Suzanne H. W. Mares

Objective: Alexithymia is implicated in both development and maintenance of Anorexia Nervosa (AN). It is unclear what defines alexithymia in AN. In this study, emotion processing related to alexithymia was examined. Method: 40 patients with AN, 43 recovered (RC) patients and 35 matched healthy controls (HC) filled out questionnaires on eating disorder pathology (EDE‐Q), depression (CES‐D), alexithymia (TAS‐20), and emotion regulation (DERS). BMI was obtained. Behavioural (naming emotions, valence and intensity ratings) and physiological responses (heart rate and skin conductance) to emotional stimuli were assessed. Data were analysed for group differences, and controlled for effects of depression. Results: Although high levels of negative affect, alexithymia and emotion regulation problems were found in self‐report questionnaires, the AN group was able to identify and name simple explicit emotions, and showed only subtle signs of reduced physiological responsiveness when viewing the emotion pictures. The RC group only showed differences to the healthy control group in self‐assessed alexithymia. Conclusions: The present results give more evidence of alexithymia as a state than a trait feature in AN. Longitudinal studies are advised to gain more insight into how eating disorder behaviours versus alexithymia and emotion regulation change during the recovery process of AN.

Objective: To evaluate moderators and predictors of response to cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) for binge‐eating disorder (BED). Method: Moderators/predictors of treatment outcome, central to CBT and to DBT treatment, were chosen from an aggregated dataset of two clinical outcome studies with non‐random allocation to treatment groups ( N = 203). Both studies compared DBT‐BED ( n = 71) to a more intensive outpatient CBT program (CBT+, n = 132) in individuals with BED. Generalized linear models examined moderators and predictors of objective binge‐eating (OBE) frequency at end of treatment (EOT) and six‐month follow up (FU). Results: Baseline shape/weight overvaluation, shape concerns and low self‐esteem significantly predicted and moderated reductions in OBE frequency at EOT whereas difficulty in identifying feelings predicted and moderated outcome at FU. Emotional eating predicted outcome at FU (medium effect) and moderated outcome at EOT (large effect). Depression levels predicted, but not moderated, treatment outcome at both EOT and FU. For shape/weight overvaluation, shape concerns and low self‐esteem, low levels were related to fewer reductions in outcome in DBT‐BED than in CBT+. Individuals with the highest levels of emotional eating and difficulty identifying feelings showed more decrease in OBE episodes with DBT‐BED than with CBT+ at EOT and FU respectively. Discussion: Findings suggest that BED treatment outcomes could be enhanced by matching individuals with certain symptom presentations to treatment overall, and to DBT‐BED or CBT+ specifically. DBT‐BED may be a promising alternative to CBT+ for those with more severe psychopathology.

Objective: Major depressive disorder (MDD) is a frequent comorbidity in anorexia nervosa (AN). This review aimed to evaluate evidence on the effectiveness of pharmacological treatments for MDD in underweight individuals. Method: A systematic review was conducted using PubMed, Medline, PsycINFO, and Web of Science through March 2025. Nineteen studies with 477 underweight patients were included, involving pharmacological treatment of depressed underweight young adults. Study designs ranged from randomised controlled trials (RCTs) to open‐label trials and case reports, with quality assessments performed. Most studies focused on patients with AN; a few included underweight individuals without eating disorders. Results: No RCTs specifically examined antidepressant treatment for MDD in AN. Most studies prioritised weight restoration and eating disorder symptoms over depressive outcomes. Some case reports indicated potential benefits of medications such as mirtazapine and ketamine. However, evidence was mixed and generally low in quality. Overall, it shows insufficient evidence for the effectiveness of pharmacological treatments in underweight individuals. There is insufficient data to determine whether being underweight affects antidepressant efficacy. Conclusions: Evidence on pharmacological treatment of MDD in underweight individuals, particularly those with AN, is scarce and inconclusive. Well‐designed RCTs are needed to assess the efficacy and safety of antidepressants in this population.

Background: Eating disorders (EDs), such as (atypical) Anorexia (AN) and Bulimia Nervosa (BN), are difficult to treat, causing socioeconomic impediments. Although enhanced cognitive behavioral therapy (CBT-E) is widely considered clinically effective, it may not be the most beneficial treatment for (atypical) AN and BN patients who do not show a rapid response after the first 4 weeks (8 sessions) of a CBT-E treatment. Alternatively, group schema therapy (GST) may be a valuable treatment for this ED population. Even though GST for EDs has yielded promising preliminary findings, the current body of evidence requires expansion. On top of that, data on cost-effectiveness is lacking. In light of these gaps, we aim to describe a protocol to examine whether GST is more (1) clinically effective and (2) cost-effective than CBT-E for (atypical) AN and BN patients, who do not show a rapid response after the first 4 weeks of treatment. Additionally, we will conduct (3) process evaluations for both treatments. Methods: Using a multicenter RCT design, 232 Dutch (atypical) AN and BN patients with a CBT-E referral will be recruited from five treatment centers. Clinical effectiveness and cost-effectiveness will be measured before treatment, directly after treatment, at 6 and at 12 months follow-up. In order to rate process evaluation, patient experiences and the degree to which treatments are implemented according to protocol will be measured. In order to assess the quality of life and the achievement of personalized goals, interviews will be conducted at the end of treatment. Data will be analyzed, using a regression-based approach to mixed modelling, multivariate sensitivity analyses and coding trees for qualitative data. We hypothesize GST to be superior to CBT-E in terms of clinical effectiveness and cost-effectiveness for patients who do not show a rapid response to the first 4 weeks of a CBT-E treatment. Discussion: To our knowledge, this is the first study protocol describing a multicenter RCT to explore the three aforementioned objectives. Related risks in performing the study protocol have been outlined. The expected findings may serve as a guide for healthcare stakeholders to optimize ED care trajectories. Trial registration: clinicaltrials.gov (NCT05812950).