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During the COVID-19 pandemic in Israel, the number of patients with eating disorders (EDs) seeking treatment increased significantly. The present study sought to evaluate whether, during the pandemic (2020-21), patients with anorexia nervosa (AN) would show more ED-related, comorbid, and COVID-19-related symptoms in comparison to a naturalistic control group, and whether differences would be found between adult and adolescent patients with AN. We also examined attitudes to telemedicine use during the pandemic in patients receiving long-distance interventions.Using online self-report questionnaires, we assessed general and COVID-19-specific symptoms with a secure digital platform (REDCapCompared with controls, patients with AN showed more symptoms of EDs, anxiety, depression, and post-traumatic stress disorder (PTSD), elevated suicidal ideation, more COVID-related emotional-behavioral disturbances, and lower resilience. Adult patients with AN fared worse than adolescent patients on most of these measures. Adult patients using telemedicine during the COVID-19 pandemic showed fewer positive attitudes toward this treatment than adolescents (telemedicine was offered to all, but used by 18/35 adolescents and 21/36 adults with AN). Last, elevated COVID-19-related symptomatology was correlated with more symptoms of ED, anxiety, depression and PTSD, and with lower resilience.Our findings suggest that the emotional-behavioral state of Israeli females with AN, particularly adults, was worse during the COVID-19 pandemic in comparison to controls. Many patients did not use telemedicine for their treatment. Adult patients using telemedicine were less satisfied with it than adolescent patients.The recent COVID-19 pandemic has been associated with increased rates of eating disorders in many countries around the globe, including Israel. Our study evaluated whether Israeli patients with anorexia nervosa would fare worse than a control group during the COVID-19 pandemic, and whether adults and adolescents with anorexia nervosa would differ. For this purpose, we administered questionnaires to 71 females with anorexia nervosa—36 adolescents and 35 adults—and to a control group of 25 adolescent and young adult women. We found that females with anorexia nervosa showed not only more eating-disordered and psychiatrically-related symptoms, but also more pandemic-related disturbances than the control group. Among the patients with anorexia nervosa, adults fared worse than adolescents. Fifty-one percent of adolescents and 58% of adults with anorexia nervosa received treatment via telemedicine, although all were offered this treatment. Adults treated with telemedicine showed fewer positive attitudes toward it than adolescents. Last, more disordered eating and other psychiatric symptoms were associated with more COVID-19-specific disturbances. Our findings suggest that the emotional-behavioral state of female Israeli patients with anorexia nervosa is worse than that of control females during the COVID-19 pandemic, especially in adults.

Abstract Background Eating disorders (EDs) are among the most difficult psychiatric disorders to treat in normal conditions. They are likely even more difficult to manage in at-risk conditions such as the COVID-19 pandemic. Currently there is limited evidence about the particular needs and recommended treatment of adolescents with EDs during the COVID-19 outbreak, in particular regarding the use of telemedicine and the involvement of the family in long distance-treatment. Aims We sought to discuss the advantages and problems associated with the use of multi-professional long-distance telemedicine treatment in the management of adolescents with EDs and their families during the COVID-19 outbreak. Methods We gathered data about the treatment of adolescents with EDs in our pediatric ED-treatment center in Israel during the COVID-19 outbreak in the first 10 months of 2020, and compared it to the respective period in the past five years (2015–2019). Second, we described the management of four young females with anorexia nervosa (AN), treated in the ambulatory, daycare and inpatient facilities of our center during the COVID-19 pandemic. Findings Slightly less patients were treated in our center during the COVID-19 pandemic than in the respective period in the past five years. These patients received at that time considerably more treatment sessions from all treatment providers (psychiatrists, clinical nutritionists and psychotherapists). This was related, in part, to the extensive use of telemedicine during that period (more than as third of all sessions were carried out with telemedicine in comparison to no use of long-distance treatment in the previous years). The condition of the four adolescents with AN was compromised at the start of the COVID-19 quarantine. The use of multi-disciplinary long-distance telemedicine treatment resulted in an improvement in the condition in three of the four adolescents, living in well-organized families, with the motivation and ability to adjust to the new conditions, but not in one adolescent whose family experienced more problems. These families might require the use of face-to-face interventions even during pandemic conditions. Conclusion The choice of the mode of treatment for adolescents with EDs during pandemic times (telemedicine vs. face-to-face) should consider the functioning of the family.

ContextGrowth retardation is an established complication of anorexia nervosa (AN); however, findings concerning the adult height of AN patients are inconsistent.ObjectiveThe objective of this work was to assess linear growth and adult height in female adolescents with AN.Design and SettingA prospective observational study was conducted in a tertiary university hospital.ParticipantsParticipants included all 255 female adolescent AN patients hospitalized in the pediatric psychosomatic department between January 1, 2000 and May 31, 2015.InterventionsHeight and weight were assessed at admission and during hospitalization. Patients were subsequently invited for measurement of adult height. Additional data collected included premorbid height data, menstrual history, skeletal age, pertinent laboratory studies, and parental heights.Main Outcome MeasureThe main outcome measure of this study was adult height.ResultsMean age at admission was 15.4 ± 1.75 years, mean body mass index (BMI) was 15.7 ± 1.8 kg/m2 (BMI SDS = –2.3 ± 1.45 kg/m2). Premorbid height SD scores (SDS) were not significantly different from those expected in normal adolescents (0.005 ± 0.96). However, height SDS at admission (–0.36 ± 0.99), discharge (–0.34 ± 0.96), and at adult height (–0.29 ± 0.95), were significantly (P ConclusionsWhereas the premorbid height of female adolescent AN patients is normal, linear growth retardation is a prominent feature of their illness. Weight restoration is associated with catch-up growth, but complete catch-up is often not achieved.

In patients with eating disorders (EDs), elevated dissociation may increase the risk of suicide. Bodily related disturbances, depression, and anxiety may intervene in the association between dissociation and suicidality. In this study we aimed to examine the influence of bodily related disturbances, depression, anxiety, severity of ED symptoms, body mass index (BMI), and type and duration of the ED on the relationship between elevated dissociation and elevated suicidality. The study included 172 inpatients: 65 with anorexia nervosa restricting type, 60 with anorexia nervosa binge/purge type, and 37 with bulimia nervosa. Participants were assessed using self-rating questionnaires for dissociation, suicidality, bodily related parameters, and severity of ED symptomatology, depression, and anxiety. We found that dissociation and suicidality were directly associated. In addition, depression and anxiety moderated the mediating role of body image parameters in the association between increased dissociation and increased suicidality. Thus, only in inpatients with high depression and anxiety, i.e., above the median range, body image disturbances were found to mediate the association between dissociation and suicidality. ED-related parameters did not moderate these relationships. Our study demonstrates that in inpatients with EDs, increased dissociation may be significantly associated with increased suicidality, both directly and via the intervening influence of body image, depression, and anxiety.

Impaired bone health is a common complication of anorexia nervosa (AN). We aimed to assess longitudinal changes in bone mineral density (BMD) and trabecular bone score (TBS), a measure of bone quality, in female adolescents with anorexia nervosa (AN). We conducted a retrospective longitudinal study of 41 female adolescents with AN who underwent two dual-energy X-ray absorptiometry (DXA) scans. Clinical data, including age, weight, height, body mass index (BMI), and DXA measurements were retrieved from the medical charts. Lumbar bone mineral apparent density (BMAD) was calculated to correct for size. Changes (Δ) in BMD, BMAD, and TBS were examined for correlations with clinical characteristics. Mean ages at the time of DXA scans were 14.8±1.9 and 16.8±2.0 years. There was a significant improvement in anthropometric parameters and DXA measurements at the second DXA scan. However, these values were still significantly lower than expected in the general population. The Δlumbar BMD Z-score was 0.3±0.7, the Δlumbar BMAD Z-score was 0.2±0.7 and the ΔTBS Z-score was 0.5±0.7. ΔTBS Z-score was positively correlated with Δheight Z-score, Δweight Z-score and ΔBMI Z-scores, and negatively correlated height Z-score, weight Z-score and TBS Z-scores at the first DXA scan (p0.05). Δheight Z-score, ΔBMI Z-score and the progression from early to late puberty were identified as significant independent predictors of Δlumbar BMAD Z-score (p0.05). During two years of treatment, both BMD and TBS increased significantly. Improvement in height and in weight status, and progression in puberty are predictors of improvement in BMD and TBS.

OBJECTIVE This study had two goals. The first was to validate and examine the potential of the Hebrew version of the Cambridge Mindreading face task (CAMHeb )-an ecological measure of emotional theory of mind (eToM)-to assess eToM in individuals with anorexia nervosa (AN). The second goal was to examine whether interpersonal mistrust would mediate the relation between mentalizing and eToM and the severity of AN. METHOD The validity of the CAMHeb was examined using well-established measures of mentalizing ability and eToM in 45 young female patients with AN and 53 control participants. Next, the mediation model was assessed using a subsample of 33 AN patients and 34 controls, in which interpersonal mistrust was additionally assessed. RESULTS The CAMHeb correlated with the measures of mentalizing ability and eToM. The CAMHeb , along with the measure of general mentalizing, significantly differentiated between the AN and control groups. The associations of general mentalizing and CAMHeb with eating disorder (ED) symptoms were mediated by interpersonal mistrust. CONCLUSION The CAMHeb is a valid measure of deficient eToM in AN. In therapy, an increase in mentalizing ability and accurate eToM may enhance interpersonal trust, which may further contribute to attenuation of AN symptoms.

Background: There are several possible facilities for the treatment of eating disorders (EDs). Specifically, there is the issue of the use of specialized daycare and ambulatory services over inpatient settings and the place of daycare programs following inpatient treatment.Aim: We sought to examine the contribution of post-hospitalization daycare program to the treatment of adolescents hospitalized with an ED.Methods: We assessed 61 female adolescents hospitalized with an ED. All but three were diagnosed with clinical or subthreshold anorexia nervosa (AN). Three were diagnosed with bulimia nervosa. Thirty-seven patients continued with a post-hospitalization daycare program for at least 5 months, whereas 24 did not enter or were enrolled in the program for Results: BMI was within normal range at follow-up, whether completing or not completing daycare treatment, and around 75% of the patients had menstrual cycles. By contrast, when using comprehensive composite remission criteria, less than a quarter of former inpatients not entering/not completing daycare program achieved remission vs. almost a half of the completers. In addition, a greater percentage of completers continued with psychotherapy following discharge. Fifty percent of both groups showed good post-discharge social functioning. No between-group differences were found in the BMI and the scores of the self-rating questionnaires at admission to, and discharge from, inpatient treatment.Conclusion: Adolescent females with EDs can maintain a normal-range BMI from discharge to 1-year follow-up, even if not completing daycare treatment. By contrast, completion of a post-hospitalization daycare program may improve the 1-year follow-up ED-related outcome of former ED inpatients.

Objective Determining resting energy expenditure (REE) may be important in the nutritional assessment of adolescents with eating disorders (EDs). Calculated equations assessing REE, developed according to data from healthy people, may under- or overestimate REE in EDs. We have sought to compare the REE measured in clinical settings to that calculated using equations in actively ill adolescents with anorexia nervosa (AN) and bulimia nervosa (BN), and following stabilization of weight and disordered eating. Methods Thirty-five female adolescents with AN and 25 with BN were assessed at admission to inpatient treatment and at discharge. REE was measured using indirect calorimetry (DELTATRAC Metabolic Monitor). Expected REE was calculated using the Harris-Benedict equation. Results An overestimation of expected versus measured REE was found for both patients with AN and BN, both at admission and discharge. Second, the differences between expected and measured REE were significantly less robust in BN versus AN. Third, REE before renourishing was lower in inpatients with AN versus BN. Fourth, the REE of patients with AN (both measured and expected) increased from admission to discharge, to a greater extent than expected solely from the increase in weight. The difference between admission and discharge expected and measured REE was significant also in patients with BN. Discussion Our findings suggest that predicted and measured REE are different in both AN and BN, and that both expected and measured REE are not useful in the planning of renourishing programs in patients with AN.

Objective Major depressive disorder (MDD) is common in anorexia nervosa (AN), associated with worse outcome and greater suicide risk. Electroconvulsive therapy (ECT) is highly effective in the treatment of MDD refractory to antidepressive treatment. We describe a case series of female adolescents with AN receiving ECT for MDD resistant to treatment and/or with severe suicide risk. Method We retrospectively analyzed the files of all 30 adolescent females hospitalized in our department because of AN between 1998 and 2017 and treated with ECT. Severity of eating disorder (ED) and depressive symptoms was retrospectively assessed using the Clinical Global Impression-Severity Scale. Results Patients were severely depressed and suicidal on admission. All were resistant to antidepressants. A significant deterioration in depression, with severe suicidality, occurred from admission to pre-ECT, with concomitant improvement in ED symptoms and increase in body mass index (BMI). Significant improvement in depressive and ED symptoms and increase in BMI occurred following ECT, continuing to discharge. Adverse effects were mostly minimal. Fifty-three percentage of the patients were rehospitalized within the first year after ECT, mostly because of deterioration of depression and attempted suicide. Several years after discharge, 46.6% of the patients had no evidence of depression, suicidality, and ED-symptomatology, and another 23% had only evidence of ED symptomatology. Discussion ECT is safe and well tolerated in AN with severe comorbid treatment resistant MDD and/or with increased suicide risk. Many AN patients undergoing ECT may be remitted at long-term follow-up.

ObjectiveTo investigate whether binge-eating in patients with eating disorders (EDs) is associated with attentional deficits.MethodsWe studied ED patients with binge-eating (n = 51), no binge-eating (n = 59) and controls (n = 58). ED patients were assessed following the stabilization of weight and ED pathology. Attention assessment included evaluation of attention deficit hyperactivity disorder (ADHD) diagnosis, the Adult ADHD Self-Report (ASRS) and ADHD Rating Scale-IV-Home Version (ADHD-RS) questionnaires, and attention functioning assessed with neuropsychological tools. The severity of eating-related pathology, depression, anxiety and obsessionality was also monitored.ResultsPatients with binge-eating showed more ADHD symptomatology on the ADHD-RS compared with non-binge-eating patients. No differences were found between binge-eating and non-binge-eating patients in ADHD diagnosis and neuropsychological functioning. Among the specific ED subtypes, patients with anorexia nervosa binge/purge type (AN-B/P) showed the highest rates of ADHD symptomatology on the ADHD-RS, and were characterized with sustained attention deficits.ConclusionBinge-eating is not associated with attention deficits as measured by objective neuropsychological tools. Nonetheless, it is associated with attentional difficulties as measured with the self-reported ADHD-RS. AN-B/P patients are the only ED category showing objective sustained attention deficits.

Research in eating disorders (EDs) suggests that outcome variables other than that of the ED per se, such as the presence of comorbid disorders and overall functioning at follow-up, may influence the ED condition at that time. We sought to assess the factors potentially predicting these different outcome variables.Eighty-eight female adolescent in-patients with an ED were assessed on admission, discharge, and around one-year post-discharge using clinical interviews and self-rating questionnaires assessing ED and other relevant symptoms.The mean body mass index (BMI) of patients with anorexia nervosa increased from admission to discharge and was maintained at follow-up. Twenty-eight patients were remitted at follow-up, whereas 48 and 12 patients had intermediate and poor ED-related outcome, respectively. Follow-up BMI was correlated with baseline BMI. Good ED-related outcome at follow-up according to accepted criteria was associated with more lifetime suicide attempts and more severe baseline ED symptomatology. Elevated psychiatric comorbidity at follow-up was associated with elevated baseline anxiety and with re-hospitalisation during the post-discharge follow-up period. Better academic/occupational functioning and social functioning at follow-up were associated with less lifetime suicide attempts, less re-hospitalisation and lower baseline anxiety.In EDs, diverse factors may predict different outcome variables.

We examined the relationship between general ability of mentalization, the specific aspect of affective mentalizing of self and others, emotion regulation strategies, and eating disorder (ED) symptoms.Twenty-five female adolescent and young adult inpatients with EDs, and 22 healthy subjects, were administered a semi-structured interview - the Reflective Function (RF) scale, self-rating scales assessing alexithymia, emotion regulation, depression and ED symptomatology, and a neurocognitive measure assessing Theory of Mind.Participants with EDs presented lower levels of RF regarding the self and higher levels of alexithymia, using more emotional suppression and less cognitive reappraisal than controls. Elevated levels of general RF and self RF and attenuated alexithymia, along with elevated cognitive reappraisal and attenuated emotional suppression, were correlated with attenuated ED symptoms. Comorbidity with depressive symptoms predicted greater ED symptomatology.High mentalization may serve as a coping mechanism to attenuate ED symptoms.

Objective To identify the threshold of total body fat percentage (TBF%) required for the resumption of menses (ROM) in hospitalized female adolescents with anorexia nervosa (AN) using bioimpedance analysis (BIA). Methods All female adolescents hospitalized with AN in our medical center were evaluated in a longitudinal prospective study during the years of 2012–2017. Anthropometric data, body fat measured by BIA, and hormonal determinants were collected periodically, in addition to routine medical and gynecological assessments. Results Sixty-two participants presented with secondary amenorrhea, of which 20 remained with amenorrhea and 42 had ROM during hospitalization. At discharge, participants with ROM regained significantly more weight, and had higher mean body mass index (BMI), BMI standard deviation scores, and TBF% than those who remained with amenorrhea. Receiver operating characteristic analysis identified that a TBF% of 21.2% had the highest discriminative ability for ROM (sensitivity = 88%, specificity = 85%, positive predictive value = 93%). Compared with the anthropometric parameters, TBF% had the highest area under curve (AUC = .895), which significantly differed from that of BMI standard deviation scores (AUC = .643, p = .007) and body weight (AUC = .678, p = .03). Conclusions BIA is a safe and relatively simple method to assess the TBF% required for the return of balanced menstrual cycles in female adolescents with AN. The TBF% with the highest discriminative ability for menstrual resumption as assessed by BIA is 21.2%.

We examined problem-solving strategies in anorexia nervosa-restricting (AN-R) type and in normal weight binge/purge (B/P) eating disorders (EDs).Twenty-four inpatients with AN-R and 22 with B/P EDs were assessed within two weeks of admission and two weeks from discharge for problem-solving, ineffectiveness, ED symptomatology, depression and anxiety; 32 controls were similarly assessed once.While we found less adaptive problem-solving strategies in patients with B/P EDs vs. controls at baseline, no such difference emerged for patients with AN-R. An improvement from admission to discharge in problem solving, depression and trait-anxiety was found for the B/P but not the AN-R group.Patients with AN-R and B/P EDs show different profiles of problem-solving strategies both in the acute stage of their illness and following symptomatic stabilization.

OBJECTIVE Strong relationships exist between obsessive-compulsive (OC) disorder and eating disorders (EDs). The aim of the study was to investigate whether OC symptoms would be expressed differently in different ED types. METHOD Ninety-four female adolescent inpatients with restricting anorexia nervosa (AN-R), 67 with binge/purge AN (AN-B/P), and 48 with bulimia nervosa (BN) were assessed on admission and discharge using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Yale-Brown-Cornell Eating Disorders Scale (YBC-EDS), Eating Attitude Test-26 (EAT-26), Beck Depression Inventory (BDI), and State-Trait Anxiety Inventory (STAI). RESULTS On admission, patients with AN-B/P exhibited higher scores on the Y-BOCS, YBC-EDS, EAT-26, and BDI in comparison with patients with AN-R or BN. A significant improvement on all psychometric variables from admission to discharge was found for all participants taken together. Nonetheless, patients with AN-B/P and/or BN showed a greater improvement on Y-BOCS, BDI, and STAI than patients with AN-R, whereas no between-group difference was found for YBC-EDS and EAT-26. CONCLUSIONS Obsessionality is more severe in acutely ill AN-B/P patients than in patients with AN-R and BN, whereas a greater improvement in obsessionality from the acutely ill to the stabilized ED condition is found in patients with binge/purge in comparison with restrictive pathology.

Patients with anorexia nervosa (AN) have been shown to display both elevated anxiety and attentional biases in threat processing. In this study, we compared threat-related attention patterns of patients with AN restricting type (AN-R; n = 32), AN binge/purge type (AN-B/P; n = 23), and healthy controls (n = 19). A dot-probe task with either eating disorder-related or general and social anxiety-related words was used to measure attention patterns. Severity of eating disorder symptoms, depression, anxiety, and stress were also assessed. Patients with AN-R showed vigilance to both types of threat words, whereas patients with AN-B/P showed avoidance of both threat types. Healthy control participants did not show any attention bias. Attention bias was not associated with any of the demographic, clinical, and psychometric parameters introduced. These findings suggest that there are differential patterns of attention allocation in patients with AN-R and AN-B/P. More research is needed to identify what causes/underlies these differential patterns.

OBJECTIVE Previous studies assessing vitamin D status in adolescents with eating disorders showed inconsistent results. The aim of the current study was to assess vitamin D status in a large cohort of adolescent inpatients with eating disorders and its relation to bone mineral density (BMD) and depression. METHOD 25-Hydroxyvitamin D (25OHD), calcium, phosphorus, and alkaline phosphatase levels as well as BMD and depression were assessed on admission in 87 inpatients (aged 16 ± 2 years, females = 81) with eating disorders [anorexia nervosa (AN) = 64; bulimia nervosa (BN) = 5; eating disorders not otherwise specified-binge/purge type (EDNOS-B/P) = 18]. RESULTS Mean 25OHD levels were 24.1 ± 7.5 ng/ml (25.0 ± 7.6, 25.4 ± 9.9, and 22.0 ± 9.9 ng/ml in patients with AB, BN, and EDNOS-B/P, respectively). Vitamin D deficiency ( 32 ng/ml, considered optimal by some experts. No associations were found between 25OHD levels and BMD or comorbid depression. 25OHD levels during winter were significantly lower than summer levels (p < .001). Mean lumbar spine BMD z-score in patients with AN and EDNOS-B/P type was low (-1.5 ± 1.1) and correlated with body mass index standard deviation score (p = .03). DISCUSSION Adolescents with eating disorders show a high prevalence of vitamin D deficiency and insufficiency. Given the risk of osteoporosis in this population, 25OHD levels found in this group may not offer optimal bone protection. Vitamin D levels should be routinely checked and supplementation should be administered as required.

Previous studies assessing vitamin D status in adolescents with eating disorders showed inconsistent results. The aim of the current study was to assess vitamin D status in a large cohort of adolescent inpatients with eating disorders and its relation to bone mineral density (BMD) and depression.25-Hydroxyvitamin D (25OHD), calcium, phosphorus, and alkaline phosphatase levels as well as BMD and depression were assessed on admission in 87 inpatients (aged 16 ± 2 years, females = 81) with eating disorders [anorexia nervosa (AN) = 64; bulimia nervosa (BN) = 5; eating disorders not otherwise specified-binge/purge type (EDNOS-B/P) = 18].Mean 25OHD levels were 24.1 ± 7.5 ng/ml (25.0 ± 7.6, 25.4 ± 9.9, and 22.0 ± 9.9 ng/ml in patients with AB, BN, and EDNOS-B/P, respectively). Vitamin D deficiency (15 ng/ml) was found in 7.8% of the patients, and insufficiency (15-20 ng/ml) in 22.2%. Only 16.7% had levels32 ng/ml, considered optimal by some experts. No associations were found between 25OHD levels and BMD or comorbid depression. 25OHD levels during winter were significantly lower than summer levels (p.001). Mean lumbar spine BMD z-score in patients with AN and EDNOS-B/P type was low (-1.5 ± 1.1) and correlated with body mass index standard deviation score (p = .03).Adolescents with eating disorders show a high prevalence of vitamin D deficiency and insufficiency. Given the risk of osteoporosis in this population, 25OHD levels found in this group may not offer optimal bone protection. Vitamin D levels should be routinely checked and supplementation should be administered as required.