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Anorexia nervosa is a potentially deadly psychiatric illness that develops predominantly in females around puberty but is increasingly being recognized as also affecting boys and men and women across the lifespan. The aim of this environmental scan is to provide an overview of best practices in anorexia nervosa treatment across the age spectrum. A triangulation approach was used. First, a detailed review of randomized controlled trials (RCTs) for anorexia nervosa published between 1980 and 2011 was conducted; second, clinical practice guidelines were consulted and reviewed; third, information about RCTs currently underway was sourced. This approach facilitated a comprehensive overview, which addressed the extant evidence base, recent advances in evidence and improvements in treatment, and future directions. The evidence base for the treatment of anorexia nervosa is advancing, albeit unevenly. Evidence points to the benefit of family-based treatment for youth. For adults no specific approach has shown superiority and, presently, a combination of renourishment and psychotherapy such as specialist supportive clinical management, cognitive behavioral therapy, or interpersonal psychotherapy is recommended. RCTs have neither sufficiently addressed the more complex treatment approaches seen in routine practice settings, such as multidisciplinary treatment or level of care, nor specifically investigated treatment in ethnically diverse populations. Methodological challenges that hinder progress in controlled research for anorexia nervosa are explained. The review highlights evidence-based and promising treatment modalities for anorexia nervosa and presents a triangulated analysis including controlled research, practice guidelines, and emerging treatments to inform and support clinical decision making.

Most studies underline the contribution of heritable factors for psychiatric disorders. However, heritability estimates depend on the population under study, diagnostic instruments, and study designs that each has its inherent assumptions, strengths, and biases. We aim to test the homogeneity in heritability estimates between two powerful, and state of the art study designs for eight psychiatric disorders. We assessed heritability based on data of Swedish siblings (N = 4 408 646 full and maternal half-siblings), and based on summary data of eight samples with measured genotypes (N = 125 533 cases and 208 215 controls). All data were based on standard diagnostic criteria. Eight psychiatric disorders were studied: (1) alcohol dependence (AD), (2) anorexia nervosa, (3) attention deficit/hyperactivity disorder (ADHD), (4) autism spectrum disorder, (5) bipolar disorder, (6) major depressive disorder, (7) obsessive-compulsive disorder (OCD), and (8) schizophrenia. Heritability estimates from sibling data varied from 0.30 for Major Depression to 0.80 for ADHD. The estimates based on the measured genotypes were lower, ranging from 0.10 for AD to 0.28 for OCD, but were significant, and correlated positively (0.19) with national sibling-based estimates. When removing OCD from the data the correlation increased to 0.50. Given the unique character of each study design, the convergent findings for these eight psychiatric conditions suggest that heritability estimates are robust across different methods. The findings also highlight large differences in genetic and environmental influences between psychiatric disorders, providing future directions for etiological psychiatric research.

Little is known about the epidemiology of bulimia nervosa outside clinical settings. We report the incidence, prevalence and outcomes of bulimia nervosa using for the first time a nationwide study design. To assess the incidence and natural course and outcomes of DSM-IV bulimia nervosa among women from the general population, women (n=2881) from the 1975-79 birth cohorts of Finnish twins were screened for lifetime eating disorders using a two-stage procedure consisting of a questionnaire screen and the Structured Clinical Interview for DSM-IV (SCID). Clinical recovery was defined as 1-year abstinence from bingeing and purging combined with a body mass index (BMI) 19 kg/m2. The lifetime prevalence of DSM-IV bulimia nervosa was 2.3%; 76% of the women suffered from its purging subtype and 24% from the non-purging subtype. The incidence rate of bulimia nervosa was 300/100000 person-years at the peak age of incidence, 16-20 years, and 150/100000 at 10-24 years. The 5-year clinical recovery rate was 55.0%. Less than a third of the cases had been detected by health-care professionals; detection did not influence outcome. After clinical recovery from bulimia nervosa, the mean levels of residual psychological symptoms gradually decreased over time but many women continued to experience significantly more body image problems and psychosomatic symptoms than never-ill women. Few women with bulimia nervosa are recognized in health-care settings. Symptoms of bulimia are relatively long-standing, and recovery is gradual. Many clinically recovered women experience residual psychological symptoms after attaining abstinence from bingeing and purging.

We internally validated previously published rates of remission, continuation and incidence of broadly defined eating disorders during pregnancy in the Norwegian Mother and Child Cohort (MoBa) at the Norwegian Institute of Public Health. A total of 77 267 pregnant women enrolled at 17 weeks gestation between 2001 and 2009 were split into a training sample (n = 41 243) from the version 2 dataset and a validation sample (n = 36 024) from the version 5 dataset who were not in the original study. Internal validation of original rate models involved fitting a calibration model to compare model parameters between the two samples and bootstrap estimates of bias in the entire version 5 dataset. Remission, continuation and incidence estimates remained stable. Pre-pregnancy prevalence estimates in the validation sample were: anorexia nervosa (AN; 0.1%), bulimia nervosa (BN; 1.0%), binge eating disorder (BED; 3.3%) and eating disorder not otherwise specified-purging disorder (EDNOS-P; 0.1%). In early pregnancy, estimates were: BN (0.2%), BED (4.8%) and EDNOS-P (<0.01%). Incident BN and EDNOS-P during pregnancy were rare. The highest rates were for full or partial remission for BN and EDNOS-P and continuation for BED. We validated previously estimated rates of remission, continuation and incidence of eating disorders during pregnancy. Eating disorders, especially BED, during pregnancy were relatively common, occurring in nearly one in every 20 women. Pregnancy was a window of remission from BN but a window of vulnerability for BED. Training to detect eating disorders by obstetricians/gynecologists and interventions to enhance pregnancy and neonatal outcomes warrant attention.

Little is known about the association of eating disorder subtypes across multiple categories of substance use in population-based samples. We examined the association between eating disorders and substance use in a large population-based sample. Female participants (n=13 297) were from the Swedish Twin Registry [Lichtenstein et al., Twin Research and Human Genetics (2006) 9, 875-882]. Substance use was examined in four defined groups - (1) anorexia nervosa (AN); (2) bulimia nervosa (BN); (3) AN and BN (ANBN); and (4) binge eating disorder (BED) as well as a referent group without eating disorder (no ED). Secondary analyses examined differences between restricting AN (RAN) and binge and/or purge AN (ANBP). In general, eating disorders were associated with greater substance use relative to the referent. The AN group had significantly increased odds for all illicit drugs. Significant differences emerged across the RAN and ANBP groups for alcohol abuse/dependence, diet pills, stimulants, and polysubstance use with greater use in the ANBP group. Across eating disorder groups, (1) the BN and ANBN groups were more likely to report alcohol abuse/dependence relative to the AN group, (2) the ANBN group was more likely to report diet pill use relative to the AN, BN and BED groups, and (3) the BN group was more likely to report diet pill use relative to the no ED, AN and BED groups. Eating disorders are associated with a range of substance use behaviors. Improved understanding of how they mutually influence risk could enhance understanding of etiology and prevention.

Recent behavioral genetic studies have emphasized the importance of investigating eating disorders at the level of individual symptoms, rather than as overall diagnoses. We examined the heritability of binge eating disorder (BED) using an item-factor analytic approach, which estimates contributions of additive genetic (A), common environmental (C), and unique environmental (E) influences on liability to BED as well as individual symptoms. Participants were 614 monozygotic and 410 dizygotic same-sex female twins from the Mid-Atlantic Twin Registry who completed a self-report measure of BED symptoms based upon DSM-IV criteria. Genetic and environmental contributions to BED liability were assessed at the diagnostic and symptom levels, using an item-factor approach. Liability to BED was moderately heritable; 45% of the variance was due to A, with smaller proportions due to C (13%), and E (42%). Additive genetic effects accounted for 29-43% of the variance in individual items, while only 8-14% was due to C. Results highlight the relevance of examining eating disorders at the symptom level, rather than focusing on aggregate diagnoses.

Few data exist examining the longer-term outcome of bulimia nervosa (BN) following treatment with cognitive behavioral therapy (CBT) and exposure with response prevention (ERP). One hundred and thirty-five women with purging BN received eight sessions of individual CBT and were then randomly assigned to either relaxation training (RELAX) or one of two ERP treatments, pre-binge (B-ERP) or pre-purge cues (P-ERP). Participants were assessed yearly following treatment and follow-up data were recorded. Eighty-one per cent of the total sample attended long-term follow-up. At 5 years, abstinence rates from binging were significantly higher for the two exposure treatments (43% and 54%) than for relaxation (27%), with no difference between the two forms of exposure. Over 5 years, the frequency of purging was lower for the exposure treatments than for relaxation training. Rates of recovery varied according to definition of recovery. Recovery continued to increase to 5 years. At 5 years, 83% no longer met DSM-III-R criteria for BN, 65% received no eating disorder diagnosis, but only 36% had been abstinent from bulimic behaviors for the past year. This study provides possible evidence of a conditioned inoculation from exposure treatment compared with relaxation training in long-term abstinence from binge eating at 5 years, and the frequency of purging over 5 years, but not for other features of BN. Differences among the groups were not found prior to 5 years. CBT is effective for BN, yet a substantial group remains unwell in the long term. Definition of recovery impacts markedly on recovery rates.

Prior research demonstrated that attention-deficit hyperactivity disorder (ADHD) is associated with binge-eating behavior, binge-eating disorder (BED), and bulimia nervosa (BN). The aim of this study was to investigate these associations in an adult twin population, and to determine the extent to which ADHD symptoms and binge-eating behavior share genetic and environmental factors. We used self-reports of current ADHD symptoms and lifetime binge-eating behavior and associated characteristics from a sample of over 18 000 adult twins aged 20-46 years, from the population-based Swedish Twin Registry. Mixed-effects logistic regression was used to examine the association between ADHD and lifetime binge-eating behavior, BED, and BN. Structural equation modeling was used in 13 773 female twins to determine the relative contribution of genetic and environmental factors to the association between ADHD symptoms and binge-eating behavior in female adult twins. ADHD symptoms were significantly associated with lifetime binge-eating behavior, BED, and BN. The heritability estimate for current ADHD symptoms was 0.42 [95% confidence interval (CI) 0.41-0.44], and for lifetime binge-eating behavior 0.65 (95% CI 0.54-0.74). The genetic correlation was estimated as 0.35 (95% CI 0.25-0.46) and the covariance between ADHD and binge-eating behavior was primarily explained by genetic factors (91%). Non-shared environmental factors explained the remaining part of the covariance. The association between adult ADHD symptoms and binge-eating behavior in females is largely explained by shared genetic risk factors.

OBJECTIVE:: To establish body mass index (BMI) norms for standard figural stimuli using a large Caucasian population-based sample. In addition, we sought to determine the effectiveness of the figural stimuli to identify individuals as obese or thin. DESIGN:: All Caucasian twins born in Virginia between 1915 and 1971 were identified by public birth record. In addition, 3347 individual twins responded to a letter published in the newsletter of the American Association of Retired Persons (AARP). All adult twins (aged 18 and over) from both of these sources and their family members were mailed a 16 page 'Health and Lifestyle' questionnaire. SUBJECTS:: BMI and silhouette data were available on 16 728 females and 11 366 males ranging in age from 18-100. MEASUREMENTS:: Self-report information on height-weight, current body size, desired body size and a discrepancy score using standard figural stimuli. RESULTS:: Gender- and age-specific norms are presented linking BMI to each of the figural stimuli. Additional norms for desired body size and discrepancy scores are also presented. Receiver operating curves (ROC) indicate that the figural stimuli are effective in classifying individuals as obese or thin. CONCLUSIONS:: With the establishment of these norms, the silhouettes used in standard body image assessment can now be linked to BMI. Differences were observed between women and men in terms of desired body size and discrepancy scores, with women preferring smaller sizes. The figural stimuli are a robust technique for classifying individuals as obese or thin. INTERNATIONAL JOURNAL OF OBESITY: (2001) 25, 1517-1524

Objective: To explore the association of eating styles with overweight and obesity in young adults, controlling for identical genetic background in monozygotic twins. Design: Prospective twin cohort study. Setting: Finland, 1991-2002. Subjects: Two-hundred and thirty-three women and 2060 men from the FinnTwin16 study, aged 16 years at baseline (T1), and ranging from 22 to 27 years at the time of the nutritional assessment (T4). Methods: Eating styles (Restrictive/overeating, health-conscious, snacking, emotional and externally induced), self-reported at T4, were contrasted with body mass indices (BMIs) at T1 and T4. Results: At T4, obesity (BMI30Kg/m2) was significantly cross-sectionally associated with restrictive eating, frequent snacks, eating in the evening, avoiding fatty foods and failure to maintain healthy eating patterns. These associations were independent of BMI at T1. Obese women self-reported more vulnerability to external eating cues and comfort eating than normal-weight women. However, in a multivariable model, only restrictive/overeating and health-conscious eating styles were significant correlates of obesity at T4, independent of gender and BMI at T1. When we controlled for genetic background restricting the analysis to the 39 female and 45 male monozygotic twin pairs discordant for obesity or overweight (BMI25Kg/m2), restrictive/overeating eating style was still statistically significantly associated with excess weight. Conclusions: The eating styles of obese young adults differ from their normal-weight counterparts: restrictive eating, overeating and fewer healthy food choices are associated with obesity. Different eating styles may partially explain weight differences in individuals with identical genetic background.