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Anorexia Nervosa

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: closed (31 January 2019) | Viewed by 75308

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Special Issue Editors

Prof. Dr. Stephan Zipfel

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Guest Editor

Department of Psychosomatic Medicine and Psychotherapy, Head of Department and Dean of Medical School, University Medical Hospital, 72076 Tübingen, Germany
Interests: anorexia nervosa; eating behavior; obesity; psychooncology; psychotherapy
Special Issues, Collections and Topics in MDPI journals

Prof. Dr. Andreas Stengel

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Guest Editor

Department of Psychosomatic Medicine and Psychotherapy, University Tübingen, Tübingen, Germany
Interests: anorexia nervosa; brain–gut axis; hunger and satiety; obesity; psychogastroenterology; psychoendocrinology

Prof. Dr. Katrin Giel

E-Mail Website
Guest Editor

Department of Psychosomatic Medicine and Psychotherapy, University Tübingen, Tübingen, Germany
Interests: anorexia nervosa; binge eating disorder; body image; impulsivity; obesity; psychotherapy
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Anorexia nervosa (AN) is a severe eating disorder characterized by substantial underweight (Body Mass Index BMI ≤ 17.5 kg/m²). Further core symptoms of the disorder encompass an intensive fear of gaining weight and body image disturbances. AN is associated with considerable morbidity and mortality and often shows a long-standing course. Quality of life is poor and the burden placed on individuals, families, and society is high. Although in recent years progress has been made in the understanding of how this disorder is developed and maintained and how affected patients can be treated, many unmet challenges remain in the management of AN. The purpose of this Special Issue is to give an update on the evidence concerning a broad range of topics related to AN, encompassing findings on pathophysiology and pathopsychology of AN, complications as well as novel and innovative treatments of the disease and bring together world-renowned experts in the field.

Prof. Dr. Stephan Zipfel
Prof. Dr. Andreas Stengel
Prof. Dr. Katrin Giel
Guest Editors

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Keywords

Anorexia nervosa
Body image
Body weight
Eating disorders
Emotion regulation
Food
Physical activity
Psychotherapy
Neurobiology
Treatment
Underweight

Published Papers (8 papers)

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Research

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16 pages, 778 KiB

Open AccessArticle

by Zaida Agüera^1,2,3,*

, Georgios Paslakis²

, Lucero Munguía⁴

, Isabel Sánchez², Roser Granero^1,5

, Jessica Sánchez-González², Trevor Steward^1,2

, Susana Jiménez-Murcia^1,2,4

and Fernando Fernández-Aranda^1,2,4,*

¹ CIBER Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, L’Hospitalet de Llobregat, 08907 Barcelona, Spain

² Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain

³ Department of Public Health, Mental Health and Maternal-Child Nursing, School of Nursing, University of Barcelona, L’Hospitalet de Llobregat, 08907 Barcelona, Spain

⁴ Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, L’Hospitalet de Llobregat, 08907 Barcelona, Spain

⁵ Departament de Psicobiologia i Metodologia de les Ciències de la Salut, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain

J. Clin. Med. 2019, 8(2), 161; https://doi.org/10.3390/jcm8020161 - 01 Feb 2019

Cited by 25 | Viewed by 5853

Abstract

Difficulties in emotion regulation (ER) are common in females with eating disorders (ED). However, no study to date has analyzed ER in males with ED. In the study at hand, we assessed ER in males with ED and compared results to both females with ED and healthy controls (HC). We also examined associations between ER difficulties, personality, and psychopathology. A total of 62 males with ED were compared with 656 females with ED, as well as 78 male and 286 female HC. ER was assessed by means of the Difficulties in Emotion Regulation Scale (DERS). We found that males and females with ED showed greater ER difficulties compared to HC. Pronounced general psychopathology was a shared factor associated with higher ER difficulties in both males and females with ED. However, whereas higher novelty seeking, higher cooperativeness, lower reward dependence, and lower self-directedness were related to higher ER difficulties in females with ED, lower persistence was associated with ER difficulties in males with ED. In sum, males and females with ED show similar ER difficulties, yet they are distinct in how ER deficits relate to specific personality traits. Research on strategies promoting ER in the treatment of males with ED is warranted. Full article

(This article belongs to the Special Issue Anorexia Nervosa)

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9 pages, 1461 KiB

Open AccessArticle

Manualised Cognitive Behaviour Therapy for Anorexia Nervosa: Use of Treatment Modules in the ANTOP Study

by Gaby Resmark^1,*

, Brigid Kennedy^1,2

, Maria Mayer¹, Katrin Giel¹, Florian Junne¹, Martin Teufel³, Martina De Zwaan⁴ and Stephan Zipfel¹

¹ Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, 72076 Tübingen, Germany

² School of Psychology, The University of Sydney, Camperdown 2006, Australia

³ Department of Psychosomatic Medicine and Psychotherapy, University of Duisburg-Essen, 45147 Essen, Germany

⁴ Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, 30625 Hannover, Germany

J. Clin. Med. 2018, 7(11), 398; https://doi.org/10.3390/jcm7110398 - 29 Oct 2018

Cited by 3 | Viewed by 3921

Abstract

Standardised treatment manuals facilitate therapy planning and enhance comparability for research purposes. Within the Anorexia Nervosa Treatment of Out Patients (ANTOP) study, the largest multisite outpatient intervention trial in anorexia nervosa (AN) to date, manualised enhanced cognitive-behavioural therapy (CBT-E) was offered as one treatment modality. The manual consisted of 9 modules, of which Motivation, Nutrition, Formulation and Relapse Prevention were compulsory. Homework worksheets were provided, to ensure the transfer of therapeutic improvements to daily life. This study investigated the use of modules and worksheets in order to explore practice styles of trained therapists in the treatment of AN. This secondary analysis was based on log-sheets (n = 2604) CBT-E therapists completed after each session. Frequencies of modules and worksheets used across all sessions were calculated. Relationships, such as that between use of module and duration of illness, were examined. The most commonly used module was Motivation. In patients with longer illness duration, the module Self Esteem seemed to be particularly important. The worksheet Scales, balancing the pros and cons of AN, was prioritised by therapists. The results underline the importance of motivational work in the treatment of AN, including validating the ambivalence experienced by most AN patients. With increasing duration of illness, resource-oriented elements, such as self esteem stabilisation, should be of focus. Full article

(This article belongs to the Special Issue Anorexia Nervosa)

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12 pages, 876 KiB

Open AccessArticle

The Role of Objectively Measured, Altered Physical Activity Patterns for Body Mass Index Change during Inpatient Treatment in Female Patients with Anorexia Nervosa

by Celine S. Lehmann^1,2

, Tobias Hofmann¹

, Ulf Elbelt^1,3, Matthias Rose¹, Christoph U. Correll^2,4,5, Andreas Stengel^1,6,*,† and Verena Haas^2,*,†

¹ Center for Internal Medicine and Dermatology, Department of Psychosomatic Medicine, Charité-Universitätsmedizin Berlin, 12200 Berlin, Germany

² Department of Child and Adolescent Psychiatry, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany

³ Center for Internal Medicine with Gastroenterology and Nephrology, Division for Endocrinology, Diabetes and Nutrition, Charité-Universitätsmedizin Berlin, 12200 Berlin, Germany

⁴ Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA

⁵ Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY 11004, USA

⁶ Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tübingen, 72076 Tübingen, Germany

^† These authors contributed equally to the manuscript.

J. Clin. Med. 2018, 7(9), 289; https://doi.org/10.3390/jcm7090289 - 18 Sep 2018

Cited by 11 | Viewed by 4295

Abstract

Increased physical activity (PA) affects outcomes in patients with anorexia nervosa (AN). To objectively assess PA patterns of hospitalized AN patients in comparison with healthy, outpatient controls (HC), and to analyze the effect of PA on Body Mass Index (BMI) change in patients with AN, we measured PA in 50 female patients with AN (median age = 25 years, range = 18–52 years; mean BMI = 14.4 ± 2.0 kg/m²) at the initiation of inpatient treatment and in 30 female healthy controls (median age = 26 years, range = 19–53 years; mean BMI = 21.3 ± 1.7 kg/m²) using the SenseWear™ armband. Duration of inpatient stay and weight at discharge were abstracted from medical records. Compared with controls, AN patients spent more time in very light-intensity physical activity (VLPA) (median VLPA = 647 vs. 566 min/day, p = 0.004) and light-intensity physical activity (LPA) (median LPA = 126 vs. 84 min/day, p < 0.001) and less time in moderate-intensity physical activity (MPA) (median MPA = 82 vs. 114 min/day, p = 0.022) and vigorous physical activity (VPA) (median VPA = 0 vs. 16 min/day, p < 0.001). PA and BMI increase were not associated in a linear model, and BMI increase was mostly explained by lower admission BMI and longer inpatient stay. In a non-linear model, an influence of PA on BMI increase seemed probable (jack knife validation, r² = 0.203; p < 0.001). No direct association was observed between physical inactivity and BMI increase in AN. An altered PA pattern exists in AN patients compared to controls, yet the origin and consequences thereof deserve further investigation. Full article

(This article belongs to the Special Issue Anorexia Nervosa)

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11 pages, 1050 KiB

Open AccessArticle

Contingency Contracts for Weight Gain of Patients with Anorexia Nervosa in Inpatient Therapy: Practice Styles of Specialized Centers

by Katrin Ziser^1,*

, Katrin E. Giel¹, Gaby Resmark¹, Christoph Nikendei², Hans-Christoph Friederich³, Stephan Herpertz⁴, Matthias Rose⁵, Martina De Zwaan⁶

, Jörn Von Wietersheim⁷, Almut Zeeck⁸

, Andreas Dinkel⁹, Markus Burgmer¹⁰, Bernd Löwe¹¹, Carina Sprute¹², Stephan Zipfel¹ and Florian Junne¹

¹ Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tuebingen, Osianderstr. 5, 72076 Tuebingen, Baden-Wuerttemberg, Germany

² Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, Baden-Wuerttemberg, Germany

³ Clinical Institute of Psychosomatic Medicine and Psychotherapy, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Nordrhein-Westfalen, Germany

⁴ Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr-University Bochum, Alexandrinenstr. 1-3, 44791 Bochum, Nordrhein-Westfalen, Germany

⁵ Division of Psychosomatic Medicine, Charité University Hospital Berlin, Hindenburgdamm 30, 12200 Berlin, Berlin, Germany

⁶ Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Niedersachsen, Germany

⁷ Department of Psychosomatic Medicine and Psychotherapy, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Baden-Wuerttemberg, Germany

⁸ Department of Psychosomatic Medicine and Psychotherapy, University Hospital Freiburg, Hauptstr. 8, 79104 Freiburg, Baden-Wuerttemberg, Germany

⁹ Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich, Langerstr. 3, 81675 Munich, Bayern, Germany

¹⁰ Department of Psychosomatic Medicine and Psychotherapy, University Hospital Muenster, Domagkstr. 22, 48149 Muenster, Nordrhein-Westfalen, Germany

¹¹ Institute and Outpatient Clinic for Psychosomatic Medicine and Psychotherapy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg-Eppendorf, Hamburg, Germany

¹² Department of Psychosomatic Medicine and Psychotherapy, LVR-University Hospital, University Duisburg-Essen, Virchowstr. 174, 45147 Essen, Nordrhein-Westfalen, Germany

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J. Clin. Med. 2018, 7(8), 215; https://doi.org/10.3390/jcm7080215 - 14 Aug 2018

Cited by 3 | Viewed by 5384

Abstract

The treatment of patients with anorexia nervosa (AN) is often challenging, due to a high degree of ambivalence towards recovery and weight gain these patients often express. One part of the multimodal treatment is the utilization of treatment contracts (i.e., contingency contracts) that aim to motivate patients to gain weight by applying positive and negative consequences for the (non-)achievement of weight goals. The main aim of this study is to assess and analyze current standards of contingency contracts’ utilization in German eating disorder centers. n = 76 mental health professionals of twelve specialized university centers in Germany that are currently or were formerly treating patients with AN in an inpatient setting participated. Most experts use contingency contracts in their clinic with weekly weight goals ranging between 500 and 700 g. Overall effectiveness and significance of contingency contracts for the inpatient treatment of patients with AN was rated high. Typical characteristics of a contingency contract in specialized German university hospital centers, such as the most frequent consequences, are described. The survey results assist the planning of further studies aiming to improve the multimodal treatment of patients with AN. For clinical practice, using external motivators such as contingency contracts as well as targeting internal motivation (e.g., by using motivational interviewing) is proposed. Full article

(This article belongs to the Special Issue Anorexia Nervosa)

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Review

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19 pages, 271 KiB

Open AccessReview

Anorexia Nervosa and the Immune System—A Narrative Review

by Dennis Gibson^1,*

and Philip S Mehler²

¹ Assistant Medical Director, ACUTE Center for Eating Disorders @ Denver Health; Assistant Professor of Medicine, University of Colorado School of Medicine; 777 Bannock St., Denver, CO 80204, USA

² President, Eating Recovery Center; Founder and Executive Medical Director, ACUTE Center for Eating Disorders @ Denver Health; Glassman Professor of Medicine, University of Colorado School of Medicine; 7351 E Lowry Blvd, Suite 200, Denver, CO 80230, USA

J. Clin. Med. 2019, 8(11), 1915; https://doi.org/10.3390/jcm8111915 - 08 Nov 2019

Cited by 62 | Viewed by 10435

Abstract

The pathogenesis of an increasing number of chronic diseases is being attributed to effects of the immune system. However, its role in the development and maintenance of anorexia nervosa is seemingly under-appreciated. Yet, in examining the available research on the immune system and genetic studies in anorexia nervosa, one becomes increasingly suspicious of the immune system’s potential role in the pathophysiology of anorexia nervosa. Specifically, research is suggestive of increased levels of various pro-inflammatory cytokines as well as the spontaneous production of tumor necrosis factor in anorexia nervosa; genetic studies further support a dysregulated immune system in this disorder. Potential contributors to this dysregulated immune system are discussed including increased oxidative stress, chronic physiological/psychological stress, changes in the intestinal microbiota, and an abnormal bone marrow microenvironment, all of which are present in anorexia nervosa. Full article

(This article belongs to the Special Issue Anorexia Nervosa)

17 pages, 267 KiB

Open AccessReview

Neural Processing of Disorder-Related Stimuli in Patients with Anorexia Nervosa: A Narrative Review of Brain Imaging Studies

by Joe J. Simon^*

, Marion A. Stopyra

and Hans-Christoph Friederich

Department of General Internal Medicine and Psychosomatics, Centre for Psychosocial Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany

J. Clin. Med. 2019, 8(7), 1047; https://doi.org/10.3390/jcm8071047 - 18 Jul 2019

Cited by 26 | Viewed by 4391

Abstract

Abnormalities and alterations in brain function are commonly associated with the etiology and maintenance of anorexia nervosa (AN). Different symptom categories of AN have been correlated with distinct neurobiological patterns in previous studies. The aim of this literature review is to provide a narrative overview of the investigations into neural correlates of disorder-specific stimuli in patients with AN. Although findings vary across studies, a summary of neuroimaging results according to stimulus category allows us to account for methodological differences in experimental paradigms. Based on the available evidence, the following conclusions can be made: (a) the neural processing of visual food cues is characterized by increased top-down control, which enables restrictive eating, (b) increased emotional and reward processing during gustatory stimulation triggers disorder-specific thought patterns, (c) hunger ceases to motivate food foraging but instead reinforces disorder-related behaviors, (d) body image processing is related to increased emotional and hedonic reactions, (e) emotional stimuli provoke increased saliency associated with decreased top-down control and (f) neural hypersensitivity during interoceptive processing reinforces avoidance behavior. Taken together, studies that investigated symptom-specific neural processing have contributed to a better understanding of the underlying mechanisms of AN. Full article

(This article belongs to the Special Issue Anorexia Nervosa)

42 pages, 734 KiB

Open AccessReview

Medication in AN: A Multidisciplinary Overview of Meta-Analyses and Systematic Reviews

by Corinne Blanchet^1,2,3, Sébastien Guillaume^3,4,5, Flora Bat-Pitault^3,6,7, Marie-Emilie Carles¹, Julia Clarke^3,8,9, Vincent Dodin^3,10,11, Philibert Duriez^3,9,12

, Priscille Gerardin^3,13,14, Mouna Hanachi-Guidoum^3,15,16

, Sylvain Iceta^3,17,18

, Juliane Leger^19,20,21, Bérénice Segrestin^3,17,22, Chantal Stheneur^3,23,24 and Nathalie Godart^3,16,25,26,*

¹ Maison de Solenn-Maison des Adolescents, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France

² CESP, INSERM 1178, Paris-Descartes University, USPC, 75014 Paris, France

³ French Federation Anorexia Bulimia (FFAB), 75014 Paris, France

⁴ Department of Psychiatric Emergency & Acute Care, Lapeyronie Hospital, CHRU Montpellier, 34090 Montpellier, France

⁵ INSERM U1061, University of Montpellier, 34090 Montpellier, France

⁶ Child and Adolescent Psychopathology Unit, Salvator Hospital, Public Assistance-Marseille Hospitals, 13009 Marseille, France

⁷ Institut de la Timone, CNRS, Aix-Marseille University, 13005 Marseille, France

⁸ Child and Adolescent Psychiatry Department, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, 75019 Paris, France

⁹ INSERM U894, Institute of Psychiatry and Neuroscience of Paris (IPNP), 75013 Paris, France

¹⁰ Clinique Médico-Psychologique, Neurosciences Hôpital Saint Vincent de Paul, 59000 Lille, France

¹¹ Faculté de Médecine et de Maïeutique de Lille, 59800 Lille, France

¹² Sainte-Anne Hospital (CMME), Paris Descartes University, 75014 Paris, France

¹³ Pôle universitaire de psychiatrie de l’enfant et de l’adolescent CH du Rouvray-CHU de Rouen, 76300 Rouen, France

¹⁴ CRFDP, UFR des Sciences de l’Homme et de la Société, Rouen University, 76130 Mont-Saint-Aignan, France

¹⁵ Clinical Nutrition Unit, Raymond Poincaré University Hospital, Assistance Publique-Hôpitaux de Paris, 92380 Garches, France

¹⁶ CESP, INSERM, UMR 1018, University Paris-Sud, UVSQ, University Paris-Saclay, 94800 Villejuif, France

¹⁷ Referral Center for Eating Disorder, Hospices Civils de Lyon, 69677 Bron, France

¹⁸ Equipe PSYR2, INSERM U1028, CNRS UMR5292, Université Lyon 1, 69002 Lyon, France

¹⁹ Pediatric Endocrinology Diabetology Department, Reference Centre for Endocrine Growth and Development Diseases, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, 75019 Paris, France

²⁰ Paris Diderot University, Sorbonne Paris Cité, F-75019 Paris, France

²¹ Institut National de la Santé et de la Recherche Médicale (INSERM), UMR 1141, DHU Protect, F-75019 Paris, France

²² INSERM 1060, Laboratoire CARMEN, Centre de Recherche en Nutrition Humaine Rhône-Alpes, Claude Bernard University, Lyon 1, Pierre Bénite, 69310 Lyon, France

²³ Centre Médical et Pédagogique, Fondation Santé des Etudiants de France, 91480 Varennes Jarcy, France

²⁴ Faculté de Médecine, Université de Montréal, Quebec, QC H3C 3J7, Canada

²⁵ Adolescent and Young Adult mental health department, Fondation Santé des Etudiants de France, 75014 Paris, France

²⁶ UFR Simone Veil-Santé, 78690 Saint-Quentin en Yvelines, France

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J. Clin. Med. 2019, 8(2), 278; https://doi.org/10.3390/jcm8020278 - 25 Feb 2019

Cited by 46 | Viewed by 7762

Abstract

Drugs are widely prescribed for anorexia nervosa in the nutritional, somatic, and psychiatric fields. There is no systematic overview in the literature, which simultaneously covers all these types of medication. The main aims of this paper are (1) to offer clinicians an overview of the evidence-based data in the literature concerning the medication (psychotropic drugs and medication for somatic and nutritional complications) in the field of anorexia nervosa since the 1960s, (2) to draw practical conclusions for everyday practise and future research. Searches were performed on three online databases, namely MEDLINE, Epistemonikos and Web of Science. Papers published between September 2011 and January 2019 were considered. Evidence-based data were identified from meta-analyses, if there were none, from systematic reviews, and otherwise from trials (randomized or if not open-label studies). Evidence-based results are scarce. No psychotropic medication has proved efficacious in terms of weight gain, and there is only weak data suggesting it can alleviate certain psychiatric symptoms. Concerning nutritional and somatic conditions, while there is no specific, approved medication, it seems essential not to neglect the interest of innovative therapeutic strategies to treat multi-organic comorbidities. In the final section we discuss how to use these medications in the overall approach to the treatment of anorexia nervosa. Full article

(This article belongs to the Special Issue Anorexia Nervosa)

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16 pages, 318 KiB

Open AccessReview

Treatment of Anorexia Nervosa—New Evidence-Based Guidelines

by Gaby Resmark^1,*

, Stephan Herpertz²

, Beate Herpertz-Dahlmann³ and Almut Zeeck⁴

¹ Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Osianderstr. 5, 72076 Tuebingen, Baden-Wuerttemberg, Germany

² Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr-University Bochum, Alexandrinenstr. 1-3, 55791 Bochum, Nordrhein-Westfalen, Germany

³ Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen, Neuenhofer Weg 21, 52074 Aachen, Nordrhein-Westfalen, Germany

⁴ Department of Psychosomatic Medicine and Psychotherapy, University Hospital Freiburg, Hauptstr. 8, 79104 Freiburg, Baden-Wuerttemberg, Germany

J. Clin. Med. 2019, 8(2), 153; https://doi.org/10.3390/jcm8020153 - 29 Jan 2019

Cited by 76 | Viewed by 32159

Abstract

Anorexia nervosa is the most severe eating disorder; it has a protracted course of illness and the highest mortality rate among all psychiatric illnesses. It is characterised by a restriction of energy intake followed by substantial weight loss, which can culminate in cachexia and related medical consequences. Anorexia nervosa is associated with high personal and economic costs for sufferers, their relatives and society. Evidence-based practice guidelines aim to support all groups involved in the care of patients with anorexia nervosa by providing them with scientifically sound recommendations regarding diagnosis and treatment. The German S3-guideline for eating disorders has been recently revised. In this paper, the new guideline is presented and changes, in comparison with the original guideline published in 2011, are discussed. Further, the German guideline is compared to current international evidence-based guidelines for eating disorders. Many of the treatment recommendations made in the revised German guideline are consistent with existing international treatment guidelines. Although the available evidence has significantly improved in quality and amount since the original German guideline publication in 2011, further research investigating eating disorders in general, and specifically anorexia nervosa, is still needed. Full article

(This article belongs to the Special Issue Anorexia Nervosa)

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