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Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally.

ObjectiveMisconceptions around which patients will and will not benefit from family-based treatment (FBT) for adolescent eating disorders (EDs) limit referrals and access to this treatment modality. The present study explored whether common demographic and clinical factors that may prevent referral to FBT predict treatment outcomes in adolescent anorexia nervosa (AN) and bulimia nervosa (BN).MethodThe following predictors of treatment outcomes were assessed: baseline family and diagnostic factors (socioeconomic status, comorbidity, illness duration, parent feelings of self-efficacy, family status, prior treatment, sex and prior hospitalizations) in a combined sample of adolescents receiving FBT compared to those randomized to other treatment conditions, across six clinical trials in the United States and Canada (total n = 724, ages 12-18, 90% female across both diagnoses). AN and BN samples were examined separately.ResultsAny prior ED treatment emerged as the only predictor of outcome in AN and BN, such that having no prior treatment predicted better outcomes in FBT for AN, and in both FBT and other treatment modalities for BN. No other sociodemographic or clinical variables predicted outcomes for AN or BN in FBT or in other evidence-based treatment modalities.ConclusionsThe findings of this exploratory analysis suggest that commonly assumed factors do not predict outcome in FBT. Specifically socioeconomic and demographic factors or clinical variability in families seeking treatment do not predict treatment outcomes in FBT, or other evidence-based treatment modalities, with the exception of prior treatment. Providers should consider referring to FBT even when these factors are present.Public significanceThis manuscript reports that commonly assumed family, sociodemographic and diagnostic factors do not predict outcome in FBT or other evidence-based treatment modalities, with the exception of prior treatment. This data may be helpful for providers when considering referrals to FBT in the context of variability in these variables.

BACKGROUND: Family-based treatment (FBT) is the first-line treatment for adolescent anorexia nervosa (AN). Yet, remission is not achieved for about half of adolescents with AN receiving FBT. Understanding patient- and parent-level factors that predict FBT response may inform treatment development and improve outcomes. METHODS: Network analysis was used to identify the most central symptoms of AN in adolescents who completed the Eating Disorder Examination (EDE) prior to FBT (N = 409). Bridge pathways between adolescent AN and parental self-efficacy in facilitating their childs recovery from AN were identified in a subset of participants (n = 184). Central and bridge symptoms were tested as predictors of early response (⩾2.4 kg weight gain by the fourth session of FBT) and end-of-treatment weight restoration [⩾95% expected body weight (EBW)] and full remission (⩾95% EBW and EDE score within 1 standard deviation of norms). RESULTS: The most central symptoms of adolescent AN included desiring weight loss, dietary restraint, and feeling fat. These symptoms predicted early response, but not end-of-treatment outcomes. Bridge symptoms were parental beliefs about their responsibility to renourish their child, adolescent discomfort eating in front of others, and adolescent dietary restraint. Bridge symptoms predicted end-of-treatment weight restoration, but not early response nor full remission. CONCLUSIONS: Findings highlight the prognostic utility of core symptoms of adolescent AN. Parent beliefs about their responsibility to renourish their child may maintain associations between parental self-efficacy and AN psychopathology. These findings could inform strategies to adapt FBT and improve outcomes.

Family-based treatment (FBT) has the largest evidence base for treating adolescents with anorexia nervosa (AN); 35-50% of cases remit at the end-of-treatment and remain remitted 3-4 years after treatment. Studies of FBT demonstrate that weight restoration by session 4 (of 2.4 kgs) predicts remission at end of treatment in 85-90% of cases. One way to improve outcomes is to tailor treatments to patients depending on successful weight restoration at session 4. Pilot data found that by adding three sessions of Intensive Parental Coaching (IPC) after session 4 improved outcomes in early non-responders. Further, data suggest that the mechanism underlying FBT is early improvements in parental self-efficacy related to re-feeding their child. This manuscript describes a study protocol to examine whether adding IPC to FBT improves outcomes in early non-responders and confirm whether change in parental self-efficacy is the mechanism by which FBT works. This two-site randomized controlled trial (RCT) will randomize 60 adolescents with a DSM-5 diagnosis of AN (30 per site) who are between the ages of 12-18 years old and do not gain 2.4 kgs by session 4 of FBT. Randomized participants will either continue standard FBT or receive the three sessions of IPC and then continue FBT as usual. Both arms include up to 18 sessions over the course of 9 months. Blinded assessments will be conducted at baseline, 3-month within-treatment, end of treatment, and at 6 and 12-month follow-up. Parental-self efficacy will be assessed using the Parent versus Anorexia Scale at all major assessment time points and at each of the first eight sessions of treatment. The primary outcome is achievement of weight remission (> 94% expected mean percent body mass index (BMI) adjusted for age, height, and gender).Clinical trial registrationhttp://www.ClinicalTrials.gov, identifier NCT03097874.

BackgroundThis secondary data analysis seeks to replicate and extend findings that early response to treatment in adolescent bulimia nervosa (BN) predicts outcome, resulting in earlier identification of patients who might need a different treatment approach.MethodsParticipants were 71 adolescents (M ± SD: 15.69 ± 1.55 years; 93% female; 75% non-Hispanic) with a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnosis of BN or partial BN enrolled in a two-site treatment study. Participants were randomized to cognitive behavioral therapy for adolescents (CBT-A), family-based treatment for BN (FBT-BN), or supportive psychotherapy (SPT). The Eating Disorder Examination was administered at baseline, end-of-treatment (EOT), 6-month, and 12-month follow-up. Binge eating and purge symptoms were self-reported at each session. Outcome was defined as abstinence of binge eating and compensatory behaviors (self-induced vomiting, laxative use, diet pills, diuretics, compensatory exercise, fasting) in the 28 days prior to assessment. Receiver operating characteristic (ROC) analyses were utilized to assess the viability of predicting treatment outcomes based on reduction of symptoms within the first 10 sessions of treatment.ResultsROC analyses suggest that reduction in purging at session 2 (AUC =.799, p < .001) and binge eating at session 4 (AUC =.750, p < .01) were independently related to abstinence of symptoms at EOT, regardless of treatment type. Symptom reduction later in treatment predicted outcome at follow-up, as change in binge eating at session 8 and purging at session 9 were the strongest predictors of abstinence at 6-month follow-up (AUCs =.726-.763, ps < .01). Change in binge eating, but not purging behaviors, was significantly related to abstinence at 12-month follow-up (AUC =.766, p < .01). Only slight differences emerged based on treatment group, such that reductions in symptoms most predictive of abstinence at EOT occurred one session sooner in FBT-BN than SPT.ConclusionReductions in binge eating and purge symptoms early in adolescent BN treatment suggest better outcome, regardless of treatment modality. Additional research with larger samples is needed to better understand which treatments, if any, contribute to earlier change in BN symptoms and/or likelihood of improved patient response.

This study examined the effect of family-based treatment for bulimia nervosa (FBT-BN) and cognitive behavioral therapy for adolescents (CBT-A) on depressive symptoms and self-esteem in adolescents with BN. Data were collected from 110 adolescents, ages 12-18, who met Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, text revision criteria for BN or partial BN. Participants were randomly assigned to FBT-BN or CBT-A and completed measures of depressive symptoms and self-esteem before and after treatment and at 6- and 12-month follow-up assessments. Depressive symptoms and self-esteem significantly improved in both treatments, and neither treatment appeared superior on these clinical outcomes. Parents often worry whether FBT-BN addresses comorbid depressive symptoms and low self-esteem. Our findings address this concern, as they demonstrate that FBT-BN does not differ from CBT-A in improving depressive symptoms and self-esteem, and both treatments result in symptom improvement. These findings can help clinicians guide families to choose a treatment that addresses BN and depressive symptoms and low self-esteem.

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) share distorted perceptions of appearance with extreme negative emotion, yet the neural phenotypes of emotion processing remain underexplored in them, and they have never been directly compared. We sought to determine if shared and disorder-specific fronto-limbic connectivity patterns characterize these disorders. FMRI data was obtained from three unmedicated groups: BDD (n = 32), weight-restored AN (n = 25), and healthy controls (HC; n = 37), while they viewed fearful faces and rated their own degree of fearfulness in response. We performed dynamic effective connectivity modeling with medial prefrontal cortex (mPFC), rostral anterior cingulate cortex (rACC), and amygdala as regions-of-interest (ROI), and assessed associations between connectivity and clinical variables. HCs exhibited significant within-group bidirectional mPFC-amygdala connectivity, which increased across the blocks, whereas BDD participants exhibited only significant mPFC-to-amygdala connectivity (P < 0.05, family-wise error corrected). In contrast, participants with AN lacked significant prefrontal-amygdala connectivity in either direction. AN showed significantly weaker mPFC-to-amygdala connectivity compared to HCs (P = 0.0015) and BDD (P = 0.0050). The mPFC-to-amygdala connectivity was associated with greater subjective fear ratings (R2 = 0.11, P = 0.0016), eating disorder symptoms (R2 = 0.33, P = 0.0029), and anxiety (R2 = 0.29, P = 0.0055) intensity scores. Our findings, which suggest a complex nosological relationship, have implications for understanding emotion regulation circuitry in these related psychiatric disorders, and may have relevance for current and novel therapeutic approaches.

Cranial electrotherapy stimulation (CES) is a U.S. Food and Drug Administration (FDA)-approved treatment for insomnia, depression, and anxiety consisting of pulsed, low-intensity current applied to the earlobes or scalp. Despite empirical evidence of clinical efficacy, its mechanism of action is largely unknown. The goal was to characterize the acute effects of CES on resting state brain activity. Our primary hypothesis was that CES would result in deactivation in cortical and subcortical regions. Eleven healthy controls were administered CES applied to the earlobes at subsensory thresholds while being scanned with functional magnetic resonance imaging in the resting state. We tested 0.5- and 100-Hz stimulation, using blocks of 22 sec "on" alternating with 22 sec of baseline (device was "off"). The primary outcome measure was differences in blood oxygen level dependent data associated with the device being on versus baseline. The secondary outcome measures were the effects of stimulation on connectivity within the default mode, sensorimotor, and fronto-parietal networks. Both 0.5- and 100-Hz stimulation resulted in significant deactivation in midline frontal and parietal regions. 100-Hz stimulation was associated with both increases and decreases in connectivity within the default mode network (DMN). Results suggest that CES causes cortical brain deactivation, with a similar pattern for high- and low-frequency stimulation, and alters connectivity in the DMN. These effects may result from interference from high- or low-frequency noise. Small perturbations of brain oscillations may therefore have significant effects on normal resting state brain activity. These results provide insight into the mechanism of action of CES, and may assist in the future development of optimal parameters for effective treatment.

This study examined the effect of pre-treatment levels of parental expressed emotion (EE) on early treatment response for adolescent anorexia nervosa (AN). Data were collected from 121 adolescents, ages 12–18, who met DSM-IV criteria for AN excluding the amenorrhea criterion, and their parents. Participants were randomized to family-based treatment (FBT) or adolescent-focused therapy (AFT). To examine the effects of different thresholds of EE, we used two different levels of EE in analyses. Results demonstrated that adolescents who had at least one parent with elevated EE indicated by a lower threshold (i.e. even mild levels) at baseline were less likely to achieve an early treatment response, suggesting that EE might interfere with treatment success from the start of treatment. When high EE was defined by a higher threshold, these effects were no longer significant, regardless of treatment type (FBT or AFT). These findings suggest that adolescents with AN may be more sensitive to EE than other mental illnesses, such that lower thresholds of EE impact the speed with which they are able to reduce symptoms and gain weight in treatment. It may be necessary to target parental EE prior to or early in treatment or pivot to parent-focused treatment to change the trajectory of treatment response. Future research is needed to explore ways parental EE can be reduced. [ABSTRACT FROM AUTHOR]

Loss of control (LOC) eating in youth is a common disordered eating behavior and associated with negative health and psychological sequalae. Family-based treatment (FBT) is an efficacious treatment for adolescent anorexia nervosa and bulimia nervosa (BN) but has not been formally evaluated for adolescents with LOC eating. This study is a secondary data analysis from a randomized controlled clinical trial (NCT00879151) testing FBT for 12–18-year-olds with BN. Data were reanalyzed to examine outcomes for LOC eating episodes, regardless of episode size. Abstinence rates, defined as zero LOC eating episodes (objective or subjective binge episodes) in the previous month, were calculated at the end-of-treatment (EOT), 6-month, and 12-month follow-up time points. Among 51 adolescent participants (M + SD: 15.94 + 1.53 y; 92% female; 23.5% Hispanic; 76.5% Caucasian), FBT significantly reduced LOC eating episodes, with 49% achieving LOC eating abstinence at EOT. At 6-month follow-up, 41% achieved LOC eating abstinence. Of those providing 12-month follow-up data, 73% achieved abstinence. This preliminary exploration suggests that FBT may be effective for youth with LOC eating, regardless of episode size. Additional research is needed to replicate these findings and extend treatments with developmental adaptations for younger children with LOC eating. [ABSTRACT FROM AUTHOR]

Objective: Test whether a group-delivered dissonance-based transdiagnostic eating disorder treatment, Body Project Treatment (BPT), produces greater reductions in eating disorder symptoms and higher abstinence from eating disorder behaviors and remittance from eating disorder diagnoses than group-delivered transdiagnostic interpersonal psychotherapy (IPT). Method: Women with a range of eating disorders (N = 73) were randomized to 8-week group-implemented BPT or IPT and completed surveys and masked diagnostic interviews at pretest, posttest, and 6-month follow-up. Results: Participants randomized to BPT versus IPT showed significantly greater reductions in eating disorder symptoms (d = −.75), pursuit of the thin ideal (d = −.87), anxiety symptoms (d = −.76), and social impairment (d = −.59) through 6-month follow-up. By end of treatment, participants randomized to the BPT versus IPT did not significantly differ on abstinence from binge eating and purging (49% vs. 40%, respectively) or remittance from eating disorder diagnoses (54% vs. 40%, respectively). Participants randomized to BPT versus IPT did not differ significantly in average session attendance (5.8 vs. 6.9, respectively) or average homework assignments completed (4.6 vs. 5.6, respectively). The within-condition reductions in eating disorder symptoms for BPT did not significantly differ when implemented in person versus via synchronous video telepsychiatry (d = −1.39 vs. −1.09, respectively), though these effects should be considered preliminary because of the small cell sizes. Conclusions: The evidence that BPT produces greater reductions in eating disorder symptoms, pursuit of the thin ideal, anxiety symptoms, and social impairment than IPT is encouraging because it provides some assurance that the effects are present equating for the effects of expectancies, demand characteristics, and nonspecific factors. What is the public health significance of this article?: This study provides evidence that a novel dissonance-based transdiagnostic eating disorder treatment produced greater reductions in eating disorder symptoms, pursuit of the thin ideal, anxiety symptoms, and social impairment relative to group-delivered transdiagnostic interpersonal psychotherapy. To our knowledge, this is the first transdiagnostic eating disorder treatment to significantly outperform an alternative active treatment through 6-month follow-up. [ABSTRACT FROM AUTHOR]