This chapter discusses the treatment of eating disorders, focusing on the treatment of anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) in adolescents. It highlights the effectiveness of family-based therapy, which has shown significant benefits for adolescents with AN, particularly those with a shorter illness duration. The chapter also examines pharmacological treatments. While evidence for the effectiveness of medications in adolescents with eating disorders is limited, treatments like antidepressants and atypical antipsychotics show promise for enhancing recovery. It emphasizes early intervention, specialized care, and individualized treatment approaches for this vulnerable population. Finally, the chapter stresses the importance of ongoing research and evaluation to refine treatment methods and improve long-term outcomes for adolescents with eating disorders.

Objective In the treatment of individuals with atypical anorexia nervosa (atypical AN), it is unclear how to determine when sufficient renourishment has been achieved. Reliance on body mass index (BMI) to define acute treatment goals in AN has led to gaps in understanding of the physiology of renourishment. Biological markers that reflect restoration of physical health during acute nutritional rehabilitation are needed to move beyond weight-based metrics.Method This Spotlight briefly describes the physiology of starvation in patients with AN and atypical AN and existing strategies for acute nutritional rehabilitation. It identifies gaps in understanding the timeline of physiological normalization during refeeding and proposes research to identify biological markers of restored physical health in individuals with AN and atypical AN.Results Physiological normalization during refeeding is not uniform across biological systems, with cardiovascular parameters correcting more rapidly than gonadal and skeletal systems. In AN, weight restoration improves most physiological indices, but the time course of biological recovery remains unclear. In atypical AN, data characterizing how biological indices of starvation change with refeeding are sparse.Discussion These observations underscore the utility of moving beyond approaches based exclusively on BMI. We propose the identification of biomarkers of physiological recovery as a necessary foundation for improved guidance regarding the renourishment of patients with AN and atypical AN.

INTRODUCTION:The Eating Disorder Examination-Questionnaire (EDE-Q) is one of the most widely used measures of eating disorder psychopathology; however, its original four-factor structure is not supported in data-driven investigations. This study examined the latent structure of the EDE-Q in a large sample of inpatients with anorexia nervosa (AN) at the beginning and end of hospitalization. METHOD:Inpatients with AN (ages 13-64 years) were included. Exploratory factor analysis (EFA) was conducted using EDE-Q data collected at admission (n = 320). Confirmatory factor analysis (CFA) was conducted using data collected just prior to discharge (n = 301). Reliability was assessed using internal consistency indices and construct validity of the proposed EDE-Q subscales was explored using correlational analyses with the eating disorder inventory (EDI) and the eating pathology symptoms inventory (EPSI). RESULTS:The original four-factor structure was not supported. A three-factor model (Body Image Dissatisfaction, Discomfort with Body Exposure, and Restrictive Eating Concerns) emerged from the EFA and was supported in CFA with improved model fit (CFI = 0.928, TLI = 0.915, RMSEA = 0.087, SRMR = 0.055). The model showed acceptable internal consistency and convergent validity. DISCUSSION:The EDE-Q was found to have a three-factor structure, comprising two body image-related domains and one domain assessing restriction and concern about eating. Findings support the emergence of a distinct factor capturing discomfort with body exposure, independent of body dissatisfaction. This highlights the need for empirically derived subscales that better disentangle overlapping eating disorder constructs.

OBJECTIVE:Patients with eating disorders (EDs) are often ill for many years before receiving treatment, a problem that may be addressed in part via improved screening. Given high rates of comorbidity with nearly all other psychiatric conditions, screening all patients in outpatient mental health settings provides an opportunity for detection and intervention. A very brief (i.e., 1-2 item) screener may be useful for determining who would benefit from additional query. METHOD:A chart review was conducted to explore the utility of two ED screening items that were administered alongside SCOFF items as part of routine clinical care. RESULTS:Over a quarter (26.3%) of patients reported either eating or body image problems at a level of at least "Moderate/more than half" of days; 42.9% reported these problems at a level of at least "Mild/Some of the days"; 14.2% had a SCOFF score ≥ 2. Equal proportions of men and women were captured by both screeners. Utilizing "Mild/Some of the days" as a cutoff, over 90% of individuals with a SCOFF score ≥ 2 were captured by the 2-item screener. DISCUSSION:Outpatients receiving mental health treatment report high rates of concerns with eating and body shape/weight. It may be possible to identify individuals in need of additional assessment via a very brief screener querying eating concerns and preoccupation with body shape/weight. Additional testing across settings, with more diverse individuals, comparison with a validated ED diagnostic assessment, and addressing other aspects of the screening process (i.e., next steps for positive screens), are critical for developing an effective screening procedure for outpatient mental health.

This chapter explores the prevention of eating disorders by identifying specific biological, behavioral, and sociocultural risk factors that predict the onset of anorexia nervosa, bulimia nervosa, binge-eating disorder, avoidant/restrictive food intake disorder, and other presentations. It emphasizes genetic vulnerabilities, neurocognitive traits, and neurobiological pathways alongside environmental influences such as dieting, body dissatisfaction, trauma, and family dynamics. The chapter discusses sociocultural influences, including internalization of the thin-ideal, cultural change, acculturation, and the global spread of Western norms through media, which interact with individual risk profiles. It also highlights disparities in diagnosis, treatment, and assessment across different populations due to cultural variations and insufficiently inclusive diagnostic tools. Finally, the chapter stresses the need for culturally sensitive assessments, global collaborations, and targeted prevention strategies to address the multifaceted and evolving nature of eating disorder risk.

This chapter outlines a comprehensive research agenda aimed at advancing understanding, diagnosis, and treatment of eating disorders in adolescents. It calls for evaluation of DSM-5 and alternative diagnostic frameworks, increased genomic studies to uncover biological mechanisms, and large-scale epidemiological research to clarify prevalence across diverse populations. The chapter highlights the need to investigate comorbidities, diagnostic migration, and medical complications, and urges development of evidence-based psychological and pharmacological treatments, relapse prevention strategies, and effective interventions across levels of care. It emphasizes exploring culturally relevant factors, the impact of social determinants, and disparities in access to care among marginalized groups. Finally, the chapter recommends refining prevention strategies by distinguishing risk factors for symptom onset, escalation, and maintenance to design targeted and inclusive interventions that avoid inadvertently increasing eating disorder risk.

OBJECTIVE:To review the history of the term atypical anorexia nervosa and the challenges surrounding its current description and to propose a new name and diagnostic criteria. METHOD:We review the use of the term "atypical" in the literature on eating disorders and in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) and note several terms in the current description that are in need of clarification. We also describe how the ICD-11 has grappled with atypical anorexia nervosa. RESULTS:The first use of atypical anorexia nervosa was by Hilde Brȕch to describe individuals who had lost substantial weight but who lacked the characteristic psychological features of anorexia nervosa. In the section on Eating Disorders Not Otherwise Specified, the DSM-IV included a description of a disorder very similar to the description of atypical anorexia nervosa; the DSM-5 slightly changed the wording and applied the term atypical anorexia nervosa. Features in the description in need of definition include "significant weight loss" and "normal or above normal weight," and the current name is problematic. DISCUSSION:We discuss these issues and several potential options for defining features in the current description and for a new name. Following other examples in the DSM-5-TR, we propose the disorder be named "anorexia nervosa-like eating disorder (weight in normal or above normal range)" (acronym: ANLED) and suggest diagnostic criteria which could be included in the DSM-5-TR section on Conditions for Further Study.

OBJECTIVE:The current study assessed whether Eating Pathology Symptoms Inventory (EPSI) scores among hospitalized patients with anorexia nervosa (AN) were associated with actual eating behavior and whether scores change with inpatient weight restoration treatment. Exploratory analyses compared outcomes between patients with restricting (AN-R) and binge-eating/purging (AN-BP) subtypes of AN. METHOD:Participants included 136 females with a DSM-5 diagnosis of AN who completed the EPSI at admission and discharge. Bivariate Pearson correlations tested associations between subscale scores and calories and fat consumed during an ad-libitum meal following admission among a subsample of participants (n = 59). Change in scores from admission to discharge was tested using paired samples t-tests and linear mixed models. RESULTS:The EPSI Restricting and Cognitive Restraint subscale scores at admission were significantly correlated with total calories consumed during the meal (ps ≤ 0.0001). From admission to discharge, most subscale scores showed significant improvement (Cognitive Restraint, Excessive Exercise, Purging, and Restricting), and Binge Eating showed significant worsening. Exploratory analyses identified subtype differences, with significantly greater correlations between subscale scores and eating behavior among patients with AN-R. CONCLUSIONS:Findings suggest the EPSI is related to the pathological restrictive eating behavior that is central to AN and captures symptom change during treatment of AN. Differences between AN subtypes warrant further consideration.

OBJECTIVE:Restrictive eating behavior in anorexia nervosa (AN) is often characterized by rigidity, dichotomous thinking, and cognitive inflexibility. These traits are also central to obsessive-compulsive personality disorder (OCPD). The current study assessed whether OCPD traits among patients with AN were associated with the severity of illness or short-term treatment outcome. METHOD:Presence of OCPD traits were measured among hospitalized adults and adolescents as well as healthy peers (HC), using the Pathological Obsessive Compulsive Personality Scale (POPS). In addition to comparing groups, patients with AN were assessed before and after weight restoration treatment to examine changes with renourishment. Associations between POPS and other indices of clinical severity were tested. RESULTS:POPS scores were significantly higher among AN (n = 208) than HC (n = 124) (Total: 173.2 ± 33.4 vs. 132.3 ± 32.6, t 330 = 10.9, p < 0.001), across all five domains (Rigidity, Emotional Overcontrol, Maladaptive Perfectionism, Reluctance to Delegate, Difficulty with Change). Among AN, higher POPS scores were positively associated with EDE-Q (r 195 = 0.29, p = < 0.001) and YBC-EDS scores (r 201 = 0.28, p = < 0.001). POPS scores did not change with weight restoration and were not significantly associated with treatment outcome. DISCUSSION:OCPD personality traits were elevated among individuals with AN, though scores were lower than populations with OCPD. These traits did relate to illness severity, but not to treatment outcome. While these traits may merit attention in treatment, co-occurring OCPD may not be central to the kind of rigidity that perpetuates AN.

Several practice guidelines exist from professional organizations in the United States to support the assessment and management of eating disorders in children and adolescents. This manuscript synthesizes the key areas of overlap from these guidelines and provides directions for future research and alignment to improve care. Consistent screening for eating disorders in primary care is recommended to ensure early identification and referral to treatment. Outpatient treatment supported by families, including family based treatment, is the first line of care recommended by guidelines. Multidisciplinary treatment teams benefit patients in covering the variety of aspects of health that eating disorders impact, including mental health, nutritional health, and physical health. Patients may require hospitalization under certain medical criteria such as bradycardia or specific lab abnormalities. Guidelines show consensus on the importance of early identification and treatment access, involvement of family in treatment, and the use of a multidisciplinary treatment team. However, future work is needed to guide care of Avoidant/Restrictive Food Intake Disorder (ARFID), as well as the impact of weight inclusive care and the development of validated screening tools for children and adolescents for all eating disorders. Several professional organizations in the U.S. provide guidelines for assessing and treating eating disorders in children and adolescents. This paper highlights key areas of agreement across these guidelines and suggests future research directions. Primary care providers should routinely screen for eating disorders to enable early detection and treatment referrals. Outpatient care, particularly family-based treatment, is the preferred first-line approach. Multidisciplinary treatment teams that include therapists, dieticians, and medical professionals are essential for comprehensive care. Hospitalization may be necessary for patients with severe medical complications.

Diagnostic criteria for avoidant/restrictive food intake disorder (ARFID) were introduced in DSM-5 in 2013. In the ensuing years, substantial research has clarified the clinical characteristics, complications, and possible treatments for individuals with ARFID. On the basis of this emerging knowledge, in the current issue of the International Journal of Eating Disorders , Zickgraf et al. usefully propose a revision of the diagnostic criteria. The proposed revisions would bring the structure of the criteria more in line with the criteria for anorexia nervosa, bulimia nervosa, and binge-eating disorder. Zickgraf et al. also propose that ARFID could be diagnosed in the presence of another eating disorder, thereby differing from the current nosological hierarchy for anorexia nervosa, bulimia nervosa, and binge-eating disorder. Zickgraf et al. have done our field a significant service with their thoughtful proposal. Research is now needed to evaluate the performance of the suggested criteria.

BACKGROUND:Pharmacological efforts to treat anorexia nervosa (AN) have predominantly repurposed medications that treat conditions with overlapping symptoms and yielded generally disappointing results. Despite limited empirical support, SSRIs are often prescribed to patients with AN. Whether SSRIs are effective in a subgroup of individuals with AN, such as those with depression, is not known. METHODS:A secondary analysis of a randomized trial of fluoxetine versus placebo for relapse prevention in AN was conducted. Participants (n = 92) were weight-restored women with AN who completed the Beck Depression Inventory (BDI) at the time of randomization. BDI scores were dichotomized to reflect moderate/severe depression (BDI > 20, n = 26). A Cox Proportional Hazards model estimated the association of the level of depression, medication, and their interaction with time to relapse. Mixed effects models examined the effects of medication on symptom trajectories in high versus low depression groups and whether depression severity modified the effect of the drug on symptom trajectory. RESULTS:There was a significant interaction between medication and depression severity in time to relapse (hazard ratio = 0.46, 95% CI: [0.25, 0.85], p = .01). Depression severity modified the effect of fluoxetine on the time course of symptoms of depression (β = -0.27, 95% CI: [-0.42,-0.12], p = 0.001) and bulimia (β = -0.15, 95% CI: [-0.25,-0.05], p = 0.004) in the twelve month follow-up period. CONCLUSIONS:Fluoxetine was more effective than placebo in reducing relapse among more depressed, weight-restored individuals with AN. These results require replication but provide support for the use of antidepressant medication for patients with AN who remain depressed following weight restoration.

Importance:Eating disorders are characterized by disturbances in eating behavior and occur worldwide, with a lifetime prevalence of 2% to 5%. They are more common among females than males and may be associated with medical and psychiatric complications, impaired functioning, and decreased quality of life. Observations:Common eating disorders include anorexia nervosa, bulimia nervosa, binge-eating disorder, and avoidant/restrictive food intake disorder. These disorders may be associated with changes in weight, electrolyte abnormalities (eg, hyponatremia, hypokalemia), bradycardia, disturbances in reproductive hormones (eg, decreased estradiol levels in females), and decreased bone density. Individuals with anorexia nervosa, bulimia nervosa, and binge-eating disorder have high lifetime rates of depression (76.3% for bulimia nervosa, 65.5% for binge-eating disorder, and 49.5% for anorexia nervosa) and higher rates of suicide attempts than those without eating disorders. Anorexia nervosa is associated with a mortality rate of 5.1 deaths per 1000 person-years (95% CI, 4.0-6.1), nearly 6 times higher than that of individuals of the same age without anorexia nervosa; 25% of deaths among individuals with anorexia nervosa are from suicide. First-line treatments for eating disorders include nutritional support, psychotherapy, and pharmacotherapy. Behaviorally focused therapies, including cognitive behavioral therapy, may be effective, especially for bulimia nervosa and binge-eating disorder. Youth with anorexia nervosa benefit from family-based treatment with parental oversight of eating, resulting in a remission rate at 6 to 12 months of 48.6% vs 34.3% with individual treatment (odds ratio, 2.08; 95% CI, 1.07-4.03; P = .03). Fluoxetine and other antidepressants decrease episodes of binge eating in individuals with bulimia nervosa, even in those without depression (fluoxetine vs placebo, standardized mean difference = -0.24 [small effect size; 95% CI, -0.41 to -0.08]). Antidepressants and the central nervous system stimulant lisdexamfetamine reduce binge frequency in binge-eating disorder compared with placebo (antidepressants vs placebo, standardized mean difference = -0.29 [small effect size; 95% CI, -0.51 to -0.06]; lisdexamfetamine vs placebo, Hedges g = 0.57 [medium effect size; 95% CI, 0.28-0.86]). There are currently no effective medications for treatment of anorexia nervosa. Individuals with serious medical or psychiatric complications of eating disorders such as bradycardia or suicidality should be hospitalized for treatment. Conclusions and Relevance:Globally, eating disorders affect 2% to 5% of individuals during their lifetime and are more common in females than males. In addition to weight changes, eating disorders may cause electrolyte abnormalities, bradycardia, disturbances in reproductive hormones, and decreased bone density, and are associated with increased risk of depression, anxiety, and suicide attempts. First-line treatments of eating disorders include nutritional support, psychotherapy, and pharmacotherapy.

INTRODUCTION:Several practice guidelines exist from professional organizations in the United States to support the assessment and management of eating disorders in children and adolescents. This manuscript synthesizes the key areas of overlap from these guidelines and provides directions for future research and alignment to improve care. RECOMMENDATIONS:Consistent screening for eating disorders in primary care is recommended to ensure early identification and referral to treatment. Outpatient treatment supported by families, including family based treatment, is the first line of care recommended by guidelines. Multidisciplinary treatment teams benefit patients in covering the variety of aspects of health that eating disorders impact, including mental health, nutritional health, and physical health. Patients may require hospitalization under certain medical criteria such as bradycardia or specific lab abnormalities. CONCLUSIONS:Guidelines show consensus on the importance of early identification and treatment access, involvement of family in treatment, and the use of a multidisciplinary treatment team. However, future work is needed to guide care of Avoidant/Restrictive Food Intake Disorder (ARFID), as well as the impact of weight inclusive care and the development of validated screening tools for children and adolescents for all eating disorders.

This report provides an overview on the relative lack of eating disorders training for healthcare students and providers, the impact of these gaps, and efforts underway to enhance eating disorders education. The training and knowledge gap in eating disorders is well-established for healthcare students and providers across disciplines, and negatively impacts attitudes about eating disorders, timely diagnosis, and referral. There is strong evidence of enthusiasm for more education on this topic. Several educational resources have been developed in the last decade, only some of which have been formally evaluated. Programmatic evaluation studies suggest even limited amounts of enhanced training, including brief, asynchronous, digital resources, can improve knowledge, confidence, and attitudes about eating disorders for trainees and experienced clinicians. More research is needed to assess educational impact on clinician behavior.

Eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and avoidant/restrictive food intake disorder (ARFID), are serious psychiatric illnesses treated primarily with psychotherapy focusing on eating behaviors. Pharmacotherapy is recommended when psychotherapy is insufficient or unavailable, or when medication treatment is preferred by the patient. Differing psychotherapeutic approaches are used depending on the illness. Family-based treatment has demonstrated utility in adolescents with AN and BN. Eating disorder-focused cognitive behavioral therapy (CBT) is consistently helpful in individuals with BN and BED. Adaptations of CBT appear promising for the treatment of ARFID. Only two medications have received FDA approval for the treatment of eating disorders – fluoxetine for BN and lisdexamfetamine for BED. Existing treatments are not universally effective, and relapse rates are still elevated among those who do respond to treatment. Psychotherapies such as the habit-interrupting REACH ​+ ​for AN and biological treatments including neuromodulation techniques that target specific brain regions implicated in the development and maintenance of eating disorders warrant further study.

INTRODUCTION:Compulsive exercise is a transdiagnostic feature of eating disorders which adversely affects aspects of recovery, such as length of hospitalisation, risk of a chronic outcome, and risk of relapse. CompuLsive Exercise Activity TheraPy (LEAP) aims to reduce compulsive exercise through a cognitive behavioural approach. This study aims to investigate the effect of LEAP on compulsive exercise behaviour using subscales of the Compulsive Exercise Test (CET), a measure of exercise in individuals with eating disorders. Predictive validity of the CET's subscales and its ability to predict eating psychopathology are investigated.METHOD:This study used data from a randomized controlled trial of LEAP (1). Linear mixed modelling was used to investigate the effect of LEAP on compulsive exercise behaviour, and the predictive ability of CET subscales on various outcomes. The CET was compared to other exercise measures to assess its superiority in predicting eating psychopathology.RESULTS:LEAP was superior in reducing the scores of the CET's Avoidance and Rule Driven Behaviour and Exercise Rigidity subscales. All subscales made a contribution to the respective models. The CET was superior to other measures in predicting eating pathology.CONCLUSION:The results lend credibility to LEAP's ability to reduce core parts of compulsive exercise. The CET has been found to target important aspects of compulsive exercise behaviour, and has was superior to other exercise measures in predicting eating psychopathology.

Other specified feeding and eating disorders (OSFED) is a diagnostic category in DSM-5 describing individuals with clinically significant eating behavioral disturbances that do not meet criteria for full-threshold eating disorder diagnoses. OSFED includes five example subgroups: atypical anorexia nervosa, sub-threshold bulimia nervosa, sub-threshold binge-eating disorder, purging disorder, and night eating syndrome. A recent review of OSFED by Dang et al. aims to examine differences between OSFED and full-threshold eating disorders as well as between OSFED and healthy populations but is limited by the lack of clear definitions of OSFED subtypes and methodological differences across studies. Clearer diagnostic definitions for OSFED subtypes are needed. Consideration should also be given to indicators of lifetime history of full-threshold conditions, diagnostic drift, and remission criteria as OSFED categories undergo further study.