Howard Steiger

Objective: Available studies comparing clinical features in treatment‐seeking adults with avoidant/restrictive food intake disorder (ARFID) to anorexia nervosa (AN) often do not distinguish between AN‐restricting (AN‐R) and AN‐binge‐eating/purging (AN‐B/P) subtypes, rely on retrospective ARFID diagnoses, and include unequal group sizes. Across relatively balanced study groups, we compared eating disorder symptoms, concurrent psychiatric symptoms, and Big Five personality traits in treatment‐seeking adults with ARFID, AN‐R, or AN‐B/P to identify unique and shared features. Methods: Participants were adults (29 ARFID, 39 AN‐R, 45 AN‐B/P) diagnosed via semi‐structured clinical interviews at the start of outpatient treatment. Data were analyzed with general linear models. Results: On measures of shape‐/weight‐centered eating pathology and depression, individuals with ARFID scored lower than did those with AN‐R ( p s < 0.05) or AN‐B/P ( p s < 0.001). On measures of anxiety, individuals with ARFID scored lower than did those with AN‐B/P ( p < 0.001) but not AN‐R ( p = 0.075). Compared with AN groups, the ARFID group had less total emotion‐regulation difficulties ( p < 0.001). There were no group differences on Big Five personality traits ( p = 0.173), including neuroticism. Discussion: Treatment‐seeking adults with ARFID reported less shape‐/weight‐centered eating pathology, depression, anxiety, and emotion‐regulation difficulties than did individuals with AN but did not differ on endorsement of Big Five personality traits. Findings suggest that individuals with ARFID display less pronounced psychopathology on assessed domains than do those with AN and highlight potential directions for future ARFID research.

Objective: Gaining access to evidence‐informed treatment for eating disorders (EDs) is challenging, and this creates interest in the possible benefits of self‐help treatment methods. We investigated the effectiveness of receiving evidence‐informed self‐guided psychoeducation, delivered to individuals while on a waitlist for specialised ED care. Method: While waitlisted for treatment, 62 adults were randomised to one of two 4‐week conditions: (a) Weekly psychoeducation related to EDs via email (Experimental condition); or (b) No psychoeducation (Control condition). Participants completed weekly measures of ED attitudes (ED‐15), body satisfaction (Body Satisfaction Scale) and motivation to change (Readiness Ruler). Results: Participants in the experimental condition showed a greater reduction in ED‐15 scores after 4 weeks of exposure to the psychoeducational materials compared to control participants. Effect sizes were in the small‐to‐medium range, with the strongest effects observed among individuals who were engaging in binge/purge behaviours. There were no effects on body satisfaction or motivation to change. Participants reported being reasonably engaged and satisfied with the materials. Conclusions: Delivering low‐intensity self‐guided psychoeducation appears to be effective in reducing ED attitudes and preoccupations among people waitlisted for specialised ED services, especially those presenting with bulimic symptoms. However, the intervention seemed not to impact motivation for change. Trial Registration: The trial was registered retroactively at Clinicaltrials.gov (NCT07319936)

Objective: Current diagnostic nomenclature includes “atypical” eating disorders (EDs) under the term other specified feeding or eating disorder (OSFED). Previous studies suggest that individuals with OSFED have similar psychological and concurrent symptoms to individuals with “classical” EDs. Our study compared people with OSFED to those with classical EDs on indices reflecting ED pathology, concurrent psychological symptoms, personality traits, functional impairment, illness duration, and pretreatment motivation. We also compared OSFED variants characterized solely by restrictive eating behaviors (OSFED‐R) to variants in which binge‐eating and/or purging symptoms predominated (OSFED‐B/P). Methods: Participants were 836 treatment‐seeking adults (185 AN‐Restricting type [AN‐R], 165 AN Binge‐eating/purging type [AN‐B/P], 276 BN, 104 OSFED‐R, and 106 OSFED‐B/P) starting outpatient ED treatment. Data were analyzed with generalized linear models. Results: Overall, findings in individuals with OSFED were comparable to those in people with a “classical” ED diagnosis on self‐reported measures of concurrent psychological symptoms, personality traits, functional impairment, illness duration, and treatment motivation. However, relative to people with AN‐R, individuals with OSFED‐R reported higher levels of psychological ED symptoms ( p < 0.001). The OSFED‐B/P group had even more ED‐related psychological symptoms than did the OSFED‐R group ( p = 0.02), but did not differ from the AN‐B/P and BN groups on any of our indices. Discussion: Findings extend previous research, underscoring the point that OSFED syndromes have serious clinical implications, comparable to those associated with full‐threshold AN and BN. Results also highlight the relevance of examining heterogeneity within the OSFED category in function of a restrictive vs. binge/purge distinction.

Background: Phenomenology in anorexia nervosa (AN) appears to be subject to epigenetic regulation via DNA methylation. The micronutrients B₁₂ and betaine contribute directly to DNA methylation and have been shown to be abnormally elevated in blood samples from people with AN. Methods: We measured plasma B₁₂ and betaine levels, as well as leukocyte DNA methylation levels, among women with active AN (AN-active group), those in 1-year remission from AN (AN-remitted group), and those who had never experienced an eating disorder (NED group). We compared the groups on micronutrient levels and on the strength of association between micronutrients and methylation. Results: We included 64 women in the AN-active group, 49 in the AN-remitted group, and 49 in the NED group. Relative to those with NED (B₁₂: mean 339.6 [standard deviation (SD) 224.3] μmol/L; betaine: mean 33.74 [SD 17.10] μmol/L), participants with active AN showed high B₁₂ and betaine (B₁₂: mean 571.0 [SD 505.2] μmol/L; betaine: mean 43.73 [SD 22.50] μmol/L); AN-remitted participants had elevated B₁₂ alone (B₁₂: mean 588.2 [SD 379.9] μmol/L; betaine: mean 33.50 [SD 19.20] μmol/L). There were also group-based differences in the strength of association between B₁₂ and site-specific DNA methylation at genes regulating insulin function, glucose metabolism, cell regulation, and neurotransmitter function. These associations between B₁₂ and methylation levels were generally stronger among those without an ED than among those with either active or remitted AN. Limitations: The extent to which plasma nutrient levels provide a meaningful proxy to cellular processes affecting DNA methylation is uncertain and the sample size limits the stability of results. We included only biological females in this investigation. Conclusion: Elevated B₁₂ levels in AN resemble elevations reported among people with autoimmune, neoplastic, or other disorders. Such elevations imply that plasma B₁₂ levels may misrepresent nutritional status among people with AN. Observed associations between levels of B₁₂ and methylation at certain gene regions have ambiguous importance, but may indicate an influence of nutritional status on epigenetic mechanisms or may be the coincidence of separate processes that independently affect levels of micronutrients and DNA methylation.

Objective: To determine the extent to which anorexia nervosa is associated with premature mortality.Method: We carried out a matched cohort study of 7332 male and female patients with anorexia nervosa and 73,215 patient controls who were admitted between 1989 and 2023 in hospital centers of Quebec, Canada. We tracked the patients longitudinally over time to identify premature deaths before age 75 years and determined the cause of death. We used stratified Cox regression models adjusted for patient characteristics to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between anorexia nervosa and premature mortality.Results: Overall, 186 (2.5%) patients with anorexia nervosa and 615 (0.8%) matched controls died before age 75 years. Compared with no anorexia, anorexia nervosa was associated with 3.02 times the risk of premature mortality among females (95% CI 2.50–3.65) and 2.23 times the risk among males (95% CI 1.35–3.70). Patients with a first anorexia nervosa admission between age 20 and 29 years were most at risk of premature mortality (HR 8.00, 95% CI 4.30–14.88), as were patients hospitalized ≥ 3 times for anorexia nervosa (HR 4.72, 95% CI 3.25–6.84). Anorexia nervosa was associated with premature mortality due to metabolic and other endocrine disorders, suicide, and a range of other causes.Discussion: Anorexia nervosa is associated with an elevated risk of premature mortality from metabolic disorders, suicide, and other causes. Patients who are female, hospitalized as young adults, or have repeated admissions for anorexia nervosa are most at risk.

Objective: Having both an eating disorder (ED) and borderline personality disorder (BPD) is associated with heightened clinical complexity, high levels of distress, and challenges in treatment. This study sought to qualitatively investigate the experiences of women with an ED and comorbid BPD as they undergo ED treatment, aiming to better understand factors that shape their perceptions of care.Methods: Fourteen women with both an ED and BPD in treatment at a public‐sector ED clinic were recruited to participate in an open‐ended qualitative interview about their lived treatment experiences.Results: Five overarching themes (with seven subthemes) emerged from the qualitative analysis: (1) Difficulties with emotions as a key factor underlying both ED and BPD; (2) Perceptions of BPD in ED maintenance and treatment; (3) Relational dynamics in treatment; (4) Treatment is “never enough”; and (5) The importance of treating the ED and BPD together.Discussion: This study highlights the lived experiences of women with both an ED and BPD. Patients expressed the need for ED treatment to target emotion dysregulation, interpersonal difficulties, and their attachment to their therapists and to treatment. This study provides insights into the experiences of patients with BPD of ED treatment that may help guide the approach to care in such individuals.

Objective: The Eating Disorder Examination Questionnaire (EDE‐Q) is a widely‐used measure of eating‐disorder symptoms. However, inconsistent replication of the subscale structure raises concern about validity. To provide a rigorous test of the EDE‐Q's dimensionality and item‐quality, we applied modern and classical test theory approaches to data obtained from a large, transdiagnostic sample of people with clinical eating disorders.Method: We analyzed data from 1197 individuals (M _age = 27.9 years, SD = 10.08, 95% female) with various eating disorders, who had been assessed for treatment at a specialized program. Exploratory analyses (including Parallel Analyses), Confirmatory Factor Analyses (CFA) and graded‐response Item Response Theory (IRT) analyses, were conducted with Mplus.Results: Factor analyses showed inappropriate fit to the original EDE‐Q subscales, as well as for alternative 1,2,3, and 4‐factor solutions. Parallel analyses suggested a one‐dimensional structure as best fit. IRT analyses showed substantial variability in EDE‐Q‐item quality and indicated that five items (fear of weight gain, feeling fat, desire to lose weight, importance of weight, importance of shape) were most pertinent to determining severity. The construct validity of the five EDE‐Q items was confirmed by a CFA, showing excellent fit.Discussion: Our results suggest that EDE‐Q scores are best interpreted as spanning a one‐factor continuum. IRT results suggest that some items are more pertinent than others for determining eating‐disorder severity. Results could be useful for establishing short EDE‐Q versions, such as a five‐item version, which, in turn, would be helpful for measurement‐based clinical practice and for data‐collection in epidemiological and experimental studies.

Objective: Previous studies have indicated that virtual treatments for eating disorders (EDs) are roughly as effective as are in‐person treatments; the present nonrandomized study aimed to expand on the current body of evidence by comparing outcomes from a virtual day treatment program with those of an in‐person program in an adult ED sample.Method: Participants were 109 patients who completed at least 60% of day treatment sessions (n = 55 in‐person and n = 54 virtual). Outcome measures included ED and comorbid symptoms, and motivation.Results: Linear mixed models showed that global EDE‐Q scores decreased during treatment (AIC = 376.396, F = 10.94, p = 0.002), irrespective of treatment modality (p = 0.186). BMI significantly increased over time (AIC = 389.029, F = 27.97, p < 0.001), with no effect of treatment modality (p = 0.779).Discussion: Our findings suggest that the virtual delivery of day treatments produces comparable outcomes to those obtained using in‐person formats, and that virtual formats may represent a pragmatic treatment option, especially in situations in which access to in‐person care is limited.