Original Article Inpatient treatment has no impact on the core thoughts and perceptions in adolescents with anorexia nervosa

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1 bs_bs_banner First Impact Factor released in June 2010 and now listed in MEDLINE! Early Intervention in Psychiatry 2015; : doi: /eip Original Article Inpatient treatment has no impact on the core thoughts and perceptions in adolescents with anorexia nervosa Silvana Fennig, 1,2,3 Anat Brunstein Klomek, 1,2,4 Ben Shahar, 4 Zohar Sarel-Michnik 1 and Arie Hadas 1,2 1 Child and Adolescent Psychiatric Unit and 2 Feinberg Child Study Center, Schneider Children s Medical Center of Israel, Petach Tikva, 3 Sackler School of Medicine, Tel Aviv University, Tel Aviv, and 4 School of Psychology, The Interdisciplinary Center (IDC), Herzliya, Israel Corresponding author: Dr Silvana Fennig, Feinberg Child Study Center, Schneider Children s Medical Center of Israel, 14 Kaplan St., Petach Tikva 49202, Israel. silvanaf@clalit.org.il Received 8 December 2014; accepted 16 February 2015 Abstract Aim: Examine changes in core perceptions and thoughts during the weight restoration phase of inpatient treatment for adolescents with anorexia nervosa. Method: Forty-four adolescents with anorexia nervosa consecutively admitted ( ) to an inpatient paediatric-psychiatric unit specializing in eating disorders. The programme consisted of a complete inpatient intervention combining weight restoration by structured supervised meals with individual and group cognitive-behavioural therapy, parental training/family intervention and educational activities, followed by a half-way day-treatment weightstabilizing phase and progressive reintroduction to the community. The study focused on changes from hospital admission to discharge in patients responses to self-report questionnaires on eating disorder symptoms, depression, anxiety and suicidal ideation. Results: No significant changes in core anorexic thoughts and perceptions as Body dissatisfaction, Drive for thinness, Weight concern and Shape concern were noted. However, a reduction in the general severity of eating disorder symptoms (including Restraint and Eating concern) was observed, mainly related to the treatment structure. Levels of depression significantly decreased but remained within pathological range. We also found a concerning increase in suicidal ideation not correlated with a concomitant increase in depressive symptomatology. Conclusions: Inpatient treatment of anorexia nervosa in adolescents does not significantly modify core anorexic thoughts and perceptions. This may explain the high relapse rates. Changes in core beliefs may be crucial for recovery and prevention of relapse in anorexia nervosa at this critical age. This study may have clinical implications for the development of better treatment strategies to target the gap between disturbed thoughts and distorted perceptions the core aspects of anorexia nervosa and physical recovery during and after the weight restoration phase. Key words: adolescent, anorexia nervosa, core symptom and perception, inpatient. INTRODUCTION Anorexia nervosa (AN) remains a challenging illness to treat, and results of different types of treatment among adults and adolescents diagnosed with AN are still unclear. 1 Specifically, the role of inpatient treatment in AN continues to be debated. 2 5 With the recent increase in economic restrains and the importance of discharge weight as an outcome predictor, intensive weight restoration has become the goal of successful inpatient treatments. 3,6,7 Studies have shown that the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment predict weight maintenance after discharge Wiley Publishing Asia Pty Ltd 1

2 Core thoughts in anorexia Although behavioural weight restoration programmes are reliably helpful in the short-term management of AN, there is uncertainty about the long-term benefit of such programmes. Unfortunately, even after successful completion of structured inpatient programmes, relapse rates are high. 8,9 Recent studies 10,11 further questioned the utility of long-term hospitalizations showing the efficacy of less restrictive programmes using a day-treatment format. Other studies highlight the finding that hospitalizations for brief time periods are required for medically unstable adolescents, coupled with short family interventions, before returning them to their families and to appropriate outpatient follow-up. 12,13 An additional goal of inpatient care is to facilitate a move towards recovery and a better quality of life. Therefore, broader factors, other than weight gain alone, have to be considered. The available studies examining changes in eating disorder psychopathology within inpatient settings show conflicting results. Some studies conclude that inpatient treatment is associated with many short-term benefits such as an improvement in eating disorder symptoms and general psychopathology, 8,14 whereas others 5 found that most patients continued to present with clinical level eating disorder symptoms at discharge following inpatient care. Those authors concluded that inpatient care produces an improvement in physical health, but psychological health remains impaired. Individual factors such as motivation to change have been associated with reduced rates of relapse at the post inpatient care phase and may be important for engendering change within the hospital setting. 15 Only a few studies focused on specific changes in core symptomatology of AN. Sala et al. reported significant reductions in both body distortion and body dissatisfaction during the inpatient treatment of adult AN. 16 Roy and Meilleur s study, conducted with a small sample, indicated that adolescents experience a positive change in body image during inpatient treatment. 17 To the best of our knowledge, no study systematically examined changes in core thoughts and perceptions of adolescent AN during inpatient weight restoration. The current study was set to examine these changes. METHODS Participants The sample consisted of 44 patients aged years with a primary diagnosis of AN who were admitted consecutively to the Child and Adolescent Medical Psychiatric Unit of a major paediatric medical centre from February 2009 to October Patients were referred by family physicians or community psychiatrists or transferred from other paediatric units in the medical centre. Due to the low number of patients with AN, purging type, we did not differentiate among subtypes of AN. Treatment programme The Child and Adolescent Medical Psychiatric Unit is an open, voluntary (unlocked doors) inpatient facility 4 that specializes in the treatment of patients with body-mind pathologies (comorbid chronic illness with psychiatric disorders) and eating disorders. We admit patients from the age of 6 to 18 years (mostly adolescents). Similar to other such units worldwide, our inpatient treatment for AN is provided for specific medical, psychiatric and social indications. More specifically, our unit proved acute medical stabilization combined with a serious decline in weight despite maximally intensive community-based care. 1,18 Our comprehensive interdisciplinary intervention is divided into an initial intensive inpatient phase and a subsequent half-way-out daytreatment phase reacquainting patients with community. Prior to being enrolled in the programme, patients undergo a pre-admission assessment using motivational interviewing techniques. Those who do not consent to hospitalization in the unit (less than 5%) are referred to other psychiatric facilities with more restrictive treatment plans. Each phase of the programme has behavioural/motivational elements. A key component is weight restoration through structured group-supervised meals. During hospitalization, patients have three meals a day (breakfast, lunch, dinner) and four snacks, in accord with the guidelines of the American Dietetic Association. 19 Behavioural therapy consists of bi-weekly sessions of individual psychotherapy, which combines dynamic understanding with a cognitivebehavioural protocol focused on themes of overevaluation of shape and weight. 20 Weekly parental guidance and family-oriented therapy are provided as well. The same therapist provides both the individual and the parent/family therapy and coordinates the treatment plan. Patients also attend group therapy five times a week, which focuses on psychodrama, dance therapy, group dynamics, discussions about the treatment programme and cooking skills/nutritional group Wiley Publishing Asia Pty Ltd

3 S. Fennig et al. Patient functioning is categorized into seven levels. In the first two weeks of the programme (baseline adjustment level), patients are observed by the treating team, which assesses their condition and formulates an individual treatment plan. In general, patients are encouraged to gain 500 g of weight per week. Secondary goals are adherence to the programme and participation in family, school and social activities, as well as improvement in family communication, self-esteem, and body image, and treatment of comorbidities. Patients who achieve their weekly goals move up successively to the next level of functioning (levels A D). There are no coercive measures in the programme. Those who refuse to continue or fail to attain their weekly goal ( risk level ) are released from the programme ( suspension level ) with consideration of alternative community settings. The primary aim of the inpatient phase and the main criterion for discharge is attainment of the weight goal and normalization of eating patterns. The parameter of target weight was adopted as the optimal aim on the basis of reports of a high likelihood of rehospitalization for individuals with AN who are discharged from inpatient wards before reaching their target weight. 21,22 Study procedure Prior to patients admission, the unit director (SF) documented all clinical diagnoses according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, text revision. 23 The diagnostic information was based on clinical interviews, patient observation, parental information and medical evaluations. The purpose and procedure of the study were explained to the patients and parents. Patients were invited to participate, and written consent was obtained from the parents. The study protocol was approved by the local Institutional Review Board. At admission, demographic and historical information was obtained from the patients, including sex, age, education, race, weight, height, onset and duration of eating problems, and frequency of previous psychiatric hospitalizations. Patients weight was measured directly, and body mass index (BMI) (weight in kilograms divided by the square of the height in meters) and BMI percentiles were calculated. Patients were then asked to complete a battery of psychopathological scales. These measures were repeated at discharge from the inpatient treatment. Psychopathological scales Eating Disorder Inventory, version 2 (EDI-2) The EDI-2 24 is a self-report measure of symptoms that provides clinical information on the psychological and behavioural dimensions of eating disorders. It consists of 91 items divided into 11 subscales: Drive for thinness, Bulimia, Body dissatisfaction, Ineffectiveness, Perfectionism, Interpersonal distrust, Interceptive awareness, Maturity fears, Asceticism, Impulse regulation and Social insecurity. Responses are rated on a 6-point scale, from always to never. The EDI-2 has been widely applied internationally, including Israeli samples. 24,25 In our sample, Cronbach s alpha for the total scale was 0.87 at admission and 0.86 at discharge. Eating Disorder Examination Questionnaire (EDE-Q) The 41-item EDE-Q 26 is a self-report version of the investigator-based Eating Disorder Examination. 27 It is composed of four subscales: Weight concern, Shape concern, Eating concern and Dietary restraint. Each item is rated on a scale of 0 6; higher scores reflect greater severity or higher frequency. The subscale scores are summed to obtain a global score. The EDE-Q has been found to have good internal consistency and test retest reliability. 26,27 In our sample, Cronbach s alpha for the total scale was 0.92 at admission and 0.94 at discharge. Beck Depression Inventory, version IA The 21-item BDI-IA 28 was designed to assess cognitive, behavioural, affective and somatic components of depression. (For the present study, we omitted items on loss of libido.) Responses range from 0 ( symptoms not present ) to 3 ( symptom is severe ); the maximum total score is 63. The cutoff used was 16. The BDI-IA has been applied in over 200 studies, many with adolescent samples, 29,30 and has accumulated a considerable evidence base. In a metaanalysis, the estimated internal consistency in psychiatric samples was α = In our sample, Cronbach s alpha for the total scale was 0.88 at admission and 0.92 at discharge. Screen for Child Anxiety-Related Emotional Disorders (SCARED) The 41-item SCARED 32 is a self-report measure that distinguishes between anxiety disorders and other disorders, and differentiates types of anxiety disorders. It is divided into five subscales: Panic/Somatic, 2015 Wiley Publishing Asia Pty Ltd 3

4 Core thoughts in anorexia Generalized anxiety, Separation anxiety, Social anxiety and School avoidance. Each item describes specific feelings and behaviours, and patients rate the frequency with which they were experienced in the last two weeks on a scale of 0 ( almost never ) to 3 ( often ). The subscale scores are summed to obtain a total anxiety score; their calculated mean constitutes the global score. The SCARED has been found to have good reliability and validity in clinical settings. 33 In our sample, Cronbach s alpha for the total scale was 0.78 at admission and 0.77 at discharge. Suicide Ideation Questionnaire Junior (SIQ-JR) The 15-item SIQ-JR 34 is used to assess the frequency of suicidal thoughts in the previous month; specifically, thoughts related to death and dying, passive and active suicidal ideation, and suicidal intent. 35 Items are rated on a Likert-like scale from 0 ( I never had this thought ) to 6 ( This thought was in my mind almost every day ). The cutoff used was 31. The SIQ-JR has been found to have high test retest reliability and validity In our sample, Cronbach s alpha for the total scale was 0.95 at admission and 0.94 at discharge. Data analysis A total of 44 patients started the intervention, of whom 9 did not complete the discharge assessments. Table 3 show Characteristics of Treatment Completers Vs. Treatment Droppers. Admission (pretreatment) and discharge data were available for the remaining 35 patients. Non-parametric tests were used to compare the pre-hospitalization scores between patients who completed the assessments and those who did not. t-test for paired samples was used to analyse differences in variables between admission and discharge. We also conducted an intent-to-treat analysis in which the admission scores of the nine patients who did not undergo discharge assessment were carried forward. As the intent-to-treat and completers analysis yielded similar results, we report the findings for the intentto-treat analysis only (n = 44). RESULTS The study group consisted of 41 female and 3 male patients aged years (M 14.80, SD 1.73). In 25% of patients, AN started before age 12 years (child-onset AN). Other demographic characteristics are shown in Table 1. The change in BMI/BMI TABLE 1. Characteristics of the study sample Sample (n = 44) Gender 3 male 41 female Age Range Mean (SD = 1.73) Place of birth Israel 40 Other 4 Current weight Range Mean (SD = 7.38) BMI Range Mean (SD = 1.78) BMI percentiles Range Mean (SD = 14.22) Duration of illness (in years) Range Mean 1.94 (SD = 3.07) Weight loss (in kg) Range Mean = (SD = 6.48) Duration of hospitalization Range (in days) Mean = (SD = 54.68) Type AN Purging 7 Restrictive 37 SES High 1 Mid 42 Low 1 AN, anorexia nervosa; BMI, body mass index; SES, socio-economic status. percentiles and in the psychopathological scale scores from admission to discharge are shown in Table 2. BMI percentiles significantly increased between the two time points (P < 0.000), with 70% of patients achieving 100% ideal body weight and 25% achieving 90% ideal body weight. The other 5% were the patients who dropped out of the study at the beginning of treatment. In terms of eating symptomatology, there was no significant change in the total or subscale scores of the EDI-2. Specifically, there were no significant changes in Body dissatisfaction and Drive for thinness. The change in total EDE-Q score was significant (t = 2.34, P < 0.05), indicating a reduction in the general severity of symptoms; specifically, there was a significant decrease in the severity of Restraint (t = 2.71, P < 0.01) and Eating concern (t = 2.96, P < 0.01). Scores for Weight concern and Shape concern subscales also decreased, but the difference from admission did not reach statistical significance. At admission, BDI scores were above the clinical cutoff, indicating clinical depression. At discharge, they were significantly reduced (t = 2.57, P < 0.05) but remained within the range of clinical depression. There was no significant change in anxiety Wiley Publishing Asia Pty Ltd

5 S. Fennig et al. TABLE 2. Change in medical and psychopathologic parameters from admission to discharge in adolescents with anorexia nervosa Admission Discharge Admission versus discharge (t-test) M SD M SD BMI ** BMI percentile ** EDI (total) EDI subscales EDI 1 Drive for thinness EDI 2 Bulimia EDI 3 Body dissatisfaction EDI 4 Ineffectiveness EDI5 Perfectionism EDI 6 Interpersonal distrust EDI 7 Interceptive awareness EDI 8 Maturity fears EDI 9 Asceticism EDI 10 Impulse EDI 11 Social insecurity EDE total * EDE subscales EDE Restraint ** EDE Eating concern ** EDE Weight concern EDE Shape concern SCARED (total) BDI * SIQ * *P < 0.05; **P < BDI, Beck Depression Inventory; BMI, body mass index; EDI-2, Eating Disorders Subscale version 2; EDE-Q, Eating Disorder Examination Questionnaire; SCARED, Screen for Child Anxiety-Related Emotion Disorders; SIQ, Suicide Ideation Questionnaire. levels over time, either by total score or by subscale. Suicide ideation was above the cutoff of suicide risk at admission and even higher at discharge. This increase was statistically significant (t = 2.18, P < 0.05). DISCUSSION The results of this study suggest that changes in BMI percentile during hospitalization for adolescent AN were not associated with significant improvement in core anorexic thoughts and perceptions, such as Body dissatisfaction, Drive for thinness, Weight concern and Shape concern. Restraint and Eating concern were significantly reduced, but this finding may have been related more to the structure of the treatment programme (supervised fixed nutritional intake) and less to real cognitive changes associated with the basic anorexic pathology. Our results agree with the study of Gowers et al., 3 which, to our knowledge, is the only study of inpatient treatment for AN in adolescents that measured core symptomatology at discharge. Intriguingly, inpatient treatment appears to have little or no impact on core cognitions such as body dissatisfaction or drive for thinness, whereas those who declined admission made improvements in these areas. Interestingly, Roy s group 17 found a significant improvement on body distortion at discharge from an adolescent inpatient unit. Our understanding of their findings is that the improved perception was about the real size of the body, but dissatisfaction remained the same. Despite the lack of significant improvement in some of the core cognitive-psychological parameters, we observed a trend of improvement or stability for anxiety and depressive symptoms associated with phobic weight gain (in contrast to the expected increased anxiety as a reaction to the weight gain.) A similar finding was reported by others and was tentatively related to the weight gain. 37 Intriguingly, in our study, the increase in suicidal ideation was not correlated with a concomitant increase in depressive symptomatology. This might be explained by the complexity of the depressive construct which includes cognitive, behav Wiley Publishing Asia Pty Ltd 5

6 Core thoughts in anorexia TABLE 3. Characteristics of treatment completers versus treatment droppers Treatment droppers (n = 13) Treatment completers (n = 31) Gender 1 male 2 male 12 female 29 female Age Range Range Mean (SD = 1.76) Mean (SD = 1.72) Place of birth Israel Other 1 3 Type AN Purging 2 5 Restrictive Current weight Range Range Mean (SD = 6.12) Mean (SD = 7.87) BMI Range Range Mean (SD = 1.76) Mean (SD = 1.77) BMI percentiles Range Range Mean 8.58 (SD = 17.20) Mean (SD = 14.77) Duration of illness (in years) Range Range Mean 1.98 (SD = 2.29) Mean 1.93 (SD = 3.37) Weight loss (in kg) Range 4 14 Range Mean = 9.09 (SD = 3.69) Mean = (SD = 7.18) Duration of hospitalization (in days) Range Range Mean = (SD = 60.01) Mean = (SD = 52.83) SES High 1 Mid Low 1 AN, anorexia nervosa; BMI, body mass index; SES, socio-economic status. ioural, affective and somatic components and may be mostly related to the patients improved nutritional state. Another factor that could be responsible for this finding is the combination of higher body weight with unchanged (high) levels of Weight and Shape concerns. Previous studies in adults have shown a correlation between suicidal ideation and weight and shape preoccupation among anorexics. 38 Further investigation is needed to determine the clinical importance of these findings, as adolescent patients discharged from intensive treatments after weight recovery may be at risk of depression and anxiety and increased suicidal ideation. The gap between the physical recovery and the level of cognitive/psychological change was also noted in previous studies 4,8 and might explain the high relapse rate of AN after discharge from inpatient units. Future studies need to identify the most effective interventions for the inpatient stay that will also promote psychological and cognitive changes, thereby preparing patients better for continuing care and preventing relapse. A new approach presented by the Della Grave and Fairburn group 39 the CBT-E work seems to be promising in encouraging cognitive changes related in part to the use of CBT-E procedures addressing the key maintaining mechanisms of eating disorder psychopathology. From the patients point of view, Offord et al. 40 reported that participants of an inpatient programme for AN felt that services which recognized the emotional impact of weight gain and addressed both psychological and physical aspects of the condition were most helpful for them on their way to recovery. Our study was limited by the small sample and the lack of a comparison group. Although our treatment programme was highly structured, it lacked a manualized cognitive behavioural or motivational protocol. It is possible that using cognitive behaviour therapy techniques with a focus on changes in core cognitions would have led to improvements in core cognitions in addition to weight recovery and normalization of eating patterns. Future studies incorporating these factors are warranted to better examine the effectiveness of inpatient interventions. Given the limitations of observational studies, it is important to note that recruitment and retention of participants is very difficult in AN populations, with consequent difficulties in evaluating the effectiveness of treatment in randomized controlled trials Wiley Publishing Asia Pty Ltd

7 S. Fennig et al. In summary, an intensive, open inpatient intervention for medically stabled adolescents with AN appears to have a significant nutritional/medical impact but only a limited effect on core anorexic thoughts and perceptions change. This gap between weight recovery and hard core symptoms change supports the importance of a continuum of care after inpatient interventions. AUTHORS CONTRIBUTIONS SF carried out the study concept and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript and supervised the study. ABS carried out the study concept and design, analysis and interpretation of data, and drafted the manuscript. BS carried out the study concept and design, analysis and interpretation of data and statistical analysis. ZS-M carried out the acquisition of data, analysis and interpretation of data, statistical analysis, and administrative, technical or material support. AH carried out the study concept and design, analysis and interpretation of data, and drafted the manuscript. REFERENCES 1. National Institute for Health and Care Excellence. Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders, National Clinical Practice Guidelines No. CG9. London: British Psychological Society and Gaskell, Vandereycken W. The place of inpatient care in the treatment of anorexia nervosa: questions to be answered. Int J Eat Disord 2003; 34: Gowers GS, Clark A, Roberts C et al. Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomized controlled trial. Br J Psychiatry 2007; 191: Fennig S, Fennig S, Roe D. Physical recovery in anorexia nervosa: is this the sole purpose of a child and adolescent medical-psychiatric unit? Gen Hosp Psychiatry 2002; 24: Goddard E, Hibss R, Raenker S et al. A multi-centre cohort study of short term outcomes of hospital treatment for anorexia nervosa in the UK. BMC Psychiatry 2013; 13: Steinhausen HC, Grigoroiu-Serbanescu M, Boyadjieva S, Neumarker KJ, Winkler Metzke C. Course and predictors of rehospitalization in adolescent anorexia nervosa in a multisite study. Int J Eat Disord 2008; 41: Kaplan AS, Kaplan AS, Walsh BT, Olmsted M et al. The slippery slope: prediction of successful weight maintenance in anorexia nervosa. Psychol Med 2009; 39: Castro J, Gila A, Puig J, Rodriguez S, Toro J. Predictors of rehospitalization after total weight recovery in adolescents with anorexia nervosa. Int J Eat Disord 2004; 36: Attia E. Anorexia nervosa in adolescents: challenges remain. Lancet 2014; 383: Herpertz-Dahlmann B, Schwarte R, Krei M et al. Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomised, open-label, non-inferiority trial. Lancet 2014; 383: Madden S, Miskovic-Wheatley J, Wallis A et al. A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents. Psychol Med 2015; 45: Golden NH, Keane-Miller C, Sainani KL, Kapphahn CJ. Higher caloric intake in hospitalized adolescents with anorexia nervosa is associated with reduced length of stay and no increased rate of refeeding syndrome. J Adolesc Health 2013; 53: Le Grange D. Examining refeeding protocols for adolescents with anorexia nervosa (again): challenges to current practices. J Adolesc Health 2013; 53: Collin P, Power K, Karatzias T, Grierson D, Yellowlees A. The effectiveness of and predictors of response to inpatient treatment of anorexia nervosa. Eur Eat Disord Rev 2010; 18: Carter JC, Mercer-Lynn KB, Norwood SJ et al. A prospective study of predictors of relapse in anorexia nervosa implications for relapse prevention. Psychiatry Res 2012; 200: Sala L, Mirabel-Sarron C, Pham-Scottez A, Blanchet A, Rouillon F, Gorwood P. Body dissatisfaction is improved but the ideal silhouette is unchanged during weight recovery in anorexia nervosa female inpatients. Eat Weight Disord 2012; 17: e Roy M, Meilleur D. Body image distortion change during inpatient treatment of adolescent girls with restrictive anorexia nervosa. Eat Weight Disord 2010; 15: e American Psychiatric Association. Practice Guideline for the Treatment of Patients with Eating Disorders. Washington, DC: American Psychiatric Association, American Dietetic Association. Position of the American Dietetic Association: nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders. J Am Diet Assoc 2006; 106: Fairburn GC. Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press, Baran SA, Weltzin TE, Kaye WH. Low discharge weight and outcome in anorexia nervosa. Am J Psychiatry 1995; 152: Lock J, Litt I. What predicts maintenance of weight for adolescents medically hospitalized for anorexia nervosa? Eat Disord 2003; 11: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR. Washington, DC: American Psychiatric Association, Garner DM, Olmsted MP, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eat Disord 1983; 2: Niv N, Kaplan Z, Mitrani E, Shiang J. Validity study of the EDI-2 in an Israeli population. Isr J Psychiatry Relat Sci 1998; 35: Fairburn CG, Cooper Z. The eating disorders examination. In: Fairburn CG, Wilson GT, eds. Binge Eating: Nature, Assessment and Treatment, 12th edn. New York: Guilford Press, 1993; Fairburn CG, Beglin SJ. The assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord 1994; 16: Beck AT, Steer RA, eds. Manual for the Beck Depression Inventory. San Antonio: Psychological Corporation, Strober M, Green J, Carlson G. Utility of the Beck Depression Inventory with psychiatrically hospitalized adolescents. J Consult Clin Psychol 1981; 49: Teri L. The use of the Beck Depression Inventory with adolescents. J Abnorm Child Psychol 1982; 10: Wiley Publishing Asia Pty Ltd 7

8 Core thoughts in anorexia 31. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988; 88: Birmaher B, Khetarpal S, Brent D et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry 1997; 36: Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry 1999; 38: Reynolds WM. SIQ Professional Manual. Odessa: Psychological Assessment Resources, Reynolds WM, Mazza JJ. Assessment of suicidal ideation in inner-city children and young adolescents: reliability and validity of the Suicidal Ideation Questionnaire-JR. School Psychol Rev 1999; 28: Reynolds WM. Development of a semi-structured clinical interview for suicidal behaviors in adolescents. Psychol Assess 1990; 2: Pollice C, Kaye WH, Greeno CG, Weltzin TE. Relationship of depression, anxiety and obsessionality to state of illness in anorexia nervosa. Int J Eat Disord 1997; 21: Milos G, Spindler A, Hepp U, Schnyder U. Suicide attempts and suicidal ideation: links with psychiatric comorbidity in eating disorder subjects. Gen Hosp Psychiatry 2004; 26: Della Grave DR, Calugi S, Doll AH, Fairburn GC. Enhanced cognitive behavior therapy for adolescents with anorexia nervosa: an alternative to family therapy? Behav Res Ther 2013; 51: R Offord A, Turner H, Cooper M. Adolescent inpatient treatment for anorexia nervosa: a qualitative study reporting young adult s retrospective view of treatment and discharge. Eur Eat Disord Rev 2006; 14: Halmi K, Agras S, Crow S et al. Predictors of treatment acceptance and completion in anorexia nervosa. Implications for future study designs. Arch Gen Psychiatry 2005; 62: Wiley Publishing Asia Pty Ltd