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The objective of this work was to further examine the status of the overvaluation of weight/shape in binge-eating disorder (BED) by examining correlates of probable BED with and without overvaluation. Subgroups of women – probable BED with overvaluation (n = 37), probable BED without overvaluation (n = 78), obese individuals who reported no binge eating (‘obese controls’) (n = 194), and normal-weight individuals who reported no binge eating (‘healthy controls’) (n = 573) – recruited from a general population sample, were compared on measures of eating disorder psychopathology, general psychological distress, and psychosocial functioning. Women with probable BED with overvaluation reported significantly higher levels of eating disorder psychopathology and general psychological distress, and significantly poorer psychosocial functioning, than those with probable BED without overvaluation. No significant differences on any outcome measures were found between women with probable BED without overvaluation and ...

Objectives Understanding attitudes to mental health issues can inform public health interventions. However, low response rates may contribute to nonresponse bias. In a randomized controlled trial we examined the effect of sending a prenotification postcard before the questionnaire and the placement of a short message on the survey envelope (teaser) on response rates to a mailed questionnaire about bulimia nervosa “mental health literacy”. Study Design and Setting Questionnaires were mailed to 3,010 adults (50.6% female and 49.4% male) aged 18–65 years. In a 2 (pre-notification–present; absent) by 2 (teaser–present; absent) design, questionnaire recipients were randomly allocated to the experimental strategies. Outcomes considered were response rate, response time, and cost. Results The overall response rate was 22.0%. Significant main effects showed higher response rates for the use of prenotification (present = 23.6%; absent = 20.3%), among female participants, and older participants. A significant interaction of teaser by gender indicated lower response rates for men who received the teaser but not for women. Older participants returned the questionnaire more promptly than younger participants. Females—but not males—who received the teaser were slower to return the questionnaire. Higher response rates for participants receiving the postcard compensated for increased costs, particularly for males and older participants. Conclusion Response rates to a mental health postal survey can be increased through the use of prenotification.

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)

Few of the limited randomized controlled trials (RCTs) for adults with anorexia nervosa (AN) have explored predictors and moderators of outcome. This study aimed to identify predictors and moderators of outcome at end of treatment (EOT) and 6- and 12-month follow-up for adults with AN (N = 63). All participants met criteria for severe and enduring AN (duration of illness ≥ 7 years) and participated in an RCT of cognitive-behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM). General linear models were utilized and included all available outcome data at all time points. Outcome was assessed across three domains: eating disorder quality of life (EDQOL), mental health (MCS), and depressive symptoms (BDI). Predictors of better outcome included: lower age, shorter duration of illness, having AN-R, being employed, not taking psychotropic medication, and better social adjustment. Four moderators of treatment outcome emerged: eating disorder psychopathology (EDE Global), depression (BDI), age, and AN subtype. Participants with higher baseline scores on these measures, older age, or binge eating/purging subtype benefited more from CBT-AN than SSCM. Older patients with more severe eating-related psychopathology and depression have better outcomes in a behaviorally targeted treatment such as CBT-AN rather than a supportive treatment such as SSCM.

This review aims to critically examine and summarise the existing research that has studied the prevalence and psychopathological correlates of compulsive exercise in adolescents with eating disorders. A systematic electronic database search (PsycINFO, Medline, and Web of Science) of published studies was completed in May 2013. A search strategy was developed to identify all studies of adolescents with eating disorders, in which the prevalence and/or psychological correlates of compulsive exercise had been formally assessed through clinical interview or reliable and valid clinical measures. A total of 11 studies met the inclusion criteria for the review, of which 10 studies provided comparable prevalence estimates and 4 studies identified psychopathological correlates of compulsive exercise. For the relevant data, the prevalence of compulsive exercise in adolescents with eating disorders ranged from 16.7% to 85.3%. There is some evidence to suggest that compulsive exercise is associated with increased eat...

The paper presents a critical review (with search date 2010) of the major psychotropic medications assessed in eating disorders, namely antipsychotics, antidepressants, mood-stabilizing medications, anxiolytic and other agents. The evidence of efficacy of drug treatments is mostly weak or moderate. In addition, attrition rates are usually higher than for psychotherapies. However, there is support for use of antidepressants, particularly high-dose fluoxetine in bulimia nervosa, and anticonvulsants (topiramate) for binge-eating disorder. Low-dose antipsychotic medication may be clinically useful as adjunct treatment in acute anorexia, particularly where there is high anxiety and obsessive eating-related ruminations and failure to engage, but more trials are needed. Drug therapies such as topiramate and anti-obesity medication may aid weight loss in obese or overweight patients with binge-eating disorder; however, common or potentially serious adverse effects limit their use.(Reprinted with permission from t...

Background: Death is a universal human experience. The experience of grief is unique for each person experiencing it. There is emerging research on modalities that provide support for bereaved individuals including bereavement massage. There is limited information in the literature about the specific role that massage can play in supporting bereaved individuals. The aim of this scoping review is to explore the literature that reports on the use and outcomes of bereavement massage so that massage therapists, consumers (the bereaved) and other health care professionals have a clearer idea about what bereavement massage is and how it may (or may not) be beneficial. Methods: A scoping review methodology as used. Findings: Whilst few, the articles identified were useful in describing bereavement massage use, putative outcomes and hypothesis generation. Bereavement massage techniques commonly used involve light pressure with treatment involving more than physical act of massage. Outcomes may be in improved somatic, physiological and/or emotional status. Summary: This review has highlighted the paucity of research in all aspects, understanding mechanisms and testing efficacy of massage for people who are bereaved. Further research on the role of massage in bereavement, potential efficacy and long and short-term outcomes is needed.

Background: Depression is commonly treated with anti-depressant medication and/or psychological interventions. Patients with depression are common users of complementary therapies, such as acupuncture, either as a replacement for, or adjunct to, their conventional treatments. This systematic review and meta-analysis examined the effectiveness of acupuncture in major depressive disorder. Methods: A search of English (Medline, PsychINFO, Google Scholar, and CINAL), Chinese (China National Knowledge Infrastructure Database (CNKI) and Wanfang Database), and Korean databases was undertaken from 1980 to November 2018 for clinical trials using manual, electro, or laser acupuncture. Results: Twenty-nine studies including 2268 participants were eligible and included in the meta-analysis. Twenty-two trials were undertaken in China and seven outside of China. Acupuncture showed clinically significant reductions in the severity of depression compared to usual care (Hedges (g) = 0.41, 95% confidence interval (CI) 0.18 to 0.63), sham acupuncture (g = 0.55, 95% CI 0.31 to 0.79), and as an adjunct to anti-depressant medication (g = 0.84, 95% CI 0.61 to 1.07). A significant correlation between an increase in the number of acupuncture treatments delivered and reduction in the severity of depression (p = 0.015) was found. Limitations: The majority of the included trials were at a high risk of bias for performance blinding. The applicability of findings in Chinese populations to other populations is unclear, due to the use of a higher treatment frequency and number of treatments in China. The majority of trials did not report any post-trial follow-up and safety reporting was poor. Conclusions: Acupuncture may be a suitable adjunct to usual care and standard anti-depressant medication.

The prevalence of obesity with comorbid binge eating behaviour is growing at a faster rate than that seen for either obesity or eating disorders as separate conditions. Approximately 6% of the population are affected and they potentially face a lifetime of poor physical and mental health outcomes and an inability to sustain long-term weight loss. Current treatment options are inadequate in that they typically address either obesity or eating disorders exclusively, not the combination of both conditions. By treating one condition without treating the other, relapse is common, and patients are often left disappointed with their lack of weight loss. An integrated approach to treating these individuals is needed to prevent a worsening of the comorbidities associated with excess body weight and eating disorders. A new therapy has recently been developed, named HAPIFED, which addresses both overweight/obesity and comorbid binge eating behaviour with the combination of behavioural weight loss therapy and cognitive behaviour therapy-enhanced (CBT-E). The aim of this paper is to document the protocol for the Real Happy Study, which will evaluate the effectiveness of the HAPIFED program in treating overweight or obesity with comorbid binge-eating behaviour in a real-world setting.

Summary Background Anorexia nervosa is a serious illness with significant morbidity. The evidence base for existing psychological and pharmacological interventions to manage anorexia nervosa is not strong, and use of new adjunctive therapies that improve the effectiveness of existing treatments, and lead to improved mental health outcomes for this patient group is highly desirable. This study investigates the views of patients with anorexia nervosa receiving an acupuncture or acupressure intervention. Method A randomised controlled trial was conducted in Sydney, Australia. Twenty-six inpatients with a diagnosis of anorexia nervosa were randomised to a six week intervention of acupuncture or acupressure with light massage. Treatment was administered twice weekly for three weeks, then weekly for three weeks. A post treatment questionnaire was administered to explore participant views, of the study consultation. Questions examined important aspects of the clinical encounter including the, patient's perception of the practitioners’ relational empathy (CARE), treatment perceptions and the, therapeutic relationship. Results Participants in both groups scored highly on the CARE scale assessing empathy and the, therapeutic relationship. There was no difference in the mean CARE scores for the acupuncture group (50 (SD 0.0)) and the acupressure group (49.5 (SD 0.8)). Participants highly valued the therapeutic, encounter and in particular the characteristics of empathy, positive regard, acceptance, non, judgemental responses and trust. Having someone to talk to, being less stressed/relaxed and contact, with the study staff were also perceived to be important. Conclusion Study participants perceive the therapeutic relationship and empathy as important qualities of the acupuncture or acupressure intervention as an adjunct therapy for the treatment of anorexia nervosa.

Objective: stigmatizing attitudes towards eating disorders negatively impacts treatment seeking. To determine the effect of interventions to reduce stigma, a measure of stigma that is simple to implement is required. This study aimed to develop a measure of stigmatizing attitudes and beliefs towards bulimia nervosa (SAB-BN) and evaluate the distribution of beliefs across gender, age, education, and income groups. Method: participants were 1828 community adults (890 men; 938 women) aged 18–65 sampled from the Australian Electoral Roll responded to a mailed questionnaire. Participants provided demographic information and completed the SAB-BN questionnaire. Results: five components of stigmatizing attitudes and beliefs were identified; advantages of BN, minimization/low seriousness, unreliability, social distance, and personal responsibility. Stigma was low except on social distance and personal responsibility sub-scales, which indicated negative attitudes toward people with bulimia. Men compared with women and lower compared with higher education and income groups held significantly higher stigmatizing attitudes and beliefs. There were few differences between age groups in stigma. Differences between demographic groups provides evidence for known-groups validity. Discussion: the SAB-BN questionnaire provides a potentially useful tool for evaluating stigma in relation to BN. Results provide insight into components of stigma and the demographic groups to whom interventions should be targeted.

Less than half of people with anorexia nervosa achieve full recovery. Previous qualitative research has identified a "tipping point" for change in people who have experienced recovery. The present study's goal was to explore factors that might contribute to this time in personal published accounts, an alternate source for understanding lived experience. Using the 5-stage framework approach for thematic analysis, 31 individual (29 female) accounts were explored. These were purposively sampled from autobiographical accounts (during 1999-2011). In all the accounts a "tipping point" or change in the person's attitude toward treatment and recovery did appear. We identified four main themes: desire for recovery, positive experiences in treatment, an aspect of life outside work or study, and positive and helpful experiences with new or renewed relationships. The themes were a mix of internal and external themes, as well as themes independent of a treatment experience. The findings support other research that indicates experiences, such as personal and spiritual relationships, in addition to specific psychotherapies or treatments, are important in recovery. Further research into how to facilitate and integrate these external factors with formal treatment is indicated in order to improve understanding of outcomes in anorexia nervosa.

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..

Background: Eating disorders (EDs), including anorexia nervosa (AN) and bulimia nervosa (BN), are prevalent disorders that carry substantial economic and social burden. The aim of the current study was to evaluate the modelled population cost-effectiveness of cognitive dissonance (CD), a school-based preventive intervention for EDs, in the Australian health care context. Method: A population-based Markov model was developed to estimate the cost per disability adjusted life-year (DALY) averted by CD relative to no intervention. We modelled the cases of AN and BN that could be prevented over a 10-year time horizon in each study arm and the subsequent reduction in DALYs associated with this. The target population was 15-18 year old secondary school girls with high body-image concerns. This study only considered costs of the health sector providing services and not costs to individuals. Multivariate probabilistic and one-way sensitivity analyses were conducted to test model assumptions. Results: Findings showed that the mean incremental cost-effectiveness ratio at base-case for the intervention was $103,980 per DALY averted with none of the uncertainty iterations falling below the threshold of AUD$50,000 per DALY averted. The evaluation was most sensitive to estimates of participant rates with higher rates associated with more favourable results. The intervention would become cost-effective (84% chance) if the effect of the intervention lasted up to 5 years. Conclusion: As modelled, school-based CD intervention is not a cost-effective preventive intervention for AN and BN. Given the burden of EDs, understanding how to improve participation rates is an important opportunity for future research.

Background Recent research has challenged the stereotype that eating disorders are largely limited to young, White, upper-class females. This study investigated the association between indicators of socioeconomic status and eating disorder features. Methods and Findings Data were merged from cross-sectional general population surveys of adults in South Australia in 2008 (n = 3034) and 2009 (n = 3007) to give a total sample of 6041 participants. Multivariate logistic regressions were employed to test associations between indicators of socioeconomic status (household income, educational level, employment status, indigenous status and urbanicity) and current eating disorder features (objective binge eating, subjective binge eating, purging, strict dieting and overvaluation of weight/shape). Eating disorder features occurred at similar rates across all levels of income, education, indigenous status, and urbanicity (p > 0.05). However, compared to working full-time, not working due to disability was associated with an increased risk of objective binge eating (odds ratio (OR) = 2.30, p < 0.01) and purging (OR = 4.13, p < 0.05), engagement in home-duties with an increased risk of overvaluation of weight/shape (OR = 1.39, p < 0.05), and unemployment with an increased risk of objective binge eating (OR = 2.02, p < 0.05) and subjective binge eating (OR = 2.80, p < 0.05). Furthermore, participants with a trade or certificate qualification were at a significantly increased risk of reporting strict dieting compared to participants without a tertiary qualification (OR = 1.58, p

This study aimed to explore and synthesize expert clinical knowledge on defining and managing unhealthy exercise in adolescents with AN. The Delphi methodology was used. Clinicians (n = 25) considered experts in the treatment of AN in adolescents were recruited internationally to form the panel. The first round of the questionnaires was comprised of five open-ended questions regarding defining, assessing, and treating unhealthy exercise in adolescents with AN. Statements were derived from this data using content analysis, and included as Likert-based items in two subsequent rounds, in which panellists were required to rate their level of agreement for each item. All 25 respondents completed the three rounds of questionnaires. Consensus was achieved for 59.0% of the items included in the second and third round of questionnaires. Although consensus was not achieved, compulsive exercise was the preferred term for the panel when referring to unhealthy exercise in adolescents with AN. The panel clearly delineated features of unhealthy and healthy exercise, and endorsed a number of items considered important to assess for when evaluating exercise in this clinical population. A variety of treatment approaches and strategies reached consensus. Notably, for those who are medically stable and progressing toward recovery, the panel recommended initial exercise restriction practices and reintroducing healthy exercise behaviors, rather than exercise cessation practices. The current findings can serve as preliminary treatment guidelines. A unified approach to labeling and defining unhealthy exercise in the eating disorder literature and clinical settings is required to achieve further progress.

This study investigated the achievement of lifestyle recommendations and use of preventive medication in people who 1) are obese, 2) or have metabolic risk factors (hypertension, dyslipidaemia, and/or diabetes), 3) or have cardiovascular disease (CVD), 4) or are healthy, and the impact this preventive health care had on their 'Health-Related Quality of Life' (HRQoL). Cross-sectional survey conducted in 2015 with 2379 South Australian adults (57.1 +/- 14 years; 51.7% females). Physical (PCS) and mental components scores (MCS) of HRQoL were assessed using the SF-12 questionnaire. Although adequate fruit/vegetable intake was lower among individuals with CVD (29.8%; p=0.049), this behaviour was associated with a better MCS. Adequate physical activity level was lower among those with metabolic risk factors (29.5%) or CVD (31.0%; p=0.008), but independent of their clinical condition, this behaviour was associated with a higher PCS. Individuals with CVD were less likely to have adequate alcohol consumption (63.4%; p=0.026), but those achieving this recommendation had poorer PCS. Nonsmoking was similar in all groups (85%; p=0.768) and was associated with a better MCS only among healthy individuals and those with CVD. In all the groups, individuals achieving all the lifestyle recommendations had a better PCS. Only 48.2% of individuals with CVD reported combined use of antithrombotic, antihypertensive, and antilipidemic drugs, but the use of these medications was not associated with HRQoL. In conclusion, the vast majority of individuals at risk of or with CVD did not achieve preventive recommendations, and only the adequacy of uptake of all recommended lifestyle behaviours showed consistent benefits for PCS and MCS. (C) 2017 Elsevier Inc. All rights reserved. Refereed/Peer-reviewed

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.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.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.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).

Reason for withdrawal from publication This protocol was withdrawn on 23rd May 2016 due to lack of progress.

AIM To discuss the application of the principles of participatory action research (PAR) in a project that developed and evaluated a mentor-mentee support programme for women with anorexia nervosa. BACKGROUND A programme was developed and implemented in which mentors and mentees participated in workshops, social activities and focus groups that sought to support and develop resilience for those experiencing anorexia nervosa. DISCUSSION PAR principles were mirrored in the programme, paying respect to the views and needs of each participant, an open trajectory to possible conclusions and a continuous feedback cycle. Mentees had a sense of empowerment, ownership of the programme and hope that recovery was possible. It allowed their voices to be heard and provided them with belief they could begin new relationships and friendships. CONCLUSION The principles of PAR suited a project aimed at developing self-determination and resilience in women with anorexia nervosa. IMPLICATIONS FOR RESEARCH/PRACTICE PAR would be readily transferable to a number of mental health settings where empowerment is of paramount concern.

The present study was designed to investigate orthorexia nervosa, or the phenomenon of being preoccupied with consuming healthy food. Specific aims were to explore relationships between orthorexia features and attitudes towards body image, fitness and health in normal weight female and male university students with high levels of healthy food preoccupation, i.e. orthorexia nervosa.Participants were 327 female (N = 283) and male (N = 44) students aged 18 to 25 years. All participants completed the Polish adaptation of the 15-item questionnaire assessing orthorexia eating behaviours (the ORTHO-15) and the Multidimensional Body-Self Relations Questionnaire (the MBSRQ). Relationships between scores on the ORTHO-15 and MBSRQ were explored in the 213 students who had high levels of preoccupation with a healthy food intake (68.55% women and 43.18% men, respectively).There were no statistically significant differences in the levels of orthorexia behaviours between females and males. In female students with orthorexia nervosa, preoccupation with consuming healthy food was significantly correlated with the MBSRQ subscale scores for overweight preoccupation, appearance orientation, fitness orientation, health orientation, body areas satisfaction and appearance evaluation. Conversely, in male students with orthorexia nervosa there were no correlations between orthorexic behaviours and the MBSRQ subscales. In female students with orthorexia nervosa multivariable linear regression analysis found high body areas (parts) satisfaction, low fitness orientation, low overweight preoccupation and low appearance orientation were independent predictors of greater fixation on eating healthy food. In male students, we found that aspects of body image were not associated with preoccupation with healthy eating.A strong preoccupation with healthy and proper food was not associated with an unhealthy body-self relationship among Polish female student with orthorexia nervosa.

Background Therapeutic alliance (TA) has been found to be a significant predictor of outcome for patients with severe and enduring anorexia nervosa (SE-AN), accounting for more variance than treatment type. To better understand how to promote TA for this population, the aim of the current study was to investigate predictors of TA in adults with SE-AN. Methods Participants were 63 adult females with SE-AN presenting to an outpatient, multi-site randomized controlled trial conducted at two clinical sites. Participants’ perception of the quality of their therapeutic relationship, demographic information, and eating disorder symptomatology were assessed via interview and questionnaire measures. Results Baseline ratings of how successful participants believed treatment would be for them was the only variable to significantly predict early (p = .01), mid (p = .009), and late treatment alliance (p = .03). No other variables investigated predicted the quality of patient rated TA at any point in treatment (ps > .57). Conclusions Results suggest instilling hope in treatment outcome may enhance TA, and in turn, outcomes for patients with SE-AN in outpatient therapy.

Background This systematic review is an evaluation of the empirical literature relating to the disordered eating behaviour Chew and Spit (CHSP). Current theories postulate that CHSP is a symptom exhibited by individuals with recurrent binge eating and Bulimia Nervosa. Aims The review aimed to identify and critically assess studies that have examined the distribution of CHSP behaviour, its relationship to eating disorders, its physical and psychosocial consequences and treatment. Methods A systematic database search with broad inclusion criteria, dated to January 2016 was conducted. Data were extracted by two authors and papers appraised for quality using a modified Downs and Black Quality Index. Results Nine studies met the inclusion criteria. All were of clinical samples and majority (n = 7) were of low quality. The pathological action of chewing food but not swallowing was reported more often in those with restrictive type eating disorders, such as Anorexia Nervosa, than binge eating type disorders. CHSP also was reported to be an indicator of overall severity of an eating disorder and to appear more often in younger individuals. No studies of treatment were found. Conclusions Conclusions were limited due to the low quality and small numbers of studies based on clinical samples only. Further research is needed to address gaps in knowledge regarding the physiological, psychological, social, socioeconomic impact and treatment for those engaging in CHSP.

Background Depressed pregnant women face difficulty navigating a course between the potentially serious consequences of leaving depression untreated and significant limitations associated with conventional therapies, such as foetal toxicity and teratogenicity. Preliminary evidence is suggestive that acupuncture may provide a safe and effective alternative treatment option for antenatal depression; however, additional research is required. The purpose of this study is to further investigate this treatment possibility, with an additional examination of a potential biomechanistic acupuncture effect. Methods/design In this pragmatic randomised controlled trial, we will compare individually tailored, flexible antenatal depression-oriented acupuncture with equivalent attention progressive muscle relaxation and routine antenatal depression hospital care. Eligible women at 24 weeks of gestation with Edinburgh Postnatal Depression Scale scores of 13 or more will be recruited from 2 antenatal clinics in South Western Sydney, Australia. The recruitment goal of 96 is powered to demonstrate a significant difference in Edinburgh Postnatal Depression Scale score severity between acupuncture and usual care, with intervention groups receiving weekly 1-h treatments for 8 weeks from 24 to 31 weeks of gestation. Mental health and quality-of-life assessments will occur at study commencement, intervention weeks 4 and 8 and 6 weeks post-natally via the collection of completed Edinburgh Postnatal Depression Scale scores, Depression, Stress and Anxiety Scale scores and World Health Organisation Quality of Life Scale scores. Adjustment to mothering will also be evaluated at 6 weeks post-natally using the Being a Mother Scale. A putative biomechanistic effect of acupuncture on the oxytocinergic system will additionally be examined by comparing baseline salivary hormone levels with those measured at intervention weeks 4 and 8, as well as leucocyte oxytocin receptor expression at baseline and intervention week 8. Discussion Ethical approval was received in February 2015, and recruitment is underway and expected to be completed in July 2016. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12615000250538, Registered on 19 March 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1204-9) contains supplementary material, which is available to authorized users.

Contributing reviewers The Journal of Eating Disorders editorial team would like to thank all reviewers who have contributed to the journal in 2015.

Objective: Many patients with anorexia nervosa develop an intractable and debilitating illness course. Our aims were to (i) conduct a systematic review of randomised controlled trials (RCTs) of treatment for chronic anorexia nervosa participants, and (ii) identify research informing novel therapeutic approaches for this group. Methods: Systematic search (SCOPUS plus previous reviews date 2011) of literature for (i) RCTs of treatment that included anorexia nervosa participants with a mean duration of illness of at least 3 years, (ii) studies reporting new treatments addressing factors associated with chronicity. Results: Evidence of efficacy for treatment approaches in severe and enduring anorexia nervosa is limited. Only one unpublished RCT designed to test a specific psychological approach for these patients was identified. There is a probable advantage for specialist psychotherapy over treatment as usual, and a promising study of relapse prevention with cognitive behaviour therapy (CBT) for anorexia nervosa (CBT-AN). Open trials have, however, reported developments in psychological therapies that warrant further specific evaluation. These include forms of CBT modified for anorexia nervosa, cognitive remediation therapy with emotion skills training, the Maudsley Model for Treatment of Adults with Anorexia Nervosa, the Community Outreach Partnership Program, Specialist Supportive Clinical Management and the approach of Strober with its emphasis on therapeutic alliance and flexible goals. Conclusions: Treatment trials need to move beyond targeting core eating disorder pathology (primarily weight restoration) and examine efficacy and effectiveness in minimising harm and reducing personal and social costs of chronic illness. There is also a need to develop better definitions of chronicity, with or without treatment ‘resistance’ specifiers.

We conducted a prospective exploration of the temporal course of eating disorder (ED) symptoms in two cohorts of community women. One hundred and twenty-two young women (Cohort 1) identified in a general population based survey with ED symptoms of clinical severity agreed to participate in a 5-year follow-up study. A comparative sample (Cohort 2) of 706 similar aged self-selected college women (221 with disordered eating) was recruited one year later. Both ED groups were given a health literacy package in the first year. ED symptoms, health related quality of life, and psychological distress were assessed annually with the Eating Disorder Examination Questionnaire, the Short Form—12 Health Survey and the Kessler Psychological Distress Scale, respectively. Forty percent (Cohort 1) and 30.3% (Cohort 2) completed questionnaires at each year of follow-up. In both groups, there was early improvement in ED symptoms which plateaued after the first year, and participants retained high EDE-Q scores at 5 years. BMI increased as expected. Mental health related quality of life scores did not change but there were small improvements in psychological distress scores. The findings suggest little likelihood of spontaneous remission of ED problems in community women.

Objective: Studies of quality of life among individuals with eating disorders have relied almost exclusively on clinical samples. We examined impairment in quality of life in a community sample of women with eating disorders recruited as part of an epidemiological study.Methods: Measures of health-related quality of life (Medical Outcomes Study 12-item Short-Form Physical and Mental Component Summary scales) and subjective well-being (WHOQOL-BREF Psychological Functioning and Social Relationships subscales) were completed by women with eating disorders ( n = 159), primarily variants of bulimia nervosa and binge eating disorder, and a comparison group of healthy women ( n = 232).Results: When compared with healthy women, women with eating disorders reported substantial impairment in aspects of quality of life relating to mental health, although item-level analysis indicated considerable variation in the extent to which specific aspects of emotional well-being were affected. Impairment in social relationship and in physical health was less pronounced and due, at least in part, to between-group differences in age, body weight and demographic characteristics. Impairment in certain aspects of perceived physical health was, however, apparent among women with eating disorders, even after controlling for between-group differences in body weight.Conclusions: Community cases of women with eating disorders experience marked impairment in quality of life as this relates to mental health functioning and at least some impairment in physical health functioning. Personality characteristics and ego-syntonic aspects of eating-disordered behaviour may complicate the interpretation of findings relating to impairment in specific aspects of quality of life.

Summary Recent research suggests that increased adiposity is associated with poor cognitive performance, independently of associated medical conditions. The evidence regarding this relationship is examined in this review article. A relatively consistent finding across the lifespan is that obesity is associated with cognitive deficits, especially in executive function, in children, adolescents and adults. However, as illustrated by contradictory studies, the relationship between obesity and cognition is uncertain in the elderly, partly because of inaccuracy of body mass index as a measure of adiposity as body composition changes with aging. This review further discusses whether obesity is a cause or a consequence of these cognitive deficits, acknowledging the possible bidirectional relationship. The possible effects of increased adiposity on the brain are summarized. Our investigations suggest that weight gain results, at least in part, from a neurological predisposition characterized by reduced executive function, and in turn obesity itself has a compounding negative impact on the brain via mechanisms currently attributed to low-grade systemic inflammation, elevated lipids and/or insulin resistance. The possible role of cognitive remediation treatment strategies to prevent and/or treat obesity is discussed.

Few with eating disorders (EDs) access evidence-based treatments. We conducted a prospective exploration of help-seeking by 57 community women with bulimic-type EDs using the Framework approach of familiarization, identifying themes, indexing, charting and mapping and interpretation. The mean age of the sample was 33 years. Results found women sought help for concerns regarding perceived (over) weight rather than for eating, although many women would have welcomed questions from professionals regarding eating behaviours. Empathy, providing information and hope were considered important features of health professionals to provide a positive experience of help-seeking. Specific personal barriers to treatment included low motivation, fear of stigma, and cost. Greater clinician and community awareness of and action on these issues would likely help close "the gap" for effective help-seeking by those with EDs.

Objective: Mental Health Literacy (MHL), namely recognition, and beliefs about treatment concerning Anorexia Nervosa (AN) were examined in a community sample of male and female (n = 983) aged 15–94 years. Method: A vignette describing a women suffering from the symptoms of AN was presented, followed by a respondent-based structured interview concerning recognition of the problem and treatment beliefs. Results: The majority of participants could identify the problem as that of an eating disorder, although only 16.1% could specifically identify it as AN. Many also believed the problem was primarily one of low self-esteem (32.5%). General practitioners and psychiatrists or psychologists were considered the most helpful treatment providers, while obtaining information about the problem and available services, followed by family therapy, were considered the most helpful treatments. Less than one-third of participants believed complete recovery was possible. Better AN MHL was found in younger, higher educated, and metropolitan domiciled females. Discussion: This study offers encouraging results in regard to AN MHL. In particular, there was moderate regard for the use of mental health specialists in the treatment of the disorder. However, there appears to be a misconception that AN is largely the manifestation of low self-esteem and confusion concerning the distinction between AN and bulimia nervosa. AN MHL was poorer in males and those with higher social and health disadvantage.

Purpose In the context of Cochrane systematic reviews/meta-analyses of randomized clinical trials, risk of bias (RoB) is assessed using categorical indicators (low, unclear, or high RoB). This study sought to evaluate the indicators of the Cochrane RoB tool available for construct validity as applied to randomized clinical trials of psychological treatments for bulimia nervosa and binge eating. Methods Bayesian confirmatory factor analysis was used to test the construct validity of the measurement model underlying the set of five categorical items, and the reliability of these indicators to measure RoB. Results In 48 primary randomized clinical trials, the model showed good fit indices and factor loadings higher than 0.4. Conclusions The results support the construct validity of the Cochrane RoB tool and the reliability of three of five items in this health intervention context.

Obesity and eating disorders are each associated with severe physical and mental health consequences, and individuals with obesity as well as comorbid eating disorders are at higher risk of these than individuals with either condition alone. Moreover, obesity can contribute to eating disorder behaviors and vice-versa. Here, we comment on the health complications and treatment options for individuals with obesity and comorbid eating disorder behaviors. It appears that in order to improve the healthcare provided to these individuals, there is a need for greater exchange of experiences and specialized knowledge between healthcare professionals working in the obesity field with those working in the field of eating disorders, and vice-versa. Additionally, nutritional and/or behavioral interventions simultaneously addressing weight management and reduction of eating disorder behaviors in individuals with obesity and comorbid eating disorders may be required. Future research investigating the effects of integrated medical, psychological and nutritional treatment programs addressing weight management and eating disorder psychopathology in individuals with obesity and comorbid eating disorder behaviors—such as binge eating—is necessary.

We sought to further explore the validity of the distinction between objective bulimic episodes (OBEs) and subjective bulimic episodes (SBEs) in the study of bulimic-type eating disorders. Drawing on data obtained at the second, interview phase of a large-scale epidemiological study, we identified mutually exclusive subgroups of women with bulimic-type eating disorders who engaged in regular OBEs but not SBEs (n = 37) or regular SBEs but not OBEs (n = 52). These subgroups were compared on a wide range of outcomes, including socio-demographic characteristics, current levels of eating disorder psychopathology, general psychological distress and impairment in role functioning, current and lifetime impairment in quality of life specifically associated with an eating problem, (self)-recognition of an eating problem, health service utilization and use of psychotropic medication. The only difference between groups was that participants who reported regular OBEs were heavier than those who reported regular SBEs. The findings converge with those of previous research in suggesting that bulimic-type eating disorders characterized by regular SBEs, but not OBEs, do not differ in any clinically meaningful way from those characterized by regular OBEs, but not SBEs. Inclusion of bulimic-type eating disorders characterized by regular SBEs as a provisional category requiring further research in DSM-V appears warranted.

Attitudes and beliefs concerning the nature and treatment of bulimia nervosa (BN) were compared among young adult women at low risk of an eating disorder (n = 332), at high risk (n = 83), or already showing symptoms (n = 94). Participants completed a self-report questionnaire that included a measure of eating disorder symptoms. A vignette of a fictional person suffering from BN was presented, followed by a series of questions addressing the nature and treatment of the problem described. High-risk and symptomatic participants were more likely than low-risk participants to report that they would not approach anyone for advice or help, were they to have BN or a similar problem, because they would not want anyone to know. Symptomatic participants were more likely to believe that someone with BN would be discriminated against, more likely to consider bulimic behaviors to be acceptable, and more likely to view BN as being common among women in the community, than low-risk participants, participants in the high-risk group being intermediate on each of these questions. The findings suggest that the attitudes and beliefs of individuals with eating disorder symptoms differ systematically from those of individuals at high risk, but who do not yet have symptoms, and from those at low risk. They also indicate specific attitudes and beliefs that may need to be addressed in prevention and early intervention programs. The potential benefits of assessing individuals' attitudes and beliefs concerning the nature and treatment of eating-disordered behaviour and tailoring program content accordingly may be worthy of investigation.

Variables associated with the use of health services were examined in a prospective, community-based study of women with bulimic-type eating disorders who did (n = 33) or did not (n = 58) receive treatment for an eating problem during a 12-month follow-up period. Participants who received treatment for an eating problem differed from those who did not in several respects, including higher body weight, higher levels of eating disorder psychopathology, general psychological distress, and impairment in role functioning, deficits in specific aspects of coping style, greater awareness of an eating problem, and greater likelihood of prior treatment for a problem with weight. However, the variables most strongly associated with treatment seeking were greater perceived impairment in role functioning specifically associated with an eating problem and greater perceived inability to suppress emotional difficulties. These were the only variables that were significantly associated with treatment seeking in multivariable analysis. The findings suggest that individuals' recognition of the adverse effects of eating-disordered behavior on quality of life may need to be addressed in prevention and early intervention programs for eating disorders.

We aimed to assess and compare emotional responses to different foods in relationship to eating disorder and associated features, across gender and age groups. We hypothesized that negative emotional responses to images of foods would be higher in (i) those with higher body dissatisfaction and (ii) older females. Five hundred and thirty-six (18% Grade 5, 39% Grade 8 or 9, and 43% Grade 11 or 12) school, and 93 university students participated. Emotive responses to images of foods were assessed with a PowerPoint presentation of 16 differing food and four 'neutral' images shown over 30s intervals. Responses were rated on three 10-cm visual analog scales measuring levels of happiness, fear and disgust. Body image concern was assessed with the nine-item body dissatisfaction subscale of the EDI and eating disorder symptoms with the Eating Disorder Examination Questionnaire. With increasing age all three emotional responses towards food fell and body dissatisfaction increased. Compared to females, males showed significantly higher levels of a 'happy' response to food, and in adult females a fear emotive response correlated positively with eating concern and body dissatisfaction. In men, positive emotive responses to food may be indicative of broader factors that reduce their vulnerability to eating disorders.

Background and Aims: Attitudes and beliefs concerning the eating disorder bulimia nervosa (BN) were examined in a community sample of women (n = 158) with BN-type eating disorders.Method: A vignette was presented describing a fictional person meeting diagnostic criteria for BN. Participants gave their opinions on a range of issues concerning the nature and treatment of the problem described.Results: Most participants believed that BN would be difficult to treat and that relapse would be likely, were initial treatment successful. Primary care practitioners, psychologists, counsellors and close friends were perceived as helpful in the treatment of BN by the vast majority of participants. Lifestyle changes, including taking vitamins and minerals, were also highly regarded, whereas participants were ambivalent about the benefits of psychiatrists and antipathetic towards the use of prescription medication. Most participants believed that BN is common among women in the community and many had occasionally or of...

Objective: Attitudes and beliefs concerning a binge eating problem were examined in a community sample of men and women (n = 1031) aged 15 to 94 years. Method: A vignette describing a fictional 32-year-old female obese binge eater was presented, followed by a series of questions concerning the nature and treatment of the problem described. Results: Most participants believed that binge eating is primarily a problem of low self-esteem or depression. Behavioral weight loss treatment and self-help interventions were the treatments considered most helpful, whereas few participants believed that psychotherapy would be helpful. General practitioners and dieticians were the treatment providers considered most helpful. Most participants were ambivalent about prognosis given treatment and pessimistic about outcome in the absence of treatment. Conclusion: The fact that binge eating is viewed primarily as a problem of negative affect, and that specific psychotherapy is not highly regarded as a treatment, may go some way to explaining why most individuals with binge eating-type disorders do not receive appropriate treatment. The benefits of specific psychotherapy in stabilizing eating behavior and improving quality of life for obese binge eaters need to be communicated to sufferers and to the health professionals they are likely to contact. © 2008 by Wiley Periodicals, Inc. Int J Eat Disord 2008

Objective and Methods In order to replicate findings from previous community-based research, conducted in Australia, in a different sample, we examined relationships between exercise behaviour, eating-disordered behaviour and quality of life among young adult women attending one of two primary care facilities in the upper Midwest region of the United States. Results A high level of guilt when exercise is missed was associated with markedly elevated levels of eating disorder psychopathology and significantly reduced quality of life. The combination of exercising solely for weight and shape and intense guilt after missing exercise was associated with very high levels of eating disorder psychopathology, comparable to those of individuals seeking specialist treatment. Conclusions The findings provide further evidence that where young adult women experience intense guilt when exercise is missed, high levels of eating disorder psychopathology and poor quality of life can be expected, particularly when exercising solely for weight or shape reasons is also reported. Information to this effect should be included in both eating disorder and obesity prevention programmes. Copyright © 2007 John Wiley & Sons, Ltd and Eating Disorders Association.

Aim: We hypothesize that a reason for the infrequent uptake of treatments by people with eating disorders is poor knowledge about treatments and outcomes for eating disorders (ED-Mental Health Literacy; ED-MHL). Our aim was to test putative health benefits of a brief ED-MHL intervention. Methods: In a community-based two-phase survey, 122 young women (mean age 28.5 SD 6.3 years) with ED symptoms meeting DSM-IV criteria for clinical severity were randomized to receive either a brief ED-MHL intervention (comprising information about efficacious treatments, reputable self-help books and where to go for further information and/or services) or information about local mental health services only. All were given feedback on their scores on measures of ED symptoms and quality of life. ED-MHL, ED symptoms and health-related quality of life were assessed prior to the intervention and at 6- and 12-month follow-up. Results: One hundred and two participants (84%) completed follow-up at 12 months. Symptomatic improvement and changes in specific aspects of ED-MHL, namely, less pessimism about how difficult EDs are to treat and improved recognition and knowledge, as well as increased help seeking, were observed in both groups. Differences between groups were uncommon but compared with control participants, those in the intervention group had improved health-related quality of life. Conclusions: A brief community-based intervention aimed to improve knowledge and beliefs about EDs and their treatments may be a valuable first step in improving health-related outcomes for people with ED, but more research is needed.

MOND, JONATHAN M., BRYAN RODGERS, PHILLIPA J. HAY, ANITA DARBY, CATHY OWEN, BERNHARD T. BAUNE, AND R. L. KENNEDY. Obesity and impairment in psychosocial functioning in women: the mediating role of eating disorder features. Obesity. 2007;15: 2769–2779. Objective: The objective was to test the hypothesis that, in women, the association between obesity and impairment in psychosocial functioning is mediated by levels of weight and shape concerns and/or binge-eating frequency. Research Methods and Procedures: Self-report measures of eating disorder psychopathology, mental health functioning, subjective quality of life in the psychological and social domains, and days “out-of-role” associated with any (physical or mental) health problem, were completed by a community sample of women classified as obese (BMI 30 kg/m 2 , n 639) or non-obese (BMI 30 kg/m 2 , n 4253). For each of the dependent measures, regression models were used to test the hypothesis of mediation by comparing the strength of the relationship between independent and dependent variables with and without inclusion of the putative mediator in the regression model. Results: On each measure, the conditions for perfect mediation were satisfied when weight or shape concerns acted as the putative mediator, indicating that there was no association between obesity and functional impairment after controlling for weight or shape concerns. In contrast, associations between obesity and impairment in psychosocial functioning remained highly significant when binge-eating frequency was the putative mediator. Discussion: The findings suggest that in women, weight and shape concerns are an important mediator of the relationship between obesity and impairment in psychosocial functioning, whereas binge eating may not be of primary importance. A greater focus on body acceptance in obesity treatment may be indicated.

Poor Mental Health Literacy (MHL), i.e. knowledge and beliefs about bulimia nervosa (BN), among health professionals may contribute to low rates of recognition and less optimal management. The aim of this study was to investigate the BN-MHL of health professionals. A total of 534 professionals selected randomly from Internet based lists were surveyed with a MHL questionnaire regarding a fictional vignette of a woman with BN. One hundred and thirty-six dieticians, 68 psychologists and 97 counselors, total 56% (n = 301) responded. The majority of respondents indicated the woman in the vignette suffered from BN (49%) or an eating disorder (20%) and endorsed evidenced based approaches. On post hoc between group analyses there was a trend (p = .02) for dieticians and psychologists to be more likely than counselors to accurately identify the diagnosis of BN. Dieticians and psychologists were also more likely than counselors to endorse a psychologist as the most helpful treatment provider (p

In the year-end editorial, the PLOS Medicine editors ask 11 researchers and clinicians about the most relevant challenges, promising research, and important initiatives in their fields as we head into 2016.

Background Around 40 % of individuals with eating disorders of recurrent binge eating, namely bulimia nervosa and binge eating disorder, are obese. In contrast to binge eating disorder, currently there is no evidence base for weight management or weight loss psychological therapies in the treatment of bulimia nervosa despite their efficacy in binge eating disorder. Thus, a manualised therapy called HAPIFED (Healthy APproach to weIght management and Food in Eating Disorders) has been developed. HAPIFED integrates the leading evidence-based psychological therapies, cognitive behavioural therapy-enhanced (CBT-E) and behavioural weight loss treatment (BWLT) for binge eating disorder and obesity respectively. The aim of the present study is to detail the protocol for a randomised controlled trial (RCT) of HAPIFED versus CBT-E for people with bulimia nervosa and binge eating disorder who are overweight/obese. Method/Design A single-blind superiority RCT is proposed. One hundred Brazilian participants aged ≥ 18 years, with a diagnosis of bulimia nervosa or binge eating disorder, BMI > 27 to