Childhood trauma and outcome trajectories in patients with longstanding eating disorders across 17 years

Background: A large proportion of patients with eating disorders (ED) report experiences of childhood trauma. Latent trajectory analysis in ED samples reveals the complexities in course and outcome and can explore the long-term impact of adverse experiences in childhood. Method: A total of 84 patients with longstanding ED were included. ED symptoms were assessed by the Eating Disorder Examination interview at discharge from inpatient treatment, and at 1-, 2-, 5-, and 17-year follow-up, respectively. Change over time was examined using growth mixture modeling, allowing the number of trajectories to emerge through the data. Prevalence of childhood trauma was assessed, and its relation to class membership was tested. Results: We identified four distinct classes: patients with (a) a continuous improvement in the entire follow-up period, and scores within normal range at the end, “continuous improvement” (54.8%); (b) a high symptom level at baseline and moderate decrease over time, “high and declining” (22.6%); (c) initial ED scores below clinical cut-off and stable symptoms throughout the course, “consistently low” (14.3%); and (d) with high scores initially, and a significant increase in symptoms over time, “high and increasing” (8.3%). A history of childhood sexual abuse (CSA) was overrepresented in classes with persistently high symptom levels and poor long-term outcome Discussion: Patients with longstanding ED displayed considerable diversity in trajectories of symptom change across 17 years. To improve long-term outcome, enhanced treatment of sequelae from CSA seems essential. Public Significance: Patients with longstanding eating disorders displayed four different trajectories of change in a 17-year follow-up study. Although there were significant changes over time, the majority of patients remained within similar symptom levels as they presented with at discharge from inpatient treatment. Exposure to childhood maltreatment was common within the sample. Childhood sexual abuse predicted poor long-term outcome, which highlights the importance of trauma informed care

A group intervention for individuals with obesity and comorbid binge eating disorder : results from a feasibility study

Purpose: A common challenge among a subgroup of individuals with obesity is binge eating, that exists on a continuum from mild binge eating episodes to severe binge eating disorder (BED). BED is common among bariatric patients and the prevalence of disordered eating and ED in bariatric surgery populations is well known. Conventional treatments and assessment of obesity seldom address the underlying psychological mechanisms of binge eating and subsequent obesity. This study, titled PnP (People need People) is a psychoeducational group pilot intervention for individuals with BED and obesity including patients with previous bariatric surgery. Design, feasibility, and a broad description of the study population is reported. Material and Methods: A total of 42 patients were from an obesity clinic referred to assessment and treatment with PnP in a psychoeducational group setting (3-hour weekly meetings for 10 weeks). Of these, 6 (14.3%) patients had a previous history of bariatric surgery. Feasibility was assessed by tracking attendance, potentially adverse effects and outcome measures including body mass index (BMI), eating disorder pathology, overvaluation of shape and weight, impairment, self-reported childhood difficulties, alexithymia, internalized shame as well as health related quality of life (HRQoL). Results: All 42 patients completed the intervention, with no adverse effects and a high attendance rate with a median attendance of 10 sessions, 95% CI (8.9,9.6) and 0% attrition. Extent of psychosocial impairment due to eating disorder pathology, body dissatisfaction and severity of ED symptoms were high among the patients at baseline. Additionally, self-reported childhood difficulties, alexithymia, and internalized shame were high among the patients and indicate a need to address underlying psychological mechanisms in individuals with BED and comorbid obesity. Improvement of HRQoL and reduction of binge eating between baseline and the end of the intervention was observed with a medium effect Conclusion: This feasibility study supports PnP as a potential group psychoeducational intervention for patients living with BED and comorbid obesity. Assessments of BED and delivery of this intervention may optimize selection of candidates and bariatric outcomes. These preliminary results warrant further investigation via a randomized control trial (RCT) to examine the efficacy and effectiveness of PnP

Metabolic profile in women with bulimia nervosa or binge-eating disorder before and after treatment: secondary analysis from the randomized PED-t trial

Purpose: Chaotic eating and purging behavior pose a risk to the metabolic health of women with bulimia nervosa (BN) and binge-eating disorder (BED). This study reports on one-year changes in blood markers of metabolic health and thyroid hormones in women with BN or BED attending two different treatments. Methods: These are secondary analyses from a randomized controlled trial of 16-week group treatment of either physical exercise and dietary therapy (PED-t) or cognitive behavior therapy (CBT). Blood samples collected at pre-treatment, week eight, post-treatment, and at 6- and 12-month follow-ups were analyzed for glucose, lipids (triglycerides (TG), total cholesterol (TC), LDL cholesterol (LDL-c), HDL cholesterol (HDL-c), apolipoprotein A (ApoA) and apolipoprotein B (ApoB) lipoproteins), and thyroid hormones (thyroxine (T4), thyroid stimulating hormone (TSH), and thyroperoxidase antibodies). Result: The average levels of blood glucose, lipids and thyroid hormones were within the recommended range, but clinical levels of TC and LDL-c were detected in 32.5% and 39.1%, respectively. More women with BED compared with BN had low HDL-c, and a larger increase over time in TC and TSH. No significant differences occurred between PED-t and CBT at any measurement. Exploratory moderator analyses indicated a more unfavorable metabolic response at follow-up among treatment non-responders. Conclusion: The proportion of women with impaired lipid profiles and unfavorable lipid changes, suggests active monitoring with necessary management of the metabolic health of women with BN or BED, as recommended by metabolic health guidelines.publishedVersio

A five-year prospective follow-up of longstanding eating disorders : influence from personality disorders and child sexual abuse

Follow-up studies have shown that 20-30% of patients with eating disorders develop longstanding symptoms seriously impairing their daily life. There are very few studies on the course of these patients. This dissertation consists of three papers on patients admitted to a specialized inpatient treatment program at the Modum Bad psychiatric hospital. The participants were assessed upon admission, discharge and at one-, two-, and five-year follow-up. Paper I reports on the course and outcome at five years after completing treatment and identifies subgroups of patients with different course and outcome. The key findings were first that among the 77 patients (90%) who participated, 46 patients (61%) had improved, and 30 (39%) did not meet diagnostic criteria for an eating disorder. Second, a cluster analysis identified a group of 21 patients (27%) with no improvement over time. Paper II reports on the change in proportions of personality disorders over time. The results showed that during inpatient treatment, 58 patients (78%) had one or more personality disorders and this was reduced to 32 patients (43%) at the five-year follow-up. Dimensional indices and a mean personality index changed significantly over time in anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified, but no significant changes between diagnoses emerged. Recovered patients had lower frequency of personality disorder (p < .01). Paper III reports on prognostic factors for the poor outcome of eating disorder symptoms and how the predictors interact. Multi-level mixed model was used to examine the predictors. In these prospective longitudinal analyses, avoidant personality disorder and child sexual abuse interacted in predicting high levels of eating disorder during a long-term course. In sum, this dissertation addressed several important topics in the eating disorder field. The main findings are: There was statistically significant reduction in eating disorder symptoms at the five-year follow-up. Cluster analysis identified a group of patients with no improvement over time. Patients had higher probability of recovery from personality disorders than from eating disorders. Avoidant personality disorder and child sexual abuse interacted in predicting high levels of eating disorder symptoms during the long-term course

«In solitude is safeness»: a patient perspective on eating disorders in the context of multiple childhood trauma

To capture the core pathology of eating disorders (EDs) in the context of multiple childhood trauma, the aim of this study was to describe variation and common features in the lived experiences of ED patients with childhood physical, emotional, and/or sexual abuse and neglect. Semi-structured interviews were conducted post-treatment with nine participants aged 25-59; data was analyzed with Interpretative Phenomenological Analysis. Four master themes emerged across EDs and trauma categories: 1) Shape and weight as regulators of closeness and distance, 2) ED as a sanctuary for counteracting feelings of helplessness and incompetence, 3) ED as a designated caregiver, and 4) ED filling an existential emptiness while emptying unwanted emotions. Informants emphasized interpersonal aspects through the overarching core theme of the ED as protective, self-preservative strategies in relationships with others. ED onset was described as related to the failure of parental figures and their functions, whereas ED maintenance related to the highly isolative and self-perpetuating nature of the disorder. The hypothesized model may have important clinical implications, especially in terms of the therapeutic working alliance, and we suggest that developmental issues are considered when developing future treatments for this ED subgroup

Covert therapeutic micro-processes in non-recovered eating disorders with childhood trauma: an interpersonal process recall study

Method To uncover therapeutic micro-processes from the perspectives of eating disorder (ED) treatment non-responders with childhood trauma (CT) late effects, we explored in-session experiences of poor long-term outcome patients. Female inpatients aged 28–59 (M = 40.2, SD = 5.0) from a randomised trial comparing Compassion Focused Therapy for EDs (n = 3) with Cognitive Behavioural Therapy for EDs (n = 3) were interviewed with video-assisted recall about a self-selected session. Data were analysed through Interpretative Phenomenological Analysis (IPA) with Grounded Theory (GT) elements. Results Covert patient strategies included self-effacement, regulating therapeutic distance to open up, and engaging with reflective rather than experiential interventions. First, self-effacement included submissive, passive or pretend responses to perceived criticising or violating therapist behaviours as well as other orientation and submission for approval. Second, some preferred a close patient–therapist alliance with therapist self-disclosure and reciprocity was a requirement for opening up; others required distance. Third, informants detached from experiential trauma work while engaging in joint reflection on post-trauma responses. Conclusion Informants were preoccupied with calibrating the emotional–relational landscape in session; we hypothesized that psychological insecurity and affective intolerance from CT limit their freedom to explore own in-session experiences

Eating disorder diagnostics in the digital era: validation of the Norwegian version of the Eating Disorder Assessment for DSM-5 (EDA-5)

Objective The Eating Disorder Assessment for DSM-5 (EDA-5) is an electronic, semi-structured interview developed to assess feeding and eating disorders following DSM-5 criteria. The original English version has strong psychometric properties, and previous research has shown high rates of agreement between diagnoses generated by the Eating Disorder Examination (EDE) interview and the EDA-5. The current study aimed to validate the Norwegian version of the EDA-5, and is the first international validation of this diagnostic tool. Method A total of 91 (87 females and 4 males) adult in- and out-patients were recruited from two of the largest eating disorder clinics in Norway. Diagnoses assigned using the EDA-5 were compared to diagnoses from the EDE interview (v. 17.0D). Results Results showed that diagnoses assigned using EDE and EDA-5 were identical for 75 (82.4%) of the 91 cases. Among individual diagnostic categories, kappas ranged from moderate (.49) to perfect (1.00) agreement. The majority of discrepant cases occurred between full- and sub-threshold AN and BN. The EDA-5 was significantly quicker to administer compared to the EDE (22 vs. 54 min). Conclusions The Norwegian EDA-5 can quickly and efficiently generate DSM-5 diagnoses without compromising diagnostic accuracy. It is a promising alternative to existing diagnostic tools, and may help streamline the identification of feeding and eating disorders in clinical settings and in research

Comparison between the brief seven-item and full eating disorder examination-questionnaire (EDE-Q) in clinical and non-clinical female Norwegian samples

Abstract Background The Eating Disorder Examination-Questionnaire (EDE-Q) is among the most widely used self-report measures of eating disorder (ED) psychopathology. There is a need for brief versions of the EDE-Q that can be used for general assessment and screening purposes. A three-factor 7-item version (EDE-Q7) seems particularly promising but there is a need for more well-powered studies to establish the psychometric properties in both patient and community samples. Moreover, comparing the EDE-Q7 with the full EDE-Q would be beneficial in determining its utility. In the present study, we provide a psychometric comparison between the brief EDE-Q7 and the full EDE-Q in a large sample of both patients and community comparisons. Methods We pooled available datasets collected in Norway to amass a large female sample comprising both patients (n = 1954, M age = 28 years) and community comparisons (n = 2430, M age = 31 years). We investigated the psychometric properties of both versions, including their internal consistency, factor structure, and ability to discriminate between patients and community comparisons. Results The EDE-Q7 showed similar distributions of scores compared to the full EDE-Q but produced higher scores. Results indicated that the EDE-Q7 have acceptable internal consistency and is adequately able to discriminate between clinical and non-clinical samples. A cut-off threshold of 3.64 was optimal in discriminating between patients and comparisons. We also found support for the three-factor solution for the EDE-Q7, indicating good structural validity. In contrast, we did not find support for the originally proposed four-factor solution of the full EDE-Q. Conclusions We find that the brief EDE-Q7 performs close to the full EDE-Q in several respects. Our findings indicate that the brief EDE-Q7 may be a viable alternative to the full EDE-Q in situations where response burden is an issue (e.g., epidemiological studies). However, the EDE-Q7 may hold limited value over the full EDE-Q in clinical settings, due to the small number of items and lack of assessment of behavioral features

Co-occurrence of avoidant personality disorder and child sexual abuse predicts poor outcome in longstanding eating disorders

Few consistent predictive factors for eating disorder have been identified across studies. In the current five year prospective study, the objective was to examine whether (1) personality disorder and child sexual abuse predict the course of severity of eating disorder symptoms after inpatient treatment and (2) how the predictors interact. A total of 74 patients with long standing eating disorder and mean age of 30 years were assessed at the beginning and end of inpatient therapy and at one-, two- and five-year follow-up. Mixed model was used to examine the predictors. Avoidant personality disorder and child sexual abuse interacted in predicting high levels of eating disorder over a long-term course. These results suggest that eating disorder, avoidant personality disorder and sequelae after child sexual abuse are potential targets for treatment that need further investigation

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

Objective 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. Methods 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. Results 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. Conclusions 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. Public Significance Statement 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