A Pilot Open Trial of a Digital Mindfulness-Based Intervention for Anorexia Nervosa

Anorexia nervosa (AN) is a chronic and debilitating psychiatric disorder. Unfortunately, current treatments are lacking, with only 30-50% of individuals with AN recovering after treatment. We developed a beta-version of a digital mindfulness-based intervention for AN called Mindful Courage-Beta, which includes: (a) one foundational multimedia module; (b) 10 daily meditation mini-modules; (c) emphasis on a core skill set called the BOAT (Breathe, Observe, Accept, Take a Moment); and (d) brief phone coaching for both technical and motivational support. In this open trial, we aimed to evaluate (1) acceptability and feasibility; (2) intervention skill use and its association with state mindfulness in daily life; and (3) pre-to-post changes in target mechanisms and outcomes. Eighteen individuals with past-year AN or past-year atypical AN completed Mindful Courage-Beta over 2 weeks. Participants completed measures of acceptability, trait mindfulness, emotion regulation, eating disorder symptoms, and body dissatisfaction. Participants also completed ecological momentary assessment of skill use and state mindfulness. Acceptability ratings were good (ease-of-use: 8.2/10, helpfulness: 7.6/10). Adherence was excellent (100% completion for foundational module and 96% for mini-modules). Use of the BOAT in daily life was high (1.8 times/day) and was significantly associated with higher state mindfulness at the within-person level. We also found significant, large improvements in the target mechanisms of trait mindfulness (d = .96) and emotion regulation (d = .76), as well as significant, small-medium to medium-large reductions in eating disorder symptoms (ds = .36–.67) and body dissatisfaction (d = .60). Changes in trait mindfulness and emotion regulation had medium-large size correlations with changes in global ED symptoms and body dissatisfaction (rs = .43 – .56). Mindful Courage-Beta appears to be promising and further research on a longer, refined version is warranted.     

Do eating disorder voice characteristics predict treatment outcomes in anorexia nervosa? A pilot study

Individuals with anorexia nervosa often describe experiencing an internal “voice” of their disorder, which previous research has associated with multiple dimensions of eating pathology. This pilot study examined whether eating disorder measures use invoice characteristics at the outset of outpatient therapy predicted changes in disordered eating over the course of treatment. Participants were 14 individuals meeting ICD-10 criteria for anorexia nervosa. Participants completed measures relating to the severity of disordered eating and voice-related characteristics (perceived voice power and metacognitive appraisals about its nature) at the start and end of therapy. Results indicated that the perceived power of the eating disorder was reduced over the course of outpatient therapy, although its other characteristics remained stable. Greater levels of voice power, omnipotence and benevolence at the outset of therapy were related to greater improvements in eating attitudes. No voice-related characteristics were associated with changes in weight. These findings suggest that voice-related appraisals do not obstruct the effectiveness of outpatient therapies for anorexia nervosa. Further studies are needed to ratify these preliminary findings.     

The experience of feeling fat for women with anorexia nervosa: An interpretative phenomenological analysis

Feeling fat has been implicated as a maintenance factor in anorexia nervosa (AN), despite limited research into the experience. This study expanded the literature by exploring the lived experience of feeling fat for women with a diagnosis of AN. Seven women participated in this study and data was collected through semi-structured interviews. Interpretive Phenomenological Analysis (IPA) was employed to explore the participants’ experience of ‘feeling fat’ and its relevance for clinical treatment. Four main themes emerged from the data: ‘negative sense of self’, ‘feeling out of control’, ‘coping with feeling fat’, and ‘making sense of feeling fat is complex’. These results highlight feeling fat as a significant experience and maintenance factor for women with a diagnosis of AN. Implications for addressing feeling fat within psychological therapy are explored.     

进食障碍影响因素的探讨

神经性厌食症和神经性贪食症是主要的进食障碍症状。进食障碍的影响因素有社会文化因素（例如媒体和同伴的影响）、家庭因素（如困惑和冲突）、消极情绪、低自尊水平和对自身的不满及认知和生物方面的因素等。     

The Cognitive‐Behavioural Theory and Treatment of Bulimia Nervosa: An Examination of Treatment Mechanisms and Future Directions

Enhanced cognitive‐behavioural therapy (CBT‐E) is the current treatment of choice for bulimia nervosa. While the cognitive‐behavioural theory and treatment of bulimia nervosa have made a substantial contribution to our understanding of the disorder, approximately half of patients treated with CBT‐E fail to achieve remission of binge eating and purging. There is evidence showing that mechanisms proposed by the CBT‐E model are associated with binge eating and purging symptoms, and therefore likely important targets for treatment. To identify future directions in improving the efficacy of this treatment, and informed by a model of the client change process, we review the evidence for the hypothesised treatment mechanisms of CBT‐E. We conclude that while the proposed treatment mechanisms of CBT‐E largely change over the course of treatment, there is limited evidence that the treatment manipulations of CBT‐E are responsible for the specific changes in the proposed treatment mechanisms. In addition, given a lack of research in this area, we could find no evidence that changes in the additional treatment mechanisms outlined in CBT‐E are associated with changes in the core symptomatology of binge eating and purging. Based on these findings, we recommend that future efforts are directed towards understanding the client change process in CBT‐E and outline three clear directions for research.     

Validation française de l’échelle de mesure de l’orthorexie ORTO-15 et étude des liens avec les troubles des conduites alimentaires et l’image du corps

IntroductionAlthough orthorexia is described as a pathological obsession over healthy food, its nature remains unclear. The results of the majority of studies, mainly using the ORTO-15 measurement scale, remain limited to certain countries and cannot be generalized to every culture. Furthermore, recent studies suggest that body image should be included in the orthorexia research, in addition to eating disorders.ObjectiveThe aim of this study was to propose a French adaptation of the ORTO-15 measurement scale using the Vallerand's transcultural validation procedure, explore its psychometric properties and the links between orthorexic behvaiour, symptoms of eating disorders and body image.MethodFour hundred and nine young adults (89% female), aged 18 to 25 years, completed the online version of the following scales: ORTO-15, Dunn et al. criteria (2016), the Eating-Attitudes Test (EAT-26), Binge Eating Scale (BES) and the Multidimensional Body Self Relations Questionnaire-Appearance Scale (MBSRQ-AS). Exploratory and confirmatory factor analysis (EFA and CFA, respectively) were carried out on two randomly split samples and links between different variables were explored using Spearman correlation coefficients.ResultsThe EFA yielded a single-factor 11-items structure explaining 24% of variance. The adjustment indices from the CFA were excellent. The stability of the scale was satisfactory (ICC = 0.71), despite a questionable internal consistency (α = .50). Links with other scales indicated good structural validity.ConclusionORTO-11-Fr presented satisfactory psychometric properties. Further studies are needed for identifying predictors of orthorexia as well as improving its definition and assessment.     

Overvaluation of shape and weight in binge eating disorder, bulimia nervosa, and sub-threshold bulimia nervosa

Increasing empirical evidence supports the validity of binge eating disorder (BED), a research diagnosis in the appendix of DSM-IV, and its inclusion as a distinct and formal diagnosis in the DSM-V. A pressing question regarding the specific criteria for BED diagnosis is whether, like bulimia nervosa (BN), it should be characterized by overvaluation of shape and weight. This study compared features of eating disorders in 436 treatment-seeking women comprising four groups: 195 BED participants who overvalue their shape/weight, 129 BED participants with subclinical levels of overvaluation, 61 BN participants, and 51 participants with sub-threshold BN. The BED clinical overvaluation group had significantly higher levels of specific eating disorder psychopathology than the three other groups which did not differ significantly from each other. Findings suggest that overvaluation of shape and weight should not be considered as a required criterion for BED because this would exclude a substantial proportion of BED patients with clinically significant problems. Rather, overvaluation of shape and weight warrants consideration either as a diagnostic specifier or as a dimensional severity rating as it provides important information about severity within BED.     

Assessment and Diagnosis of Eating Disorders: A Guide for Professional Counselors

Despite the prevalence of and risk associated with disordered eating, there are few guidelines for counselors on how to conduct an eating disorder assessment. Given the importance of the clinical interview, the purpose of this article is to provide recommendations for the assessment and diagnosis of eating disorders that (a) specifically focus on assessment in the context of a clinical interview and (b) can be used by counselors whether or not they specialize in eating disorder treatment.     

An evaluation of the enhanced cognitive-behavioural model of bulimia nervosa

The original cognitive-behavioural model of bulimia nervosa (BN) has been enhanced to include four additional maintaining mechanisms: low self esteem, clinical perfectionism, interpersonal problems, and mood intolerance. These models have been used to guide cognitive-behavioural treatment for BN, but the enhanced model has yet to be directly evaluated as a whole in a clinical sample. This study aimed to compare and evaluate the original and the enhanced cognitive-behavioural models of BN using structural equation modelling. The Eating Disorder Examination and self-report questionnaires were completed by 162 patients seeking treatment for BN (N = 129) or atypical BN (N = 33). Fit indices suggested that both the original and enhanced models provided a good fit to the data, but the enhanced model accounted for more variance in dietary restraint and binge eating. In the enhanced model, low self esteem was associated with greater overevaluation of weight and shape, which, in turn, was associated with increased dietary restraint. Interpersonal problems were also directly associated with dietary restraint, and binge eating was associated with increased purging. While the current study provides support for some aspects of the enhanced cognitive-behavioural model of BN, some key relationships in the model were not supported, including the important conceptual relationship between dietary restraint and binge eating.     

Night-time eating in men and women with binge eating disorder

This study examined the frequency of night-time eating (NE) and its correlates in men and women with binge eating disorder (BED). Two-hundred and seven consecutively evaluated adults (45 men and 162 women) with BED were assessed with semi-structured interviews and a battery of behavioral and psychological measures. Overall, 28% (N = 58) of the participants reported NE. A significantly higher proportion of men (42%) than women (24%) reported NE. Overall, participants who reported NE had a significantly higher body mass index, but otherwise differed little from those who did not report NE. Men and women without NE differed little on behavioral and psychological measures, whereas women with NE had significantly higher levels of eating-, weight-, and shape-concerns than men with NE.     

Objective and subjective bulimic episodes in the classification of bulimic-type eating disorders: Another nail in the coffin of a problematic distinction

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

Assessing the specific psychopathology of binge eating disorder patients: Interview or self-report?

Research addressing the assessment of binge eating and associated eating disorder psychopathology has steadily increased in recent years. Few studies have examined the relationship between the various assessment methods. This study compared an investigator-based interview, the Eating Disorder Examination (EDE), with a self-report version of that interview, the EDE-Q. Fifty-two individuals (six men and 46 women) with binge eating disorder (BED) completed both instruments. Modest-to-good agreement and significant correlations (P < 0.0001) were found between the two methods on all four subscales assessing specific eating disorder psychopathology (i.e., Restraint, Eating Concern, Weight Concern, and Shape Concern subscales). However, higher levels of disturbance were consistently reported on the EDE-Q than the EDE interview. The two methods were not significantly or reliably related to one another when assessing binge eating. This may be due in part to the difficulty inherent in identifying binges in subjects with BED. Examination of individual item scores suggest that it might be possible to improve the performance of the EDE-Q by clarifying the definitions of certain complex features, although this should not be at the expense of compromising the practical utility of its self-report format.     

Relation between the syndromes of bulimia nervosa and obsessive compulsive disorder

Bulimia nervosa (BN) has been conceptualized as similar to obsessive compulsive disorder (OCD). The results of studies investigating the relation between BN and OCD, however, are inconclusive. Our goal was to attempt to clarify the relation between the syndromes of BN and OCD. The Padua Inventory (PI), a measure of OCD, and the Bulimia Test—Revised (BULIT-R), a measure of bulimic behaviors, were administered to 981 women and 722 men. A significant relationship, equal in magnitude for women and men, was found between BN and OCD. Bulimic symptoms also had a stronger relation to obsessions than compulsions. Finally, 6 of 23 women (26%) who met the diagnostic criteria for BN also met the criteria for OCD, while 1 of 1 man who met the criteria for BN also met the criteria for OCD. Implications for similarities between the two disorders as well as future issues in the study of comorbidity are discussed.This report is based on the first author's masters thesis, which was supervised by the second author.     

Enhanced Cognitive Behavior Therapy: A Single Treatment for All Eating Disorders

Eating disorders are serious mental illnesses affecting a significant proportion of women and a smaller number of men. Approximately half of those with an eating disorder (ED) will not meet the criteria for anorexia or bulimia nervosa, and will be diagnosed with an eating disorder not otherwise specified (EDNOS). Until recently, there were no recommended treatments for EDNOS. This article provides an overview of enhanced cognitive behavior therapy, a validated treatment for all forms of EDs.     

Is anorexia nervosa a neuropsychological disease?

Evidence for central nervous system, and more particularly cortical, etiology of anorexia nervosa is reviewed. Topics covered are neuropsychiatric comorbidity, inheritance patterns, the neurobiology of body-image disturbance and of the eating function, perinatal and alcoholic insult to the brain, neurochemical and neuroelectric disturbance, anatomic and metabolic brain imaging, and neuropsychological impairment. It is concluded that there is indeed an important neuropsychological etiological dimension to anorexia nervosa. The profile most frequently associated with anorexia nervosa is right posterior hypometabolism, followed by right anterior hypermetabolism, both associated with right-sided abnormal electroencephalogram spiking. It is also proposed that bulimia consists of a positive neurological subtype and that restricting anorexia represents a negative neurological subtype. Priorities for further research into anorexia nervosa are specified to include twin adoption studies, brain electrical topography studies, postmortem histological studies, and experimentally inspired neuropsychological studies.     

An exploratory assessment of theory of mind and psychological impairment in patients with bulimia nervosa

This study aimed to investigate psychosocial functioning and different dimensions of theory of mind (ToM) in people with bulimia nervosa (BN) and Eating Disorder Not Otherwise Specified‐BN type (EDNOS‐BN). Psychosocial functioning and ToM were assessed in a sample of young adult females, 16 BN and 16 EDNOS‐BN outpatients and 16 healthy controls (HCs). They were assessed using the Eating Disorder Inventory‐Symptom Checklist‐2 (EDI‐2 SC) for evaluating psychological traits associated with eating disorders; the Symptom Checklist‐90‐Revised (SCL‐90‐R) for evaluating psychopathological status; and the Theory of Mind Assessment Scale (Th.o.m.a.s.), a semi‐structured interview aimed at assessing a person's different dimensions of ToM. The BN and EDNOS‐BN groups exhibited worse performance than the control group on all dimensions of the SCL‐90‐R, and on all dimensions of the EDI‐2 SC. The only difference for perfectionism was that BN obtained higher scores than EDNOS‐BN group. Our results also revealed an impairment of third‐person and second‐order ToM in patients with bulimia (BN and EDNOS‐BN) with respect to control subjects. These preliminary data have important implications for future empirical work, in that they provide valuable information regarding the importance of investigating the various facets of ToM ability separately, in order to provide a more detailed profile of ToM functioning in the clinical samples.     

Loss of control over eating reflects eating disturbances and general psychopathology

This study examined the clinical significance of the loss of control over eating as a key component of eating disorders. It investigated the association of eating-related psychopathology and general psychopathology with objective bulimic episodes (OBEs; experiencing a loss of control while consuming large amounts of food) and subjective bulimic episodes (SBEs; experiencing a loss of control while consuming small/moderate amounts). A community sample of 81 women with a range of disordered eating was recruited: binge-eating disorder, bulimia nervosa, subclinical eating disturbances, or no eating disorders. They were interviewed using the Eating Disorder Examination and completed measures of eating-related and general psychopathology. Both OBE and SBE frequencies correlated significantly with measures of eating-related and general psychopathology, and no significant differences were found between the magnitudes of the correlations with either binge episode type. SBE frequency significantly and independently predicted global eating disorder psychopathology. The loss of control over eating, without consuming large amounts of food, was as closely associated with specific eating disorder psychopathology and general mental health as were traditionally defined OBEs. SBEs may be an important target of treatment and should be considered for future diagnostic classifications of eating disorders.     

Effectiveness of parent counselling in eating disorders

ABSTRACT

Eating Disorders (ED) are often severe illnesses entailing a heavy burden for families. Family therapy is recommended for young patients, but only a few studies have investigated therapeutic interventions with families tailored also to adult and longstanding patients. We recruited 87 families with daughters affected by an ED, aiming to assess the effectiveness of eight sessions of parent counselling. The primary outcome was the improvement of parents' coping abilities to achieve more effective support skills. Before treatment, 54% of parents showed poor coping resources whereas 43.7% of the sample improved after parent counselling. Parents with good coping resources responded significantly better to this treatment. Although future research is warranted, these preliminary findings support the effectiveness of parent counselling in ED.     

Eating behavior in obese BED, obese non-BED, and non-obese control participants: A naturalistic study

Laboratory studies have shown considerable differences between the eating behavior, particularly binge eating behavior, of participants with and without binge eating disorder (BED). However, these findings were not replicated in two field experiments employing ecological momentary assessment (EMA) in which obese BED and obese non-BED participants reported comparable binge eating behavior. In the current study, we examined differences in binge eating with an innovative assessment scheme employing both EMA and a standardized computer-based dietary recall program to avoid some of the limitations of past laboratory and field research. Obese BED, obese non-BED, and non-obese control participants reported significant differences in eating patterns, loss of control, overeating, and binge eating behavior. Of particular importance was the finding that BED participants engaged in more overeating and more binge eating episodes than non-BED participants. These findings suggest that the use of EMA in combination with dietary recall may be a relatively objective and useful approach to assessing binge eating behavior. The findings further suggest that individuals with BED are observably different from those without the disorder, which may have implications for eating disorder diagnoses in DSM-V.     

Can we fight stigma with science? The effect of aetiological framing on attitudes towards anorexia nervosa and the impact on volitional stigma

The present study experimentally investigated the way in which exposure to various aetiological explanations of anorexia nervosa (AN) differentially affected stigmatisation and behavioural intention outcomes. University students (N = 161) were randomly assigned to read one of four aetiological vignettes presenting the causes of AN as biological/genetic, socio‐cultural, environmental, or multifactorial. Results indicate that those who received a socio‐cultural explanation made stronger socio‐cultural causal attributions, fewer biological/genetic causal attributions, and were significantly less willing to sign a health insurance petition for AN. Unexpectedly, the multifactorial group considered individuals with AN as more responsible and blameworthy for their condition. Overall, findings were comparative with previous research and partially support the propositions of attribution theory. Results also suggest that by conceptualising the aetiology of AN as biological or genetic, or at least increasing one's knowledge of these contributing factors, it may be possible to decrease the level of blame‐based stigma associated with AN.