Katharine L. Loeb

Academy for Eating Disorders Position Paper: The Role of the Family in Eating Disorders

Position It is the position of the Academy for Eating Disorders (AED) that whereas family factors can play a role in the genesis and maintenance of eating disorders, current knowledge refutes the idea that they are either the exclusive or even the primary mechanisms that underlie risk. Thus, the AED stands firmly against any etiologic model of eating disorders in which family influences are seen as the primary cause of anorexia nervosa or bulimia nervosa, and condemns generalizing statements that imply families are to blame for their child’s illness. The AED recommends that families be included in the treatment of younger patients, unless doing so is clearly ill advised on clinical grounds. The position articulated in this article is in line with the World Wide Charter for Action on Eating Disorders.

Therapeutic Alliance and Treatment Adherence in Two Interventions for Bulimia Nervosa: A Study of Process and Outcome

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist x Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment.

Classification of Eating Disturbance in Children and Adolescents: Proposed Changes for the DSM-V

Childhood and adolescence are critical periods of neural development and physical growth. The malnutrition and related medical complications resulting from eating disorders such as anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified may have more severe and potentially more protracted consequences during youth than during other age periods. The consensus opinion of an international workgroup of experts on the diagnosis and treatment of child and adolescent eating disorders is that (a) lower and more developmentally sensitive thresholds of symptom severity (e.g. lower frequency of purging behaviours, significant deviations from growth curves as indicators of clinical severity) be used as diagnostic boundaries for children and adolescents, (b) behavioural indicators of psychological features of eating disorders be considered even in the absence of direct self-report of such symptoms and (c) multiple informants (e.g. parents) be used to ascertain symptom profiles. Collectively, these recommendations will permit earlier identification and intervention to prevent the exacerbation of eating disorder symptoms.

Early response to family‐based treatment for adolescent anorexia nervosa

OBJECTIVE The purpose of this study was to determine if early weight gain predicted remission at the end of treatment in a clinic sample of adolescents with anorexia nervosa (AN). METHOD Sixty five adolescents with AN (mean age = 14.9 years, SD = 2.1), from two sites (Chicago n = 45; Columbia n = 20) received a course of manualized family-based treatment (FBT). Response to treatment was assessed using percent ideal body weight (IBW) with remission defined as having achieved ≥ 95% IBW at end of treatment (Session 20). RESULTS Receiver operating characteristic analyses showed that a gain of at least 2.88% in ideal body weight by Session 4 best predicted remission at end of treatment (AUC = 0.674; p = 0.024). DISCUSSION Results suggest that adolescents with AN, receiving FBT, who do not show early weight gain are unlikely to remit at end of treatment.

Early identification and treatment of eating disorders: prodrome to syndrome

The onset of eating disorder psychopathology is most common in the adolescent age group. Acute psychopathology or subsyndromal eating disorders are perhaps less intractable in these young patients. Subsyndromal eating disorders in children and adolescents are not only clinically significant in their present state, but may represent legitimate candidates for preventive efforts in light of: (i) a risk of progression from subthreshold anorexia nervosa (SAN) to AN or subthreshold bulimia nervosa (SBN) to BN; (ii) the detrimental effects on outcome of delaying treatment; and (iii) the refractory, severe nature of eating disorders once the diagnostic threshold is crossed. Moreover, children and adolescents with SAN and SBN may in fact be exhibiting early ‘caseness’ of these disorders. Given that AN is notoriously difficult to treat, and there are limited efficacy data for adolescent BN, attempts to disrupt these disorders in what is arguably their early phases is an important goal in preventing more chronic and treatment‐resistant forms of these disorders. Future research should address whether the best interventions for SAN and SBN should be derived from the prevention or intervention fields.

Anxiety in anorexia nervosa and its management using family-based treatment.

Anorexia nervosa (AN) is characterized by its similarity to anxiety disorders, especially obsessive-compulsive disorder (OCD). Family-based treatment (FBT) has shown promising initial results for treatment of AN in adolescents, yet the precise mechanisms of action are unknown. We present a theoretical argument and model, suggesting that FBT may work via exposure (and habituation) to food and its consumption. First, we review the evidence for pathological anxiety in AN, and suggest a framework for identifying specific anxious triggers, emotions (fear and worry) and avoidance strategies. Second, we briefly review evidence indicating that cognitive-behavioural therapy (CBT) and specifically exposure in its various forms is most effective for treating anxiety disorders in youth. Third, we consider distinct approaches to exposure therapy based on the pattern of triggers, anxious emotions and avoidance. We conclude that the interventions utilized in FBT share clear similarities to exposure with response prevention, a type of exposure therapy commonly used with OCD, and may work via facilitating habituation to food and eating in ones natural environment. We also highlight how parents facilitate this process in between sessions by effectively coaching their children and facilitating naturalistic exposure to food and related triggers. Options for future research are considered.

Eating Disorders with and without Comorbid Depression and Anxiety: Similarities and Differences in a Clinical Sample of Children and Adolescents

OBJECTIVE This study aimed to describe and compare the demographic and clinical characteristics of children and adolescents with an eating disorder (ED) and comorbid depression or anxiety. METHOD Data were drawn from intake assessments of children and adolescents at a specialist ED clinic. Demographic characteristics (e.g. age and gender) and clinical characteristics (e.g. body mass, binge eating and purging) were compared between 217 ED participants without comorbidity, 32 with comorbid anxiety, 86 with comorbid depression and 36 with comorbid anxiety and depression. RESULTS The groups with comorbid depression had more complex and severe presentations compared with those with an ED and no comorbid disorder and those with comorbid anxiety alone, especially in regard to binge eating, purging, dietary restraint and weight/shape concerns. DISCUSSION Depression and anxiety were differentially related to clinical characteristics of EDs. The findings have implications for understanding the relations between these disorders and their potential to impact outcome of ED treatments.

Resumption of menses in anorexia nervosa during a course of family-based treatment

BackgroundThe resumption of menses (ROM) is considered an important clinical marker in weight restoration for patients with anorexia nervosa (AN). The purpose of this study was to examine ROM in relation to expected body weight (EBW) and psychosocial markers in adolescents with AN.MethodsWe conducted a retrospective chart review at The University of Chicago Eating Disorders Program from September 2001 to September 2011 (N = 225 females with AN). Eighty-four adolescents (Mean age = 15.1, SD = 2.2) with a DSM-IV diagnosis of AN, presenting with secondary amenorrhea were identified. All participants had received a course of outpatient family-based treatment (FBT), i.e., ~20 sessions over 12 months. Weight and menstrual status were tracked at each therapy session throughout treatment. The primary outcome measures were weight (percent of expected for sex, age and height), and ROM.ResultsMean percent EBW at baseline was 82.0 (SD = 6.5). ROM was reported by 67.9% of participants (57/84), on average at 94.9 (SD = 9.3) percent EBW, and after having completed an average of 13.5 (SD = 10.7) FBT sessions (~70% of standard FBT). Compared to participants without ROM by treatment completion, those with ROM had significantly higher baseline Eating Disorder Examination Global scores (p = .004) as well as Shape Concern (p < .008) and Restraint (p < .002) subscale scores. No other differences were found.ConclusionsResults suggest that ROM occur at weights close to the reference norms for percent EBW, and that high pre-treatment eating disorder psychopathology is associated with ROM. Future research will be important to better understand these differences and their implications for the treatment of adolescents with AN.

Development and Validation of the Appearance and Performance Enhancing Drug Use Schedule

Appearance-and-performance enhancing drug (APED) use is a form of drug use that includes use of a wide range of substances such as anabolic-androgenic steroids (AASs) and associated behaviors including intense exercise and dietary control. To date, there are no reliable or valid measures of the core features of APED use. The present study describes the development and psychometric evaluation of the Appearance and Performance Enhancing Drug Use Schedule (APEDUS) which is a semi-structured interview designed to assess the spectrum of drug use and related features of APED use. Eighty-five current APED using men and women (having used an illicit APED in the past year and planning to use an illicit APED in the future) completed the APEDUS and measures of convergent and divergent validity. Inter-rater agreement, scale reliability, one-week test-retest reliability, convergent and divergent validity, and construct validity were evaluated for each of the APEDUS scales. The APEDUS is a modular interview with 10 sections designed to assess the core drug and non-drug phenomena associated with APED use. All scales and individual items demonstrated high inter-rater agreement and reliability. Individual scales significantly correlated with convergent measures (DSM-IV diagnoses, aggression, impulsivity, eating disorder pathology) and were uncorrelated with a measure of social desirability. APEDUS subscale scores were also accurate measures of AAS dependence. The APEDUS is a reliable and valid measure of APED phenomena and an accurate measure of the core pathology associated with APED use. Issues with assessing APED use are considered and future research is considered.

Dissecting the Core Fear in Anorexia Nervosa: Can We Optimize Treatment Mechanisms?

Anorexia nervosa (AN) is uniquely placed in the spectrum of psychiatric nosology as the only disorder in which an actualization of the core symptomatic fear (ie, weight gain) is directly targeted as a primary treatment goal. While treatment outcomes are generally indexed along dimensions of both weight-based and cognitive symptomatology, the initial focus on immediate weight restoration raises an important question relating to how the fear of weight gain might be abated throughout treatment when this primary symptomatic fear (ie, weight gain) is targeted and confirmed. Here, we address an important gulf between extinction theory and the practice of exposure therapy for AN. Recent fear extinction literature posits that the amelioration of acquired fear does not operate solely according to habituation processes, such that exposure to feared stimuli alone is insufficient in ensuring longterm fear reduction.1 Rather, fear reduction more centrally operates via mechanisms of inhibitory learning, which is an active learning process in which the violation of expected feared outcomes results in the new learning of nonthreat associations relating to the originally feared stimulus, which in turn serves to inhibit anxiety1 (Figure). As such, exposure therapies are now tailored toward maximally violating fear expectancies, rather than aiming for habituation, per se, with longterm consolidation of fear extinction being centrally linked to treatment outcome.2 However, this theoretical framework is predicated on the clear distinction drawn between feared cues/ stimuli and feared outcomes, which, in turn, may be violated throughout treatment to generate inhibitory learning.1 This is particularly relevant in the context of AN, for which, despite the inherent centrality of exposure processes, sparse empirical evidence has precisely deconstructed core fear associations, which may nullify the most salient pathway of fear extinction.