Little information is available on the prevalence of Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 eating disorders in adolescence, and eating disorders remain unique in the DSM for ...not systematically including a criterion for clinical significance. This study aimed to provide the first prevalence report of the full suite of DSM-5 eating disorders in adolescence, and to examine the impact of applying a criterion for clinical significance.
In total, 5191 (participation rate: 70%) Australian adolescents completed a survey measuring 1-month prevalence of eating disorder symptoms for all criterial, 'other specified' and unspecified eating disorders, as well as health-related quality of life and psychological distress.
The point prevalence of any eating disorder was 22.2% (12.8% in boys, 32.9% in girls), and 'other specified' disorders (11.2%) were more common than full criterial disorders (6.2%). Probable bulimia nervosa and binge eating disorder, but not anorexia nervosa (AN), were more likely to be experienced by older adolescents. Most disorders were associated with an increased odds for being at a higher weight. The prevalence of eating disorders was reduced by 40% (to 13.6%) when a criterion for clinical significance was applied.
Eating disorders, particularly 'other specified' syndromes, are common in adolescence, and are experienced across age, weight, socioeconomic and migrant status. The merit of adding a criterion for clinical significance to the eating disorders, similar to other DSM-5 disorders, warrants consideration. At the least, screening tools should measure distress and impairment associated with eating disorder symptoms in order to capture adolescents in greatest need for intervention.
Other Specified Feeding and Eating Disorders (OSFED) are characterized by less frequent symptoms or symptoms that do not meet full criteria for another eating disorder. Despite its high prevalence, ...limited research has examined differences in severity and treatment outcome among patients with OSFED compared to threshold EDs Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED). The purpose of the current study was to examine differences in clinical presentation and treatment outcome between a heterogenous group of patients with OSFED or threshold EDs.
Patients with threshold EDs (
= 42,
= 50, BED = 14) or OSFED (
= 66) presenting for eating disorder treatment completed self-report questionnaires at intake and discharge to assess eating disorder symptoms, depression symptoms, impairment, and self-esteem.
At intake, OSFED patients showed lower eating concerns compared to patients with BN, but similar levels compared to AN and BED. The OSFED group showed higher restraint symptoms compared to BED, and similar restraint to AN and BN. Global symptoms as well as shape and weight concerns were similar between OSFED and threshold ED groups. There were no differences between diagnostic groups in self-esteem, depression scores, or symptom change from intake to discharge.
Our findings suggest that individuals with OSFED showed largely similar ED psychopathology and similar decreases in symptoms across treatment as individuals diagnosed with threshold EDs. Taken together, findings challenge the idea that OSFED is less severe and more resistant to treatment than threshold EDs.
•Access to evidence-based treatments for bulimia nervosa (BN) remains inadequate.•Online self-help interventions increase access to evidence-based treatments in a scalable and cost-effective ...manner.•Both clinician-supported and self-help delivery of online CBT were more effective than WLC in reducing BN symptoms.•Clinician-supported was superior to self-help in regards to two secondary variables (laxative use and dietary restraint).
High dropout rates and poor adherence associated with digital interventions have prompted research into modifications of these treatments to improve engagement and completion rates. This trial aimed to investigate the added benefit of clinician support when paired alongside a ten-session, online cognitive behaviour therapy (CBT) self-help intervention for bulimia nervosa (BN). As part of a three-arm, phase II randomised controlled trial, 114 participants (16 years or over) with full or subthreshold BN were randomly assigned to complete the intervention in a self-help mode (with administrative researcher contact; n = 38), with adjunct clinician support (weekly 30-minute videoconferencing sessions; n = 37), or a no-treatment waitlist control (WLC; n = 39). Baseline to post-treatment (12-weeks) decreases in objective binge episode frequency were significantly greater for clinician-supported participants as compared to WLC, but not for self-help when compared to WLC. However, due to continued improvements for self-help across follow-up (24-weeks), both arms outperformed WLC when analysed as an overall rate of change across three timepoints. Clinician-supported participants outperformed self-help in regards to laxative use and dietary restraint. Our results demonstrate that good clinical outcomes can be achieved with a relatively brief online CBT-based program even in the absence of structured clinical support, indicating a possible overreliance upon clinician support as a primary adherence-facilitating mechanism.
Objective
To map and examine the systematic review evidence base regarding the effects of cognitive‐behavioral therapy (CBT) for eating disorders (EDs), especially against active interventions.
...Method
This systematic review is an extension of an overview of CBT for all health conditions (CBT‐O). We identified ED‐related systematic reviews from the CBT‐O database and performed updated searches of EMBASE, MEDLINE, and PsychInfo in April 2021 and September 2022.
Results
The 44 systematic reviews included (21 meta‐analyses) were of varying quality. They focused on “high intensity” CBT, delivered face‐to‐face by qualified clinicians, in BN, BED and mixed, not specifically low‐weight samples. ED‐specific outcomes were studied most, with little consensus on their operationalization. The, often insufficient, reporting of sample characteristics did not allow assessment of the generalizability of findings. The meta‐analytic syntheses show that high intensity one‐to‐one CBT produces better short‐term effects than a mix of active controls especially on ED‐specific measures for BED, BN, and transdiagnostic samples. There is little evidence favoring group CBT or low intensity CBT against other active interventions.
Discussion
While this study found evidence consistent with current ED treatment recommendations, it highlighted notable gaps that need to be addressed. There were insufficient data to allow generalizations regarding sex and gender, age, culture and comorbidity and to support CBT in AN samples. The evidence for group CBT and low intensity CBT against active controls is limited, as it is for the longer‐term effects of CBT. Our findings identify areas for future innovation and research within CBT.
Public Significance
This study provides a comprehensive mapping and quality assessment of the current large systematic review research base regarding the effects of cognitive behavioral therapy (CBT) for eating disorders (EDs), with a focus on comparisons to other active interventions. By transcending the more limited scope of individual systematic reviews, this overview highlights the gaps in the current evidence base, and thus provides guidance for future research and clinical innovation.
Resumen
Objetivo
Mapear y examinar la base de evidencia de la revisión sistemática con respecto a los efectos de la terapia cognitivo‐conductual (TCC) para los trastornos de la conducta alimentaria (TCA), especialmente contra las intervenciones activas.
Método
Esta revisión sistemática es una extensión de una visión general de la TCC para todas las afecciones de salud (TCC‐O, Fordham et al., 2021a). Se identificaron revisiones sistemáticas relacionadas con los TCA a partir de la base de datos TCC‐O y se realizaron búsquedas actualizadas en EMBASE, MEDLINE y PsychInfo en abril de 2021 y septiembre de 2022.
Resultados
Las 44 revisiones sistemáticas incluidas (21 metanálisis) fueron de calidad variable. Se centraron en la TCC de “alta intensidad”, administrada cara a cara por clínicos calificados, en BN, TpA y muestras mixtas, no específicamente de bajo peso. Los resultados específicos de los TCA fueron los más estudiados, con poco consenso sobre su operacionalización. El informe, a menudo insuficiente, de las características de la muestra no permitió evaluar la generalización de los hallazgos. Las síntesis metaanalíticas muestran que la TCC uno a uno de alta intensidad produce mejores efectos a corto plazo que una combinación de controles activos, especialmente en medidas específicas de TCA para TpA, BN y muestras transdiagnósticas. Hay poca evidencia a favor de la TCC grupal o la TCC de baja intensidad frente a otras intervenciones activas.
Discusión
Si bien este estudio encontró evidencia consistente con las recomendaciones actuales de tratamiento de los TCA, también destacó las brechas notables que deben abordarse. No hubo datos suficientes para permitir generalizaciones con respecto al sexo y el género, la edad, la cultura y la comorbilidad y para apoyar la TCC en las muestras de AN. La evidencia para la TCC grupal y la TCC de baja intensidad contra los controles activos es limitada, al igual que para los efectos a más largo plazo de la TCC. Nuestros hallazgos identifican áreas para la innovación y la investigación futuras dentro de la TCC.
To quantify eating disorder (ED) stability and diagnostic transition among a community-based sample of adolescents and young adult females in the United States.
Using 11 prospective assessments from ...9,031 U.S. females ages 9–15 years at baseline of the Growing Up Today Study, we classified cases of the following EDs involving bingeing and purging: bulimia nervosa (BN), binge ED, purging disorder (PD), and subthreshold variants defined by less frequent (monthly vs. weekly) bingeing and purging behaviors. We measured number of years symptomatic and probability of maintaining symptoms, crossing to another diagnosis, or resolving symptoms across consecutive surveys.
Study lifetime disorder prevalence was 2.1% for BN and roughly 6% each for binge ED and PD. Most cases reported symptoms during only one survey year. Twenty-six percent of cases crossed between diagnoses during follow-up. Among participants meeting full threshold diagnostic criteria, transition from BN was most prevalent, crossing most frequently from BN to PD (12.9% of BN cases). Within each disorder phenotype, 20%–40% of cases moved between subthreshold and full threshold criteria across consecutive surveys.
Diagnostic crossover is not rare among adolescent and young adult females with an ED. Transition patterns from BN to PD add support for considering these classifications in the same diagnostic category of disorders that involve purging. The prevalence of crossover between monthly and weekly symptom frequency suggests that a continuum or staging approach may increase utility of ED classification for prognostic and therapeutic intervention.
Objective
Patients with atypical anorexia nervosa (AN) have many features overlapping with AN in terms of genetic risk, age of onset, psychopathology and prognosis of outcome, although the weight ...loss may not be a core factor. While brain structural alterations have been reported in AN, there are currently no data regarding atypical AN patients.
Method
We investigated brain structure through a voxel‐based morphometry analysis in 22 adolescent females newly‐diagnosed with atypical AN, and 38 age‐ and sex‐matched healthy controls (HC). ED‐related psychopathology, impulsiveness and obsessive‐compulsive traits were assessed with the Eating Disorder Examination Questionnaire (EDE‐Q), Barratt Impulsiveness Scale (BIS‐11) and Obsessive‐compulsive Inventory Revised (OCI‐R), respectively. Body mass index (BMI) was also calculated.
Results
Patients and HC differed significantly on BMI (p < .002), EDE‐Q total score (p < .000) and OCI‐R total score (p < .000). No differences could be detected in grey matter (GM) regional volume between groups.
Discussion
The ED‐related cognitions in atypical AN patients would suggest that atypical AN and AN could be part of the same spectrum of restrictive‐ED. However, contrary to previous reports in AN, our atypical AN patients did not show any GM volume reduction. The different degree of weight loss might play a role in determining such discrepancy. Alternatively, the preservation of GM volume might indeed differentiate atypical AN from AN.
Objective
Atypical anorexia nervosa (AN) is a serious eating disorder that is more common in the population than AN. Despite this, people with atypical AN are less likely to be referred or admitted ...for eating disorder treatment and there is evidence that they are less likely to complete or benefit from existing interventions. This study examined whether baseline readiness and/or confidence moderated outcomes from 10‐session cognitive behavioral therapy among people with atypical AN and bulimia nervosa (BN), and whether the impact of these variables differed between diagnoses.
Methods
Participants (n = 67; 33 with atypical AN) were a subset from an outpatient treatment study. Linear mixed model analyses were conducted to examine whether baseline readiness and/or confidence moderated outcomes.
Results
People with BN who had higher levels of readiness or confidence at baseline had steeper decreases in eating disorder psychopathology over time. There was no evidence that readiness or confidence moderated outcomes for people with atypical AN.
Discussion
This study suggests that the moderators that have been identified for other eating disorders may not apply for people with atypical AN and highlights a need for future work to routinely investigate whether theoretically or empirically driven variables moderate outcomes in this little‐understood population.
Public Significance Statement
People with bulimia nervosa with higher readiness and confidence experienced greater decreases in eating disorder symptoms than people with lower readiness and confidence when treated with cognitive behavioral therapy. These findings did not apply to people with atypical anorexia nervosa. Results demonstrate that future work is urgently required to identify helpful treatments for people with atypical anorexia nervosa as well as the variables that have a positive impact on outcomes in treatment for these individuals.
Objective
Literature comparing “atypical” anorexia nervosa (atypical AN) and anorexia nervosa (AN) suggests these diagnoses share significant similarities in eating disorder (ED) pathology and ...psychiatric comorbidities. This study evaluated potential differences in ED pathology, psychiatric comorbidity, associated mechanisms (i.e., ED fears and perfectionism), and demographic factors (i.e., ethnicity and age) between individuals with atypical AN and AN.
Method
Data from seven protocols were combined for a total 464 individuals diagnosed with atypical AN (n = 215) or AN (n = 249). Between‐group differences in ED severity and behaviors, psychiatric comorbidities, ED fears, perfectionism, and demographic factors were assessed using t‐tests, Wilcoxon rank‐sum tests, and Fisher's exact test.
Results
Participants with atypical AN reported higher levels of overvaluation of weight and shape than those with AN. Participants with AN scored higher on food‐related fears (anxiety about eating, food avoidance behaviors, and feared concerns) and fears of social eating, as well as obsessive‐compulsive symptoms. Participants with AN were more likely to identify as Asian or Pacific Islander. No other statistically significant differences were found between groups for overall ED severity, ED behaviors, psychiatric comorbidities, general ED fears, perfectionism, or demographic factors.
Discussion
Overall, results support previous literature indicating limited differences between individuals with atypical AN and AN, though individuals with atypical AN reported more overvaluation of weight and shape and those with AN reported higher food and social eating fears and obsessive‐compulsive symptoms. Relatively few overall differences between atypical AN and AN highlight the importance of exploring dimensional conceptualizations of AN as an alternative to the current categorical conceptualization.
Public Significance
This study assessed differences among individuals with atypical anorexia nervosa and anorexia nervosa in eating disorder severity and behaviors, comorbid psychiatric diagnoses, associated mechanisms, and demographic factors. Few differences emerged, though participants with atypical anorexia nervosa reported more overvaluation of weight and shape, while those with anorexia nervosa reported more food and social eating fears and higher obsessive‐compulsive symptoms. Results support exploration of these diagnoses as a spectrum disorder.
The diagnostic criteria for Other Specified Feeding or Eating Disorder (OSFED) have been arbitrary and are not always research driven.Therefore, for atypical anorexia nervosa (AAN), there are ...inconsistencies in defining low weight, weight loss, and the timing of weight loss.For purging disorder (PD), it is unclear whether subjective binge-eating episodes and loss of control over eating need to be included.For night eating syndrome (NES), comorbidity with binge-eating disorder (BED) and other sleep-related disorders complicate diagnosis.For subthreshold bulimia nervosa (Sub-BN)/BED, the frequency and duration of symptoms has not been defined.Agreed-upon diagnostic standards for OSFED are needed for consistent study results.
Atypical anorexia nervosa (AAN), purging disorder (PD), night eating syndrome (NES), and subthreshold bulimia nervosa and binge-eating disorder (Sub-BN/BED) are the five categories that comprise the ‘Other Specified Feeding or Eating Disorder’ (OSFED) category in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5). In this review, we examine problems with the diagnostic criteria that are currently proposed for the five OSFED types. We conclude that the existing diagnostic criteria for OSFED are deficient and fall short of accurately describing the complexity and individuality of those with these eating disorders (EDs). Therefore, to enhance the quality of life of people with OSFED, diagnostic criteria for the condition should be applied uniformly in clinical and research settings.
Atypical anorexia nervosa (AAN), purging disorder (PD), night eating syndrome (NES), and subthreshold bulimia nervosa and binge-eating disorder (Sub-BN/BED) are the five categories that comprise the ‘Other Specified Feeding or Eating Disorder’ (OSFED) category in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5). In this review, we examine problems with the diagnostic criteria that are currently proposed for the five OSFED types. We conclude that the existing diagnostic criteria for OSFED are deficient and fall short of accurately describing the complexity and individuality of those with these eating disorders (EDs). Therefore, to enhance the quality of life of people with OSFED, diagnostic criteria for the condition should be applied uniformly in clinical and research settings.
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