, malnutrition, and the state of the brain. Systematic review registration PROSPERO CRD42020180921

Objective Little research exists on Rome IV disorders of gut-brain interaction (DGBI; formerly called functional gastrointestinal disorders) in outpatients with eating disorders (EDs). These data are particularly lacking for avoidant/restrictive food intake disorder (ARFID), which shares core features with DGBI. We aimed to identify the frequency and nature of DGBI symptoms among outpatients with EDs. Method Consecutively referred pediatric and adult patients diagnosed with an ED (n = 168, 71% female, ages 8-76 years) in our tertiary care ED program between March 2017 and July 2019 completed a modified Rome IV Questionnaire for DGBI and psychopathology measure battery. Results The majority (n = 122, 72%) of participants reported at least one bothersome gastrointestinal symptom. Sixty-six (39%) met criteria for a DBGI, most frequently functional dyspepsia-post-prandial distress syndrome subtype (31%). DGBI were surprisingly less frequent among patients with ARFID (30%) versus EDs that are associated with shape or weight concerns (45%; X2 [1] = 3.61, p = .058, Cramer's V = .147). Among those with ARFID, DGBI presence was associated with the fear of aversive consequences prototype and multiple comorbid prototype presence. Discussion We demonstrated notable overlap between DGBI and EDs, particularly post-prandial distress symptoms. Further research is needed to examine if gastrointestinal symptoms predict or are a result of greater ED pathology, including ARFID prototypes.

Rumination syndrome (RS) is often treated in medical settings with 1–2 sessions of diaphragmatic breathing to target reflexive abdominal wall contraction in response to conditioned cues (e.g., food). However, many patients remain symptomatic and require additional behavioral interventions. In an attempt to augment diaphragmatic breathing with additional interventions, we tested the proof-of-concept of a comprehensive Cognitive-Behavioral Therapy (CBT) for RS. In an uncontrolled trial, adults with RS completed a 5–8 session CBT protocol, delivered by one of two psychology behavioral health providers. CBT included two main phases: awareness training and diaphragmatic breathing (Phase 1) and modularized interventions chosen by the therapist and patient to target secondary maintenance mechanisms (Phase 2). At pre-treatment, post-treatment, and 3-month follow-up, participants completed a semi-structured interview on RS symptoms with an independent evaluator. Of 10 eligible individuals (ages 20–67 years, 50% female) offered treatment, all 10 initiated treatment and eight completed it. All participants endorsed high treatment credibility at Session 1. Permutation-based repeated measures ANOVA showed participants achieved large reductions in regurgitations across treatment [F(1,7) = 17.7, p = .007, η p 2 = .69]. Although participants reduced regurgitations with diaphragmatic breathing during Phase 1, addition of other CBT strategies in Phase 2 produced further large reductions [F(1,7) = 6.3, p = .04, η p 2 = .47]. Of eight treatment completers, treatment gains were maintained at 3-month follow-up for n = 6. Findings provide evidence of feasibility, acceptability, and proof-of-concept for a comprehensive CBT for RS that includes interventions in addition to diaphragmatic breathing to target secondary maintenance mechanisms. Randomized controlled trials are needed.

OBJECTIVE: Little is known about the optimal treatment of avoidant/restrictive food intake disorder (ARFID). The purpose of this study was to evaluate feasibility, acceptability, and proof-of-concept for cognitive-behavioral therapy for ARFID (CBT-AR) in children and adolescents. METHODS: Males and females (ages 10–17 years) were offered 20–30 sessions of CBT-AR delivered in a family-based or individual format. RESULTS: Of 25 eligible individuals, 20 initiated treatment, including 17 completers and three dropouts. Using intent-to-treat analyses, clinicians rated 17 patients (85%) as “much improved” or “very much improved.” ARFID severity scores (on the Pica, ARFID, and Rumination Disorder Interview) significantly decreased per both patient and parent report. Patients incorporated a mean of 16.7 (SD = 12.1) new foods from pre- to post-treatment. The underweight subgroup showed a significant weight gain of 11.5 (SD = 6.0) pounds, moving from the 10(th) to the 20(th) percentile for body mass index. At post-treatment, 70% of patients no longer met criteria for ARFID. CONCLUSIONS: This is the first study of an outpatient manualized psychosocial treatment for ARFID in older adolescents. Findings provide evidence of feasibility, acceptability, and proof-of-concept for CBT-AR. Randomized controlled trials are needed.

Objective\ud \ud The coronavirus pandemic has led to a dramatically different way of working for many therapists working with eating disorders, where telehealth has suddenly become the norm. However, many clinicians feel ill equipped to deliver therapy via telehealth, while adhering to evidence‐based interventions. This article draws together clinician experiences of the issues that should be attended to, and how to address them within a telehealth framework.\ud \ud \ud \ud Method\ud \ud Seventy clinical colleagues of the authors were emailed and invited to share their concerns online about how to deliver cognitive‐behavioral therapy for eating disorders (CBT‐ED) via telehealth, and how to adapt clinical practice to deal with the problems that they and others had encountered. After 96 hr, all the suggestions that had been shared by 22 clinicians were collated to provide timely advice for other clinicians.\ud \ud \ud \ud Results\ud \ud A range of themes emerged from the online discussion. A large proportion were general clinical and practical domains (patient and therapist concerns about telehealth; technical issues in implementing telehealth; changes in the environment), but there were also specific considerations and clinical recommendations about the delivery of CBT‐ED methods.\ud \ud \ud \ud Discussion\ud \ud Through interaction and sharing of ideas, clinicians across the world produced a substantial number of recommendations about how to use telehealth to work with people with eating disorders while remaining on track with evidence‐based practice. These are shared to assist clinicians over the period of changed practice.

The COVID‐19 pandemic has forced an abrupt change in the delivery of clinical services, including for individuals with an eating disorder. We present this Virtual Issue as a resource for the eating disorder community to showcase research published in the International Journal of Eating Disorders that provides information on effective strategies to help address the challenges arising from COVID‐19‐related disruptions. Articles included describe original research or systematic reviews on obstacles to health services use and strategies to improve access to care; technological tools to provide or enhance interventions; patients' and clinicians' attitudes or perspectives on using digital tools for clinical care; factors influencing therapeutic alliance; and ideas for improving reach and uptake of digital interventions. We hope that readers will find ways to observe and record their own experiences during this global crisis; the experiences of people at risk for developing or exhibiting an eating disorder; and the experiences of those who care for people with an eating disorder. These lived experiences will be invaluable in formulating hypotheses for future studies in service of advancing the understanding of eating disorders and improving interventions and policies for reducing the burden of suffering attributable to eating disorders.

ImportanceIndividuals with anorexia nervosa maintain extremely low body weights despite elevations in the circulating orexigenic hormone ghrelin. Whether circulating levels of endogenous ghrelin are associated with weight gain in anorexia nervosa is unknown.ObjectiveTo examine the association between baseline ghrelin and future weight change in individuals with anorexia nervosa.Design, Setting, and ParticipantsThis prospective cohort study was conducted between April 1, 2014, and March 31, 2020, in the US. Girls and women aged 10 to 22 years were recruited from the greater Boston area from community and area treatment centers, enrolled, and followed up for 18 months. Statistical analyses were performed between January and August 2022.ExposuresPresence or absence of anorexia nervosa and elevations in endogenous ghrelin.Main Outcomes and MeasuresChanges in age- and sex-standardized body mass index percentiles from baseline to 9- and 18-month follow-up were the main outcomes of interest.ResultsA total of 68 girls and young women (11 [16%] Asian, 4 [6%] Hispanic or Latina, 51 [75%] White [non–Hispanic or Latina], and 2 [3%] other race or ethnicity), including 35 with anorexia nervosa and 33 healthy controls of similar Tanner stage, were included in this study. Anorexia nervosa and healthy control groups were not statistically different by race and ethnicity, Tanner stage, number completing follow-up visits, and the duration between baseline and follow-up visits. At baseline, individuals with anorexia nervosa were slightly older (median [IQR], 20.1 [18.5-21.0] vs 18.7 [14.7-19.4] years; P = .005), had lower body mass index percentiles (median [IQR], 2.4 [0.3-4.7] vs 52.9 [40.4-68.3]; P P = .003) compared with healthy individuals. In linear mixed-effects regression analyses, baseline ghrelin was associated with prospective weight gain after adjusting for diagnosis, age, race, and duration of follow-up (odds ratio, 2.35; 95% CI, 1.43-3.73; P = .004).Conclusions and RelevanceIn this cohort study, endogenous ghrelin was associated with longitudinal weight gain in individuals with anorexia nervosa. Further studies are warranted to confirm this result and examine its potential clinical utility in treatment development.

Context In healthy individuals, serum levels of oxytocin, an anxiolytic hypothalamic-pituitary hormone involved in appetite regulation and response to stress, decrease post-prandially. Oxytocin response to a meal in Avoidant/Restrictive Food Intake Disorder (ARFID), a psychiatric disorder characterized by restrictive eating driven by lack of interest in food, sensory sensitivity, and/or fear of aversive consequences and associated with comorbid anxiety, is unknown. We compared the pattern of postprandial oxytocin levels in individuals with ARFID to healthy controls (HC). We hypothesized that overall oxytocin levels would be higher in ARFID vs HC as an adaptive response to stress. Methods 109 participants (55 with ARFID and 54 HC) were instructed to eat a ∼400-kcal standardized mixed meal. Serum oxytocin was sampled fasting and 30, 60, and 120 minutes post-meal. Anxiety was assessed using the trait scale of the State-Trait Anxiety Inventory (STAI). All data are presented as mean±SEM. Multivariate regression analysis was used to control for confounding variables. Results Mean age did not differ across groups (ARFID: 16.9±0.5 and HC: 17.8±0.5 years, p=0.197). Mean body mass index percentile (BMIp) was lower in ARFID compared to HC (37.3±4.9 vs 53.7±2.9, respectively, p=0.004). Sex distribution differed between groups [ARFID: 27 (50%) males, 27 (50%) females vs HC: 15 (27%) males and 40 (73%) females, p=0.019)]. Anxiety symptoms were higher in ARFID compared to HC (38.5±1.8 vs 30.3±1.0, respectively, p=0.0007). By study design, quantity of food consumed did not differ across groups (p=0.238), however, ARFID participants ate a higher % of fat than HC (22.8±0.5 vs. 21.6±0.4, p=0.027). Mean oxytocin levels were higher in ARFID compared to HC at all time points (fasting: 1487±94 vs 1268±60 pg/mL, p=0.049; 30 min: 1477±86 vs 1202±48 pg/mL, p=0.006; 60 min: 1473±89 vs 1214±52 pg/mL, p=0.015; 120 min: 1470±102 vs 1253±50 pg/mL, respectively, p=0.056), and AUC (p=0.023). While mean oxytocin decreased postprandially as expected in HC (30 min p=0.028 and 60 min p=0.072), there was no postprandial change in oxytocin levels in ARFID from fasting to any postprandial timepoint (p≥0.746). Multivariate regression analysis revealed that both ARFID group (β=41,213, η2p = 0.084, p=0.004) and BMIp (β=779, η2p = 0.129, p Conclusions This is the first study to determine the pattern of endogenous oxytocin secretion in response to a meal in a large group of individuals with ARFID. Mean oxytocin levels fasting and in response to a meal are higher in ARFID compared to HC, irrespective of sex, quantity of fat consumed, and anxiety symptoms. Unlike in healthy individuals, oxytocin levels in ARFID do not decrease in response to eating. These data suggest that dysregulated oxytocin secretion may play a role in the pathophysiology of ARFID. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

This editorial seeks to encourage the increased application of three open science practices in eating disorders research: Preregistration, Registered Reports, and the sharing of materials, data, and code. For each of these practices, we introduce updated International Journal of Eating Disorders author and reviewer guidance. Updates include the introduction of open science badges; specific instructions about how to improve transparency; and the introduction of Registered Reports of systematic or meta-analytical reviews. The editorial also seeks to encourage the study of open science practices. Open science practices pose considerable time and other resource burdens. Therefore, research is needed to help determine the value of these added burdens and to identify efficient strategies for implementing open science practices.

Avoidant/restrictive food intake disorder (ARFID) is a feeding/eating disorder introduced in the fifth edition of the DSM-5 that is characterized by inadequate volume and/or variety of food intake.1 ARFID represents an expansion of the prior DSM-IV disorder "Feeding Disorder of Early Childhood" that can be diagnosed across the lifespan.1,2DSM-5 clearly states that ARFID cannot be diagnosed in the context of significant shape/weight concerns and associated behaviors.1 However, our clinical team has observed multiple instances in which adolescent girls have presented with frank ARFID and simultaneously reported, or ultimately developed, traditional eating-disorder psychopathology. The following two cases are representative of the most common presentations of this diagnostic overlap that we have seen. We discuss possible reasons for this overlap and suggest two revisions to DSM criteria that may help in treatment planning for this unexpected comorbidity. Each patient provided written consent for her case to be included.

Objective The cognitive-behavioral therapy (CBT) model of eating disorders suggests that compensatory purging behaviors (e.g., self-induced vomiting, inappropriate laxative use) are primarily driven by binge eating. However, many individuals endorse purging in the absence of binge eating (i.e., noncompensatory purging [NCP]). Research is needed to understand why some individuals purge in the absence of objective or subjective binge-eating episodes. Method Given the importance of overvaluation of shape/weight in the CBT model, and the existing evidence linking temperamental characteristics like behavioral inhibition (i.e., the tendency to withdraw in response to threat cues) with purging in general, we tested whether behavioral inhibition moderated the relationship between overvaluation of shape/weight and NCP in a sample of individuals in a residential eating disorder treatment center (N = 143). Results Overvaluation was more strongly related to NCP in individuals with high (relative to low) levels of behavioral inhibition. Among individuals low in behavioral inhibition, overvaluation predicted engagement in NCP to a much weaker extent. Discussion For those high (relative to low) in behavioral inhibition, both emotional avoidance and overvaluation may be important targets in the treatment of NCP, particularly in the absence of binge eating.

Cognitive inflexibility and attention to detail bias represent a promising target in eating disorder (ED) treatment. While prior research has found that adults with eating disorders exhibit significant cognitive inflexibility and heightened attention to detail, less is known about these cognitive impairments among adolescents, and across EDs transdiagnostically. To address this gap, adolescent females (N = 143) from a residential ED program with anorexia nervosa, bulimia nervosa, or other specified feeding or eating disorder completed the Detail and Flexibility Questionnaire (DFlex) and measures of ED and general psychopathology. Transdiagnostically, adolescents with EDs scored higher than an archival sample of healthy control adolescents on both cognitive rigidity (p < .001; Cohen's d = 1.92) and attention to detail (p < .001; Cohen's d = 1.16). These cognitive impairments were significantly associated with severity of eating pathology, and these relationships existed independent of age, duration of illness, or body mass index (BMI). Our findings suggest cognitive inflexibility and heightened attention to detail occur transdiagnostically in adolescents with eating disorders and are unlikely to be a scar of the disorder. Future prospective research is needed to determine whether these cognitive styles represent an endophenotype of eating disorders.

Objective There is increasing public and scientific focus on women's pursuit of a muscular and toned appearance. However, the psychological correlates of women's drive for muscularity are currently unclear. Therefore, we examined the associations of drive for muscularity with four important negative psychological indices among women: eating disorder (ED) symptoms, and symptoms of depression, anxiety, and stress. Method A sample of 221 university women completed an online survey that included measures assessing the aforementioned constructs. Results Drive for muscularity evidenced positive associations with all negative psychological indices, except for anxiety. Muscularity-oriented attitudes, as opposed to behaviors, demonstrated the strongest associations with ED and depression symptoms. Discussion Our findings make a novel contribution to the scant literature by demonstrating that women who endorse attitudes and/or behaviors geared toward attaining the female muscular ideal may be susceptible to experiencing ED symptoms and negative emotional states. This study provides preliminary evidence that muscularity-oriented attitudes, in particular, may be a promising target for the treatment of EDs and negative emotional states in women with a preoccupation toward muscularity.

Background Avoidant/restrictive food intake disorder (ARFID) is characterized by restrictive eating patterns without shape or weight concerns, leading to nutritional deficits and psychosocial impairment. Three distinct phenotypes have been described that can co-occur: 1) sensory sensitivity, 2) lack of interest in eating or food, and 3) food avoidance due to fear of aversive consequences. Hyperactivation of a "defensive motive system", characterized by a neurocircuit activation of the amygdala and the hypothalamic-pituitary-adrenal (HPA) axis, could mediate fear/threat pathways in ARFID. We hypothesized that youth with ARFID would show amygdala hyperactivation in response to an ARFID-specific fear paradigm, and greater amygdala activation would be associated with higher levels of cortisol. Method76 youth with ARFID assessed using the Pica, ARFID and Rumination Disorder Interview and 27 healthy controls (HC) underwent functional MRI scanning (3T Siemens) during a novel visual fear task. Subjects viewed a series of developmentally appropriate images: ARFID-specific fear (e. g., a person vomiting or choking) and neutral (e. g., household items, geometric shapes). Serum cortisol was measured prior to the MRI in the late morning after a 2-hour fast. Amygdala activation was compared between ARFID and HC for the contrast ARFID-specific fear vs. neutral images using SPM12. For this contrast, beta values were extracted and correlated with fasting cortisol levels using Pearson's correlation coefficient. Results Groups did not differ for age, sex, or BMI z-score (ARFID mean (SD) age 16.5 (3.9) years, HC 17.8 (4. 0) years (p=0.14); ARFID 50% male, HC 42% male (p=0.66); ARFID BMI z-score -0.5 (1.7), HC 0. 0 (0.8) (p=0.15). In response to ARFID-specific fear vs. neutral images, both HC and ARFID exhibited increased activation in the bilateral amygdala (p Conclusion Using a novel fMRI paradigm, our results show that images related to ARFID-specific fears elicit robust increases in amygdala activation across ARFID and HC subjects, but no between-group differences. While higher amygdala activation was associated with higher cortisol levels in HC, this relationship was absent in ARFID, suggesting a disconnect of amygdala response and basal HPA activation to fear inducing stimuli. Future research will be important to improve our understanding of endocrine modulation of the fear response and relationship to restrictive eating in ARFID. Presentation: No date and time listed

There are currently no evidence-based treatments for adults with avoidant/restrictive food intake disorder (ARFID). The purpose of this study was to evaluate the acceptability, feasibility, and proof-of-concept of cognitive-behavioral therapy for ARFID (CBT-AR) for adults. Males and females (ages 18-55 years) were offered 20-30 outpatient sessions of CBT-AR delivered by one of five therapists. Of 18 eligible adults offered CBT-AR, 15 chose to participate and 14 completed treatment. All patients endorsed high ratings of treatment credibility and expected improvement after the first session, and 93% of completers provided high ratings of satisfaction at the conclusion of treatment. Therapists rated the majority (80%) of patients as "much improved" or "very much improved." Based on intent-to-treat analyses, ARFID severity on the Pica, ARFID, and Rumination Disorder Interview (PARDI) showed a large and significant decrease from pre- to post-treatment; and patients incorporated a mean of 18.0 novel foods. The underweight subgroup (n = 4) gained an average of 11.38 pounds, showing a large and significant increase in mean BMI from the underweight to the normal-weight range. At post-treatment, 47% of patients no longer met criteria for ARFID. To our knowledge, this is the first prospective treatment study of ARFID in adults. The findings of this study provide preliminary evidence of feasibility, acceptability, and proof-of-concept of CBT-AR for heterogeneous presentations of ARFID in adults. Randomized controlled trials are needed to confirm these findings. ClinicalTrials.gov Identifier: NCT02963220.

Objective The Nine Item Avoidant/Restrictive Food Intake Disorder (ARFID) Screen (NIAS) has three subscales aligned with ARFID presentations but clinically validated cutoff scores have not been identified. We aimed to examine NIAS subscale (picky eating, appetite, fear) validity to: (1) capture clinically-diagnosed ARFID presentations; (2) differentiate ARFID from other eating disorders (other-ED); and (3) capture ARFID symptoms among individuals with ARFID, individuals with other-ED, and nonclinical participants. Method Participants included outpatients (ages 10-76 years; 75% female) diagnosed with ARFID (n = 49) or other-ED (n = 77), and nonclinical participants (ages 22-68 years; 38% female, n = 40). We evaluated criterion-related concurrent validity by conducting receiver operating curve (ROC) analyses to identify potential subscale cutoffs and by testing if cutoffs could capture ARFID with and without use of the Eating Disorder Examination-Questionnaire (EDE-Q). Results Each NIAS subscale had high AUC for capturing those who fit versus do not fit each ARFID presentation, resulting in proposed cutoffs of ≥10 (sensitivity = .97, specificity = .63), ≥9 (sensitivity = .86, specificity = .70), and ≥ 10 (sensitivity = .68, specificity = .89) on the NIAS-picky eating, NIAS-appetite, and NIAS-fear subscales, respectively. ARFID versus other-ED had high AUC on the NIAS-picky eating (≥10 proposed cutoff), but not NIAS-appetite or NIAS-fear subscales. NIAS subscale cutoffs had a high association with ARFID diagnosis, but only correctly classified other-ED in combination with EDE-Q Global Discussion To screen for ARFID, we recommend using a screening tool for other-ED (e.g., EDE-Q) in combination with a positive score on any NIAS subscale (i.e., ≥10, ≥9, and/or ≥10 on the NIAS-picky eating, NIAS-appetite, and NIAS-fear subscales, respectively).

This editorial reports on an anonymous survey question posed to eating disorders researchers about changes the International Journal of Eating Disorders (IJED) should implement to support the eating disorders research community affected by COVID‐19. The editorial accompanies an IJED article that details responses to the larger survey focusing more broadly on COVID‐19‐related research disruptions. Survey invitations were sent to editorial board members of eating disorders journals, members of eating disorder scientific organizations (e.g., Eating Disorders Research Society), and individuals who provided at least three IJED reviews in the prior 12 months. We reviewed the responses of 187 participants and identified three categories of changes that: (a) had already been implemented by the journal, (b) cannot be implemented because they fall outside the scope of IJED, or (c) will be implemented in coming weeks or months. The latter category includes publishing topical COVID‐19 papers, making some COVID‐19‐related content available open access, revising statistical guidelines, and issuing author guidance on reporting protocol changes caused by COVID‐19‐related disruptions. IJED recognizes the disruptive impacts that COVID‐19 has on all activities in our field, including clinical work, teaching, and advocacy, and is committed to supporting authors during this difficult time while striving to publish high‐quality research.

Rumination syndrome (RS) is characterized by the repeated regurgitation of material during or soon after eating with the subsequent rechewing, reswallowing, or spitting out of the regurgitated material. Rumination syndrome is classified as both a “Functional Gastroduodenal Disorder” (by the Rome Foundation’s Functional Gastrointestinal Disorders: Disorders of Gut-Brain Interaction, 4th edition) and a “Feeding and Eating Disorder” (by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition). Rumination syndrome is a disorder that is often inaccurately diagnosed or missed, resulting in patients experiencing protracted symptoms and not receiving treatment for long periods. There is a lack of clear consensus for RS diagnosis, mechanisms that maintain RS, and treatment. Guided by existing research and our clinical expertise, we synthesize available evidence and provide recommendations for clinical use. We present a case example and critically summarize the literature to date to (i) increase clinicians’ understanding of heterogeneous clinical presentations, (ii) suggest assessment strategies to facilitate accurate diagnosis, and (iii) provide a schematic for intervention options. Overall, we recommend clinicians recognize the heterogeneous features of RS when considering diagnosis, assess for RS symptoms by clinical history, and treat RS with targeted diaphragmatic breathing while using other methods as augmented intervention or alternative treatment.

OBJECTIVE: Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated highlighting lack of clarity in how ARFID is defined. // METHOD: In September 2018, a small multi-disciplinary pool of international experts in feeding disorder and eating disorder clinical practice and research convened as the Radcliffe ARFID workgroup to consider operationalization of DSM-5 ARFID diagnostic criteria to guide research in this disorder. // RESULTS: By consensus of the Radcliffe ARFID workgroup, ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); nutritional deficiencies (defined by laboratory assay or dietary recall); dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition); and/or psychosocial impairment. // CONCLUSIONS: This article offers definitions on how best to operationalize ARFID criteria and assessment thereof to be tested in existing clinical populations and to guide future study to advance understanding and treatment of this heterogeneous disorder.

PURPOSE OF REVIEW: Avoidant/restrictive food intake disorder (ARFID) was added to the psychiatric nomenclature in 2013, but little is known about its optimal treatment. The purpose of this paper is to review the recent literature on ARFID treatment and highlight a novel cognitive-behavioral approach presently under study. RECENT FINDINGS: The current evidence base for ARFID treatment relies primarily on case reports, case series, and retrospective chart reviews, with only a handful of randomized controlled trials in young children. Studies in adults are lacking. ARFID treatments recently described in the literature include family-based treatment and parent training; cognitive-behavioral approaches; hospital-based re-feeding including tube feeding; and adjunctive pharmacotherapy. A novel form of outpatient cognitive-behavioral therapy for ARFID (CBT-AR) is one treatment currently under study. CBT-AR is appropriate for children, adolescents, and adults ages 10 and up; proceeds through four stages across 20–30 sessions; and is available in both individual and family-supported versions. SUMMARY: There is no evidence-based psychological treatment suitable for all forms of ARFID at this time. Several groups are currently evaluating the efficacy of new psychological treatments for ARFID—particularly family-based and cognitive-behavioral approaches—but results have not yet been published.

OBJECTIVE Little epidemiological evidence exists on rumination disorder behavior (RB) and pica behavior (PB). We examined prevalence of RB and PB and presence of comorbid feeding/eating disorder symptoms among school-aged children. METHOD In elementary schools in Switzerland, 1,430 children (54.0% female) ages 7-13 completed the Eating Disorder Examination-Questionnaire for children (ChEDE-Q) and the Eating Disturbances in Youth Questionnaire (EDY-Q). RESULTS EDY-Q behavior frequency showed 9.7% reported RB only, 10.0% reported PB only, and 3.1% reported RB + PB (≥1 on 0-6 Likert scale). At a clinical cut-off score of ≥ 4, 1.7% had RB only, 3.8% had PB only, and 1.1% had RB + PB. Avoidant/restrictive food intake disorder symptoms were most common in those with RB + PB, and more common in those with RB or PB than those without. The degree of eating disorder symptoms (by ChEDE-Q) over the past 28 days were similar among those with RB, PB, or RB + PB, but less common in those without RB or PB. DISCUSSION RB and PB were commonly reported in our sample of school-aged children, even at a potential clinically significant cut-off. Our findings also suggest that the degree of eating disorder symptom comorbidity is similar between those with RB and PB.

Fear and disgust are distinct emotions that have been independently linked with EDs and may motivate avoidance behaviors that may be relevant targets for ED interventions (e.g., food rejection). Despite similar motivational function, it is possible that one emotion is more strongly associated with ED symptoms, relative to the other. Given that emerging evidence suggests that disgust-based behavior may be more difficult to change than fear-based behaviors, research is needed to evaluate whether each emotion differentially relates to ED symptoms. Therefore, the current study tested the relative importance of fear and disgust in accounting for variance in ED symptoms. Participants included undergraduate men (n = 127) and women (n = 263) from a university in the northeast US. Participants completed self-report measures assessing demographics, disordered eating attitudes and behaviors, and visual analog scales assessing fear and disgust responses to high-calorie food images, low-calorie food images, and non-food fear and disgust images. Bivariate correlations revealed significant positive associations among fear, disgust, and EDE-Q global symptom scores. Relative weights analysis results yielded relative importance weights that suggested disgust responding to high calorie food images accounts for the greatest total variance in EDE-Q global symptom scores in men, and fear responding to high calorie food images accounts for the greatest total variance in EDE-Q scores in women. Findings provide initial evidence that investigative and clinical efforts should consider fear and disgust as unique facets of negative affect with different patterns of relative importance to ED symptoms in undergraduate men and women.

Background: Avoidant/Restrictive Food Intake Disorder (ARFID) is a condition characterized by lack of interest in eating or food, sensory sensitivity, and/or fear of aversive consequences of eating; as opposed to the body image disturbance and fear of weight gain that characterize anorexia nervosa (AN). While appetite regulating hormones and their associations with bone mineral density (BMD) have been well studied in AN, little is known regarding BMD and its association with appetite regulating hormones in ARFID. Peptide YY (PYY), a gut derived anorexigenic hormone, acts via the Y2 receptor to inhibit osteoblastic activity in mammals. In AN, levels of PYY are higher than in healthy controls (HC) and are negatively associated with BMD. We hypothesized that similar to AN, low-weight female adolescents with ARFID would have lower BMD and higher PYY levels than in HC and that PYY levels would be inversely associated with BMD. Methods: We studied 24 adolescent females (10 low weight with ARFID and 14 HC). BMD variables were measured by Dual-Energy X-ray Absorptiometry. We performed cross sectional analysis to compare BMD and fasting PYY levels between low weight ARFID and HC and to determine the relationship between BMD and PYY levels. Results: ARFID and HC were 15.1±2.9 (mean ± SEM) and 17.1±3.8 years old, respectively (p=0.178), with mean BMI Z-scores of -1.74±0.88 kg/m2 and 0.24±0.51 kg/m2, respectively (p Conclusion: Female adolescents with low-weight ARFID have lower BMD and a trend toward higher levels of PYY compared with HC. Increased PYY levels may contribute to the lower BMD observed in ARFID. These findings are an initial step in understanding the neuroendocrine dysregulation in low weight adolescents with ARFID, which may predict bone outcomes in this condition.

Background: Avoidant/restrictive (A/R) food intake disorder (ARFID) is characterized by restrictive eating defined by lack of interest in food, sensory sensitivity, and/or fear of aversive consequences of eating resulting in a failure to meet adequate nutritional and/or energy needs. The complex psychopathology that differentiates ARFID from other eating disorders highlights the need to explore the role of sensory systems in disease etiology. Olfaction has an important role in eating behavior. Specifically, olfactory dysfunction is associated with decreased food intake and appetite. Olfactory performance and associated clinical characteristics have yet to be examined in individuals with ARFID. We hypothesized that higher levels of PYY, which signals satiety, would be associated with poorer olfactory performance; whereas greater food fussiness and A/R eating severity would be associated with stronger olfactory performance. Methods: We evaluated a cross-sectional sample of children and adolescents with full and subthreshold ARFID (n=82, 46.2% female, mean age 15.8±3.8). We measured olfactory performance with the Sniffin’ Sticks test (Burghardt®, Wedel, Germany) which captures odor discrimination, odor identification, and odor threshold. Higher scores on all three indices represent stronger olfactory performance. We also measured fasting serum PYY; severity of A/R eating on the Pica, ARFID and Rumination Disorder Interview (PARDI); and food fussiness as a measure of food-related sensory sensitivity on the Adult Eating Behavior Questionnaire. Statistical analyses included T-test and spearman’s correlations. Results: Greater fasting serum PYY levels were associated with significantly poorer performance on the odor threshold test (r=-0.4, p=0.003). Greater severity of A/R eating (r=-0.3 p=0.008) and food fussiness (r=-0.2, p=0.03) were both associated with significantly poorer performance on the odor discrimination test. Conclusions: As predicted, we found that higher levels of PYY were associated with poorer olfactory performance in youth with full and subthreshold ARFID. However, contrary to hypotheses, we found that greater food fussiness and severity of A/R eating were associated with poorer olfactory performance. Future research should investigate whether high levels of PYY and poor olfactory performance are causes, consequences, or correlates of A/R eating.

Background: Avoidant/Restrictive Food Intake Disorder (ARFID) is a recent diagnosis incorporated into the DSM-5 to provide diagnostic specificity to individuals who may have avoidant/restrictive eating behavior unrelated to body image/weight concerns and display three core profiles: insufficient intake/low interest in feeding, fear of aversive consequences related to food intake (e.g., choking) and avoidance based on sensory characteristics of food. Various studies have shown a higher preponderance of male patients in ARFID compared to other eating disorder groups. To elucidate potential sex differences in the neurobiology of ARFID, we examined food motivation pathways by assessing levels of key appetite regulating hormones, anorexigenic peptide YY (PYY) and orexigenic ghrelin, and fMRI activation of relevant brain circuitry in females compared to males with ARFID. Based on prior fMRI studies in healthy controls, we hypothesized that in a fasted state, females (vs. males) would demonstrate greater blood-oxygen-level-dependent (BOLD) activation in response to high-calorie food (vs. non-food) images in the orbitofrontal cortex (OFC) and the right lateral prefrontal cortex (LPFC), while males (vs. females) would demonstrate greater activation in the right hippocampus. Methods: Seventy-five adolescents and young adults with ARFID and sub-threshold ARFID (43 female) were studied after a 10-hour overnight fast. PYY and ghrelin levels were assessed in a subset of 62 individuals (31 female). All participants completed fMRI imaging in a 3T scanner while viewing images of foods, non-food items, and fixation stimuli. Functional MRI data were analyzed using SPM12. A priori regions of interest included the right lateral prefrontal cortex (LPFC), right hippocampus and orbitofrontal cortex (OFC). Secondary exploratory whole-brain analysis was also performed. Statistical significance is reported at the p Results: Females and males did not differ in age ((mean±SD): 16.1±3.7 years) or BMI (19.9±5.4 kg/m2). There were no statistically significant differences between females and males in PYY (p=0.10) or ghrelin (p=0.47) levels. Furthermore, analysis of fMRI data yielded no significant differences between females and males with ARFID in a priori regions of interest (OFC: p(FWE-corr)>0.50; R LPFC: no suprathreshold clusters, or R hippocampus: p(FWE-corr)=0.25 and 0.33) or in the secondary whole-brain analysis (cluster p(FWE-corr)=0.304). Conclusion: This is the first study to investigate sex differences in the neurobiology of ARFID, an important line of research to advance treatment approaches. We found no sex-specific neurobiological differences in adolescents and young adults with ARFID. Future studies with larger sample sizes are needed to further investigate potential sex differences across the different ARFID profiles.

Objective: Avoidant/restrictive food intake disorder (ARFID) occurs across the weight spectrum, however research addressing the coexistence of ARFID with overweight/obesity (OV/OB) is lacking. We aimed to establish co-occurrence of OV/OB and ARFID and to characterize divergent neurobiological features of ARFID by weight. Method: Youth with full/subthreshold ARFID (11 with healthy weight [HW], 12 with OV/OB) underwent fasting brain fMRI scan while viewing food/non-food images (M age = 16.92 years, 65% female, 87% white). We compared groups on BOLD response to high-calorie foods (HCF) (vs. objects) in food cue processing regions of interest. Following fMRI scanning, we evaluated subjective hunger pre- vs. post-meal. We used a mediation model to explore the association between BMI, brain activation and hunger. Results: Participants with ARFID and OV/OB demonstrated significant hyperactivation in response to HCF (vs. objects) in the orbitofrontal cortex (OFC) and anterior insula compared with HW subjects with ARFID. Mediation analysis yielded a significant indirect effect of group (HW vs. OV/OB) on hunger via OFC activation (effect=18.39, SE=11.27, 95% CI [-45.09, -3.00]), suggesting that OFC activation mediates differences in hunger between ARFID participants with HW and OV/OB. Conclusions: Compared to youth with ARFID and HW, those with OV/OB demonstrate hyperactivation of brain areas critical for reward value of food cues. Postprandial changes in subjective hunger depend on BMI and are mediated by OFC activation to food cues. Whether these neurobiological differences contribute to selective hyperphagia in ARFID presenting with OV/OB and represent potential treatment targets is an important area for future investigation.

Objective Anorexia nervosa is associated with social-emotional functioning deficits and low levels of the social neurohormone oxytocin, even after weight gain. The relationship between low oxytocin levels and social-emotional functioning impairment has not been studied. Method We performed a cross-sectional study of 79 women (19 who were less than 85% of ideal body weight [IBW] with anorexia nervosa [AN], 26 who were 90–120% IBW with a history of AN [AN-WR], and 34 who were 90–120% IBW with no eating disorder history [H]). We administered the Eating Disorder Examination–Questionnaire (EDE-Q), Leibowitz Social Anxiety Scale–Self Report (LSAS-SR), Dimensional Assessment of Personality Pathology–Basic Questionnaire (DAPP-BQ; suspiciousness and insecure attachment subscales), and the Toronto Alexithymia Scale (TAS-20). We also analyzed fasting serum oxytocin levels. Results Most measures of social-emotional functioning showed impairment in women with AN and AN-WR compared to H. Oxytocin levels were low in AN-WR compared to H. Across groups, low oxytocin levels were associated with difficulty identifying feelings (r = −.45, p = .008) and overall alexithymia (r = −.34, p = .0489). Discussion We speculate that low oxytocin levels may contribute to alexithymia in women with anorexia nervosa.

Objective Anxiety is a risk factor for disordered eating, but the mechanisms by which anxiety promotes disordered eating are poorly understood. One possibility is local versus global cognitive processing style, defined as a relative tendency to attend to details at the expense of the “big picture.” Anxiety may narrow attention, in turn, enhancing local and/or compromising global processing. We examined relationships between global/local processing style, anxiety, and disordered eating behaviors in a transdiagnostic outpatient clinical sample. We hypothesized that local (vs. global) processing bias would mediate the relationship between anxiety and disordered eating behaviors. Method Ninety-three participants completed the eating disorder examination—questionnaire (EDE-Q), State-Trait Anxiety Inventory (STAI)—trait subscale, and the Navon task (a test of processing style in which large letters are composed of smaller letters both congruent and incongruent with the large letter). The sample was predominantly female (95%) with a mean age of 27.4 years (SD = 12.1 years). Results Binge eating, but not fasting, purging, or excessive exercise, was correlated with lower levels of global processing style. There was a significant indirect effect between anxiety and binge eating via reduced global level global/local processing. Discussion In individuals with disordered eating, being more generally anxious may encourage a detailed-oriented bias, preventing individuals from maintaining the bigger picture and making them more likely to engage in maladaptive behaviors (e.g., binge eating).

Objective This study evaluated the DSM-5 severity specifiers for treatment-seeking groups of participants with anorexia nervosa (AN), the purging form of bulimia nervosa (BN), and binge-eating disorder (BED). Method Hundred and sixty-two participants with AN, 93 participants with BN, and 343 participants with BED were diagnosed using semi-structured interviews, sub-categorized using DSM-5 severity specifiers and compared on demographic and cross-sectional clinical measures. Results In AN, the number of previous hospitalizations and the duration of illness increased with severity, but there was no difference across severity groups on measures of eating pathology, depression, or measures of self-reported physical or emotional functioning. In BN, the level of eating concerns increased across the severity groups, but the groups did not differ on measures of depression, self-esteem, and most eating pathology variables. In BN, support was also found for an alternative severity classification scheme based upon number of methods of purging. In BED, levels of several measures of eating pathology and self-reported physical and emotional functioning increased across the severity groups. For BED, however, support was also found for an alternative severity classification scheme based upon overvaluation of shape and weight. Preliminary evidence was also found for a transdiagnostic severity index based upon overvaluation of shape and weight. Discussion Overall, these data show limited support for the DSM-5 severity specifiers for BN and modest support for the DSM-5 severity specifiers for AN and BED.

Background: Psychiatric comorbidity is common in eating disorders (EDs) and associated with poor outcomes, including increased risk for relapse and premature death. Yet little is known about comorbidity following ED recovery. Methods: We examined two common comorbidities, major depressive disorder (MDD) and substance use disorder (SUD), in adult women with intake diagnoses of anorexia nervosa and bulimia nervosa who participated in a 22-year longitudinal study. One hundred and seventy-six of 228 surviving participants (77.2%) were interviewed 22 years after study entry using the Eating Disorders Longitudinal Interval Follow-up Evaluation to assess ED recovery status. Sixty-four percent (n = 113) were recovered from their ED. The Structured Clinical Interview for DSM-IV was used to assess MDD and SUD at 22 years. Results: At 22-year follow-up, 28% (n = 49) met criteria for MDD, and 6% (n = 11) met criteria for SUD. Those who recovered from their ED were 2.17 times more likely not to have MDD at 22-year follow-up (95% CI [1.10, 4.26], p = .023) and 5.33 times more likely not to have a SUD at 22-year follow-up than those who had not recovered from their ED (95% CI [1.36, 20.90], p = .008). Conclusion: Compared to those who had not fully recovered from their ED, those who had recovered were twice as likely not to be diagnosed with MDD in the past year and five times as likely not to be diagnosed with SUDs in the past year. These findings provide evidence that long-term recovery from EDs is associated with recovery from or absence of these common major comorbidities. Because comorbidity in EDs can predict poor outcomes, including greater risk for relapse and premature death, our findings of reduced risk for psychiatric comorbidity following recovery at long-term follow-up is cause for optimism. Keywords: Eating disorders, Recovery, Major depressive disorder, Substance use disorder