Anorexia nervosa (AN) is associated with high morbidity and mortality and significant barriers to recovery, including food-related anxiety and avoidance behaviours. Virtual reality (VR) interventions offer immersive, safe exposure to feared stimuli and may enhance engagement with treatment. The OASIS feasibility study aimed to evaluate the acceptability, feasibility, and preliminary effectiveness of a VR-based, AI-personalized adjunct to treatment as usual (TAU) in adults with AN.

This is a single-site feasibility study conducted at South London and Maudsley NHS Foundation Trust (SLaM). Up to 45 adults with AN from inpatient, day-care, and outpatient services will participate in a one-week VR intervention alongside TAU. The OASIS app, delivered via Pico 4 headset, will provide personalized sessions including psychoeducation, graded food exposure, motivational support from a virtual companion, and relaxation exercises. Primary outcomes will include recruitment, adherence, retention, and acceptability. Secondary outcomes will include anxiety, relaxation, BMI, and qualitative feedback from focus groups with patients, carers, and clinicians. Data will be analysed descriptively, and thematic analysis will be applied to qualitative data.

The OASIS study will provide evidence on the feasibility and acceptability of a VR-based intervention for adults with AN and will inform the design of a future randomized controlled trial. Insights from patient, carer, and clinician feedback will guide refinement of the intervention and identify barriers and facilitators to implementation in routine clinical care.

Anorexia nervosa (AN) is often regarded as ‘difficult to treat’. This may in part be due to co-occurring diagnoses and traits that are less directly targeted either at the point of formulation or in treatment. Schema therapy may be suitable for individuals with AN who have not benefited from first-line interventions. It offers a schema formulation and change techniques that target broader characterological ways of being. However, schema therapy is typically 18 months duration or longer, and therefore not well-suited to services with resource constraints. We present a schema-informed cognitive behavioural therapy (CBT) approach for AN, based on a formulation that encapsulates the experience of chronic unmet emotional need and which uses cognitive and behavioural techniques to target schema and schema mode change over a relatively brief treatment. We argue that the experiential techniques of schema therapy can augment the change process for those with AN, by gradually turning up the ‘emotional heat’ and increasing tolerance for emotion. After outlining this proposed model, we present findings from a case series of n=11 patients with AN or atypical AN. All patients had received first-line eating disorder treatment(s) previously and n=8/11 had prior experience of day or in-patient treatment. Results supported the acceptability and feasibility of schema-informed CBT for AN: no patients discontinued treatment early, mean number of sessions was 31 (SD 10.28), and patient satisfaction was high. Improvements were seen in AN psychopathology, depression/anxiety, schemas and schema modes, mostly with medium effect sizes. We propose areas for future research and consideration.

1. (1) To understand the rationale for a schema-informed CBT approach for anorexia nervosa.

2. (2) To understand the key components of schema-informed CBT for anorexia nervosa, including treatment objectives, stages of treatment and core methods.

3. (3) To evaluate the empirical evidence for schema-informed CBT with anorexia nervosa.

4. (4) To critically reflect on future opportunities for research and clinical practice with schema-informed CBT and eating disorders.

Disruptive behavior disorders (DBD) are heterogeneous at the clinical and the biological level. Therefore, the aims were to dissect the heterogeneous neurodevelopmental deviations of the affective brain circuitry and provide an integration of these differences across modalities.

We combined two novel approaches. First, normative modeling to map deviations from the typical age-related pattern at the level of the individual of (i) activity during emotion matching and (ii) of anatomical images derived from DBD cases (n = 77) and controls (n = 52) aged 8–18 years from the EU-funded Aggressotype and MATRICS consortia. Second, linked independent component analysis to integrate subject-specific deviations from both modalities.

While cases exhibited on average a higher activity than would be expected for their age during face processing in regions such as the amygdala when compared to controls these positive deviations were widespread at the individual level. A multimodal integration of all functional and anatomical deviations explained 23% of the variance in the clinical DBD phenotype. Most notably, the top marker, encompassing the default mode network (DMN) and subcortical regions such as the amygdala and the striatum, was related to aggression across the whole sample.

Overall increased age-related deviations in the amygdala in DBD suggest a maturational delay, which has to be further validated in future studies. Further, the integration of individual deviation patterns from multiple imaging modalities allowed to dissect some of the heterogeneity of DBD and identified the DMN, the striatum and the amygdala as neural signatures that were associated with aggression.

The First Episode Rapid Early Intervention for Eating Disorders (FREED) service model is associated with significant reductions in wait times and improved clinical outcomes for emerging adults with recent-onset eating disorders. An understanding of how FREED is implemented is a necessary precondition to enable an attribution of these findings to key components of the model, namely the wait-time targets and care package.

This study evaluated fidelity to the FREED service model during the multicentre FREED-Up study.

Participants were 259 emerging adults (aged 16–25 years) with an eating disorder of <3 years duration, offered treatment through the FREED care pathway. Patient journey records documented patient care from screening to end of treatment. Adherence to wait-time targets (engagement call within 48 h, assessment within 2 weeks, treatment within 4 weeks) and care package, and differences in adherence across diagnosis and treatment group were examined.

There were significant increases (16–40%) in adherence to the wait-time targets following the introduction of FREED, irrespective of diagnosis. Receiving FREED under optimal conditions also increased adherence to the targets. Care package use differed by component and diagnosis. The most used care package activities were psychoeducation and dietary change. Attention to transitions was less well used.

This study provides an indication of adherence levels to key components of the FREED model. These adherence rates can tentatively be considered as clinically meaningful thresholds. Results highlight aspects of the model and its implementation that warrant future examination.

Brain imaging studies have shown altered amygdala activity during emotion processing in children and adolescents with oppositional defiant disorder (ODD) and conduct disorder (CD) compared to typically developing children and adolescents (TD). Here we aimed to assess whether aggression-related subtypes (reactive and proactive aggression) and callous-unemotional (CU) traits predicted variation in amygdala activity and skin conductance (SC) response during emotion processing.

We included 177 participants (n = 108 cases with disruptive behaviour and/or ODD/CD and n = 69 TD), aged 8–18 years, across nine sites in Europe, as part of the EU Aggressotype and MATRICS projects. All participants performed an emotional face-matching functional magnetic resonance imaging task.

Differences between cases and TD in affective processing, as well as specificity of activation patterns for aggression subtypes and CU traits, were assessed. Simultaneous SC recordings were acquired in a subsample (n = 63). Cases compared to TDs showed higher amygdala activity in response to negative faces (fearful and angry) v. shapes. Subtyping cases according to aggression-related subtypes did not significantly influence on amygdala activity; while stratification based on CU traits was more sensitive and revealed decreased amygdala activity in the high CU group. SC responses were significantly lower in cases and negatively correlated with CU traits, reactive and proactive aggression.

Our results showed differences in amygdala activity and SC responses to emotional faces between cases with ODD/CD and TD, while CU traits moderate both central (amygdala) and peripheral (SC) responses. Our insights regarding subtypes and trait-specific aggression could be used for improved diagnostics and personalized treatment.

Patients with co-occurring anorexia nervosa and autism respond differently to eating disorder treatments. Previous interviews with patients with both conditions and clinicians working in eating disorder services has highlighted service and treatment adaptations might be beneficial and could improve outcomes for these individuals.

The aim of this study was to explore carers’ experiences of current treatment approaches for people with autism who have anorexia nervosa, and their views on how these can be improved.

Ten carers of a loved one diagnosed with autism and anorexia nervosa were interviewed using a semi-structured interview schedule and the transcripts were analysed with thematic analysis.

Four key themes emerged from the interviews: the role of autism in anorexia nervosa, carers’ problems with clinical services, the impact on carers and suggestions for future improvements.

Carers agreed that autism played a significant role in the development and maintenance of their daughters’ anorexia nervosa. However, this comorbidity does not appear to be appropriately addressed in current treatment provisions. They described several difficulties, including problems getting an autism diagnosis and the perception that eating disorder services did not accept or adapt around the condition. This resulted in feelings of frustration and isolation for families, a scenario exacerbated by a perceived lack of support or specific resources for carers of individuals on the autism spectrum. Clinical recommendations on the basis of the current and previous studies are outlined.