Eric F. van Furth

Norms and discriminative validity of the Eating Disorder Examination Questionnaire (EDE-Q)

The first aim of this study was to provide norms for the Eating Disorder Examination Questionnaire (EDE-Q) in a diverse and large clinical sample of individuals with an eating disorder (ED), and a general population sample without an ED. Norms for individuals with obesity without an ED were also provided, as a more relevant comparison group for individuals with binge eating disorder. The second aim was to investigate the discriminative validity of the EDE-Q. A sample of females with an ED (N=935), women from the general population without an ED (N=235), and obese females without an ED (N=321) completed the EDE-Q. Explorative factor analyses did not support the theorized four subscales of the EDE-Q. Norms for EDE-Q global scores were provided for each of the three samples. Within the ED sample, norms were provided separately for patients with different ED diagnoses. Receiver operating characteristic analyses showed the EDE-Q global score to be highly accurate in discriminating individuals with an ED from those without, and moderately accurate in discriminating individuals with binge eating disorder from those with obesity. The presented norms contribute to a more accurate interpretation of EDE-Q scores, providing an index of the severity level of ED psychopathology. Furthermore, these norms can be used to assess clinical significant change during treatment. In addition, this study demonstrates that the EDE-Q, when using its global score, is a valid instrument to assess levels of ED psychopathology.

Attentional bias for body and food in eating disorders: increased distraction, speeded detection, or both?

Previous research suggests that eating disorder patients show an attentional bias for body- and food-related information. However, so far little is known about the mechanisms that underlie the attentional favoring of this particular information in eating disorder patients. In the present study, we used both a body and a food visual search task to study speeded detection and increased distraction in eating disorder patients (n=67) and healthy controls (n=60). Compared with controls, eating disorder patients showed evidence of speeded detection of body-related information, and increased distraction by food information. These results suggest that the mechanism underlying the biased attentional allocation of eating disorder patients varies, and is dependent upon the type of information they are presented with.

Treating eating disorders over the internet: A systematic review and future research directions

OBJECTIVE To review the literature regarding internet-based treatment of eating disorders (ED). METHOD Relevant studies were identified by searching electronic databases (including Medline, Embase, PsycInfo, and Web of Science). Eligible studies evaluated an internet-based treatment for ED, or an ED treatment that included at least one internet-based component. RESULTS Twenty-one studies were included. Methodological quality varied. Internet-based treatments were superior to waiting lists in reducing ED psychopathology, frequency of binge eating and purging, and in improving (ED-related) quality of life. Internet-based treatment was more effective for individuals with less comorbid psychopathology, binge eating as opposed to restrictive problems, and individuals with binge eating disorder as opposed to bulimia nervosa. Higher levels of compliance were related to more improvements in ED symptoms. Study dropout ranged from 5.3 to 76.8%. Inclusion of face-to-face assessments and therapist support seemed to enhance study compliance. Overall, the internet can be considered an acceptable vehicle for delivering ED treatment. DISCUSSION Future research should determine the utility of internet-based treatment by comparing them to face-to-face treatment. Research should furthermore focus on unraveling predictors and mediators of treatment outcome, compliance, and dropout, respectively. Studies with good methodological quality are needed with reports according to CONSORT guidelines.

The Quality of Life of Family Caregivers of Eating Disorder Patients

Having a relative with an eating disorder (ED) affects the life of family caregivers and may thus affect their quality of life. To study this aspect, 40 caregivers of ED patients filled out a health-related quality of life questionnaire (Short Form-36) and a questionnaire on the impact of the ED on various areas of life domains, and on the relationship with the ED patient and the need for professional support. Quality of life of caregivers was worse than in a normal reference group. Specifically, mental health, vitality and emotional role functioning were reported to be most impaired. ED appeared to affect families’ lives substantially. In response to the ED, caregivers felt anxious, powerless, sad, or desperate. The relationship of the caregiver with the ED patient had also changed. Caregivers were more worried, lost their trust, and reported more conflicts. Seventy five percent welcomed professional support. Caregivers need practical advice, information on ED, and emotional support. Quality of life of caregivers should be addressed in the treatment of ED.

Binge eating disorder psychopathology in normal weight and obese individuals

OBJECTIVE Although Binge Eating Disorder (BED) is associated with obesity and unstable weight and the diagnosis was originally predicated with the obese in mind, obesity is not a criterion for BED. In fact, BED is not uncommon in nonobese individuals. The aim of this study was to compare the psychopathology of obese (BMI >30) and nonobese individuals (BMI < 30) with BED. METHOD Within a group of 174 individuals diagnosed with BED, 51 (29%) were classified as nonobese and 123 (71%) as obese. The Eating Disorder Examination (EDE) and Beck Depression Inventory (BDI) were administered to assess eating disorder psychopathology and depressive symptoms. RESULTS The nonobese BED group was significantly younger and was less likely to receive treatment. The obese group had more concerns about weight and reported more objective binge eating episodes. No differences were found on any other subscales of the EDE or BDI. DISCUSSION Our main finding was that there are more similarities than differences between the nonobese and obese individuals with BED. The severity of the psychopathology does not seem to be related to BMI. More awareness of the existence of nonobese individuals with BED is needed. Early detection and treatment may prevent the development of overweight and its consequences.

The effectiveness of cognitive remediation therapy in patients with a severe or enduring eating disorder: a randomized controlled trial.

Background: Individuals with eating disorders show deficits in neuropsychological functioning which might preexist and underlie the etiology of the eating disorders and influence relapse. Deficits in cognitive flexibility, i.e. set-shifting and central coherence, might perpetuate the symptoms. Cognitive remediation therapy (CRT) was developed to improve cognitive flexibility, thereby increasing the likelihood of improved outcome. The focus of CRT is on how patients think, rather than on what patients think. The present study investigated the effectiveness of CRT for patients with a severe or enduring eating disorder by means of a randomized controlled trial comparing intensive treatment as usual (TAU) to CRT plus TAU. Methods: Eighty-two patients were randomly assigned to CRT plus TAU (n = 41) or TAU alone (n = 41). Outcome measures were set-shifting, central coherence, eating disorder and general psychopathology, motivation, quality of life and self-esteem. Assessments were performed at baseline (n = 82) and after 6 weeks (T1; n = 75) and 6 months (T2; n = 67). Data were analyzed by means of linear mixed model analyses. Results: Patients who received CRT in addition to TAU improved significantly more with regard to eating disorder-related quality of life at the end of treatment (T1) and eating disorder psychopathology at follow-up (T2), compared to those who received TAU only. Moreover, moderator analyses revealed that patients with poor baseline set-shifting abilities benefited more from CRT than patients with no deficits in set-shifting abilities at baseline; the quality of life of the former group was higher than that of the latter at follow-up. Conclusions: CRT seems to be promising in enhancing the effectiveness of concurrent treatment.

Course and outcome of eating disorders in a primary care-based cohort.

OBJECTIVE To study the course and outcome of patients with eating disorder detected in primary care. METHOD General practitioners (GPs) provided information on the course and outcome of eating disorders in patients (n = 147) diagnosed with anorexia nervosa (AN) or bulimia nervosa (BN) identified during a Dutch nationwide primary care-based incidence study. The research team determined the outcome based on the data provided by the GPs. The mean duration of the follow-up was 4.8 years. RESULTS About 57% of the patients initially diagnosed with AN and 61% of those diagnosed with BN were fully recovered. AN binge/purge subtype (ANBP) demonstrated the most extended median survival time of all diagnostic subgroups (the point at which half of the group has reached full recovery). Diagnostic crossover was low. A younger age at detection predicted recovery at outcome for AN and BN. One patient (AN) died. DISCUSSION The results of this study on differences in outcome and low crossover support the diagnostic distinction between AN and BN in the DSM-IV. Early detection is of major importance for a favorable outcome.

Eating disorders: from twin studies to candidate genes and beyond.

Substantial effort has been put into the exploration of the biological background of eating disorders, through family, twin and molecular genetic studies. Family studies have shown that anorexia (AN) and bulimia nervosa (BN) are strongly familial, and that familial etiologic factors appear to be shared by both disorders. Twin studies often focus on broader phenotypes or subthreshold eating disorders. These studies consistently yielded moderate to substantial heritabilities. In addition, there has been a proliferation of molecular genetic studies that focused on Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) AN and BN. Seven linkage regions have been identified in genome-wide screens. Many genetic association studies have been performed, but no consistent association between a candidate gene and AN or BN has been reported. Larger genetic association studies and collaborations are needed to examine the involvement of several candidate genes and biological pathways in eating disorders. In addition, twin studies should be designed to assist the molecular work by further exploring genetic determinants of endophenotypes, evaluating the magnitude of contribution to liability of measured genotypes as well as environmental risk factors related to eating disorders. In this manner twin and molecular studies can move the field forward in a mutually informative way.

The Val66Met polymorphism of the BDNF gene in anorexia nervosa: New data and a meta-analysis

Abstract Objectives. The Val66Met polymorphism (rs6265) of the BDNF gene is a non-synonymous polymorphism, previously associated with anorexia nervosa (AN). Methods. We genotyped rs6265 in 235 patients with AN and 643 controls. Furthermore, we performed a systematic review of all case–control and family-based studies testing this SNP in AN, and combined the results in a meta-analysis. Results. The results of the case–control study were non-significant. For the meta-analysis, nine studies were identified (ncases = 2,767; ncontrols = 3,322, ntrios = 53) and included. Primarily, the analyses indicated an association with OR of 1.11 (P = 0.024) in the allelic contrast, and OR of 1.14 (P = 0.025) for the dominant effect of the Met allele. However, additional analyses revealed that the first published study (from those included in the meta-analysis) overly influenced the pooled effect size (possibly due to a phenomenon known as a winners curse). When this case–control study was replaced by a trio study (ntrios = 293) performed on a largely overlapping sample, the effect size became smaller and non-significant, both for the allelic contrast (OR = 1.07, P = 0.156) and the dominant effect (OR = 1.07, P = 0.319). The quality of included studies was good and there was no significant heterogeneity across the effect sizes. Conclusions. Our analyses indicate that the BDNF Val66Met variant is not associated with AN at detectable levels.

Eating disorders : the big issue

A new report from the King’s Fund entitled Bringing Together Physical and Mental Health: a New Frontier for Integrated Care not only reviews the case for integration, but also provides real practical examples of how it has been achieved. Importantly, the report describes both the barriers to and facilitators of its successful implementation on the basis of interviews of those involved. The barriers are many and not all will be overcome simply by colocation of services (colocation is not integration). They include deeply ingrained cultural factors in the workforce that reinforce division and the separate organisational and payment systems for physical and mental health care. Key facilitators to achievement of integration include strong leadership for change at both clinical and board level and a willingness to innovate in the relevant organisations. Policy developments in various countries, including the new models of care introduced by the National Health Service Five Year Forward View in England and the growth of accountable care organisations in the USA have the exciting potential to facilitate integration of physical and mental health care. However, this integration will only happen if psychiatrists and other professionals now actively engage with these developments and use them as opportunities to advocate for and lead new forms of collaborative or even integrated working. The idea of so-called parity of esteem for patients’ mental and physical health care, which has been successfully championed by the Royal College of Psychiatrists, has achieved considerable influence. Indeed, in England, the Health and Social Care Act 2012 created a new legal responsibility for the National Health Service to deliver parity of esteem between physical and mental health, something that the Government has pledged to achieve by 2020. However, interpretations of parity of esteem vary. One interpretation is simply for existing mental health services to be as well funded and provide as good care as existing physical health services. Although this interpretation is an important ambition, the report from the King’s Fund7 raises sights much higher than this ambition to a vision in which mental health care is not only as good as physical care is, but is also delivered as part of all health and care services. This challenge should be addressed and the opportunity seized if we are to repair the harm caused by 100 years of separation.