Thursday, April 11, 2019

Current Research and News 2/2019


Eating Recovery Center’s Binge Eating Treatment and Recovery Program launches study to examine successful treatment elements. Eating Recovery Center (ERC), announces the launch of a new study that will examine elements of treatment that are necessary for successful reduction of and/or abstinence from binge eating and other eating disordered behaviors in a sample of patients with binge eating disorder (BED) and Bulimia Nervosa (BN). Conducted through ERC’s Binge Eating Treatment and Recovery (BETR) Program, this groundbreaking study will examine predictors of successful treatment in 100 consecutive patients admitted to ERC’s Residential and Partial Hospitalization program. The study will also look at how treatment impacts psychosocial variables, behavioral indices – such as binge eating intensity, frequency, and duration – and medical and health related outcomes. To learn more, click here.

An experimental investigation into the use of eye-contact in social interactions in women in the acute and recovered stages of anorexia nervosa. People with anorexia nervosa (AN) report significant difficulties in social functioning and a growing literature is beginning to explain some of the differences in social skills that might underlie the social challenges experienced by patients. One vital area of social functioning that has been largely neglected to date is how eye-contact is used in the context of social stimuli and in social situations. METHODS: This cross-sectional, experimental study used eye-tracking to measure the frequency and duration of eye-contact made with the eye region of interest (ROI) of (1) static social stimuli (man and woman Ekman faces displaying basic emotions); (2) moving social stimuli (a video of two actors conversing); and (3) during a real-life social interaction in 75 women (25 with AN, 25 recovered from AN, and 25 non-AN controls; mean age = 27.18, SD = 6.19). RESULTS: Participants showed greater eye-contact during a real-life social interaction than when viewing static social stimuli. Those with AN made contact with the eye ROI of the static and moving social stimuli and during a real-life social interaction significantly less often and for significantly less time than non-AN controls. Those recovered from AN showed greater eye-contact than the acute group but significantly less eye-contact with the eye ROI across the static and moving social stimuli and during the real-life social interaction than non-AN controls. DISCUSSION: These findings contribute new knowledge regarding the types of social skills that people with AN may need additional support with to allow them to make greater use of social support in their recovery. Int J Eat Disord. 2018 Dec 22. doi: 10.1002/eat.22993. [Epub ahead of print]

Large-scale genomic studies of anorexia and bulimia are turning up clues about the conditions’ development and persistence. Find the links here:

The University of Chicago's Eating Disorders Program (PI: Dr. Jennifer Wildes) is looking for adolescent girls aged 12-19 for a research study being conducted to better understand relations between biological measures, cognitive function, and eating problems in adolescent girls. The study includes interviews, questionnaires, behavioral tasks, an MRI brain scan, and a blood draw. Individuals may be eligible to participate if… They are female. They are between the ages of 12 and 19 years old. They are currently restricting the amount of food they eat. The study will occur across at least 2 study visits at the University of Chicago in Hyde Park. Participants can receive $150 for taking part in study activities. For more information, please call (773) 834-0362 or email

Differential diagnosis of eating disorders. The clinical symptoms of eating disorders can mimic those of other chronic diseases including gastrointestinal and endocrine disorders making the diagnosis and management of both conditions challenging. The review listed below describes what is known about eating disorders in adolescents with chronic gastrointestinal and endocrine diseases, focusing on celiac disease, inflammatory bowel disease, diabetes, and thyroid disorders. Click on the link for more:  (purchase required for the full article)

Current Research and News 3/2019

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Changes in eating disorder characteristics over the years. Since 1980, the diagnostic criteria of patients with eating disorders (ED) have changed over the years. Are these changes also expressed in the clinical features of the ED patients? A cross-sectional sample was drawn consisting of 100 consecutive female patients' files diagnosed with anorexia nervosa (AN) and bulimia nervosa (BN) and bulimia nervosa and admitted at an inpatient unit from the first of January 1990, 2000, and 2010, respectively. Several reliable and well-validated questionnaires (Eating Disorder Inventory, Body Attitude Test, Symptom Checklist, and the Beck Depression Inventory) were administered and scores were compared. The ratio AN/BN remained the same (65/35). No differences were found between the three cohorts except for depression, which increased over the years. This pattern is the same for the subsamples of anorexia nervosa and bulimia nervosa. Specific characteristics of eating disorder pathology did not change across time. Eur Eat Disord Rev. 2018 Sep;26(5):417-421. doi: 10.1002/erv.2603. Epub 2018 May 17.

Treatment of Anorexia Nervosa-New Evidence-Based Guidelines. Evidence-based practice guidelines aim to support all groups involved in the care of patients with anorexia nervosa by providing them with scientifically sound recommendations regarding diagnosis and treatment. The German S3-guideline for eating disorders has been recently revised. In this paper, the new guideline is presented and changes, in comparison with the original guideline published in 2011, are discussed. Further, the German guideline is compared to current international evidence-based guidelines for eating disorders. Many of the treatment recommendations made in the revised German guideline are consistent with existing international treatment guidelines. Although the available evidence has significantly improved in quality and amount since the original German guideline publication in 2011, further research investigating eating disorders in general, and specifically anorexia nervosa, is still needed. J Clin Med. 2019 Jan 29;8(2). pii: E153. doi: 10.3390/jcm8020153. Read the full article here:

A new study has found that a persistent low body mass index (BMI) in children, starting as young as age 2 for boys and 4 for girls, may be a risk factor for the development of anorexia nervosa in adolescence…see below.

Developmental Premorbid Body Mass Index Trajectories of Adolescents With Eating Disorders in a Longitudinal Population Cohort. Objective: To examine whether childhood body mass index (BMI) trajectories are prospectively associated with later eating disorder (ED) diagnoses. Method: Using a subsample from the Avon Longitudinal Study of Parents and Children (N = 1,502), random-coefficient growth models were used to compare premorbid BMI trajectories of individuals who later developed anorexia nervosa (n = 243), bulimia nervosa (n = 69), binge-eating disorder (n = 114), and purging disorder (n = 133) and a control group without EDs or ED symptoms (n = 966). BMI was tracked longitudinally from birth to 12.5 years of age and EDs were assessed at 14, 16, and 18 years of age. Results: Distinct developmental trajectories emerged for EDs at a young age. The average growth trajectory for individuals with later anorexia nervosa veered significantly below that of the control group before 4 years of age for girls and 2 years for boys. BMI trajectories were higher than the control trajectory for all other ED groups. Specifically, the mean bulimia nervosa trajectory veered significantly above that of controls at 2 years for girls, but boys with later bulimia nervosa did not exhibit higher BMIs. The mean binge-eating disorder and purging disorder trajectories significantly diverged from the control trajectory at no older than 6 years for girls and boys. Conclusion: Premorbid metabolic factors and weight could be relevant to the etiology of ED. In anorexia nervosa, premorbid low weight could represent a key biological risk factor or early manifestation of an emerging disease process. Observing children whose BMI trajectories persistently and significantly deviate from age norms for signs and symptoms of ED could assist the identification of high-risk individuals. Journal of the American Academy of Child and Adolescent Psychiatry, February 2019 Volume 58, Issue 2, Pages 191–199 Read the full text here:

Children with avoidant/restrictive food intake disorder and anorexia nervosa in a tertiary care pediatric eating disorder program: A comparative study. The purpose of this study was to examine the medical and psychological characteristics of children under the age of 13 years with avoidant restrictive food intake disorder (ARFID) and anorexia nervosa (AN) from a Canadian tertiary care pediatric eating disorders program. Method: Participants included 106 children assessed between 2013 and 2017 using the Diagnostic and Statistical Manual for Mental Disorders, 5th edition (DSM-5). Data were collected through clinical interviews, psychometric questionnaires, and chart review. Information collected included medical variables (e.g., weight, heart rate, need for inpatient admission, and duration of illness from symptom onset); medical comorbidities (e.g., history of food allergies, infection, and abdominal pain preceding the eating disorder); and psychological variables (e.g., psychiatric comorbidity, self-reported depression and anxiety, and eating disorder related behaviors and cognitions). Results: Children with ARFID had a longer length of illness, while those with AN had lower heart rates and were more likely to be admitted as inpatients. Children with ARFID had a history of abdominal pain and infections preceding their diagnoses and were more likely to be diagnosed with a comorbid anxiety disorder. Children with AN had a higher drive for thinness, lower self-esteem, and scored higher on depression. Discussion: This is the first study to look at DSM-5 diagnosis at assessment and include psychometric and interview data with younger children with AN and ARFID. Understanding the medical and psychological profiles of children with AN and ARFID can result in a more timely and accurate diagnosis of eating disorders in younger children. Int J Eat Disord. 2019 Feb 1. doi: 10.1002/eat.23027. [Epub ahead of print]

Long-term outcome and psychiatric comorbidity of adolescent-onset anorexia nervosa. To assess the outcome of adolescents with anorexia nervosa (AN) about 20 years after first treatment. Methods: Sixty-two women diagnosed with AN during adolescence were invited to participate. Of these 62 patients, 38 agreed to participate and were assessed with a battery of questionnaires and interviews. A control group of 30 women of similar age was also assessed. Results: Of the patients who completed the full assessment, 13 (34%) presented some degree of eating disorder (ED) at follow-up (10 (26%) met full Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria for an ED and 3 (8%) showed partial remission of an ED). The remaining 25 (66%) patients had fully recovered from AN. The duration of untreated illness before admission was significantly associated with an increased risk of a current ED (odds ratio (OR) = 3.334 (1.3-8.7); p = .014). Of the patients who had recovered totally from their ED, 24% showed another psychiatric disorder. This percentage rose to 70% in patients with a current ED. Conclusion: Sixty-six percent of adolescents who completed the assessment achieved remission of their AN. Comorbidity was more common in the current ED group. The variable that best predicted complete remission was the number of years without treatment, showing the importance of detection and early intervention. Clin Child Psychol Psychiatry. 2019 Feb 15:1359104519827629. doi: 10.1177/1359104519827629.

How Genetic Variation May Impact Antidepressant Efficacy in Eating Disorder Treatment

Understanding the role of dietary deficiencies and genetic factors on the efficacy of medication can be an effective tool when treatment planning with patients and families.
Incorporating information about individualized genetics as part of a larger conversation about medication trials or compliance may be useful for some patients and their treatment allies, including in confronting treatment resistance and limiting time spent pursuing treatment strategies with poor or limited evidence for success.
Also, patients’ belief of themselves as having “treatment-resistant depression” or being “non-responders” to medications may be compassionately challenged if they understand, biologically, why previous trials were not expected to be successful, and that future trials could be.
In concert with nutritional and psychotherapies, many eating disorders patients referred to an inpatient level of care utilize antidepressant medications in an effort to alleviate symptoms. The majority of antidepressant medications rely on monoamine presence in the brain, either serotonin, as in “selective serotonin reuptake inhibitors” (SSRIs), or serotonin and norepinephrine, as in “serotonin-norepinephrine reuptake inhibitors” (SNRIs), or similar mechanisms.
Norepinephrine action also indicates dopamine reuptake in the prefrontal cortex of the brain, which is the third monoamine action, though not often mentioned in the medication titles. With the best intentions, families and sufferers may seek relief of depression, anxiety and OCD symptoms with these otherwise recommended and effective medications. Without exception, however, every antidepressant medication trial in malnourished eating disorder patient populations shows these medications are no more effective than placebo. Below are factors that contribute to this phenomenon.
From here forward, monoamines will refer to serotonin, norepinephrine, and dopamine unless stated individually. Proteins from nutritional intake are processed in the human body through a series of mechanisms that lead to the production of monoamines. This is a complex process, with many contributing factors, such as folic acid, tryptophan or tyrosine, gonadal steroid levels, and individualized genetic considerations.
It is well established that common eating disorder behaviors, including food restriction, purging, and excessive exercise, impact nutrient availability in the body. Sustained starvation or significant purging would limit both proteins and vitamins, and excessive exercise would drive the body to use those resources for other purposes.
These nutritional deficits lead to a diminished capacity to produce monoamines. For example, excluding proteins rich in tyrosine and tryptophan would limit the basic building blocks for monoamine production.
Folate, which is the naturally occurring form of folic acid found in leafy vegetables, legumes, and fruits, is also an integral part of monoamine synthesis. Cereals and breads are often fortified with synthetic folate (folic acid). Folate is metabolized by the body into L-methylfolate, which is one of several critical components of neurotransmitter production. If L-methylfolate is deficient, monoamine synthesis is reduced.

Folic Acid & Genetics

Being human involves myriad and mysterious quirks, among them, the occurrences of genetic variations, termed polymorphisms, in the general population. There are several widespread polymorphisms which can impact an individual’s ability to metabolize folate or folic acid into L-methylfolate naturally. One particular polymorphism, at MTHFR (methylenetetrahydrofolate reductase), is becoming increasingly well known, accessible for testing and extremely relevant to this discussion.
Approximately sixty percent of the general population has at least one polymorphism at this site reducing the synthesis of L-methylfolate, and thirty percent has both polymorphisms at the foci, significantly impacting L-methylfolate synthesis.
Therefore, eating disorders suffers from the MTHFR gene polymorphism can compound their genetic L-methylfolate deficit (and therefore their monoamine deficit) significantly through nutritional restriction.


Clinicians, sufferers and treatment allies may consider whether testing for the common polymorphism is worthwhile and worth the potential expense. L-methylfolate augmentation in sufferers with known MTHFR polymorphyisms may significantly improve medication efficacy in those with a history of “failed” medication trials or family history of poor response to medications if genetic factors limited response. However, in eating disorder patients, even with recognition and appropriate treatment of the genetic considerations, it remains clear that nutritional restoration remains the gold standard for optimal response to medications to be possible.

1. Corrina P. Ferguson, et al; Are Serotonin Selective Reuptake Inhibitors Effective in Underweight Anorexia Nervosa; Int J Eat Disord 25: 11-17, 1999.
2. Tanaka, T et al; Genome-wide Association Study of Vitamin B6, Vitamin B12, Folate and Homocysteine Blood Concentrations; The American Journal of Human Genetics 84, 477-482, April 10, 2009; Fava M, et al Folate in Depression: Efficacy, Safety and Differences in Formulations, and Clinical Issues, Journal of Clinical Psychiatry 2009; 70 (suppl 5):12-17; Stahl, S.M., Stahl’s Essential Psychopharmacology; neuroscientific basis and practical application, 4th edition; 2013, p. 347 – 348
3. Stahl, S.M., Stahl’s Essential Psychopharmacology; neuroscientific basis and practical application, 4th edition; 2013, p. 347 – 349

About the Author:
Katherine Godwin, M.D., has served as medical director and attending physician of the Laureate adult eating disorders program since 2010. She joined the program as medical director of outpatient services in 2008 and was the medical director of Laureate’s independent living program for outpatient eating disorder care, Magnolia House, from 2007-2010. She has practiced at Laureate since 2005.
Dr. Godwin is board certified by the American Board of Psychiatry and Neurology She received her medical degree from Creighton University in Omaha, Nebraska, and completed her residency in psychiatry at the University of California, San Diego where she served as chief resident.
Katherine Godwin, M.D., shares her expertise locally and nationally about psychopharmacologic considerations with eating disorders. Dr. Godwin is an advocate for patients and their families. She encourages her patients to participate actively in treatment and to work together with their care team for optimal symptom management.

Tuesday, February 26, 2019

Launch of the National Center of Excellence for Eating Disorders

Launch of the National Center of Excellence for Eating Disorders
The National Center of Excellence for Eating Disorders (NCEED) is dedicated to educating and training healthcare providers on the evidence-based management of eating disorders and improving eating disorder awareness among the public. NCEED’s mission is closely tied to the Anna Westin Act provisions within 21st Century Cures and Mental Health Reform Act and is thus poised to have meaningful and lasting impact on the ability for individuals with eating disorders to be detected and provided with evidence-based treatment. This week’s launch is the first in a series of programming phases for NCEED and will offer an initial set of resources for healthcare providers and the public as well as information on upcoming events of interest. Subsequent phases will provide online trainings, interactive webinars, and a mechanism for submitting technical assistance requests. Learn more at their website,

Disordered Eating in Middle-aged and Older Women

Vol. 30 / No. 1  

A large Norwegian sample highlights a sometimes overlooked community health problem.
Disordered eating, emerging from body dissatisfaction, weight preoccupation, and dysfunctional eating patterns, has generally been described as a problem of younger patients. However, the fact that disordered eating can occur at any age, from childhood to advanced years, has been reinforced in a cross-sectional study of more than 90,000 middle-aged Norwegian women (PLoS ONE
When Dr. Marie Sigstad Lande and colleagues at the Arctic University of Norway, Tromo, analyzed disordered eating among 90, 592 women 46 and 76 years of age (median age: 55 years) who had completed questionnaires from the Norwegian Women and Cancer study from 2002 to 2005, they found the prevalence of disordered eating was 0.28%, and this was highest among women older than 66 years of age. Disordered eating was strongly associated with a history of depression, being unemployed, and single. In this study, depression was he strongest correlate of disordered eating: women with disordered eating had three-fold higher odds of also  being diagnosed with depression. Women with disordered eating were also more likely to report low energy intake, and less likely to be   moderately physically active. Just as in earlier studies, Dr. Lande and colleagues’ finding that the oldest age group—women 66 to 76 years of age—had the highest prevalence of disordered eating.
This large-scale study confirms the findings of earlier smaller studies showing that disordered eating can arise in mid-life and older age. The authors feel that their study “underscores a somewhat under-communicated community health problem that needs attention in terms of age-specific treatment and prevention.”

BED and Food Addiction

Vol. 30 / No. 1  

Nearly all participants in one study had at least a mild food addiction.
It’s unclear how binge eating disorder (BED) and the newer concept of food addiction are related. BED is very commonly assessed by eating disorder professionals; food addiction, somewhat less often. A new tool, the Yale Food Addiction Scale, has been developed to assess for food addiction (Gearhardt and colleagues, 2011). This scale measures addictive qualities of eating behavior. It was recently revised to become the YFAS 2.0, adjusted for changes to the diagnostic criteria from DSM 5. Carter and colleagues (Appetite. 2019; 133:362) recently described the results of measuring food addiction using the YFAS 2.0in a group of people with BED (n=71) and controls (n=79). In this study, participants completed the YFAS 2.0,as well as an Eating Disorders Examination(EDE) interview to establish an eating disorder diagnosis.
Interestingly, nearly all the BED participants in this study (overall, 92%)   scored positive for at least mild food addiction, while very few of the controls who did not have an eating disorder endorsed food addiction symptoms (only 6%). Among those with BED and at least moderate food addiction scores, higher EDEsubscale scores were seen (except for the Restraint Subscale), and indications of greater levels of depression and anxiety were seen as well.
These interesting findings highlight the frequency with which food addiction may be present in individuals seen in eating disorder settings. This should stimulate further interest in the use of such screenings to increase awareness about food addiction, and as we learn more about how food addiction, this may influence treatment approaches.

Links Between Binge Eating Disorder and Suicide

Vol. 30 / No. 1  

New information in a largely unexplored area
Binge eating disorder (BED) is still the most common eating disorder in the US, with a lifetime prevalence of 3.5% for women and 2.0% for men. Despite this, much of its course and correlation to other factors remain relatively unknown, compared to other eating disorders such as anorexia nervosa and bulimia nervosa, for example. A collaborative study found that both binge eating behaviors and body mass index (BMI) are independently related to suicidal ideation and suicide attempts among US adults (BMC Psychiatry. 2018; 18:196).
Dr. Kristal Lyn Brown of Virginia Commonwealth University School of Medicine, Richmond, and colleges at the University of Michigan School of Public Health, Ann Arbor, reported that one impetus for their study was that the relationship between BED and suicidality had not yet been examined in a population-based study of adults in the US. In addition, unlike other eating disorders, patients with BED do not use compensatory or restorative behaviors such as excessive exercise or laxative abuse, and thus are at higher risk for gaining weight and becoming obese. The authors examined three hypotheses: BED is linked to an elevated likelihood of suicidality; 2) BMI is associated with likelihood of suicidality in a nonlinear manner, and 3) the relationship between BED and suicidality is exacerbated by BMI, and any differences by gender.
One-third of adults were affected
The study results were based on the 2001-2003 Collaborative Psychiatric Epidemiologic Surveys, a set of three nationally representative cross-sectional household surveys. (The data used for the analysis are available at Studies/20240.)   The data were limited to persons with complete data on BMI, BED, and suicidality and the initial sample included 14,497 individuals. While BMI did not substantially explain the association between binge eating and suicidal behavior, there was evidence that suicidality was exacerbated by high BMI.
A third of the adults with BED had a history of suicidality, compared to 19% of those without BED. BMI was associated with suicidality in a curvilinear manner and this relationship was exacerbated by binge eating/ BED.
Finding that binge eating/BED  is associated with suicidality echoes the broader literature on eating disorders and associated psychiatric comorbidities: nearly a third of women with BED report a lifetime history of suicidal ideation and 15% reported having attempted suicide (Arch Gen Psychiatry.2011; 68:714). Several studies have shown a link between binge eating and mood disorders, novelty seeking, and impulsiveness, all of which have been linked to suicidal behaviors.  The researchers found that the relationship between BMI and suicidal thoughts did not differ by gender, unlike earlier reports. As for depression, there was an inverse relationship between BMI and suicide attempts among men regardless of depression history and a curvilinear relationship among women, with a higher incidence of attempts among those with low BMIs compared to normal-weight women without histories of depression.
Dr. Brown and colleagues hope that their findings lead to thoughtful integration of psychiatric care into weight loss programs for adults with a history of binge eating behavior.

Finding a Better Definition for Severe and Enduring Anorexia Nervosa

Vol. 30 / No. 1  

Many patient variables make the definition challenging. 
As the 11thedition of the International Classification of Diseases(ICD-11) is nearing pre-release this spring, Drs. Phillipa Hay and Stephen Touyz have commented on the lack of clear definitions for severe and enduring anorexia nervosa (AN). In an editorial in the Journal of Eating Disorders(2018; 6:41), the two well-known eating disorders experts lament the lack of consensus or clear-cut definitions for recovery or definitions of severe AN. (ICD-11will be presented at the World Health Assembly in May, for adoption by member states, and will officially come into effect on January 1, 2022).
The authors point out three components of severe and enduring AN (Table 1): a decade or more years of a body mass index above the DSM-5severe range; marked morbidity from chronic starvation and longstanding illness; years of experiencing diagnostic level eating disorder symptoms with previous failed treatment attempts; and 3 to 10 years of illness; and treatment resistance. The criteria they propose are based on such factors as the clinically significant functional impact of the disorder ( for example, poor quality of life and unrelenting symptoms, the duration of disease of several years of AN, and exposure to at least two evidence-based treatments delivered by an appropriate clinician or treatment facility, with a diagnostic assessment and formulation that incorporates an assessment of the person’s eating disorder health literacy with an assessment of the patient’s stage of change.
Both authors point out some of the problems with the term, “treatment resistant,” which they are reluctant to use in the eating disorders field because it is viewed as pejorative and places blame on the physician and patient. Treatment resistance is also not well understood, according to the authors, and there is no real consensus on the definition—for example, how many attempts have been made at re-feeding or how many treatment sessions are felt to be enough before they are discarded?

Loss of Control Eating Among Teens Linked to Perceived Family Function

Vol. 30 / No. 1  

Poor family function was linked with obesity in adolescent girls.
Loss of control (LOC) eating, a feeling that one cannot stop or control what or how much he or she consumes, affects approximately a third of children who are overweight or obese. It has also been linked to the development of partial or full-syndrome binge eating disorder, or BED (J Abnorm Psychol. 2011. 120:108;J Abnorm Psychol. 2013. 122:684).
Dr. Manuela Jaramillo, from the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health, Bethesda, MD, and her collaborators recently concluded that among girls with LOC eating and high body mass indexes, poor family function plays a role in greater consumption of obesity-producing macronutrients during binge episodes (Nutrients. 2018. 10:1869). The researchers reported the connection after studying the relationship between perceived family functioning and energy intake during a laboratory test meal designed to model a binge episode. The team had hypothesized that lower levels of adaptability and cohesion would lead to greater total energy consumption, a larger percentage of energy consumed from fat and carbohydrates, with lower percentage of energy from protein.
The study group
The study group included 108 adolescent girls 12 to 17 years of age who were at high risk for developing eating disorders and excess weight gain, and who had experienced at least one LOC eating episode during the prior month. All were between the75th and 97thpercentile for body mass index (BMI, kg/m2). Then, family functioning was defined as the teen’s perceived level of adaptability and cohesion of her family; this was assessed by the researchers with the Family Adaptation and Cohesion Scale III, a 20-iem self-report that measures perceived levels of family adaptability. A sample item would be, “Family members like to spend time with each other.” Higher scores equal greater adaptability and cohesion.
The test method used included analysis of energy intake, pre-meal hunger, depressive symptoms, and post-meal subjective evaluation of LOC eating. At 11 am participants were presented with a 9835-kcal buffet test meal with a wide assortment of foods, and were advised via a tape recording to “Let yourself go and eat as much as you want.” Participants were left alone in the room until they signaled that they were finished eating. The test foods were then weighed and compared after the meal. A single item was used to measure pre-meal hunger with a question, “How hungry do you feel right now?” The Brunel Mood Scale was used to measure depressive symptoms, and a single-item assessment was used to measure post-meal evaluation of LOC eating.
The authors concluded that adolescent girls with diagnoses of LOC eating who perceived their families as being relatively less adaptable consumed significantly more carbohydrates and less protein from the test meal, which was designed to model an LOC episode.  They also noted that the study findings underscored the importance of addressing family function in a clinical setting and, when possible, to include family members in interventions that may help modify adolescent girls’ eating behaviors.

Update: Another Possible Cause Linked to BED and Obesity

Vol. 30 / No. 1  
Two seemingly polar opposites, food insecurity, or lack of food, often due to poverty, and binge-eating disorder, or BED, are associated, according to a recent report by Janet Lydecker, PhD, of the Department of Psychiatry Yale School of Public Health, New Haven, CT. She and her colleagues reported their findings in the International Journal of Eating Disorders, published online December 19, 2018.
The study recruited 1,2651 participants using Amazon’s Mechanical Turk, a web-based recruitment platform; participants then reported their weight and height, and the researchers calculated body mass index (kg/m2) for each.  After this, the study participants were divided into three groups. More than half (56.8%; n=710) were classified as having a healthy weight with no eating disorder; 85 participants (6.8%) Had diagnoses of BED, and 456 patients (36.5%) were obese but had no eating disorder.
The researchers defined food security in three categories (1) if the individuals were able to afford regular nutritious meals, (2) low food insecurity if they modified food quality, variety, or desire to satisfy hunger, and (3) very low food security if they reduced their food intake or quality to the point of having physiological hunger. One-third (33.7%; n=422) were found to have food insecurity; 18,5% (n=231) had low food security; and 15.3% (n=191) had very low food security.  Compared with persons who had healthy weights, those deemed to have low food security were 2.5 times more likely to have BED. The same pattern was associated with an increased likelihood of being obese. Other researchers, such as Tomoko Udo, PhD, of the School of Public Health at SUNY University at Albany, NY, have noted that the dietary restraint model of binge eating suggests that when a person engages in dietary restriction as a way to control calories or due to lack of access to food, he or she is more likely to engage in binge eating due to deprivation.
Dr. Lydecker noted that clinician s traditionally associate self-imposed dieting, seen as skipping meals or cutting back on calories to lose weight, as one of the causes of binge eating. However, she added, externally imposed restrictions on food, skipping meals or cutting back on intake because food isn’t available is also related to binge eating.  “Food insecurity could be a factor making it more difficult for patients to get better if they cannot address it. By addressing it, clinicians and patients with BED can collaborate more effectively to treating binge eating,” she said.

Nature-based Therapy for Binge Eating Disorder

Vol. 29 / No. 6  

A pilot study showed significant differences between nature-based therapy and standard group therapy.
(Note: see also September-October issue’s lead article, Needed: More Vitamin ‘N’.)
In Denmark, binge eating disorder, or BED, is not yet recognized as an autonomous eating disorder, although it will presumably become “official” there with the coming publication of ICD-11. Currently, support group meetings are the only publicly available form of support for patients with BED. Based on prevalence estimates from a variety of studies, 1.3% to 1.8% of the population is affected by BED (Biol Psychiatry. 2013; 73:904). Thus, it’s estimated that from 40,000 to 50,000 Danes currently have BED, and most are treated by private practitioners or at support group meetings.
Dr. Sus Sola Corazon and colleagues recently reported their findings from a small pilot study comparing nature-based therapy vs group support therapy for patients with BED (Int J Environ Res Public Health. 2018; 15:2486). In this study, the nature-based psychotherapeutic approach was based on Acceptance and Commitment Therapy.  The authors noted that since nature-based therapy is characterized by experiences and activities in Nature as therapeutic tools, its physical approach to creating mental change seemed potentially beneficial. The mirroring process also comes into play because being in a natural environment is perceived as comforting by clients and offers metaphor they can use as a mirror and a way to frame their anxieties.
A series of interviews, questionnaires, and sessions in a therapy garden setting were used and then analyzed for the 19 women and 1 man who participated in the overall study (10 in each study group; mean age: 47 years in the nature-based therapy group and 41 in the group support therapy section). Recordings of the interviews were reviewed several times and sections of interest were marked, and then analyzed.
Eight participants in the nature-based intervention and 7 from the group intervention completed the study. EDEinterviews showed that all the participants still fulfilled the criteria for BED at the end of the interventions but diminishments in binge eating were substantial for the NBT group (21.5 episodes per 28 days to 3.5 per 28 days). Binge eating frequency changed little in the group treatment condition (13.7 to 10.9). Both interventions improved psychological well-being and increased self-esteem, although not all results were significant.
How participants experienced natural surroundings and nature-based activities
Although the therapeutic mechanisms at work in outdoor psychotherapy are still far from understood, most participants in the nature-based therapy program experienced nature therapy to be safe and protective.  They used words such as “calming,” “supportive,” “protective,” a feeling of refuge,” and “providing mental space” to describe their experience. Being in a natural environment apparently helped them feel more grounded and present. Also, integrating the natural environment into the exercises was reported to be motivating; one participant said, “It’s a step beyond being stuck in your own head all the time.” Others selected natural objects such as a tall tree or a pine cone, which helped them work to be more present in the moment.
The authors note that one of the potential benefits of nature-based therapy is that it helps “anchor” therapeutic content through physical experiences and exercises, making this more accessible and applicable for participants.  Because the study had several limitations, such as size, an overrepresentation of women, and the difficulty of determining the effects of nature-based therapy vs psychotherapy, Dr. Corazon and colleagues suggest that future studies use a different design, using randomization and a control group receiving the same psychotherapeutic intervention without nature-based activities and experiences as therapeutic tools.

Eating Disorders Patients and the Internet

Vol. 29 / No. 6  

Although the Internet has many benefits, negative effects emerged from concentration on body image, weight, and comparisons with the ‘thin ideal.’
One area often overlooked in treatment is the time eating disorders patients spend on the Internet, according to a group of Israeli researchers (Front Psychol. 2018; 9:2128. d/fpsyg.2018.02128. doi 10.3389). And, the social interactions online can have positive and negative effects; patients can gain a sense of connectedness but also face comparing themselves unfavorably to the “thin ideal.”
Dr. Rachel Bachner-Melman and colleagues at Soroka University Medical Center, Beersheba, Israel, compared the scope, Internet use patterns, and degree of online need satisfaction of girls and women with and without a lifetime eating disorder diagnosis. The study group included 122 females 12 to 30 years of age; 53 had an eating disorder and were recruited from a hospital-based treatment program, and 69 age-matched controls with no current or prior eating disorder who were recruited from social media sites. All participants completed questionnaires that assessed disordered eating, body image, positive and negative affect, general distress and life satisfaction, and also completed an online survey about their Internet use, how often they watched and posted pictures and videos, online friendships and social comparisons, and their mood after leaving the Internet.
Similar time spent online, but distinct differences 
Both study groups spent a mean of 6 1/2 hours online each day. However, those with eating disorders spent more of their online time visiting forums and reading blogs than did control group members. In fact, more than half of their time online was devoted to eating, weight, and body image, significantly more than control participants (56.7% versus 29.1%, respectively).
The group with eating disorders watched significantly more videos online than did controls. However, both groups were equally likely to view pictures posted by others, but those with lifetime diagnoses of eating disorders were less likely to post pictures of themselves and others online than were controls.
After being active online, as, for example, commenting, posting pictures and offering advice to others online, those with eating disorders reported feeling sadder than did control group members. There was, however, no significant difference between the groups in their experience of relief, fear of others’ reactions to their comments, and satisfaction from having contributed something positive to the sites.
The authors noted that the study results showed several negative aspects of Internet use by women with eating disorders, and areas that might be targeted in treatment. Women with eating disorders tended to use the Internet to focus on eating, weight, and body image. They also tended to have a higher ratio of online to offline friends, to compare their appearance to others’ online photos, and to leave the Internet with negative feelings. This pattern was also associated with the severity of symptoms, body dissatisfaction, negatively associated with satisfaction with life.
The researchers had several suggestions for clinicians treating patients who frequently use the Internet to visit forums and blogs. Use of the Internet should be a topic in therapy with people who have an eating disorder.  Parents can also be informed about Internet use and take a greater interest in the eating- and body image-related Internet options open to young people and to be alert for possible signs of negative effects.
While encouraging the sense of connectedness that patient feel with being online, clinicians can also help patients develop “real life” social skills, such as social problem-solving and better recognition of facial expressions. Patients can also be encouraged to create connections with healthy people around them, and to speak about their disorders, helping reduce the need to do so exclusively or mainly online.

From Across the Desk: Working toward Better Guidelines for Severe and Extreme Eating Disorders

Vol. 30 / No. 1  
It is well known that the mortality rate from anorexia nervosa makes it the most deadly of psychiatric illnesses.  Two articles this month turn to the challenging task of matching the level of care to severe eating disorders. Jeana Cost and Philip Mehler, of the Eating Recovery Center in Denver (“Level of Care Considerations for Severe and Extreme Eating Disorders”) note that historically clinicians have followed the guidelines from the American Psychiatric Association but, as the authors note, the guidelines fail to outline medical treatment for these patients. The authors offer helpful guidelines, including considerations for patients with normal to higher body mass indices, and stress the importance of medical stabilization.
In the article, “Finding a Better Definition for Severe and Enduring Anorexia Nervosa,”Phillipa Hay and Stephen Touyz lament the lack of consensus for clear-cut definitions of severe AN and for recovery. They offer three components of severe and enduring anorexia nervosa. They would also like to delete the term “treatment resistant,” which they feel blames the physician and patient for the disorder.  The first-look release of the ICD-11 at the World Health Assembly in May might offer some solutions, according to Drs. Hay and Touyz.

Level of Care Considerations for Severe and Extreme Eating Disorders

Vol. 30 / No. 1  
by Jeana J. Cost, MS, LPC, CEDS, and Philip S. Mehler, MD, FACP, FAED, CEDSEating Recovery Center, Denver, Colorado
Determining what level of care a patient with an eating disorder needs can be one of the most challenging aspects of referring to treatment. Between client resistance and the body’s ability to feign stability, it can be easy to accept the least intensive route.
The eating disorder industry has an ongoing need for even more definitive level of care guidelines, supported by empirical evidence and embraced by the eating disorder community. Historically, there has been reliance on the guidelines published by the American Psychiatric Association (APA), but there remains some degree of deficient integration of changing diagnostic criteria, as well as definition of what each level of care means. Additionally, the APA guidelines outline the five levels of care between outpatient and inpatient, but fail to completely outline a sixth level of care – medical treatment.  The provision of additional information for the eating disorder community about all levels of care, appropriate admission guidelines, as well as appropriate treatment options, is critically important to optimize a successful outcome for the patient suffering with an eating disorder.
Using the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5)
Positive strides towards appropriate diagnosis and referrals were made in 2013, when theDSM-5was updated and released. It included several clinically relevant criterions. One of the most important changes was adding the severity index for evaluating one’s body mass index (BMI, kg/m2), which primarily impacts the diagnosis of anorexia nervosa (AN). The index is as follows: Mild(BMI > or = 17.0), Moderate(16.0-16.99), Severe(15.0-15.99), and Extreme(< 15.0). This not only helps clinicians to diagnose Anorexia Nervosa in someone above 85% of ideal body weight (previous marker), but it also highlights the concerning fact that there are also a number of patients with extremely low BMIs. We often think about eating disorder treatment as singularly behavioral in nature, but the “extreme” category should compel families and clinicians to consider a patient’s needs beyond that.
Severe and extreme eating disorders can cause life threatening medical complications including dangerous electrolyte imbalances, re-feeding syndrome, severe dehydration, edema, gastrointestinal complications, superior mesenteric artery syndrome (SMA), bradycardia and organ failure, to name but a few. It is important that there is appreciation and consideration that these potential complications exist not infrequently, especially at lower BMIs, and thus the need to intervene in a timely fashion.
Intervention should include medical stabilization in a highly sophisticated and specialized medical unit, prior to a patient starting traditional eating disorder treatment. Many experts espouse that this should happen when a BMI is < 14.0, or when that patient’s weight is < 70% ideal body weight (IBW). Thus, in general, patients with AN or Avoidant/Restrictive Food Intake Disorder (ARFID) who are below 70% IBW, should first be treated in a specialized medical unit for the medical stabilization of those patients.
In general, if the patients’ weight is between 70-84% of IBW, they are best served in an inpatient or residential treatment center, and if they are 85% to 95% of IBW, a partial hospitalization program (PHP) will generally suffice.  But nothing is absolute, and thus the frequency of purging behaviors and other physical or psychiatric considerations can further qualify the level of care that may be needed.
Considerations with Normal to Higher BMIs
More recently it has been being recognized that harm may occur by assuming that those with a “normal” or “higher” BMI are stable enough to access lower levels of care. Not only can these patients be presenting with a falsely elevated weight, but they can also be at risk for dangerous complications due to excessive purging behaviors followed by abrupt cessation or significant and rapid “weight disruption” from weight loss. Thus, the need to consider the severity of purging behaviors (also outlined in theDSM-5) and the severity of absolute weight loss when choosing an appropriate level of care. Again, consider medical stabilization first for those showing severe weight disruption as well as those needing to safely “detox” from severe substance, laxative or diuretic abuse.  Starting in the appropriate level of care can have a significant impact on the patient’s health, success in recovery, and satisfaction with treatment.
Suggested Reading
  1. Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition(DSM-5).
  2. Garber, A. K. (2018). Moving beyond “skinniness”: presentation weight is not sufficient to assess malnutrition in patients with restrictive eating disorders across a range of body weights. Journal of Adolescent Health, 63(6), 669-670.
  1. Academy for Eating Disorders (2016). Critical points for early recognition & medical risk management in the care of individuals with eating disorders (3rd ed.). Reston, VA: Academy for Eating Disorders.
  1. American Psychiatric Association (2006). Practice guideline for the treatment of patients with eating disorders (3rd ed). Washington, DC: American Psychiatric Association.

When People with Anorexia Injure Themselves

Vol. 29 / No. 6  
Difficulty regulating emotions is a common component of an eating disorder, and self-injury  may act as a coping mechanism for dealing with overwhelming emotions. This was one finding from a recent study of patients with anorexia nervosa or eating disorders not otherwise specified (J Eat Disord. 2018; 6:26).
Dr. Linda Smithius and colleagues at Parnassus Psychiatric Institute, Rotterdam, used a cross-sectional design and a self-report questionnaire to measure the prevalence and characteristics of self-harm behavior among 136 patients with eating disorders. The authors found that 41% of their study subjects had injured themselves during the previous 30 days. Those who injured themselves had been in treatment longer and were more likely to have a secondary psychiatric diagnosis, suggesting more severe illness than those who did not injure themselves. These patients also stated they a reduction in negative feelings and increased relief after hurting themselves. Afterwards they also could articulate the emotions that led them to injure themselves. The Dutch researchers were also able to isolate the intensity of two emotions in particular, “feeling angry at myself” and “feeling angry at others.”
The authors noted that emotion regulation appears to differ between subtypes of anorexia nervosa, so that patients with the purging subtype have reported greater difficulty regulating their emotions than do patients with restrictive-type anorexia nervosa (J Eat Disord. 2016; 4:17). The findings replicate work using intensive self-monitoring strategies such as ecological momentary assessment to measure the impact of self-injury on emotion regulation