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.

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:The COVID-19 pandemic was associated with a worldwide increase in hospitalizations among adolescents with anorexia nervosa (AN). The factors contributing to this remain unclear and may include alterations in healthcare systems and/or clinical factors. This study examined the possibility that pandemic-related stress led to more severe illness in adolescents with AN. METHODS:Participants included adolescents with AN and healthy controls (HC) enrolled in a longitudinal study between 2017 and 2022. Illness severity and response to treatment were compared between individuals enrolled pre-COVID-19 and mid-COVID-19, with HC providing an additional reference for community levels of mood, anxiety, and eating symptoms. Exposure to COVID-19-related stress was assessed systematically, and the effect on illness severity was evaluated. RESULTS:There were no significant differences in age, body mass index (BMI), or eating disorder/depression/anxiety severity between individuals who presented for evaluation of AN pre-COVID-19 (n = 60) versus mid-COVID-19 (n = 31). Illness duration was shorter in the mid-COVID-19 group (Mmid-COVID = 0.30 ± 0.35 vs. Mpre-COVID = 0.83 ± 1.07 years, t88 = 2.62, p = 0.01). Duration of restrictive eating was also shorter in the mid-COVID-19 group (Mmid-COVID = 1.4 ± 1.1 years vs. Mpre-COVID = 2.4 ± 2.1 years, t88 = 2.36, p = 0.02). Individuals with AN and HC showed similar levels of COVID-related stress, and there was little association between COVID-19-related stress and symptom severity or response to treatment. DISCUSSION:This study suggests that while the pandemic led to increased incidence and hospitalizations for AN, there may have been less impact on overall illness severity and treatment response. For some, pandemic-related circumstances might have influenced hospitalization rates more than the level of pandemic-related stress.

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.

Individuals often consume tasty, calorically dense foods in response to negative emotions, a phenomenon exemplified by notions of “stress eating” and “comfort food.” While this link between food and mood can become pathological in binge eating, the decision-making processes underlying this link are poorly understood. Here, we investigated the impact of acute increases in negative affect on when and how strongly the perceived tastiness and healthiness of foods influence food choices in healthy adults and individuals with bulimia nervosa (BN), an eating disorder characterized by cycles of over- and under-consumption of food. In a randomized crossover design, 25 women with BN and 21 healthy controls completed two sessions where they received either a neutral or negative affect induction and then completed a food choice task. Using a time-varying diffusion decision model, we assessed how negative affect influences food choice dynamics for high- and low-fat foods. In the neutral affect condition, individuals with BN considered tastiness relative to healthiness of high-fat foods sooner than healthy controls but maintained a restrictive food choice policy by reducing the weight on tastiness. After a negative affect induction, both groups showed a stronger bias towards considering tastiness before healthiness, but this bias was exaggerated in individuals with BN. This affect-induced bias for high-fat foods was associated with more frequent subjective binge episodes over three months. These results provide insights into how negative emotion influences food choices and may explain why binge eating in BN is more likely during high negative affect, while dietary restriction is more likely during low negative affect.

The brain is wired to drive behavior towards foods that are high in sugar and fat. This natural pattern is reversed in individuals with anorexia nervosa (AN), who prefer low-sugar and low-fat foods to the point of starvation and even death. Here, we aimed to understand how changes in the brain contribute to the pattern of maladaptive food-related decisions in AN. We combined decision-making tasks with computational modeling of behavior and fMRI to examine food and non food-related decisions in individuals with AN and healthy controls (HC). Results from this pre-registered study suggest that patients with AN employ a decision process that relies on sampling and evaluating evidence that is similar to that in healthy individuals, regardless of the type of decision. However, when deliberating about what to eat, while HC engage the hippocampus, individuals with AN engage the striatum in addition to the hippocampus, apparently as sources of evidence in the decision process. These findings suggest that the maladaptive reversal of preferences in AN is related to reliance on different inputs to the process that leads to choice of food, rather than a maladaptive decision process per se.

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.

Feeding and eating disorders (FEDs) are a heterogeneous grouping of disorders at the mind-body interface, with typical onset from childhood into emerging adulthood. They occur along a spectrum of disordered eating and compensatory weight management behaviors, and from low to high body weight. Psychiatric comorbidities are the norm. In contrast to other major psychiatric disorders, first-line treatments for FEDs are mainly psychological and/or nutrition-focused, with medications playing a minor adjunctive role. Patients, carers and clinicians all have identified personalization of treatment as a priority. Yet, for all FEDs, the evidence base supporting this personalization is limited. Importantly, disordered eating and related behaviors can have serious physical consequences and may put the patient's life at risk. In these cases, immediate safety and risk management considerations may at least for a period need to be prioritized over other efforts at personalization of care. This paper systematically reviews several key domains that may be relevant to the characterization of the individual patient with a FED aimed at personalization of management. These domains include symptom profile, clinical subtypes, severity, clinical staging, physical complications and consequences, antecedent and concomitant psychiatric conditions, social functioning and quality of life, neurocognition, social cognition and emotion, dysfunctional cognitive schemata, personality traits, family history, early environmental exposures, recent environmental exposures, stigma, and protective factors. Where possible, validated assessment measures for use in clinical practice are identified. The limitations of the current evidence are pointed out, and possible directions for future research are highlighted. These also include novel and emerging approaches aimed at providing more fine-grained and sophisticated ways to personalize treatment of FEDs, such as those that utilize neurobiological markers. We additionally outline remote measurement technologies designed to delineate patients' illness and recovery trajectories and facilitate development of novel intervention approaches.

Abstract Anorexia nervosa presents a clinical challenge due to the persistence of maladaptive restrictive eating behaviors, even among individuals undergoing treatment. The habit-centered hypothesis of anorexia nervosa proposes that these behaviors become entrenched due to their acquisition of habitual characteristics, rendering them cue-dependent and outcome-insensitive. This chapter explores the biological framework underlying habit formation, focusing on the transition from goal-directed to habitual behavior mediated by ventral and dorsal striatal function. The chapter introduces Relapse Prevention and Changing Habits, a habit-focused intervention for outpatients following acute treatment. Relapse Prevention and Changing Habits emphasizes cue awareness, behavioral experiments, and reward-based reinforcement to interrupt maladaptive habits and promote adaptive behavior. Alternative perspectives and criticisms are discussed, including the integration of habit-focused interventions with existing approaches. Overall, the habit-centered hypothesis provides a novel framework for understanding and targeting the persistent behaviors characteristic of anorexia nervosa, offering promise for improving long-term treatment outcomes.

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.

Lee and Chi analyze publication trends and research themes on eating disorders over the last five decades. Among the factors driving increased annual citations were publications in journals focused on neuroscience. This observation underscores a growing focus on the neurobiological basis of eating disorders. This commentary highlights a few features of this development and outlines several potentially fruitful areas for future neuroscience-based research.

OBJECTIVE:Individuals with anorexia nervosa persistently restrict their food intake while often severely underweight. This maladaptive food choice behavior and related decision-making processes have mainly been investigated in adults. It is unknown whether the same decision-making processes drive food choices in adolescents, given their more favorable treatment outcomes. This study investigated maladaptive food choice behavior in adolescents with AN and examined whether they display the same decision-making processes as adults. METHOD:Adolescents with AN (n = 42) and age-matched controls (n = 42) completed a computer-based food choice task, rating food images for healthiness and tastiness before choosing between two food items. RESULTS:Adolescents with AN chose high-fat foods less frequently than controls, with food choices more influenced by their perceived "healthiness" and less by their "tastiness" than they did among controls. Relative to controls, adolescents with AN also reported lower overall tastiness ratings and greater habit strength of restrictive eating, which was, however, not related to food choices. DISCUSSION:Adolescents with AN display the same maladaptive food choice behavior as adults, namely the persistent restriction of high-fat food choices. Their choices were more strongly influenced by the perceived healthiness of a food item, compared to the choices of controls.

ABSTRACTObjectiveAnorexia nervosa (AN) is characterized by a tendency to limit intake of food, with specific restriction of foods that are generally considered highly palatable. This observation raises questions about whether reward processing is disturbed in AN. This study examined whether adolescents with AN differ from healthy control peers (HC) in anticipatory and consummatory reward processing.MethodAdolescents with AN (n = 71) and HC (n = 41) completed the Temporal Experience of Pleasure Scale (TEPS). The TEPS Anticipatory Pleasure scale was divided into two further subscales (Food and Non‐food). Anticipatory (Food and Non‐food) and Consummatory Pleasure (Non‐food) scores were compared between adolescents with AN and HC using independent t‐tests.ResultsTEPS scores were significantly lower among adolescents with AN than HC in Anticipatory Pleasure Food (t(110) = 7.80, p < 0.001) and Non‐food (t(110) = 4.36, p < 0.001), and Consummatory Pleasure (t(110) = 2.60, p = 0.01) subscales. When controlling for BDI score, there was no significant group difference in TEPS Consummatory Pleasure scores (t(108) = 0.88, p = 0.38). Among adolescents with AN, Food Anticipatory Pleasure was significantly negatively correlated with all EDE‐Q subscales and global score (r(68) = −0.38, p = 0.002) and positively correlated with food intake at a laboratory buffet meal (r(61) = 0.53, p < 0.001).DiscussionMeasures of both anticipatory and consummatory reward were reduced among adolescents with AN with a short duration of illness. In this study, eating disorder symptoms were related to diminished reward responses in anticipation of food. Dampened anticipatory reward response may comprise a mechanism of illness in AN that should be subject to further study.

Anorexia nervosa (AN) is a severe mental illness with substantial morbidity and mortality. The central, salient disturbance in AN is restriction of food intake, leading to inappropriately low body weight. Onset of illness is most common during mid-adolescence, and approximately 1% of female individuals are affected over a lifetime, across all socioeconomic classes.1 Despite advancements in treatment for adolescents with AN, remission rates remain disappointing-less than 50% of teens typically respond to initial treatment.2 Among those who achieve remission, subsequent relapses of AN are common, as is the presence of affective disorders later in life.2.

This Viewpoint describes the importance of understanding the neurocomputational mechanisms by which individuals with anorexia nervosa assign value to food.

OBJECTIVE:Impaired insight and illness denial are common in anorexia nervosa (AN). Missing an AN diagnosis may delay treatment and negatively impact outcomes. METHOD:The current retrospective study examined the prevalence and characteristics of AN symptom non-endorsement (i.e., scoring within the normal range on the Eating Disorder Examination Questionnaire [EDE-Q] or the Eating Disorder Examination [EDE] interview) in three independent samples of hospitalised patients with AN (N1 = 154; N2 = 300; N3 = 194). A qualitative chart review of a subsample of non-endorsers (N4 = 32) extracted reports of disordered eating behaviours observed by the treatment team. RESULTS:The prevalence of non-endorsement ranged from 11% to 34% across sites. Non-endorsers were more likely to be diagnosed with AN restricting type (AN-R) and reported fewer symptoms of co-occurring psychopathology than endorsers. Groups benefitted equally from treatment. The qualitative chart review indicated that objective symptoms of AN were recorded by staff in over 90% of non-endorsers. CONCLUSIONS:Eating disorder symptom assessments using the EDE-Q or EDE may miss symptomatology in up to a third of individuals hospitalised with AN. This study highlights the potential utility of multi-modal assessment including patient interviews, collateral informants, and behavioural observation to circumvent non-endorsement.

BACKGROUND:Adolescence is a critical developmental period for the study of anorexia nervosa (AN), an illness characterized by extreme restriction of food intake. The maturation of the reward system during adolescence combined with recent neurobiological models of AN led to the hypothesis that early on in illness, restrictive food choices would be associated with activity in nucleus accumbens reward regions, rather than caudate regions identified among adults with AN. METHODS:Healthy adolescents (HC, n = 41) and adolescents with AN or atypical AN (atypAN, n = 76) completed a Food Choice Task during fMRI scanning. Selection of high-fat foods and choice-related activation in nucleus accumbens and anterior caudate regions-of-interest (ROIs) were compared between individuals with AN/atypAN and HC. Associations were examined between choice-related activation and choice preferences among the AN group. Exploratory analyses examined associations between choice-related activation and psychological assessments among the patient group. RESULTS:Adolescents with AN or atypAN selected fewer high-fat foods than HC (t = -5.92, p < .001). Counter to predictions, there were no significant group differences in choice-related activation in the ROIs. Among individuals with AN or atypAN, choice-related neural activity in the anterior caudate was significantly negatively associated with high-fat food selections in the task (r = -.32, p = .024). In exploratory analyses, choice-related anterior caudate activation was positively associated with psychological measures of illness severity among patients (p's < .05, uncorrected). CONCLUSIONS:In this large cohort of adolescents with AN/atypAN, there was no evidence of altered reward system engagement during food choice. While there was no group difference in choice-related caudate activation, the associations with choices and psychological measures continue to suggest that this neural region is implicated in illness. Longitudinal analyses will clarify whether neural variability relates to longer-term course.