Publications by authors named "Angela S Guarda"

46 Publications

Brain imaging of cannabinoid type I (CB ) receptors in women with cannabis use disorder and male and female healthy controls.

Addict Biol 2021 May 24:e13061. Epub 2021 May 24.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Cannabis effects are predominantly mediated by pharmacological actions on cannabinoid type 1 (CB ) receptors. Prior positron emission tomography (PET) studies in individuals who use cannabis included almost exclusively males. PET studies in females are needed because there are sex differences in cannabis effects, progression to cannabis use disorder (CUD), and withdrawal symptom severity. Females with CUD (N = 10) completed two double-blind cannabis smoking sessions (Session 1: placebo; Session 2: active), and acute cannabis effects were assessed. After Session 2, participants underwent 3 days of monitored cannabis abstinence; mood, craving, and withdrawal symptoms were assessed and a PET scan (radiotracer: [ C]OMAR) followed. [ C]OMAR Distribution volume (V ) from these participants was compared with V of age/BMI-similar female non-users of cannabis ("healthy controls"; N = 10). V was also compared between female and male healthy controls (N = 7). Females with CUD displayed significantly lower V than female healthy controls in specific brain regions (hippocampus, amygdala, cingulate, and insula). Amygdala V was negatively correlated with mood changes (anger/hostility) during abstinence, but V was not correlated with other withdrawal symptoms or cannabis effects. Among healthy controls, females had significantly higher V than males in all brain regions examined. Chronic cannabis use appears to foster downregulation of CB receptors in women, as observed previously in men, and there are inherent sex differences in CB availability. Future studies should elucidate the time course of CB downregulation among females who use cannabis and examine the relation between CB availability and cannabis effects among other populations (e.g., infrequent users; medicinal users).
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http://dx.doi.org/10.1111/adb.13061DOI Listing
May 2021

Change in normative eating self-efficacy is associated with six-month weight restoration following inpatient treatment for anorexia nervosa.

Eat Behav 2021 May 8;42:101518. Epub 2021 May 8.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States of America.

Anorexia nervosa (AN) is a disorder characterized by rigid and restrictive eating behaviors, resulting in significantly low body weight. While specialized behavioral intensive treatment programs can reliably support individuals with AN to normalize eating and weight control behaviors and achieve weight restoration, prognostic factors predicting relapse following treatment are unclear. We examined whether changes in (i) normative eating self-efficacy, (ii) body image self-efficacy, (iii) drive for thinness, and (iv) body dissatisfaction from inpatient admission to six-month follow-up were associated with weight restoration status at program discharge and at six-month follow-up. The sample comprised 146 participants with AN admitted to a meal-based inpatient-partial hospitalization program. Participants completed questionnaires at inpatient admission and six months following program discharge. Additionally, at follow-up, participants reported the frequency of engaging in normalized eating behaviors since discharge (e.g. eating with others and preparing a balanced meal). The majority (73.3%) of participants attained a BMI > 19 at discharge and 59.6% were weight restored at six-month follow-up. Change in normative eating self-efficacy was significantly associated with weight restoration at follow-up, whereas change in body image self-efficacy, drive for thinness, and body dissatisfaction were not. For each one unit increase in normative eating self-efficacy, patients were 4.65 times more likely to be weight restored at follow-up (p = .002). Additionally, individuals reporting a higher frequency of normalized eating behaviors at follow-up were more likely to be weight restored. Normative eating self-efficacy and normalized eating behaviors may represent vital treatment targets for relapse prevention interventions for this high-risk population.
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http://dx.doi.org/10.1016/j.eatbeh.2021.101518DOI Listing
May 2021

Gastrointestinal symptomatology, diagnosis, and treatment history in patients with underweight avoidant/restrictive food intake disorder and anorexia nervosa: Impact on weight restoration in a meal-based behavioral treatment program.

Int J Eat Disord 2021 Jun 11;54(6):1055-1062. Epub 2021 May 11.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.

Objective: Gastrointestinal (GI) concerns are often presumed to complicate nutritional rehabilitation for restrictive eating disorders, yet their relationship to weight restoration outcomes is unclear. This retrospective chart review examined GI history and weight-related discharge outcomes in primarily adult, underweight inpatients with anorexia nervosa (AN, N = 107) or avoidant/restrictive food intake disorder (ARFID, N = 22) treated in a meal-based, behavioral eating disorder program.

Method: Lifetime GI symptomatology, diagnoses, diagnostic tests, and procedures were abstracted from medical records. Generalized linear models examined associations of GI diagnoses, tests, and procedures with discharge BMI and rate of weight gain.

Results: Ninety-nine percent of patients reported GI symptomatology and 83% had one or more GI diagnoses; with constipation and GERD most common. GI diagnoses (p <.01) and testing (p <.001) were more common in ARFID than AN. Average inpatient weight gain (1.59 kg/week), and discharge BMI (18.5 kg/m ), did not differ by group. Slower weight gain in patients with (1.3 kg/week), versus without (1.7 kg/week), history of tube feeding (p = .02), accounted for a main effect of GI procedures on inpatient rate of gain (p = .01).

Discussion: Despite ubiquitous GI symptomatology, meal-based weight restoration achieved average weekly weight gain above recommended APA guidelines for hospitalized patients with an eating disorder. History of tube feeding was associated with slower mean weight gain, which remained, however, within recommended APA guidelines.
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http://dx.doi.org/10.1002/eat.23535DOI Listing
June 2021

How Should Compassion Be Expressed as a Primary Clinical and Ethical Value in Anorexia Nervosa Intervention?

AMA J Ethics 2021 04 1;23(4):E298-304. Epub 2021 Apr 1.

Stephen and Jean Robinson Associate Professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine and director of the Eating Disorders Program at Johns Hopkins Hospital in Baltimore, Maryland.

Use of force in the care of patients with severe anorexia nervosa is controversial but can be justified when the disorder becomes life-threatening. This commentary examines the role of force in compassionate care of an adolescent patient hospitalized with extreme anorexia nervosa and suggests strategies for reaching consensus, minimizing harm, and maximizing the chance of a therapeutic outcome when forced intervention is a compassionate thing to do.
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http://dx.doi.org/10.1001/amajethics.2021.298DOI Listing
April 2021

Discharge Body Mass Index, Not Illness Chronicity, Predicts 6-Month Weight Outcome in Patients Hospitalized With Anorexia Nervosa.

Front Psychiatry 2021 25;12:641861. Epub 2021 Feb 25.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

Proposed treatments for severe and enduring anorexia nervosa (SE-AN) focus on quality of life, and psychological and social functioning. By de-emphasizing weight restoration as a priority, however, premature diagnosis of SE-AN may reduce potential for recovery. The present study assessed the effect of weight restoration, illness duration, and severity on treatment outcome 6 months after discharge from an intensive, meal-based behavioral treatment program. Participants included hospitalized adult women ( = 191) with AN or underweight other specified feeding and eating disorder (OSFED). Participants were characterized as short-term (ill <7 years; = 74) or long-term ill (ill ≥ 7 years; = 117). Compared with short-term ill, long-term ill patients were older, had lower lifetime body mass index (BMI), more prior admissions, and exhibited greater depression and neuroticism. Long-term vs. short-term ill patients gained weight at the same rate (~2 kg/wk) and were equally likely to be weight restored by discharge (>75% reached BMI ≥ 19 kg/m in both groups). At 6-month follow-up ( = 99), both groups had equivalent self-reported BMI, and depression, drive for thinness, body dissatisfaction, and bulimia scores. The only predictor of BMI ≥ 19 kg/m at follow-up was discharge BMI. The likelihood of a BMI ≥ 19 kg/m at follow-up was 5-fold higher for those with discharge BMI ≥ 19 kg/m. Few studies of long-term ill inpatients with AN have examined the impact of full weight restoration on short-term outcomes. This study supports the therapeutically optimistic stance that, regardless of illness duration, hospitalized patients with AN benefit from gaining weight to a BMI ≥ 19 kg/m.
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http://dx.doi.org/10.3389/fpsyt.2021.641861DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946839PMC
February 2021

Acceptability and tolerability of a meal-based, rapid refeeding, behavioral weight restoration protocol for anorexia nervosa.

Int J Eat Disord 2020 12 7;53(12):2032-2037. Epub 2020 Oct 7.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Objective: Safe, tolerable, effective approaches to weight restoration are needed for adults with anorexia nervosa (AN). We examined weight outcomes and patient satisfaction with an integrated, inpatient-partial hospitalization, meal-based behavioral program that rapidly weight restores a majority of patients.

Method: Consecutively discharged inpatients (N = 149) treated on weight gain protocol completed an anonymous questionnaire assessing treatment satisfaction at inpatient discharge. Responders (107/149) rated their satisfaction with program components, feeling included in treatment, and likelihood of returning, or recommending the program to others. Clinical and demographic data were abstracted by chart review on all cases.

Results: Over 70% of adult patients met BMI≥19 kg/m by program discharge. Mean inpatient rate of gain was 1.85 kg/week (SD = 0.89). A majority (83.2%) would recommend the program to others and 71.4% endorsed a willingness to return if needed. The behavioral treatment focus was rated highly by 82.9% of respondents and was the strongest predictor of likelihood of referring others.

Discussion: Results indicate a behaviorally focused, integrated, meal-based specialty program for eating disorders that includes rapid weight gain is acceptable to most participants. Data have implications for quality care, outcome reporting, and cost-effectiveness of inpatient behavioral weight restoration programs for individuals with AN.
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http://dx.doi.org/10.1002/eat.23386DOI Listing
December 2020

A modified inpatient eating disorders treatment protocol for postbariatric surgery patients: patient characteristics and treatment response.

Surg Obes Relat Dis 2019 Sep 10;15(9):1612-1619. Epub 2019 Jul 10.

Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, Maryland.

Background: Bariatric surgery is currently the most effective treatment for obesity. However, outcomes vary and disordered eating may persist or emerge postsurgically. Severe postsurgical eating disorders may require inpatient treatment, and guidelines for the modification of inpatient nutritional treatment protocols for this population are lacking.

Objectives: This paper describes a modified inpatient nutritional protocol for postsurgical patients with eating disorders treated on a behavioral eating disorders unit, and reports patient characteristics and treatment response.

Settings: This research was conducted at a university hospital.

Methods: Cases (n = 19) comprised 2% of all eating disorder admissions; 5 were underweight and required weight restoration. Clinical data collected via chart review included disordered eating behaviors, medical and psychiatric co-morbidity, and treatment course.

Results: All cases were status post Roux-en-Y gastric bypass (median 5 yr postsurgery). Onset of disordered eating preceded surgery in the majority, and intentional vomiting was the most commonly reported postsurgical disordered eating behavior. The sample was notable for a high level of psychiatric and medical co-morbidity. Patients responded well to the modified treatment protocols, with a majority of patients on the weight gain (60%) and weight maintenance (78%) post-bariatric surgery protocols discharged for clinical improvement.

Conclusions: Postsurgical bariatric patients with eating disorders can be successfully treated on a specialized eating disorders unit. Modification of inpatient eating disorder protocols for those who have undergone bariatric surgery is necessary to address the different physiologic needs of this patient population while providing them with effective psychiatric care.
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http://dx.doi.org/10.1016/j.soard.2019.06.042DOI Listing
September 2019

Hospital course of underweight youth with ARFID treated with a meal-based behavioral protocol in an inpatient-partial hospitalization program for eating disorders.

Int J Eat Disord 2019 04 19;52(4):428-434. Epub 2019 Feb 19.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Objective: Information on nutritional rehabilitation for underweight patients with avoidant/restrictive food intake disorder (ARFID) is scarce. This study characterized hospitalized youth with ARFID treated in an inpatient (IP)-partial hospitalization behavioral eating disorders (EDs) program employing an exclusively meal-based rapid refeeding protocol and compared weight restoration outcomes to those of patients with anorexia nervosa (AN).

Method: Data from retrospective chart review of consecutive underweight admissions (N = 275; age 11-26 years) with ARFID (n = 27) were compared to those with AN (n = 248) on clinical features, reason for discharge, and weight restoration variables. For patients with ARFID, presenting phenomenology was further characterized by detailed chart review.

Results: At admission, 53% of patients with ARFID were vomiting regularly. The predominant ARFID subtype was ARFID-aversive, with close to a third being mixed subtype. Gastrointestinal (GI) symptomatology (81.5%) was the most commonly endorsed reason for restriction. A third had undergone unsuccessful parenteral or enteral tube feeding. Patients with ARFID were more likely male, had higher admission BMI, and slower IP weight gain (1.36 kg /week vs 1.92) compared to patients with AN. Fewer patients with ARFID transitioned to the partial hospitalization program, although the proportion discharged for clinical improvement did not differ and both groups had a mean program discharge BMI >18.5.

Discussion: GI symptoms appear a common contributor to restrictive eating amongst hospitalized youth with ARFID. Despite a slightly lower rate of IP weight gain, clinical improvement and weight restoration at discharge were similar for patients with ARFID compared to AN.
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http://dx.doi.org/10.1002/eat.23049DOI Listing
April 2019

Olanzapine Versus Placebo in Adult Outpatients With Anorexia Nervosa: A Randomized Clinical Trial.

Am J Psychiatry 2019 06 18;176(6):449-456. Epub 2019 Jan 18.

From the Department of Psychiatry, Columbia University Irving Medical Center, New York (Attia, Steinglass, Walsh, Wang); the Department of Biostatistics, Mailman School of Public Health, Columbia University, New York (Wang, Wu); the Eating Disorders Research Program, New York State Psychiatric Institute, New York (Attia, Steinglass, Walsh); the Center for Eating Disorders, Weill Cornell Medical College, New York (Attia); the Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine (Schreyer, Guarda); the Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh (Wildes, Marcus); the Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (Wildes); the Center of Excellence for Eating Disorders, University of North Carolina (Yilmaz); and the Department of Psychiatry and the Toronto Center for Addiction and Mental Health, University of Toronto (Kaplan).

Objective: This study evaluated the benefits of olanzapine compared with placebo for adult outpatients with anorexia nervosa.

Methods: This randomized double-blind placebo-controlled trial of adult outpatients with anorexia nervosa (N=152, 96% of whom were women; the sample's mean body mass index [BMI] was 16.7) was conducted at five sites in North America. Participants were randomly assigned in a 1:1 ratio to receive olanzapine or placebo and were seen weekly for 16 weeks. The primary outcome measures were rate of change in body weight and rate of change in obsessionality, assessed with the Yale-Brown Obsessive Compulsive Scale (YBOCS).

Results: Seventy-five participants were assigned to receive olanzapine and 77 to receive placebo. A statistically significant treatment-by-time interaction was observed, indicating that the increase in BMI over time was greater in the olanzapine group (0.259 [SD=0.051] compared with 0.095 [SD=0.053] per month). There was no significant difference between treatment groups in change in the YBOCS obsessions subscale score over time (-0.325 compared with -0.017 points per month) and there were no significant differences between groups in the frequency of abnormalities on blood tests assessing potential metabolic disturbances.

Conclusions: This study documented a modest therapeutic effect of olanzapine compared with placebo on weight in adult outpatients with anorexia nervosa, but no significant benefit for psychological symptoms. Nevertheless, the finding on weight is notable, as achieving change in weight is notoriously challenging in this disorder.
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http://dx.doi.org/10.1176/appi.ajp.2018.18101125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7015155PMC
June 2019

A path to defining excellence in intensive treatment for eating disorders.

Int J Eat Disord 2018 09 6;51(9):1051-1055. Epub 2018 Sep 6.

Department of Psychiatry, Columbia University Medical Center, New York, New York, U.S.A.

In the United States, the past decade has seen rapid growth in treatment centers providing specialty care to patients with eating disorders. Much of this growth has been in higher levels of care, including hospital-based and residential treatment. Despite this expansion, there remains lack of agreement regarding the most important components of care, such as staff training or specifics of treatment delivery. Additionally there is no consensus on how best to assess outcome and compare performance across programs. This leaves patients, families, public and private insurance programs, and policy makers with limited information to help facilitate treatment decisions. The present paper considers implications of these changes in the eating disorder treatment landscape and examines two ideas that, if implemented, may enhance the quality of eating disorder care. First, we explore the proposal to develop a network of centers of excellence in eating disorder treatment and the value this may have for improving overall treatment quality. This idea was discussed at an expert meeting held at SAMSHA in 2017 regarding issues important to the field following passage of the 21st Century Cures Act. Second, we consider the potential utility of a study using the Delphi method to promote expert consensus regarding clinical outcome assessments.
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http://dx.doi.org/10.1002/eat.22899DOI Listing
September 2018

Atypical purging behaviors in a patient with anorexia nervosa: consumption of raw red kidney beans as an emetic.

Eat Weight Disord 2018 Aug 4;23(4):537-539. Epub 2017 Sep 4.

Department of Psychiatry and Behavioral Sciences, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA.

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http://dx.doi.org/10.1007/s40519-017-0433-6DOI Listing
August 2018

Self-selection bias in eating disorders outcomes research: Does treatment response of underweight research participants and non-participants differ?

Int J Eat Disord 2017 05 22;50(5):602-605. Epub 2017 Feb 22.

Johns Hopkins School of Medicine, Baltimore, Maryland.

Observational treatment studies provide a valuable alternative to RCTs but are often criticized due to potential self-selection biases. Studies comparing those who do and do not participate in research on eating disorder treatment are scarce, but necessary to evaluate the impact of self-selection bias on outcomes. All consecutive underweight adult first admissions (N = 392) to an integrated inpatient (IP)-partial hospital (PH) behavioral specialty program were invited to participate in a longitudinal study of eating disorder treatment. Demographic and hospital course data were collected on participants (n = 234) and non-participants (n = 158). Participants and non-participants had similar BMI at admission, lengths of stay, and weight gain rates. Participants were less likely than non-participants to end treatment prematurely from IP and were discharged at a higher BMI; the effect size was small. Few differences in hospital course were observed between participants and non-participants. Although participants were more likely to transition to PH and were discharged at a higher BMI, completion of step-down to PH within this integrated IP-PH program rather than research participation status at admission was a better indicator of discharge BMI, which remains the strongest predictor of long-term weight-maintenance in eating disorders.
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http://dx.doi.org/10.1002/eat.22650DOI Listing
May 2017

Weight gain trajectories in hospital-based treatment of anorexia nervosa.

Int J Eat Disord 2017 Mar 10;50(3):266-274. Epub 2017 Feb 10.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Weight gain is a primary treatment goal for anorexia nervosa (AN); however little is known about heterogeneity in weight gain pattern during treatment. Preliminary evidence suggests weight gain trajectory is associated with treatment outcome. This study grouped patients using mixture modeling into weight gain trajectories, and compared predictors and treatment outcomes between trajectory groups. Women diagnosed with AN or subthreshold AN (N = 211) completed self-report measures at admission and six-months after discharge from an integrated inpatient (IP)-partial hospitalization (PH) behavioral specialty eating disorders program. Gowned weights were measured daily. Three distinct trajectories emerged: negative quadratic (Optimal), negative quadratic with fast weight gain (Fast), and positive linear with slower weight gain (Slow). The majority of patients were assigned to the Optimal group. Trajectory groups differed on admission, discharge, and follow-up variables. The Fast group emerged as most distinct. Women in this group were more than twice as likely to binge and or vomit regularly compared with the other two groups and were most likely to achieve weight restoration by discharge and to have more positive weight outcomes at short-term follow-up. There were no group differences in eating disorder behavioral frequencies at follow-up when adjusting for behavioral severity at admission. Weight gain trajectory may serve as a personalized in-treatment marker of outcome and could inform research on moderators and mediators of treatment response. Randomized controlled treatment studies, utilizing weight gain trajectories to determine group membership, may help identify subgroups of patients with differential responses to treatment interventions.
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http://dx.doi.org/10.1002/eat.22679DOI Listing
March 2017

The need for consistent outcome measures in eating disorder treatment programs: A proposal for the field.

Int J Eat Disord 2017 03 27;50(3):231-234. Epub 2017 Jan 27.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1002/eat.22665DOI Listing
March 2017

Intensive treatment for adults with anorexia nervosa: The cost of weight restoration.

Int J Eat Disord 2017 Mar 27;50(3):302-306. Epub 2017 Jan 27.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Objective: Weight restoration in anorexia nervosa (AN) is associated with lower relapse risk; however rate of weight gain and percent of patients achieving weight restoration (BMI ≥ 19 at discharge) vary among treatment programs. We compared both cost/pound of weight gained and cost of weight restoration in a hospital-based inpatient (IP)-partial hospitalization (PH) eating disorders program to estimates of these costs for residential treatment.

Method: All adult first admissions to the IP-PH program with AN (N = 314) from 2003 to 2015 were included. Cost of care was based on hospital charges, rates of weight gain, and weight restoration data. Results were compared with residential treatment costs extracted from a national insurance claims database and published weight gain data.

Results: Average charge/day in the IP-PH program was $2295 for IP and $1567 for PH, yielding an average cost/pound gained of $4089 and $7050, respectively, with 70% of patients achieving weight restoration. Based on published mean weight gain data and conservative cost/day estimates, residential treatment is associated with higher cost/pound, and both higher cost and lower likelihood of weight restoration for most patients.

Discussion: The key metrics used in this study are recommended for comparing the cost-effectiveness of intensive treatment programs for patients with AN.
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http://dx.doi.org/10.1002/eat.22668DOI Listing
March 2017

Neuroticism and clinical course of weight restoration in a meal-based, rapid-weight gain, inpatient-partial hospitalization program for eating disorders.

Eat Disord 2017 Jan-Feb;25(1):52-64. Epub 2016 Oct 24.

a Department of Psychiatry and Behavioral Sciences , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA.

We evaluated the impact of personality on weight restoration in 211 underweight (BMI ≤ 19 kg/m) females admitted to an inpatient-partial hospitalization program for eating disorders. Symptomatology and personality were assessed by questionnaires, and clinical and demographic variables were assessed by chart review. Neuroticism, a personality trait associated with reactivity to stress, was correlated with higher symptomatology, chronicity, length of stay, and income source. Contrary to our hypothesis, neuroticism was positively associated with weight restoration. Length of stay mediated this relationship such that longer length of stay in patients with high neuroticism explained their higher likelihood of weight restoration prior to program discharge. Higher neuroticism is therefore associated with better weight restoration outcomes but may also indicate greater difficulty transitioning out of intensive treatment.
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http://dx.doi.org/10.1080/10640266.2016.1241056DOI Listing
February 2017

Speaking of that: Is the term "refeeding" offensive, and should it be avoided in the eating disorders literature?

Int J Eat Disord 2016 09 16;49(9):900. Epub 2016 Aug 16.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1002/eat.22591DOI Listing
September 2016

Marketing Residential Treatment Programs for Eating Disorders: A Call for Transparency.

Psychiatr Serv 2016 06 14;67(6):664-6. Epub 2016 Mar 14.

Dr. Attia is with the Department of Psychiatry, and Ms. Blackwood and Dr. Rothman are with the Center on Medicine as a Profession, all at Columbia University Medical Center, New York City (e-mail: ). Dr. Attia is also with the Department of Psychiatry, Weill Cornell Medical College, White Plains, New York. Dr. Guarda is with the Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland. Dr. Marcus is with Western Psychiatric Institute, Pittsburgh, Pennsylvania.

Residential behavioral treatment is a growing sector of the health care industry and is used by a large proportion of adolescent and adult patients with eating disorders. These programs and the organizations that own them have developed extensive marketing strategies that target clinicians and include promotional gifts, meals, travel reimbursement, and continuing education credit. Legislation and policy changes have limited these types of activities when conducted by the pharmaceutical industry, and awareness of conflicts of interest associated with clinician-targeted advertising of drugs and devices has increased. However, similar practices by the behavioral health care industry have evolved without oversight. The authors urge clinicians to consider how marketing strategies by treatment facilities may influence their referral behaviors and call for improved transparency regarding gifts and payments from treatment facilities.
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http://dx.doi.org/10.1176/appi.ps.201500338DOI Listing
June 2016

A systematic review of approaches to refeeding in patients with anorexia nervosa.

Int J Eat Disord 2016 Mar 12;49(3):293-310. Epub 2015 Dec 12.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine.

Objective: Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings.

Methods: Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic.

Results: Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (≥1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown;

Discussion: Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings.
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http://dx.doi.org/10.1002/eat.22482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6193754PMC
March 2016

Perceived coercion in inpatients with Anorexia nervosa: Associations with illness severity and hospital course.

Int J Eat Disord 2016 Apr 18;49(4):407-12. Epub 2015 Nov 18.

Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287.

Objective: The use of coercion in the treatment for anorexia nervosa (AN) is controversial and the limited studies to date have focused on involuntary treatment. However, coercive pressure for treatment that does not include legal measures is common in voluntarily admitted patients with AN. Empirical data examining the effect of non-legal forms of coerced care on hospital outcomes are needed.

Method: Participants (N = 202) with AN, Avoidant/Restrictive Food Intake Disorder (ARFID), or subthreshold AN admitted to a hospital-based behavioral specialty program completed questionnaires assessing illness severity and perceived coercion around the admissions process. Hospital course variables included inpatient length of stay, successful transition to a step-down partial hospitalization program, and achievement of target weight prior to program discharge.

Results: Higher perceived coercion at admission was associated with increased drive for thinness and body dissatisfaction, but not with admission BMI. Perceived coercion was not related to inpatient length of stay, rate of weight gain, or achievement of target weight although it was predictive of premature drop-out prior to transition to an integrated partial hospitalization program.

Discussion: These results, from an adequately powered sample, demonstrate that perceived coercion at admission to a hospital-based behavioral treatment program was not associated with rate of inpatient weight gain or achieving weight restoration, suggesting that coercive pressure to enter treatment does not necessarily undermine formation of a therapeutic alliance or clinical progress. Future studies should examine perceived coercion and long-term outcomes, patient views on coercive pressures, and the effect of different forms of leveraged treatment.
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http://dx.doi.org/10.1002/eat.22476DOI Listing
April 2016

Pediatric loss of control eating syndrome: Association with attention-deficit/hyperactivity disorder and impulsivity.

Int J Eat Disord 2015 Sep 9;48(6):580-8. Epub 2015 Apr 9.

Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Objective: Despite data linking Attention-deficit/Hyperactivity Disorder (ADHD) and adult binge eating, there are limited data in children with loss of control (LOC) eating. We examined inhibitory control in children with LOC eating syndrome (LOC-ES) and its association with ADHD.

Method: 79 children (8-14 years) over the fifth weight percentile were recruited, irrespective of LOC eating or ADHD status. The Eating Disorder Examination for Children and the Standard Pediatric Eating Episode Interview assessed LOC-ES. ADHD diagnosis was determined by the Schedule for Affective Disorders and Schizophrenia for children and Conners-3 (Parent Report) DSM-IV Scales of Inattention and/or Hyperactivity (T score > 65). The Go/No-Go (GNG) Task and the Behavior Regulation Inventory of Executive Function (BRIEF) assessed impulse control.

Results: Odds of LOC-ES were increased 12 times for children with ADHD (adjusted odds ratio [aOR] = 12.68, 95% confidence interval [CI] = 3.11, 51.64, p < 0.001), after adjusting for BMI z scores and relevant covariates. Children had 1.17 times higher odds of reporting LOC-ES with every 5% increase in GNG Commission Rate (aOR = 1.17, CI = 1.01, 1.36, p < 0.05) and 1.25 times higher odds of reporting LOC-ES with every 5 unit T-score increase in BRIEF Inhibit Scale (aOR = 1.25, CI = 1.04, 1.50, p < 0.05).

Discussion: Children with ADHD had significantly greater odds of LOC-ES compared to children without ADHD. Children with LOC-ES had significantly greater impulse control deficits on performance-based neuropsychological assessments and on parent reports than children without LOC-ES. These findings suggest a need to investigate possible shared mechanisms such as impulse control deficits, among children with LOC-ES and ADHD.
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http://dx.doi.org/10.1002/eat.22404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607309PMC
September 2015

Anorexia nervosa as a motivated behavior: Relevance of anxiety, stress, fear and learning.

Physiol Behav 2015 Dec 3;152(Pt B):466-72. Epub 2015 Apr 3.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA. Electronic address:

The high comorbidity between anorexia nervosa (AN) and anxiety disorders is well recognized. AN is a motivated behavioral disorder in which habit formation is likely to contribute to the persistence of abnormal eating and exercise behaviors. Secondary alterations in brain circuitry underlying the reward value of food and exercise, along with disturbances in neuroendocrine hunger and satiety signaling arising from starvation and excessive exercise, are likely contributors to the maintenance of anorectic behaviors in genetically vulnerable individuals. The potential role of fear conditioning in facilitating onset of AN, or of impaired fear extinction in contributing to the high relapse rates observed following weight restoration, is of interest. Evidence from animal models of anxiety and human laboratory studies indicate that low estrogen impairs fear extinction. Low estradiol levels in AN may therefore play a role in perpetuating fear of food and fat in recently weight restored patients. Translational models including the activity based anorexia (ABA) rodent model of AN, and neuroimaging studies of fear extinction and conditioning, could help clarify the underlying molecular mechanisms and neurocircuitry involved in food avoidance behaviors in AN. Moreover, the adaptation of novel treatment interventions with efficacy in anxiety disorders may contribute to the development of new treatments for this impairing disorder.
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http://dx.doi.org/10.1016/j.physbeh.2015.04.007DOI Listing
December 2015

Refeeding and weight restoration outcomes in anorexia nervosa: Challenging current guidelines.

Int J Eat Disord 2015 Nov 27;48(7):866-73. Epub 2015 Jan 27.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Objective: Cohort study from February 2003 through May 2011 to determine weight restoration and refeeding complication outcomes for patients with anorexia nervosa (AN) treated in an integrated inpatient-partial hospital eating disorder program designed to produce rapid weight gain and weight restoration in the majority.

Method: Consecutive admissions (females and males, adolescents and adults; N = 361 patients, 461 admissions) at least 1.8 kg below target weight with AN or subthreshold variants were included. Main outcome measures were rates of hypophosphatemia, transfer to medicine, or death; rates of weight gain and percent achieving weight restoration.

Results: Hypophosphatemia was present in 7.9% of cases at admission and in 18.5% at some point during treatment. Hypophosphatemia was mild to moderate. Lower admission body mass index (BMI), but not rate of weight gain, predicted hypophosphatemia [OR = 0.65; p < .00001 (95% CI 0.57-0.76)]. Five patients (1.1%) were transferred to medicine or surgery, none because of refeeding. There were no deaths. Mean inpatient weight gain was 1.98 kg/week; mean partial hospital weight gain was 1.36 kg/week. By program discharge, 71.8% of adults reached a BMI of 19, 58.5% a BMI of 20. For adolescents, 80.4% came within 2 kg of their target weight; 76.1% came within 1 kg.

Discussion: Refeeding patients with AN using a hospital-based, behavioral protocol may be accomplished safely and more rapidly than generally recognized, weight restoring most patients by discharge. Helpful elements may include the program's integrated, step-down structure; multidisciplinary team approach emphasizing group therapy to effect behavior change; and close medical monitoring for those with BMI < 15.
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http://dx.doi.org/10.1002/eat.22390DOI Listing
November 2015

Chewing and spitting: a marker of psychopathology and behavioral severity in inpatients with an eating disorder.

Eat Behav 2015 Apr 20;17:59-61. Epub 2014 Dec 20.

The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD 21287, USA.

Chewing and spitting out food is a frequent behavior in hospitalized patients with eating disorders (ED). Personality characteristics of those who frequently chew-spit (CHSP), the amount of food consumed during CHSP episodes, associated sense of loss of control overeating (LOC), and clinical response to hospital-based treatment have not been examined and were the focus of this study. Participants (N=324) were inpatients on a behavioral ED specialty unit. A third of the sample (n=107) reported engaging in CHSP in the 8weeks prior to admission with 21% (n=69) reporting CHSP at least once per week. Those who engaged in the behavior at least weekly (CHSP+) were compared to those with less frequent or no CHSP (CHSP-) on demographic and clinical indices and on the EDI, BDI, and the NEO-FFI. Participants were also asked if their CHSP behavior involved a binge-like amount of food (≥1000kcal) or was associated with LOC. The CHSP+ group was more likely to have purging diagnoses. After controlling for purging diagnosis, CHSP+ were found to engage in more restricting, diet pill and laxative use, and excessive exercise, and endorsed greater drive for thinness, body dissatisfaction, depression, and neuroticism than CHSP-. Among all CHSP+ participants, LOC was present in 70% and a minority (n=10, 18%) endorsed recent CHSP on binge-like amounts of food. This behavior should be assessed routinely in all patients, as it appears associated with increased eating behavior severity and increased psychiatric comorbidity at hospital admission.
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http://dx.doi.org/10.1016/j.eatbeh.2014.12.012DOI Listing
April 2015

Electroconvulsive therapy in an adolescent with severe major depression and anorexia nervosa.

J Child Adolesc Psychopharmacol 2014 Mar;24(2):94-8

1 Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine , Baltimore, Maryland.

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http://dx.doi.org/10.1089/cap.2014.2422DOI Listing
March 2014

A screening tool to assess and manage behavioral risk in the postoperative bariatric surgery patient: The WATCH.

J Clin Psychol Med Settings 2013 Dec;20(4):456-63

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street. Meyer 101, Baltimore, MD, 21287, USA,

Bariatric surgery is increasingly recognized as a highly effective treatment for individuals who are severely obese. Amount of weight loss and resolution of comorbidities surpass those of nonsurgical approaches; however, suboptimal weight loss and weight regain are not uncommon. These outcomes, though not fully understood, are likely at least partially explained by failure to make long-term behavioral and/or cognitive changes. We are unaware of any established clinical tools to guide providers in assessing postoperative behaviors and identifying those who may require specialized treatment. The goal of this paper is to introduce a brief screening tool, The WATCH, to help clinicians assess and identify patients who may be at risk for poor or untoward outcomes post bariatric surgery. We first review the literature on postoperative outcomes, including weight loss, resolution of comorbidities, suboptimal outcomes, and development of problematic eating behaviors. We then provide an easily-recalled, five-item tool that assesses outcomes, and discuss patient responses that may necessitate further intervention or referral.
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http://dx.doi.org/10.1007/s10880-012-9358-4DOI Listing
December 2013

Cosmetic surgery in inpatients with eating disorders: attitudes and experience.

Body Image 2012 Jan 26;9(1):180-3. Epub 2011 Nov 26.

The Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD 21287, United States.

Body image disturbance is frequent among individuals undergoing cosmetic surgery and core to the pathology of eating disorders (ED); however, there is little research examining cosmetic surgery in ED. This study examined body image related measures, ED behaviors, and depression as predictors of attitudes toward cosmetic surgery in 129 women with ED. Patients who had undergone surgery (n=16, 12%) were compared to those who had not. Having a purging diagnosis, linking success to appearance, and making physical appearance comparisons were predictive of more favorable cosmetic surgery attitudes. All of those who had undergone surgery had purging diagnoses and, on average, were older, had higher BMIs, and were more likely to make physical appearance comparisons and know someone who had undergone surgery. In ED, acceptance and pursuit of cosmetic surgery appears to be related to social group influences more than weight and shape disturbance, media influences, or mood.
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http://dx.doi.org/10.1016/j.bodyim.2011.10.007DOI Listing
January 2012

Dietary conditions and highly palatable food access alter rat cannabinoid receptor expression and binding density.

Physiol Behav 2012 Feb 6;105(3):720-6. Epub 2011 Oct 6.

Department of Animal Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ 08901, USA.

Endogenous cannabinoid signaling, mediated predominately by CB1 receptor activation, is involved in food intake control and body weight regulation. Despite advances in determining the role of the CB1 receptor in obesity, its involvement in the driven nature of eating pathologies has received little attention. The present study examined CB1 receptor alterations as a consequence of dietary-induced binge eating in female Sprague Dawley rats. Four control groups were used to control for calorie restriction and highly palatable food variables characterizing this behavioral model. All groups were kept on their respective feeding schedules for 6-weeks and were given a uniform 33% calorie restriction (~22 h food deprivation) prior to sacrifice. Our findings indicate that regional CB1 mRNA and density were influenced by dietary conditions, but were not specific to the dietary-induced binge eating paradigm used. An increase of approximately 50% (compared with naive controls) in CB1 receptor mRNA levels in the nucleus of the solitary tract as measured by in situ hybridization was found in animals receiving continuous access to a highly palatable food (i.e., vegetable shortening with 10% sucrose). This group also had a significant increase in body weight and adiposity. An approximate 20% reduction in CB1 mRNA was observed in the cingulate cortex (areas 1 and 2) in animals exposed to an intermittent schedule of feeding, compared with groups that had ad libitum feeding schedules (i.e., continuous access and naive controls). Receptor density as measured by [(3)H]CP55,940 autoradiography, was reduced by approximately 30% in the nucleus accumbens shell region in groups receiving repeated access to the highly palatable food. Taken together, these findings indicate that dietary conditions can differentially influence CB1 receptors in forebrain and hindbrain regions.
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http://dx.doi.org/10.1016/j.physbeh.2011.09.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3621143PMC
February 2012

Reversible vision loss secondary to malnutrition in a woman with severe anorexia nervosa, purging type, and alcohol abuse.

Int J Eat Disord 2011 Apr;44(3):281-3

Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA.

Objective: To report a case of severe reversible vision loss in a woman with a 7-year history of anorexia nervosa, purging type, alcohol abuse and a severely restricted, vitamin-deficient diet.

Method: Psychiatric, ophthalmologic, and medical records were reviewed, and a literature search was performed on visual complications associated with anorexia nervosa and malnutrition.

Discussion: Ophthalmologic complications of malnutrition are rare but include both oculomotor and visual sensory disturbances. Thiamine deficiency can cause both types of disorders. Vitamin B12 and folate deficiencies are typically associated with optic neuropathy. Clinicians treating eating disorders should be aware of the potential for vitamin deficiencies and associated visual loss in patients with anorexia nervosa. This case highlights the importance of a detailed dietary history to guide vitamin rehabilitation and to minimize or reverse nutritional visual loss.
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http://dx.doi.org/10.1002/eat.20806DOI Listing
April 2011

Oral sensory and cephalic hormonal responses to fat and non-fat liquids in bulimia nervosa.

Physiol Behav 2010 Apr 4;99(5):611-7. Epub 2010 Feb 4.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.

Sensory evaluation of food involves endogenous opioid mechanisms. Bulimics typically limit their food choices to low-fat "safe foods" and intermittently lose control and binge on high-fat "risk foods". The aim of this study was to determine whether the oral sensory effects of a fat versus a non-fat milk product (i.e., traditional versus non-fat half-and-half) resulted in different subjective and hormonal responses in bulimic women (n=10) compared with healthy women (n=11). Naltrexone (50mg PO) or placebo was administered 1h before, and blood sampling began 30 min prior to and 29 min after, a 3 min portion controlled modified sham-feeding trial. Following an overnight fast, three morning trials (fat, naltrexone; fat, placebo; and non-fat, placebo) were administered in a random double-blind fashion separated by at least 3 days. Overall, there were no differences between Fat and Non-Fat trials. Hunger ratings (p<0.001) and pancreatic polypeptide levels (p<0.05) were higher for bulimics at baseline. Bulimics also had overall higher ratings for nausea (p<0.05), fatty taste (p<0.01), and fear of swallowing (p<0.005). Bulimics had approximately 40% higher total ghrelin levels at all time points (p<0.001). Hormones and glucose levels were not altered by the modified sham-feeding paradigm. Naltrexone, however, resulted in an overall increase in blood glucose and decrease in ghrelin levels in both groups (p<0.05, for both). These data suggest that bulimic women have different orosensory responses that are not influenced by opioid receptor antagonism, evident in hormonal responses, or dependent on the fat content of a similarly textured liquid.
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http://dx.doi.org/10.1016/j.physbeh.2010.01.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840197PMC
April 2010
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