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In adults, low-weight restrictive eating disorders, including anorexia nervosa (AN), are marked by chronicity and diagnostic crossover from restricting to binge-eating/purging. Less is known about the naturalistic course of these eating disorders in adolescents, particularly atypical AN (atyp-AN) and avoidant/restrictive food intake disorder (ARFID). To inform nosology of low-weight restrictive eating disorders in adolescents, we examined outcomes including persistence, crossover, and recovery in an 18-month observational study.We assessed 82 women (ages 10-23 years) with low-weight eating disorders including AN (Among all diagnoses, the likelihood of remaining stable within a given diagnosis was greater than that of transitioning, with the greatest probability among ARFID (0.84) and AN-R (0.62). Persistence of BP and atypical presentations at follow-up periods was less stable (AN-BP probability 0.40; atyp-AN-R probability 0.48; atyp-AN-BP probability, 0.50). Crossover from binge-eating/purging to restricting occurred 72% of the time; crossover from restricting to binge-eating/purging occurred 23% of the time. The likelihood of stable recovery (e.g., recovery at both 9 M and 18 M) was between 0.00 and 0.36.Across groups, intake diagnosis persisted in about two-thirds, and recovery was infrequent, underscoring the urgent need for innovative treatment approaches to these illnesses. Frequent crossover between AN and atyp-AN supports continuity between typical and atypical presentations, whereas no crossover to ARFID supports its distinction.

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

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

The mechanisms through which cognitive-behavioral therapies (CBTs) for avoidant/restrictive food intake disorder (ARFID) may work have yet to be elucidated. To inform future treatment revisions to increase parsimony and potency of CBT for ARFID (CBT-AR), we evaluated change in food neophobia during CBT-AR treatment of a sensory sensitivity ARFID presentation via a single case study.An adolescent male completed 21, twice-weekly sessions of CBT-AR via live video delivery. From pre- to mid- to post-treatment and at 2-month follow-up, we calculated percent change in food neophobia and ARFID symptom severity measures. Via visual inspection, we explored trajectories of week-by-week food neophobia in relation to clinical improvements (e.g., when the patient incorporated foods into daily life).By post-treatment, the patient achieved reductions across food neophobia (45%), and ARFID severity (53-57%) measures and no longer met criteria for ARFID, with sustained improvement at 2-month follow-up. Via visual inspection of week-by-week food neophobia trajectories, we identified that decreases occurred after mid-treatment and were associated with incorporation of a food directly tied to the patient's main treatment motivation.This study provides hypothesis-generating findings on candidate CBT-AR mechanisms, showing that changes in food neophobia were related to food exposures most connected to the patient's treatment motivations.Cognitive-behavioral therapies (CBTs) can be effective for treating avoidant/restrictive food intake disorder (ARFID). However, we do not yet have evidence to show how they work. This report of a single patient shows that willingness to try new foods (i.e., food neophobia), changed the most when the patient experienced a clinical improvement most relevant to his motivation for seeking treatment.

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

Recent reports document avoidant/restrictive food intake disorder (ARFID) symptoms among 13-40% of adults presenting to neurogastroenterology clinics, but ARFID in pediatrics is understudied. We conducted a retrospective review of charts from 129 consecutive referrals (ages 6-18 years; 57% female) for pediatric neurogastroenterology examination, from January 2016 through December 2018. Eleven cases (8%) met the full criteria for ARFID by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition and 19 cases (15%) had clinically significant avoidant/ restrictive eating behaviors with insufficient information for a definitive ARFID diagnosis. Of patients with ARFID symptoms (n = 30), 20 (67%) cited fear of gastrointestinal symptoms as motivation for their avoidant/ restrictive eating. Compared to patients without ARFID symptoms, patients with ARFID symptoms were older (P .001), more likely to be female (51% vs 79%, P = 0.014), and more frequently presented with eating/weight-related complaints (15% vs 33%, P = 0.026). This pilot retrospective study showed ARFID symptoms present in 23% of pediatric neurogastroenterology patients; further research is needed to understand risk and maintenance factors of ARFID in the neurogastroenterology setting.

Longitudinal associations between eating disorders (EDs) and comorbid psychiatric disorders are poorly understood but important to examine as comorbidities are common and can impede ED recovery. We examined two common comorbidities, major depressive disorder (MDD) and substance use disorder (SUD), in adult women with intake diagnoses of anorexia nervosa (AN) and bulimia nervosa (BN) who participated in a longitudinal study. To test the longitudinal reciprocal relations among ED, MDD, and SUD, we conducted a multi-group autoregressive cross-lagged path analysis. We tested whether ED, MDD, and SUD in a given three-month period (t – 1) each predicted ED, MDD, and SUD during the subsequent three-month period (t) over 5 years. We examined the moderating effect of intake diagnosis (AN vs. BN). Among AN (but not BN) participants, having MDD at t – 1 predicted having an ED at time t, OR = 1.98, B = .68, z = 2.49, p = .01. Among BN (but not AN) participants, having a SUD at t – 1 predicted having an ED at time t, OR = 5.16, B = 1.64, z = 2.34, p = .01. In contrast, having an ED at t – 1 did not predict MDD or SUD at time t for AN or BN participants. These results suggest for individuals with AN and MDD, treating MDD may facilitate ED recovery. For individuals with BN and SUD, treating SUD may facilitate ED recovery. These identified temporal associations between ED and comorbid disorders may guide cognitive behavioral researchers and therapists in prioritizing treatment targets given the high rate of comorbidity in EDs.

Anhedonia, or loss of pleasure, is related to deficits in reward processing across a variety of psychiatric disorders. In light of research suggesting abnormal reward processing in eating disorders (EDs), the study of anhedonia in EDs may yield important insights into the role of reward in eating pathology. This meta-analysis and review aimed to provide both a quantitative and qualitative synthesis of the existing literature on this topic.We conducted this research (or these meta-analyses) according to PRISMA guidelines. We searched four databases for both peer-reviewed and unpublished literature, and included studies only if a self-report or clinical interview measure of anhedonia was administered to a sample with an ED diagnosis.We included 21 studies in the systematic review, and 10 studies in two meta-analyses that compared anhedonia between ED and control samples (n = 9 studies) and within different ED diagnoses (n = 5 studies). Meta-analyses revealed that anhedonia was significantly higher in ED groups compared to healthy controls, but there was no significant difference in anhedonia between ED diagnostic groups. A qualitative review of the literature also suggested that anhedonia may be correlated with increased ED symptom severity.Findings indicated that anhedonia is elevated in EDs and may be a relevant treatment target. Future research should examine how self-reported anhedonia may correlate with components of reward processing in EDs in order to improve theoretical models as well as targeted interventions.La anhedonia, o pérdida de placer, está relacionada con déficits en el procesamiento de recompensas en una variedad de trastornos psiquiátricos. A la luz de la investigación que sugiere una anormalidad en el proceso de la recompensa en los trastornos de la conducta alimentaria (TCA), el estudio de la anhedonia en los TCA puede producir información importante sobre el papel de la recompensa en la patología alimentaria. Este metanálisis y revisión tuvo como objetivo proporcionar una síntesis cuantitativa y cualitativa de la literatura existente sobre este tema. MÉTODO: Se realizó esta investigación (o estos metanálisis) de acuerdo con las guías PRISMA. Se realizaron búsquedas en cuatro bases de datos de literatura revisada por pares y no publicada, y se incluyeron estudios solo si se administró una medida de anhedonia en el autoreporte o en una entrevista clínica a una muestra con un diagnóstico de TCA.Se incluyeron 21 estudios en la revisión sistemática y 10 estudios en dos metanálisis que compararon la anhedonia entre TCA y las muestras de control (n = 9 estudios) y dentro de diferentes diagnósticos de TCA (n = 5 estudios). Los metanálisis revelaron que la anhedonia fue significativamente mayor en los grupos de TCA en comparación con los controles sanos, pero no hubo diferencias significativas en la anhedonia entre los grupos de diagnóstico de TCA. Una revisión cualitativa de la literatura también sugirió que la anhedonia puede estar correlacionada con una mayor gravedad de los síntomas de TCA. DISCUSIÓN: Los hallazgos indicaron que la anhedonia está elevada en los TCA y puede ser un objetivo de tratamiento relevante. La investigación futura debe examinar cómo la anhedonia autoreportada puede correlacionarse con los componentes del procesamiento de recompensas en los TCA para mejorar los modelos teóricos, así como las intervenciones dirigidas.

Exclusion diets for gastrointestinal symptom management have been hypothesized to be a risk factor for avoidant/restrictive food intake disorder (ARFID; a non-body image-based eating disorder). In a retrospective study of pediatric and adult neurogastroenterology patients, we aimed to (1) identify the prevalence and characteristics of an exclusion diet history and (2) evaluate if an exclusion diet history was concurrently associated with the presence of ARFID symptoms.We conducted a chart review of 539 consecutive referrals (ages 6-90, 69% female) to adult (n = 410; January-December 2016) and pediatric (n = 129; January 2016-December 2018) neurogastroenterology clinics. Masked coders (n = 4) retrospectively applied DSM-5 criteria for ARFID and a separate coder assessed documentation of exclusion diet history. We excluded patients with no documentation of diet in the chart (n = 35) or who were not orally fed (n = 9).Of 495 patients included, 194 (39%) had an exclusion diet history, and 118 (24%) had symptoms of ARFID. Of reported diets, dairy-free was the most frequent (45%), followed by gluten-free (36%). Where documented, exclusion diets were self-initiated by patients/parents in 66% of cases, and recommended by gastroenterology providers in 30%. Exclusion diet history was significantly associated with the presence of ARFID symptoms (OR = 3.12[95% CI 1.92-5.14], p 0.001).History of following an exclusion diet was common and was most often patient-initiated among pediatric and adult neurogastroenterology patients. As patients with self-reported exclusion diet history were over three times as likely to have ARFID symptoms, providers should be cognizant of this potential association when considering dietary interventions.

Avoidant/restrictive food intake disorder (ARFID) symptoms are common (up to 40%) among adults with disorders of gut-brain interaction (DGBI), but treatments for this population (DGBI + ARFID) have yet to be evaluated. We aimed to identify initial feasibility, acceptability, and clinical effects of an exposure-based cognitive-behavioral treatment (CBT) for adults with DGBI + ARFID.Patients (N = 14) received CBT as part of routine care in an outpatient gastroenterology clinic. A two-part investigation of the CBT included a retrospective evaluation of patients who were offered a flexible (8-10) session length and an observational prospective study of patients who were offered eight sessions. Feasibility benchmarks were ≥75% completion of sessions, quantitative measures (for treatment completers), and qualitative interviews. Acceptability was assessed with a benchmark of ≥70% patients reporting a posttreatment satisfaction scores ≥3 on 1-4 scale and with posttreatment qualitative interviews. Mixed model analysis explored signals of improvement in clinical outcomes.All feasibility and acceptability benchmarks were achieved (and qualitative feedback revealed high satisfaction with the treatment and outcomes). There were improvements in clinical outcomes across treatment (all p's .0001) with large effects for ARFID fear (-52%; Hedge's g = 1.5; 95% CI = 0.6, 2.5) and gastrointestinal-specific anxiety (-42%; Hedge's g = 1.0; 95% CI = 0.5, 16). Among those who needed to gain weight (n = 10), 94%-103% of expected weight gain goals were achieved.Initial development and testing of a brief 8-session CBT protocol for DGBI + ARFID showed high feasibility, acceptability, and promising clinical improvements. Findings will inform an NIH Stage 1B randomized control trial.While cognitive-behavioral treatments (CBTs) for ARFID have been created in outpatient feeding and eating disorder clinics, they have yet to be developed and refined for other clinic settings or populations. In line with the recommendations for behavioral treatment development, we conducted a two-part investigation of an exposure-based CBT for a patient population with high rates of ARFID-adults with disorders of gut-brain interaction (also known as functional gastrointestinal disorders). We found patients had high satisfaction with treatment and there were promising improvements for both gastrointestinal and ARFID outcomes. The refined treatment includes eight sessions delivered by a behavioral health care provider and the findings reported in this article will be studied next in an NIH Stage 1B randomized controlled trial.

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

The present study investigated whether critical consciousness (CC) and feminist identity help explain emerging adult women's participation in actions to reduce gender inequality. CC is an applied tool marginalized and oppressed youth can use to combat inequality. It is conceptualized as three components: Critical reflection, critical efficacy, and critical action. Youth who have reflected on inequality are theorized to act against injustice if they have critical efficacy. However, empirical support for connections among components is mixed and questions remain concerning the contexts in which and people for whom CC serves as a resource. For instance, CC has rarely been examined as a tool to reduce sexism. Furthermore, researchers theorize that social identity is related to CC, yet little empirical evidence exists testing these associations. Finally, CC is typically examined within samples of children and adolescents, although advances in cognitive development and identity suggest emerging adulthood is an ideal time to use CC. To begin to fill these gaps, we investigated whether the components of CC in association with feminist identity could predict when emerging adult women act against sexism. A serial mediation model revealed reflection may lead to action for women who identify as feminist and who report greater internal efficacy. The pathway through external efficacy was not significant. Findings suggest CC together with feminist identity may be tools women can employ to transform unjust social conditions and improve their lives. Applied applications of findings are considered.

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

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

Posttraumatic stress disorder (PTSD) and eating disorders (EDs) are individually debilitating and highly comorbid conditions. Childhood abuse is a prominent risk factor for PTSD and ED symptoms both individually and as a comorbid syndrome (PTSD-ED). There may be a functional association between comorbid PTSD-ED symptoms whereby disordered eating behaviors are used to avoid trauma-related thoughts and feelings. The current study used a network analytic approach to examine key associations between PTSD and ED symptom subscales (i.e., PCL-5 and EPSI, respectively) in a community sample of 120 adults who endorsed at least one experience of childhood abuse (i.e., physical, sexual, or emotional abuse; witnessing domestic violence). Participants completed an anonymous online survey using Amazon's Mechanical Turk Prime. We used three network analysis indices (i.e., strength centrality, key players, and bridge symptoms) to identify symptoms that may maintain the comorbid PTSD-ED network. The results indicated that reexperiencing symptoms had the highest strength centrality in the PTSD-ED network and bridged the PTSD and ED clusters. For ED, cognitive restraint was a bridge to all PTSD symptoms. Hyperarousal, negative alterations in cognitions and mood (NACM), and purging were key players, indicating they are integral to the network structure. If replicated in prospective studies, these results may indicate that reexperiencing and cognitive restraint are core drivers of PTSD-ED comorbidity, whereas hyperarousal, NACM, and purging may be downstream consequences maintaining the comorbid condition. Concurrent treatments that address PTSD and ED symptoms simultaneously may result in the best outcomes.

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

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

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

Objective Rumination disorder (RD) is a feeding/eating disorder and disorder of gut-brain interaction characterized by repeated, effortless regurgitations. Diaphragmatic breathing is the most widely used treatment technique for RD, theoretically as a competing response to the habitual contraction of the abdominal wall. However, in light of diaphragmatic breathing’s lack of effectiveness for some patients, we created a comprehensive treatment to test the incremental effect of behavioral exposure on symptom change. Method In a single-case experimental design, we present the treatment of a 27-year-old patient with a 9-year history of untreated RD. The patient completed a comprehensive six-session cognitive-behavioral treatment for RD, comprising a 1-week phase of self-monitoring regurgitations + psychoeducation (Phase A), a 6-week phase of diaphragmatic breathing (+ identification of secondary maintenance mechanisms) (Phase B), and a 3-week phase of diaphragmatic breathing + behavioral exposure (Phase C). We compared change in daily symptom data between Phases B and C, and also report 20-month follow-up data. Results The patient’s daily regurgitation frequency did not change during Phase B (diaphragmatic breathing alone), even with the elimination of foods that had become associated with regurgitations. However, she achieved a significant reduction in regurgitations during Phase C, with symptom remission extending to 20-month follow-up. Phase C included purposefully breaking learned associations with food stimuli using behavioral exposure. Conclusions Our data suggest that when diaphragmatic breathing alone is not effective in reducing symptoms, further cognitive and behavioral techniques like behavioral exposure can augment the effect of diaphragmatic breathing on symptom reduction.

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

Despite the negative emotional experiences that often accompany the pursuit of an idealized appearance, we know little about emotion regulation in the context of female drive for muscularity. To address this knowledge gap, we examined whether distress tolerance and difficulties in emotion regulation were significantly associated with the drive for toned muscularity among women. In this study, 221 Australian university women completed an online survey assessing drive for muscularity, distress tolerance, and emotion regulation difficulties. Results revealed that low distress tolerance and emotion regulation difficulties were positively associated with drive for muscularity attitudes and behaviors, after controlling for body mass index and general negative affect. Our findings suggest that women with a range of distress tolerance and emotion regulation difficulties, particularly the urgent need to regulate, and non-acceptance of, distress may experience a higher drive for muscularity. This study provides preliminary evidence that specific aspects of distress tolerance and poor emotion regulation may be promising targets in prevention and treatment interventions aimed to address the excessive drive for muscularity among women.

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

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

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

Eating disorders are prevalent in adulthood and have high rates of morbidity and mortality. In many cases, primary care physicians (PCPs) are the first and/or only medical professionals to interact with individuals with eating disorders. However, PCPs often do not receive adequate training to confidently and appropriately care for these patients. This review includes up-to-date screening and treatment guidelines and relevant studies concerning the care of adult patients with eating disorders and provides concise guidance for PCPs regarding the outpatient management of these patients in primary care. Three case reports are also included to provide real-life examples of patients with eating disorders that PCPs may encounter. Although eating disorders can have grave consequences, recovery is possible and common, even after patients have been ill for many years. PCPs can play an integral role in promoting recovery by following evidence-based guidelines, by identifying when medical or psychiatric hospitalization is indicated, by monitoring for medical complications, and by referring early to evidenced-based therapies.

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

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

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