Characterize the presence and nature of disordered eating behavior documentation in women veterans' mental health (MH) services. Retrospective chart review. A subset of MH progress notes was reviewed from participants in a research study on self-reported disordered eating behaviors. Notes were reviewed and coded to establish the frequency and context in which disordered eating was addressed within MH services. Two-hundred twenty-two unique notes were reviewed across 28 patients. 19.8% of notes across 16 patients included documentation of disordered eating behaviors. Documentation most frequently referenced routine, non-specific questions related to medication/medical conditions, and patient-initiated prompts. Documentation of disordered eating behaviors appeared infrequent across MH appointments. When charted, notes typically referenced medication side effects or other medical conditions (e.g. flu) as opposed to linkage with disordered eating or MH symptoms. Disordered eating behaviors may be an important area of clinical query, in particular among patients with known comorbidities.
Night Eating Syndrome (NES) is an eating disorder associated with circadian rhythm disruption, but its clinical relevance in metabolic diseases remains unclear. This study aimed to determine the prevalence of NES in individuals with type 1 and type 2 diabetes and to examine its associations with glycemic control and metabolic risk markers within each subtype. This cross-sectional study included 500 patients with diabetes (108 with type 1 and 392 with type 2). NES was assessed using the Night Eating Questionnaire (NEQ), with a score ≥ 25 indicating NES. Group comparisons, correlation analyses, and binary logistic regression were performed to identify factors independently associated with metabolic syndrome. The overall prevalence of NES was 23.2%, with no significant difference between type 1 and type 2 diabetes. In exploratory analyses conducted separately within each subtype, NEQ scores in type 1 diabetes showed weak positive correlations with fasting glucose and glycated hemoglobin (HbA1c), while in type 2 diabetes NEQ scores showed weak positive correlations with waist circumference, triglycerides, and the atherogenic index of plasma. In multivariable analysis, the NEQ score was independently associated with metabolic syndrome (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.046-1.122). NES is common among individuals with diabetes and, in the overall diabetic population, is independently associated with metabolic syndrome. These findings suggest that NES may represent a clinically relevant metabolic phenotype in diabetes. Given the cross-sectional design, prospective studies are needed; however, early identification of NES may support a more comprehensive metabolic risk assessment.
Instantaneous vital signs are affected by momentary confounding factors such as anxiety. This study evaluated serum triiodothyronine (T3) levels as a biomarker of hemodynamic instability in 249 adolescents presenting with restrictive eating disorders. Hemodynamic instability was defined as significant bradycardia [minimal heart rate (HR)<50 beats per minute] and/or hypotension [systolic/diastolic blood pressure (BP)<90 mmHg/<45 mmHg]. T3 levels were categorized as normal, low, or extremely low (>4.7, 3.5-4.7, <3.5 pmol/L, respectively). Adolescents with low (74, 30%) or extremely low (125, 50%) T3, as compared to those with normal levels, had significantly lower HR (p = .004), lower BP (p < .001), greater weight loss (p = .02), longer hospital stay (p = .01), and longer duration of amenorrhea (p = .01). T3 levels showed significant negative correlations with weight loss (r = -0.2, p = .004). As a biomarker less susceptible to acute confounding factors than vital signs, T3 may enhance clinical assessment and risk stratification at initial presentation.
Lifestyle interventions tend to reduce disordered eating short-term in children, but little is known about long-term changes. This study aimed to investigate changes in appetitive traits and episodes of overeating and binge-eating up to three years after a 10-week multicomponent lifestyle camp in 7-14-year-olds. Participants were referred to the lifestyle camp due to overweight/obesity, and/or psychosocial challenges. The Children's Eating Behavior Questionnaire (CEBQ) and selected items from the Eating Disorder Examination Questionnaire (EDE-Q) were completed at baseline, after camp, and at one- and three-year follow-ups. The majority of participants (mean age 15.4 ± 1.3 years) were living with overweight (30%) or obesity (53%) at the three-year follow-up. Appetitive traits improved with sustained effect; however, the effects attenuated from post-treatment to the three-year follow-up. Compared to baseline (41%), a smaller proportion reported regular binge-eating at the three-year follow-up (14%), and only a small group of children reported new onset overeating and binge-eating during follow-up. In conclusion, the lifestyle camp setting is a safe and effective intervention that improves appetitive traits and reduces binge-eating over a three-year follow-up period. However, continued support may be needed to sustain improvements, and future studies should examine whether addressing disordered eating within childhood obesity treatment enhances long-term outcomes.
Evidence examining whether intolerance of uncertainty (IU) and cognitive inflexibility are risk factors for compulsive exercise (CE) remains scarce in athletes and adolescents with eating disorders (EDs). The main aims of this study were twofold: 1) to analyse whether there are significant differences in IU dimensions and cognitive inflexibility between athletes and adolescents with EDs with high CE compared to those with low CE; 2) to explore the associations between IU, cognitive inflexibility and elements of CE. A total of 52 female adolescents with EDs (AN = 29; BN = 5; OSFED = 18) and 72 adolescent female athletes (footballers = 38; dancers = 34) completed self-reported measures of IU, cognitive inflexibility, CE and ED symptoms. Results showed that high CE groups (in both the athlete and ED groups) scored significantly higher in cognitive inflexibility compared to low CE groups. Indeed, cognitive inflexibility remained significantly linked to the CE dimension of avoidance of negative affect, even when controlling for ED symptoms, anxiety and depression. Moreover, in the athlete group, those with high CE scored significantly higher on IU dimensions compared to those with low CE. The findings suggest that cognitive inflexibility and IU may be hallmarks of CE.
Quality of life (QoL) is markedly impaired in eating disorders (EDs) and often remains compromised after treatment. Although adverse childhood experiences (ACEs) are linked to ED severity and prognosis, less is known about how specific ACE subtypes are associated with changes in functional outcomes. A sample of 221 cisgender women inpatients with EDs completed the Childhood Trauma Questionnaire (CTQ) and the Eating Disorder Quality of Life questionnaire (EDQoL) at admission and discharge. Moderation models examined whether ACE dimensions were associated with differences in the association between baseline and discharge QoL, adjusting for age, body mass index, and illness duration. Patients showed marked QoL impairment at admission and significant improvement by discharge. Emotional and physical neglect were differentially associated with QoL change patterns: higher emotional neglect was associated with weaker baseline-discharge continuity, whereas higher physical neglect was associated with stronger continuity. Overall, 54% of patients achieved reliable improvement. Abuse-only and neglect-only profiles were associated with a lower likelihood of reliable QoL improvement compared with no CTQ elevation. Specific forms of childhood adversity, particularly neglect, are differentially associated with short-term functional recovery during inpatient treatment for EDs, highlighting the relevance of ACE-informed, subtype-sensitive clinical approaches.
The Night Eating Questionnaire (NEQ) was developed to evaluate symptom severity for night eating syndrome-a historically under-studied eating disorder primarily characterized by evening hyperphagia and/or nocturnal awakenings. Given limited prior psychometric investigations of this measure, the present study aimed to evaluate NEQ factor structure, reliability, and convergent validity. Exploratory (n = 202) and confirmatory factor analyses (n = 203) were completed using a random split-sample approach in a U.S. veteran sample. The original 13-item first- and second-order four-factor models could not be replicated. A two-factor six-item model (NEQ-6) demonstrated good fit, inclusive of evening hyperphagia and sleep factors. Adequate fit for a partial bifactor model suggested support for a global factor and a specific evening hyperphagia factor. The NEQ-6 also demonstrated adequate internal consistency and high correlations with global eating pathology, binge eating, insomnia, and depression. Morning anorexia and mood disturbance items did not share common variance with other items, suggesting that these constructs may not be as prominent in night eating presentations for veterans; however, results need to be replicated in larger clinical samples. Additional research is needed to better understand lived experiences of veterans with night eating syndrome to inform valid and reliable measurement in this population. Support for a briefer NEQ version has important research and clinical implications in both veteran and general populations and should be further evaluated.
Six-month follow-up results from a trial investigating the effects of Radically Open Dialectical Behavior Therapy (RO-DBT) in individuals with anorexia nervosa are presented. Participants (N = 23; median age 20 years; 96% female) completed a 32-week RO-DBT intervention. Repeated Measures ANOVAs were used to examine changes over time. The primary outcome was eating disorder psychopathology. Exploratory outcomes were BMI, obsessive-compulsive personality traits, emotion regulation, work function and treatment utilization. Statistically significant reductions in eating disorder psychopathology, albeit mean EDE-Q scores remained above the established clinical cutoff, and increases in BMI from pre-treatment to post-treatment were sustained at 6-month follow-up with significant effects of time. A statistically significant reduction in the doggedness scale in FFOCI-SF was observed between pre-treatment and the 6-month follow-up. Findings suggest that participation in RO-DBT is associated with sustained improvements in eating disorder symptoms and BMI for individuals with anorexia nervosa, suggesting that RO-DBT is a treatment alternative for anorexia nervosa that warrants further evaluation in controlled trials.
Eating disorders (EDs) are severe conditions with high relapse rates. Residential treatment may support recovery, yet long-term outcomes require further evaluation. This study examined changes in psychological symptoms and weight-related outcomes from intake to discharge and one-year follow-up in 275 female adolescents and adults admitted to a residential ED program. Participants completed measures of ED symptoms, anxiety, depression, and weight (BMI or %mBMI for adolescents) at each timepoint. Multilevel modeling, reliable change index (RCI), and clinically significant change (CSC) analyses evaluated symptom trajectories and treatment response. Adolescents and adults demonstrated large, clinically meaningful group-level improvements from intake to discharge across ED symptoms, anxiety, depression, and BMI. While small rebounds occurred between discharge and follow-up, net gains were substantial (p's < .001). Adults presented with more severe ED and anxiety symptoms than adolescents, but these differences were no longer significant by one-year follow-up. RCI/CSC analyses indicated that approximately 30-50% of the participants maintained clinically significant improvements at one-year follow-up on various outcomes. Most participants (70.9%) did not return to inpatient hospitalization or residential treatment within the year following discharge. Overall, residential treatment was associated with meaningful group-level symptoms and weight improvements that were generally sustained over a year, with substantial individual-level variation, providing additional data for its role in supporting ED recovery.
Dropout from eating disorder (ED) psychotherapy remains a significant clinical challenge, yet treatment discontinuation has historically been conceptualised primarily through patient-centred frameworks emphasising ambivalence, resistance, illness severity, or poor motivation. This perspective paper critically examines dominant conceptualisations of dropout and explores how lived experience literature and research on adverse treatment experiences may broaden current understandings of disengagement. Drawing on qualitative, lived experience-led, conceptual, and empirical scholarship, the paper highlights how relational rupture, epistemic injustice, coercion, cultural and relational unsafety, misattunement, and iatrogenic harm may contribute to treatment withdrawal for some individuals. The paper additionally examines structural and systemic contributors to disengagement, including culturally incongruent care, and inequitable access to services. Implications for research and clinical practice are discussed, including routine monitoring of treatment-related harm, reconsideration of retention-focused frameworks, and greater incorporation of co-produced approaches within ED care.
Autistic children and young people receiving eating disorder focused family therapy (FT-ED) for anorexia nervosa (AN) are more likely than their non-Autistic peers to require longer and more intensive treatment. Qualitative evidence suggests that Autistic young people and their parents struggle with a perceived inflexible delivery of FT-ED that can be mis-attuned to autistic needs. Clinicians delivering this care report a lack of confidence when adapting FT-ED to this population, and there is limited guidance on how to do this. This paper describes evidence informed and coproduced guidelines, developed via a series of workshops with Autistic people with lived experience of an eating disorder, parents and carers, clinicians, researchers, and third sector representatives. The intention of these guidelines is to support clinicians in the adaptation of FT-ED for Autistic young people with AN and their families, with the aim of delivering more appropriate and effective care. Young people and their parents or carers may also find these guidelines helpful when advocating for autism-affirming care within FT-ED.
Interoceptive dysfunction is a known risk and maintenance factor for eating disorders (EDs), yet few interventions directly target this domain. This pilot study evaluated the feasibility, acceptability, and preliminary effects of Reconnecting to Internal Sensations and Experiences for Eating Disorders (RISE-ED), an adapted interoceptive awareness program delivered in intensive ED treatment. Fifty-four individuals completed pre-assessments; due to discharge and ID entry errors, the analytic sample was 17. Feasibility was assessed via completion rates and staff feedback, and acceptability via self-report and qualitative data. Changes in interoceptive deficits were examined using paired-samples t-tests with bootstrapped confidence intervals. RISE-ED was rated as acceptable (M = 5.00, SD = 1.71) and effective (M = 4.50, SD = 2.13). All analytic participants completed ≥3 modules. Interoceptive deficits were reduced in this preliminary sample (d = 0.68). RISE-ED was feasible and acceptable in intensive treatment; findings provide preliminary support for feasibility and signal detection, and larger randomized studies are needed.
Although research suggests high rates of comorbidity between eating and substance use disorders, relatively few studies examine weight concern and its relationship to both substance use and eating pathology in women in drug treatment settings. This study explored these relationships in a clinical sample of 1,533 women in outpatient and residential treatment for substance use. Results revealed that 12.3% had a lifetime eating disorder diagnosis and 21% reported eating pathology without a formal diagnosis. About 44% strongly agreed that they started using substances for weight loss purposes and more than half were concerned about weight gain in recovery (59%). The most commonly endorsed appearance-related motivations for drug use were "drugs make me feel attractive" (59%) and "drugs help me stay thin" (53%). Concern about weight gain in treatment was positively correlated with weight-related substance use motivation, body dissatisfaction, binge eating, and general eating pathology. Regression analyses indicated that as motivation to use drugs for weight loss increased so did the severity of body dissatisfaction and binge eating. These findings suggest that conceptualizing weight concern as a multidiagnostic factor that can motivate, maintain or trigger both substance use and eating pathology would benefit many women in drug treatment.
Self-concept clarity (SCC) refers to the degree to which the self-concept is well defined, internally consistent, and temporally stable, and has been theorized as a vulnerability factor in the development and maintenance of eating disorders (EDs). This systematic review examined the association between SCC, related aspects of identity functioning, and ED symptoms. Peer-reviewed quantitative studies in English, conducted in clinical, at-risk, or community samples, that measured SCC/identity and ED symptoms were included (while qualitative studies, theoretical studies, reviews, case reports, and grey literature were excluded). The search was conducted using PubMed, PsycINFO, Scopus, and Web of Science, supplemented by citation tracking and screening of reference lists. The risk of bias was assessed using the AXIS tool, and the results were summarized narratively due to heterogeneity, which precluded a meta-analysis. A total of 23 studies were included. Lower SCC and poorer identity functioning were consistently associated with higher levels of ED symptoms. Moreover, some longitudinal studies provided preliminary support for bidirectional associations between identity functioning and specific ED symptoms (particularly bulimia and body dissatisfaction). The association between SCC and ED symptoms was frequently mediated by thin-ideal internalization, social comparison, perfectionism, and emotional dysregulation. In conclusion, the results supported the hypothesis that SCC deficits and identity disturbances represent vulnerability mechanisms in ED onset and maintenance, highlighting the importance of interventions targeting self and identity functioning.
Prior research in clinical eating disorder populations suggests that altered inhibition-underactive and overactive-contribute to overeating/purging and restrictive eating, respectively. However, it remains unclear whether these alterations manifest at non-clinical levels, which is particularly important from a preventive perspective. Currently, research in non-clinical DEBs is fairly limited, generally relying on small samples and restrictive DEB. This study examined behavioral (reactive and proactive) and dispositional (Behavioral Approach/Inhibition Systems (BIS/BAS), Effortful Control (EC)) measures of inhibition among different non-clinical DEBs in a large sample of adults (N = 425), classified into a restrictive (n = 80), binge-eating/purging (n = 173), and comparison (n = 172) group. Participants completed two inhibition tasks (Stop-Signal Task, Go/NoGo Task) and self-report questionnaires (BIS/BAS scales, EC scale). Results revealed that individuals with restrictive DEB exhibited increased proactive inhibition, whereas no significant differences were observed for reactive inhibition. No behavioral differences were found for the binge-eating/purging group, though they reported lower self-reported EC. Elevated BIS levels were observed in both DEB groups relative to comparisons. These findings provide preliminary support for inhibitory alterations among non-clinical DEBs and highlight the potential utility of assessing and targeting inhibitory processes in future longitudinal research as part of a broader preventive framework for DEBs.
Black, Indigenous, and People of Color (BIPOC) experience eating disorder (ED) symptoms at rates consistent with non-Hispanic White individuals. Yet, there remains a lack of evidence-based treatment and outcomes research for BIPOC with EDs. Transdiagnostic approaches can address symptoms related to EDs and co-occurring mental health conditions by targeting underlying factors that present across emotional disorders. The purpose of the study was to examine the long-term effects of the Unified Treatment Model for Eating Disorders and Comorbidity (UTM) on transdiagnostic factors, specifically anxiety sensitivity, experiential avoidance, and mindfulness, in BIPOC with EDs. The sample included 470 BIPOC clients who received the UTM in residential ED treatment. Using repeated measures ANOVA, we examined changes in core transdiagnostic mechanisms using the Anxiety Sensitivity Index (ASI), Brief Experiential Avoidance Questionnaire (BEAQ), and Southampton Mindfulness Questionnaire (SMQ) to determine treatment differences during treatment admission, discharge, and six months post-discharge. Results revealed statistically significant differences in ASI, BEAQ, and SMQ scores from admission to discharge, with treatment progress maintained between discharge and six-month follow-up. The UTM represents a promising treatment approach for BIPOC in residential ED treatment, targeting core transdiagnostic mechanisms across emotional disorders. Clinical implications are discussed, including culturally responsive conceptualization and treatment, as well as recommendations for future research.
This study examined whether lifetime nonsuicidal self-injury (NSSI) in patients with Eating Disorders (ED) is associated with more severe clinical presentations and moderates clinical outcomes in a partial hospitalization treatment program. Data on eating symptomology, quality of life, and functional impairment were obtained from 1,234 patients at admission and discharge. Analyses included t-tests, linear regression, and repeated measures mixed models with two- and three-way interactions to examine if outcomes varied by lifetime NSSI. Nearly half of the ED patients reported lifetime NSSI. Those with NSSI were most likely to be younger, female, and diagnosed with ED Not Otherwise Specified, and had a more severe clinical presentation. Outcomes, however, did not vary by lifetime NSSI.
Prolonged waitlists for eating disorder (ED) treatment are a growing concern in Australia, with limited access to specialised services contributing to delays in care. Despite increasing awareness of these systemic barriers, little is known about the lived experience of adults awaiting psychological treatment for EDs. This study explored the psychological and emotional impacts of being on a waitlist and the coping strategies individuals employ during this time. Fourteen females (M = 27.1 years) who were currently, or had recently been, on a waitlist for ED treatment in Australia participated in semi-structured interviews. Data were analysed using reflexive thematic analysis within a critical-realist framework. Participants described feeling deprioritised, not "sick enough", and that the waitlist itself contributed to symptom escalation. Four key themes were generated: living in limbo, reflecting uncertainty and disempowerment; incubation period, describing exacerbation of ED symptoms and psychological distress; reliance on other support, illustrating variable use of formal and informal networks; and alternative coping mechanisms, highlighting the use of previously learned strategies. Findings suggest that prolonged waiting can intensify distress, entrench ED behaviours, and undermine recovery motivation. Enhancing communication, interim support, and structured self-help may help mitigate these harms and improve service responses during the waitlist period.
Higher-level-of-care eating disorder (ED) treatment programs are often designed specifically for individuals with restrictive EDs, and those with binge-eating spectrum disorders (BESD) have different needs. The present study sought to understand predictors of outcome in a residential treatment program designed specifically for BESD. Ninety-nine participants (81% female, 80% White, Mage = 34) admitted to a residential program designed specifically for BESD completed assessments at admission, discharge, 6-month follow-up, and 12-month follow-up. We examined ED-related and comorbid symptom predictors of binge eating severity at discharge and follow-up. In multivariate regression models, cognitive restraint, depression, anxiety, and trauma symptoms significantly predicted binge eating severity at discharge, but at 12-month follow-up, only depression and trauma symptoms remained significant predictors. Individuals with lower cognitive restraint and comorbid symptoms may benefit more from this type of treatment. Further tailoring BESD residential treatment to provide additional skills for managing cognitive restraint and comorbid symptoms may be warranted.
Enhanced cognitive behaviour therapy (CBT-E) remains a cornerstone of evidence-based treatment for eating disorders (EDs). While effective for many individuals, its conceptual and procedural scope may not fully capture the clinical realities of some autistic, neurodivergent, multidiagnostic, and treatment-experienced populations. Drawing on recent research and clinical experience, we describe how ED behaviours in these groups are often shaped by sensory and interoceptive processes, neurobiological threat responses, chronic invalidation, trauma histories, and difficulties with emotional and interpersonal regulation that may operate alongside, or independently of, weight and shape concerns. When such mechanisms are under-specified, behaviour is more likely to be misinterpreted as resistance or non-compliance, and lived experience may lack uptake within dominant treatment frameworks. The challenge for the field is not to replace CBT-E, but to recognise the limits of any single model and to develop integrative treatment architectures that incorporate neurobiological, biosocial, and contextual determinants of behaviour. Using Multidiagnostic Eating Disorders-Dialectical Behavior Therapy (MED-DBT) an adaptation of DBT designed for individuals with eating disorders and co-occurring high-risk and regulatory difficulties, as an illustrative example, we outline a dialectical approach that supports epistemic humility, reduces misinterpretation, and promotes more inclusive and effective care for individuals least well served by existing models.
