Longstanding Eating Disorders Research Articles

Kognitiv atferdsterapi for spiseforstyrrelser

Background: Few studies have evaluated the effectiveness of enhanced cognitive behaviour therapy (CBT-E) in clinical settings with a transdiagnostic patient population. The current study aimed to evaluate the effectiveness of CBT-E in a specialised outpatient eating disorder clinic in southeastern Norway. Method: The study involved a transdiagnostic sample of 96 patients (age 30.7 (SD = 9.4), 92.7% women) with longstanding eating disorders and previous failed treatment attempts. We used multilevel modelling to examine change in eating disorder pathology from pre-treatment (T1) to post-treatment (T2) and follow-up 25 weeks later (T3). A total of 57 patients had sufficient data at T2 and 35 patients at T3. Results: We found statistically significant reductions in eating disorder pathology from pre- to post-treatment. Of those who completed treatment, 49.1% met criteria for remission at post-treatment. These changes were stable at follow-up. Implications: CBT-E may lead to reductions in eating disorder pathology and should be considered an acceptable form of treatment for adult patients with eating disorders. Keywords: anorexia nervosa, binge eating disorder, bulimia nervosa, cognitive behaviour therapy, eating disorders, effectiveness

Care pathways for longstanding eating disorders must offer paths to recovery, not managed decline.

Eating disorders are historically underserved in healthcare, but are increasingly prevalent and recognised for their high costs regarding mortality, quality of life and the economy. Those with longstanding eating disorders are commonly labelled 'severe and enduring' (SEED), which has been challenged for its conceptual vagueness and potential to discourage patients. Attempts to define individuals from this cohort as having 'terminal' illness have also gained traction in recent years. This paper is grounded in lived/living experience and relevant research. It challenges the logical coherence and utility of SEED, arguing that the word 'enduring' unhelpfully situates intractability of longstanding illness within patients themselves and the nature of their illness. This risks a sense of inevitability and overlooks the important role of contextual factors such as lacking resources and insufficient evidence for withholding active treatment. Recommendations suggest approaches to dismantling unhelpful binaries between early intervention and intensive support, recovery and decline.

Reciprocal relationships between personality disorders and eating disorders in a prospective 17-year follow-up study.

This study aimed to report the presence of categorical and dimensional personality disorders (PD) in adults with longstanding eating disorders (ED) over a period of 17 years and to investigate whether changes in PD predict changes in ED symptoms or vice versa. In total, 62 of the 80 living patients (78% response rate) with anorexia nervosa (n=23), bulimia nervosa (n=25), or other specified feeding or ED (n=14) at baseline were evaluated during hospital treatment and at 1-year, 2-year, 5-year, and 17-year follow-up. PD were assessed using the Structured Clinical Interview for DSM-IV Axis II disorders, and the eating disorder examination (EDE) interview was used to assess ED. Data were analyzed using multilevel modeling. From baseline to the 17-year follow-up, the number of patients with any PD decreased significantly from 74.2% to 24.2%, and the total number of PD diagnoses declined from 80 to 22. Mean EDE score was significantly reduced from 4.2 (SD: 1.1) to 2.0 (SD: 1.6). There was a positive association between ED and PD where the initial level of either disorder was followed by similar levels of the other disorder throughout the entire follow-up period. High baseline levels of borderline PD predicted less decrease in ED symptoms. No significant within-person effects were found. Both ED and PD significantly declined over time. As the severity of either disorder seems to be associated with the other, thorough assessment and treatment that incorporates both the ED psychopathology and the personality disturbances are advisable. While personality disorders were highly prevalent in the sample of patients with longstanding eating disorders, both disorders were significantly reduced at the 17-year follow-up. The disorders are related in the sense that an initial high level of either disorder is associated with a high level of the other over time. A thorough assessment and attention to both illnesses are advisable in therapy. NCT03968705.

Creating a care pathway for patients with longstanding, complex eating disorders

BackgroundRecovery rates for people with eating disorders are low; fewer than half recover and approximately 20% develop a longstanding eating disorder. Patients with longstanding eating disorders are often referred to as “SEED” (severe and enduing eating disorders) although this remains controversial and is not acknowledged in the British treatment guidance. This project aimed to generate recommendations for a longstanding eating disorder care pathway by identifying what proportion of patients have longstanding eating disorders and how to best identify and support them.MethodsInitially, a literature review was completed, followed by interviews with service-users who consider themselves to have longstanding eating disorders, and focus groups with staff members. The results were combined to create a definition of a longstanding eating disorder which was used to establish how many service-users could benefit from the pathway. The qualitative data was used to produce recommendations for a tailored pathway for those with longstanding eating disorders.ResultsThe results highlighted that, although “SEED” is often used, participants preferred to be referred to as “longstanding” or having no label. Qualitative analysis identified four themes in relation to supporting this population group which described how to structure the service and individualise care, as well as patients’ relationship to the service, and how to build a life after eating disorder services.ConclusionsRecommendations included promoting a hopeful message, focusing on quality of life and introducing peer support. Crucially, accessing the pathway should not result in being labelled “SEED”, nor should it prevent access to recovery focused interventions including weight restoration. The full list of recommendations are included as well as the implications of the project and limitations.

Differentiating Eosinophilic Esophagitis and Eating/Feeding Disorders.

Eosinophilic esophagitis (EoE) is an inflammatory condition of the esophagus that causes symptoms of esophageal dysmotility. Patients with feeding or eating disorders (ED) can have similar symptoms, and there is a paucity of literature exploring these similarities. Furthermore, EoE can occur in addition to an ED, requiring clinicians to obtain a thorough history, make accurate diagnoses, and adequately treat all underlying conditions. We present 4 pediatric cases highlighting the similarities between EoE and ED symptomatology. Patients 1 to 3 were presumed to have an ED and were subsequently diagnosed with EoE. Patient 4 had a history of previously diagnosed and inadequately treated EoE, but was later found to also have a longstanding ED. The patients presented to the University of Rochester Pediatric Ambulatory Clinics in 2020. This series demonstrates that symptoms of EoE can overlap with those of an ED, such as anorexia nervosa or avoidant restrictive food intake disorder. Therefore, assessment for either EoE or an ED should include questions related to both diagnoses. Symptoms that may raise suspicion of EoE are indigestion, acute (versus chronic) weight loss, and dysphagia, including the inability to swallow pills, particularly in the presence of personal or family history of atopy. Patients with known EoE should be periodically evaluated for the presence of an ED. This case series illustrates that EoE can either present as an ED or complicate the diagnosis and/or treatment of an ED, making prompt diagnosis and treatment essential for successful management of all conditions.

Self-admission in the treatment of eating disorders: an analysis of healthcare resource reallocation

BackgroundSelf-admission to psychiatric inpatient treatment is an innovative approach to healthcare rationing, based on reallocation of existing resources rather than on increased funding. In self-admission, patients with a history of high healthcare utilization are invited to decide for themselves when brief admission is warranted. Previous findings on patients with severe eating disorders indicate that self-admission reduces participants’ need for inpatient treatment, but that it does not alone lead to symptom remission.MethodsThe aim of this study was to evaluate if, from a service provider perspective, the resource reallocation associated with self-admission is justified. The analysis makes use of data from a cohort study evaluating the one-year outcomes of self-admission at the Stockholm Centre for Eating Disorders.ResultsParticipants in the program reduced their need for regular specialist inpatient treatment by 67%. Thereby, hospital beds were made available for non-participants due to the removal of a yearly average of 13.2 high-utilizers from the regular waiting list. A sensitivity analysis showed that this “win-win situation” occurred within the entire 95% confidence interval of the inpatient treatment utilization reduction.ConclusionsFor healthcare systems relying on rationing by waiting list, self-admission has the potential to reduce the need for hospitalization for patients with longstanding eating disorders, while also offering benefits in the form of increased available resources for other patients requiring hospitalization.Trial RegistrationClinicalTrials.gov ID: NCT02937259 (retrospectively registered 10/15/2016).

The 17-year outcome of 62 adult patients with longstanding eating disorders-A prospective study.

Although studies with short and intermediate observation time suggest favorable outcomes in regard to eating disorders (ED), there is limited knowledge on long-term outcomes. The present study aimed to investigate the 5- and 17-year outcome of adult patients with longstanding ED who were previously admitted to an inpatient ED unit. ED diagnoses and recovery, comorbid and general psychopathology, along with psychosocial functioning and quality of life were evaluated. Sixty-two of the 80 living patients (78% response rate) with anorexia nervosa (n = 23), bulimia nervosa (n = 25), or other specified feeding or eating disorders (n = 14) at admission were evaluated. The mean age at the 17-year follow-up point was 46.2 (SD 7.5). The Eating Disorder Examination (EDE) was used to assess recovery. The Mini International Neuropsychiatric Interview (M.I.N.I.) and self-report instruments provided additional information. There was a significant reduction in patients fulfilling criteria for an ED from the 5-year to the 17-year follow-up, meanwhile recovery rates were stable. A total of 29% of the patients were fully recovered and 21% were partially recovered while the remaining 50% had not recovered. No significant changes were found in any self-report measures and more than 70% had a comorbid disorder at both assessments. The findings illustrate the protracted nature of ED for adults with longstanding ED. A long illness duration prior to treatment is unfortunate and early detection and treatment is advisable.

Exercise Obsession and Compulsion in Adults With Longstanding Eating Disorders: Validation of the Norwegian Version of the Compulsive Exercise Test.

ObjectivesThe objectives of this study were to (1) validate the Norwegian version of the Compulsive Exercise Test (CET) in adults with longstanding eating disorders, and (2) explore predictors of high CET-score.Methods:Adult inpatients (n = 166) with longstanding DSM-IV Anorexia Nervosa, Bulimia Nervosa (BN) or Eating Disorder not Otherwise Specified (EDNOS) completed the CET instrument, Eating Disorder examination questionnaire (EDE-Q), Beck Depression Inventory-II (BDI-II) and Symptom checklist-90 (SCL-90). A total CET score of 15 or above was defined as high CET-score. ANOVA, Confirmatory factor analysis, Pearson’s correlation, and logistic regression were used to analyze the data.ResultsCronbach’s alpha varied from 0.68 to 0.96 for the CET and its subscales. The confirmatory factor analysis showed adequate fit. Convergent validity of the CET demonstrated correlation between EDE-Q global and subscale scores and CET total score. The same pattern was found for correlation between CET subscales and EDE-Q subscales. EDE-Q global score and frequency of exercise episodes predicted high CET-score, yet 21% of the patients with high CET score had less than one episode of exercise per week.ConclusionThe Norwegian version of CET is valid and useful for assessing compulsive exercise in a sample with longstanding ED. The understanding of compulsive exercise must to a greater extent differ between obsessions and compulsions, as a significant number of patients with high CET score showed no or little exercise behavior.

An investigation of the process of change in psychopathology and exercise during inpatient treatment for adults with longstanding eating disorders

BackgroundExcessive exercise is recognized as a predictor of poor outcome in eating disorders. However, little is known about how excessive exercise might affect the treatment process. The aim of this study was to describe process of weekly changes in eating disorder psychopathology, general psychopathology and exercise, and the possible interactive effects of excessive exercise on these changes during inpatient treatment of longstanding eating disorders.MethodsEighty-four patients meeting the DSM-IV criteria for Anorexia Nervosa, Bulimia Nervosa, or Eating Disorders Not Otherwise Specified received inpatient cognitive-behavioural therapy including, physical activity and nutritional counselling treatment over 12 weeks. Excessive exercise was defined as having ≥6 episodes of driven exercise during week 1 of treatment. Excessive exercisers received one additional session of individual counseling with the clinical exercise physiologist. The study used repeated measurements during treatment and collected measures of eating disorders: psychopathology (EDE-Q), general psychopathology (SCL-5), and frequencies of exercise and body mass index (BMI). Statistical analysis was performed using repeated measures ANOVA.ResultsBoth eating disorders and general psychopathology were reduced from admission to discharge in excessive exercisers and non-exercisers. There was an overall interaction effect between time (week) and excessive exercise for the process of exercise and eating disorders psychopathology reduction. This interaction effect was also found in week 10 vs 11 regarding general psychopathology. The excessive exercisers showed steep reduction at first, followed by a smaller increase towards the end of treatment in both eating disorder and general psychopathology; this pattern was not found among the non-exercisers.ConclusionThe process of change in exercise and psychopathology during inpatient treatment of longstanding eating disorders differs across excessive and non-excessive exercisers. Although excessive exercisers were given special attention for their exercise cognition and behavior during treatment, it is apparent that this part of treatment must be further developed.

Changes in Physical Fitness, Bone Mineral Density and Body Composition During Inpatient Treatment of Underweight and Normal Weight Females with Longstanding Eating Disorders

The purpose of this study was to examine changes in aerobic fitness, muscular strength, bone mineral density (BMD) and body composition during inpatient treatment of underweight and normal weight patients with longstanding eating disorders (ED). Twenty-nine underweight (BMI < 18.5, n = 7) and normal weight (BMI ≥ 18.5, n = 22) inpatients (mean (SD) age: 31.0 (9.0) years, ED duration: 14.9 (8.8) years, duration of treatment: 16.6 (5.5) weeks) completed this prospective naturalistic study. The treatment consisted of nutritional counseling, and 2 × 60 min weekly moderate intensive physical activity in addition to psychotherapy and milieu therapy. Underweight patients aimed to increase body weight with 0.5 kg/week until the weight gain goal was reached. Aerobic fitness, muscular strength, BMD and body composition were measured at admission and discharge. Results showed an increase in mean muscular strength, total body mass, fat mass, and body fat percentage, but not aerobic capacity, among both underweight and normal weight patients. Lumbar spine BMD increased among the underweight patients, no changes were observed in BMD among the normal weight patients. Three out of seven underweight patients were still underweight at discharge, and only three out of nine patients with excessive body fat (i.e., >33%) managed to reduce body fat to normal values during treatment. These results calls for a more individualized treatment approach to achieve a more optimal body composition among both underweight and normal to overweight patients with longstanding ED.

Exercise dependence score in patients with longstanding eating disorders and controls: The importance of affect regulation and physical activity intensity

To examine associations among exercise dependence score, amount of physical activity and eating disorder (ED) symptoms in patients with longstanding ED and non-clinical controls. Adult female inpatients (n = 59) and 53 age-matched controls participated in this cross sectional study. Assessments included the eating disorders examination, eating disorders inventory, exercise dependence scale, reasons for exercise inventory, and MTI Actigraph accelerometer. Positive associations were found among vigorous, not moderate, physical activity, exercise dependence score and ED symptoms in patients. In the controls, ED symptoms were negatively associated with vigorous physical activity and not correlated with exercise dependence score. Exercise for negative affect regulation, not weight/appearance, and amount of vigorous physical activity were explanatory variables for exercise dependence score in both groups. The positive associations among exercise dependence score, vigorous physical activity and ED symptoms need proper attention in the treatment of longstanding ED.

Physical activity and exercise dependence during inpatient treatment of longstanding eating disorders: An exploratory study of excessive and non‐excessive exercisers

To describe changes in physical activity (PA) and exercise dependence score during treatment of eating disorders (ED), and to explore correlations among changes in PA, exercise motivation, exercise dependence score and ED psychopathology in excessive and non-excessive exercisers. Thirty-eight adult females receiving inpatient treatment for anorexia nervosa, bulimia nervosa or ED not otherwise specified participated in this prospective study. Assessments included accelerometer assessed PA, Exercise Dependence Scale, Reasons for Exercise Inventory, ED Examination, and ED Inventory. Amount of PA was significantly reduced in non-excessive exercisers during treatment, in excessive exercisers there was a trend towards reduced amount of PA from admission to discharge. In excessive exercisers, reduced ED psychopathology was correlated with reduction in exercise dependence score and perceived importance of exercise to regulate negative affects, but not with importance of exercise for weight/appearance. These associations were not found in non-excessive exercisers. Excessive exercise is an important issue in longstanding ED, and the excessive exercising patients need help to develop alternative strategies to regulate negative affects.

“I'm not physically active ‐ I only go for walks”: Physical activity in patients with longstanding eating disorders

To examine self reported versus objectively assessed moderate-to-vigorous physical activity (MVPA), and different reasons for exercise, in patients with longstanding eating disorders (ED) when compared with controls. Inpatient females (n = 59, mean 30.1 years) and nonclinical age matched controls (n = 53, mean 31.3 years) accepted participation in this cross sectional study. Instruments included accelerometer ActiGraph, physical activity diary, Reasons for Exercise Inventory, and Eating Disorders Examination interview. Self reported and objectively assessed MVPA were higher across all ED diagnoses when compared with controls. The patients' self reported MVPA was lower than the objectively assessed MVPA; no difference was found in controls. Regulation of negative affects, not weight/appearance, was a more important, whereas fitness/health was a less important reason for exercise in patients than controls. The underreporting of MVPA in some patients with ED may warrant clinical attention.

Five‐year prospective study of personality disorders in adults with longstanding eating disorders

To (1) report the occurrence of personality disorders (PDs) in adults with eating disorders (EDs) during inpatient treatment, and at 1-, 2-, and 5-year follow-up, (2) compare the changes of PDs in anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS), and (3) investigate if recovered patients had lower frequency of PDs. Seventy-four patients with EDs were assessed with Structured Clinical Interview for DSM-IV Axis II disorders during inpatient treatment, and at 1-, 2-, and 5-year follow-up. During inpatient treatment, 58 patients (78%) had one or more PDs and this was reduced to 32 (43%) at 5-year follow-up. Dimensional PD scores changed significantly over time in both AN, BN, and EDNOS, but no significant differences emerged among the ED groups. Recovered patients had lower frequency of PDs (p < 0.01). The substantial 5-year follow-up reductions in the frequency of PDs in patients with EDs present an optimistic clinical scenario for treating patients with comorbid ED and PD.

The course of illness following inpatient treatment of adults with longstanding eating disorders: A 5‐year follow‐up

The objectives of this article were to study the course and outcome of longstanding eating disorders (ED) 5 years after completing treatment and to identify subgroups of patients with different course and outcome. A total of 77 patients with a mean age of 30 years were assessed at the beginning and end of in-patient therapy and at 1-, 2- and 5-year follow-up, respectively. Of the 90% who participated in the 5-year follow-up, 46 patients (61%) had improved, and 30 (39%) did not meet diagnostic criteria for an ED. Cluster analysis identified a group of patient with no improvement over time. Overall, the course is favourable, but a subgroup of patients with no improvement over time may need intensified treatment efforts.

Two-year prospective study of personality disorders in adults with longstanding eating disorders

The current study had three objectives: to report the presence of personality disorders (PDs) in adults with longstanding eating disorders (EDs) at admission to inpatient treatment, and at 1 and 2-year follow-up; to compare the frequency of PDs in anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS); and to investigate whether recovered patients had lower frequency of PDs. Seventy-four patients with a mean age of 30 years and long-lasting EDs were assessed with the Structured Clinical Interview for DSM-IV Axis-II disorders at admission to inpatient treatment, and at 1 and 2-year follow-up. At admission, 57 patients (77%) had one or more PDs, whereas 42 patients (57%) had one or more PDs at 2-year follow-up No statistically significant differences in frequencies of PDs among patients with AN, BN, and EDNOS were found. Recovered patients had a lower frequency of PDs (p < .01). At 2-year follow-up, there were substantial reductions in the frequency of PDs in patients with long-lasting EDs.

A Review of Eating Disorders and Suicide Risk in Adolescence

This review examines the literature during the past 10 years about suicide risk and suicide during adolescence and young adulthood of individuals with eating disorders. Epidemiological surveys are summarized, including suicide rates, parasuicidal behaviors, associated risk factors, and comorbid psychopathology. Critical implications for the comprehensive assessment and treatment planning, including safety considerations, are discussed. Two clinical cases of women with long-standing eating disorders are described to highlight both the pragmatic considerations and the complex clinical challenges of working with patients with eating disorders who become suicidal. The potentially life-threatening issues of safety have not received sufficient attention, neither in the medical literature nor by the treating clinicians. All health care professionals who are treating patients with an eating disorder must be keenly aware of the serious risks of suicidal behavior and of suicide in this population.

The interaction of personality disorders and eating disorders: A two-year prospective study of patients with longstanding eating disorders

The current study aimed to investigate the relation between personality disorders and symptoms of both eating disorders and general psychopathology over time. Seventy-four patients, with a mean age of 30 years and admitted to a hospital for treatment of a chronic eating disorder, were assessed using the Eating Disorder Inventory (EDI), the Eating Disorder Examination (EDE), the Symptom Check List-90-Revised (SCL-90-R), and the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II) at admission, and after 1 and 2 years. At the 2-year follow-up, there was considerable reduction in both personality and symptoms (effect size = 0.83-0.94). Panel modeling using structural equation modeling techniques indicated that symptomatic changes generally preceded changes in the personality disorder. Eating disorder symptoms and general symptomatology had direct effects on a dimensional personality disorder index. Thus, personality disorders may be at least partially a consequence of general symptomatology in chronic eating disorders. Symptom improvement appears to precede changes in personality in this sample of patients with chronic eating disorders.