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  • 1.
    Birgegard, Andreas
    et al.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Abbaspour, Afrouz
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Borg, Stina
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Clinton, David
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Forsén Mantilla, Emma
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Savva, Androula
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Termorshuizen, Jet D.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Bulik, Cynthia M.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden.;Univ N Carolina, Dept Psychiat, Chapel Hill, NC 27515 USA.;Univ N Carolina, Dept Nutr, Chapel Hill, NC 27515 USA..
    Longitudinal experiences and impact of the COVID-19 pandemic among people with past or current eating disorders in Sweden2021Inngår i: Eating Disorders, ISSN 1064-0266, E-ISSN 1532-530X, Vol. 30, nr 6, s. 602-617Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The study aimed to document the impact of the COVID-19 pandemic on the health and well-being of individuals with past and current eating disorders (ED) in Sweden. We re-contacted participants with a known lifetime history of ED from two previous Swedish studies. Participants completed an online survey about health and functioning at baseline early in the pandemic (Wave 1 ca May/June 2020; N= 982) and six months later (Wave 2 Dec/Jan 2020/21; N= 646). Three important patterns emerged: 1) higher current ED symptoms were associated with greater anxiety, worry, and pandemic-related ED symptom increase; 2) patterns were fairly stable across time, although a concerning percentage (23%) who were symptom-free at Wave 1 reported the re-emergence of symptoms at Wave 2; and 3) only a minority of participants (<50%) with a current ED were in treatment, and of those in treatment, many reported fewer treatment sessions and decreased quality of care. The COVID-19 pandemic appears to pose serious health challenges for individuals with an ED, whether currently symptomatic or in remission. We encourage health service providers and patient advocates to be alert to the needs of individuals with ED and to take active measures to ensure access to appropriate evidence-based care both during and following the pandemic.

  • 2.
    Birgegard, Andreas
    et al.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden.;Karolinska Inst, MEB, Nobels Vag 12A, SE-17177 Stockholm, Sweden..
    Forsén Mantilla, Emma
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Breithaupt, Lauren E.
    Massachusetts Gen Hosp, Eating Disorders Clin & Res Program, Boston, MA USA.;Harvard Med Sch, Dept Psychiat, Boston, MA USA..
    Borg, Stina
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Sanzari, Christina M.
    SUNY Albany, Dept Psychol, Albany, NY USA.;Univ North Carolina Chapel Hill, Dept Psychiat, Chapel Hill, NC USA..
    Padalecki, Sophie
    Univ North Carolina Chapel Hill, Dept Psychiat, Chapel Hill, NC USA.;Elon Univ, Coll Arts & Sci, Dept Publ Hlth, Elon, NC USA..
    Hedlund, Elin
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Bulik, Cynthia M.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden.;Univ North Carolina Chapel Hill, Dept Psychiat, Chapel Hill, NC USA.;Univ North Carolina Chapel Hill, Dept Nutr, Chapel Hill, NC USA..
    Proposal for increasing diagnostic clarity in research and clinical practice by renaming and reframing atypical anorexia nervosa as "Restrictive Eating Disorder" (RED)2023Inngår i: Eating Behaviors, ISSN 1471-0153, E-ISSN 1873-7358, Vol. 50, artikkel-id 101750Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Atypical anorexia nervosa (AAN) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM5), is characterized by meeting all criteria for anorexia nervosa (AN) except for weight being within or above the "normal" range despite significant weight loss. The current definition is plagued by several problems, resulting in widely heterogeneous operationalizations in research and clinical practice. As such, the poorly defined diagnosis of AAN negatively impacts affected individuals and frustrates research attempts to better understand the syndrome. We consider conceptual flaws in the AAN description and contend that the undefined weight range and nature of weight loss renders these two factors functionally inapplicable in research and practice. They also represent a departure from the originally intended use of the AAN category, i.e., arresting a negative weight trajectory likely to result in AN, making the target population, and the application of the label, unclear. We propose revised criteria and a new name, restrictive eating disorder (RED), intended to reduce stigma and encompass a wide but better-defined range of presentations. The RED criteria focus on clinically significant restrictive behavior that disrupts normal living (i.e., impairment), and cognitive symptoms of overevaluation, disturbed experience, and lack of recognition of illness seriousness. We believe that RED may enable more appropriate clinical application, but also inspire coordinated research toward a more valid psychiatric nosology in the eating disorders field.

  • 3.
    Birgegard, Andreas
    et al.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Nobels Vag 12A, S-17177 Stockholm, Sweden..
    Forsén Mantilla, Emma
    Karolinska Inst, Dept Med Epidemiol & Biostat, Nobels Vag 12A, S-17177 Stockholm, Sweden..
    Dinkler, Lisa
    Karolinska Inst, Dept Med Epidemiol & Biostat, Nobels Vag 12A, S-17177 Stockholm, Sweden..
    Hedlund, Elin
    Karolinska Inst, Dept Med Epidemiol & Biostat, Nobels Vag 12A, S-17177 Stockholm, Sweden..
    Savva, Androula
    Karolinska Inst, Dept Med Epidemiol & Biostat, Nobels Vag 12A, S-17177 Stockholm, Sweden..
    Larsson, Henrik
    Karolinska Inst, Dept Med Epidemiol & Biostat, Nobels Vag 12A, S-17177 Stockholm, Sweden..
    Bulik, Cynthia M.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Nobels Vag 12A, S-17177 Stockholm, Sweden..
    Validity of eating disorder diagnoses in the Swedish national patient register2022Inngår i: Journal of Psychiatric Research, ISSN 0022-3956, E-ISSN 1879-1379, Vol. 150, s. 227-230Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The Swedish National Patient Register (NPR) includes population-level longitudinal data, and determining the validity of NPR diagnoses is critical to undergirding the research and policy recommendations they inform. Sweden also has the integrated "Riksa & BULL;t " and "Stepwise " National Quality Registers (QR), with data from specialized eating disorder (ED) treatment based on structured, valid assessment methods. To validate NPR ED diagnoses, we compared ICD-10-based anorexia nervosa (AN), bulimia nervosa (BN), and unspecified ED in NPR to DSM-IV-based AN, BN, and ED not otherwise specified category (EDNOS) in QR. Patients' first diagnoses registered in QR between February 2008 and August 2013 were compared with NPR diagnoses entered within & PLUSMN;1 month (N = 2074). QR registration includes the semi-structured DSM-IV-based Structured ED Interview. Each ED diagnosis was analyzed separately for degree of match using several indices: overall agreement, sensitivity, positive predictive value, specificity, negative predictive value, area under the curve, and Cohen's kappa. Results showed moderate to excellent agreement depending on estimate (e.g. positive predictive values AN: 0.747; BN:.836; EDNOS: 0.761), except for a somewhat low sensitivity for BN, and EDNOS agreement was overall the lowest. Case prevalence in the NPR and QR was highly similar for AN, and within five percentage points for BN and EDNOS. Generalizability is hampered by limited age range and diagnostic resolution as well as few males. Available data precluded study of presence/absence of ED, and complementary approaches are considered for future research. We conclude that NPR ED diagnoses have acceptable validity and are appropriate for use in research.

  • 4.
    Forsén Mantilla, Emma
    et al.
    Karolinska Inst, Dept Clin Neurosci, Resource Ctr Eating Disorders, S-11364 Stockholm, Sweden..
    Bergsten, Katja
    Uppsala Univ, Dept Psychol, S-75312 Uppsala, Sweden..
    Birgegard, Andreas
    Karolinska Inst, Dept Clin Neurosci, Resource Ctr Eating Disorders, S-11364 Stockholm, Sweden..
    Self-image and eating disorder symptoms in normal and clinical adolescents2014Inngår i: Eating Behaviors, ISSN 1471-0153, E-ISSN 1873-7358, Vol. 15, nr 1, s. 125-131Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Eating disorders (ED) are psychiatric disorders of multifactorial origin, predominantly appearing in adolescence. Negative self-image is identified as risk factor, but the association between self-image and ED in adolescents or sex differences regarding such associations remains unclear. The study aimed to investigate the relationship between specific self-image aspects and ED symptoms in normal and clinical adolescents, including sex differences. Participants included 855 ED patients (girls = 813, boys = 42) and 482 normal adolescents (girls = 238, boys = 244), 13-15 years. Stepwise regression demonstrated strong associations between self-image and ED in normal adolescents (girls: R-2 = .31, boys: R-2 = .08), and stronger associations in patients (girls: R-2 = .64, boys: R-2 = .69). Qualitative sex differences were observed in patients. Connections between specific self-image aspects and ED have implications for clinical management of ED. The strong link between self-image variables and ED symptoms in normal girls, but not boys, is discussed in terms of the continuity-discontinuity hypothesis. (C) 2013 Elsevier Ltd. All rights reserved.

  • 5.
    Forsén Mantilla, Emma
    et al.
    Karolinska Inst, Dept Clin Neurosci, Stockholm, Sweden..
    Birgegard, A.
    Karolinska Inst, Dept Clin Neurosci, Stockholm, Sweden..
    Insidious: The relationship between patients and their eating disorders and its impact on ED symptoms, illness duration and self-image2017Inngår i: European psychiatry, ISSN 0924-9338, E-ISSN 1778-3585, Vol. S41, nr S1, s. S552-S552Artikkel i tidsskrift (Annet vitenskapelig)
  • 6.
    Forsén Mantilla, Emma
    et al.
    Karolinska Inst, Dept Clin Neurosci, Resource Ctr Eating Disorders, Norra Stationsgatan 69,Plan 7, S-11364 Stockholm, Sweden..
    Birgegard, Andreas
    Karolinska Inst, Dept Clin Neurosci, Resource Ctr Eating Disorders, Norra Stationsgatan 69,Plan 7, S-11364 Stockholm, Sweden..
    Eating disorder examination questionnaire: Norms and clinical reference data from adolescent boys and girls in Sweden2016Inngår i: Psychiatry Research, ISSN 0165-1781, E-ISSN 1872-7123, Vol. 239, s. 156-162Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The study investigated norms and clinical reference values for the 14-day time frame version of the Eating Disorders Examination Questionnaire (EDE-Q) specifically developed to suit adolescent populations. The EDE-Q is a self-report instrument measuring problematic eating behaviors and attitudes. A general population sample (N=487, 239 girls and 248 boys) and a clinical sample (N=1051, 989 girls and 62 boys) aged 12-14 years were analyzed. Descriptive statistics for EDE-Q subscales and Global scale, as well as key behaviors, are presented, along with sex differences and diagnostic differences (clinical sample). General population sample sex differences were consistent and medium to large, with some evidence of floor effects for boys. In the clinical sample there was a main effect of gender, with girls scoring higher overall. The covariate age accounted for more variance in EDE-Q subscale scores than did diagnostic group. Results are discussed in terms of the appropriateness of the EDE-Q for boys, and possible denial of illness among patients. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

  • 7.
    Forsén Mantilla, Emma
    et al.
    Karolinska Inst, Dept Clin Neurosci, Norra Stn Gatan 69,7 Tr, S-11364 Stockholm, Sweden.;Stockholm Cty Council, Ctr Psychiat Res, Norra Stn Gatan 69,7 Tr, S-11364 Stockholm, Sweden..
    Birgegard, Andreas
    Karolinska Inst, Dept Clin Neurosci, Norra Stn Gatan 69,7 Tr, S-11364 Stockholm, Sweden.;Stockholm Cty Council, Ctr Psychiat Res, Norra Stn Gatan 69,7 Tr, S-11364 Stockholm, Sweden..
    Clinton, David
    Karolinska Inst, Dept Clin Neurosci, Norra Stn Gatan 69,7 Tr, S-11364 Stockholm, Sweden.;Stockholm Cty Council, Ctr Psychiat Res, Norra Stn Gatan 69,7 Tr, S-11364 Stockholm, Sweden.;Inst Eating Disorders, Kruses Gata 8, N-0263 Oslo, Norway..
    Factor analysis of the adolescent version of the Eating Disorders Examination Questionnaire (EDE-Q): results from Swedish general population and clinical samples2017Inngår i: Journal of Eating Disorders, E-ISSN 2050-2974, Vol. 5, artikkel-id 19Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Although the Eating Disorder Examination Questionnaire (EDE-Q) is perhaps the single most widely used self-report measure of eating disorder (ED) symptoms, important questions remain about its validity and applicability in relation to particular groups of individuals, especially adolescents of both genders. Methods: The present study investigated the factor structure of the adolescent version of the Eating Disorder Examination Questionnaire (EDE-Q) in samples of Swedish girls and boys from the general population and girls with a diagnosed eating disorder. Girls (N = 239) and boys (N = 248) aged between 13 and 15 years who were attending school, and girls (N = 570) aged between 12 and 14 years who were in treatment for an eating disorder at a specialist eating disorder clinic were assessed on the adolescent version of the EDE-Q. Results: The adolescent version of the EDE-Q demonstrated satisfactory levels of internal consistency. However, confirmatory factor analysis (CFA) failed to support the four-factor model of the EDE-Q. Parallel analysis (PA) and subsequent exploratory factor analysis (EFA) suggested that the adolescent version of the EDE-Q comprises one underlying factor in young adolescent girls (both clinical and general population), centred on Dissatisfaction with Shape and Weight. In boys three factors were found: Weight-related Concerns, Body Discomfort and Restraint. Conclusions: The EDE-Q appears to measure different underlying aspects of eating disorder psychopathology in young teenagers compared to adults. The dimensions underlying disordered eating in young girls may become increasingly differentiated with time. There appear to be important gender-based differences in the dimensions underlying the EDE-Q in young teenagers. Therapists should be alert to beliefs that girls have about the importance of shape and weight, while in boys it may be more important to be attentive to how they feel about their bodies in relation to weight.

  • 8. Forsén Mantilla, Emma
    et al.
    Birgegård, Andreas
    The enemy within: the association between self-image and eating disorder symptoms in healthy, non help-seeking and clinical young women2015Inngår i: Journal of Eating Disorders, E-ISSN 2050-2974, Vol. 3, artikkel-id 30Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Previous research has shown self-image according to the interpersonal Structural Analysis of SocialBehavior model, to relate to and predict eating disorder symptoms and outcomes.

    Methods: We examined associations between self-reported self-image and ED symptoms in three groups of 16–25year old females: healthy (N = 388), non help-seeking (N = 227) and clinical (N = 6384). Analyses were divided intoage groups of 16–18 and 19–25 years, and the patient sample was divided into diagnostic groups.

    Results: Stepwise regressions with self-image aspects as independent variables and eating disorder symptoms asdependent showed that low self-love/acceptance and high self-blame were associated with more eating disordersymptoms in all groups, except older patients with bulimia nervosa where self-hate also contributed. Associationswere generally weaker in the healthy groups and the older samples.

    Conclusions: We put forward that older age, low desirability of symptoms, poorly working symptoms, and beingacknowledged as ill, may weaken the association, with implications for treatment and prevention.

  • 9.
    Forsén Mantilla, Emma
    et al.
    Karolinska Inst, Dept Clin Neurosci, Ctr Psychiat Res, Norra Stn Gatan 69, S-11364 Stockholm, Sweden.;Stockholm Cty Council, Stockholm Hlth Care Serv, Stockholm, Sweden..
    Clinton, David
    Karolinska Inst, Dept Clin Neurosci, Ctr Psychiat Res, Norra Stn Gatan 69, S-11364 Stockholm, Sweden.;Stockholm Cty Council, Stockholm Hlth Care Serv, Stockholm, Sweden.;Inst Eating Disorders, Oslo, Norway..
    Birgegard, Andreas
    Karolinska Inst, Dept Clin Neurosci, Ctr Psychiat Res, Norra Stn Gatan 69, S-11364 Stockholm, Sweden.;Stockholm Cty Council, Stockholm Hlth Care Serv, Stockholm, Sweden..
    Insidious: The relationship patients have with their eating disorders and its impact on symptoms, duration of illness, and self-image2018Inngår i: Psychology and Psychotherapy: Theory, Research and Practice, ISSN 1476-0835, E-ISSN 2044-8341, Vol. 91, nr 3, s. 302-316Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    ObjectivesIn published clinical and autobiographical accounts of eating disorders, patients often describe their disorder in personified ways, that is, relating to the disorder as if it were an entity, and treatment often involves techniques of externalization. By encouraging patients to think about their eating disorder as a relationship, this study aimed to examine how young female patients experience their eating disorder as acting towards them, how they react in response, and whether these interactions are associated with symptoms, illness duration, and self-image. DesignStructural Analysis of Social Behavior (SASB) was used to operationalize how patients experience the actions of their eating disorder and their own reactions to the disorder. MethodThe relationship between patients (N=150) and their eating disorders was examined with respect to symptoms, duration of illness, and self-image. Patients were also compared on their tendency to react with affiliation in relation to their disorder. ResultsPatients' responses on the SASB indicated that they tended to conceptualize their eating disorders as blaming and controlling, and they themselves as sulking and submitting in response. Greater experience of the eating disorder as being controlling was associated with higher levels of symptomatology. Patients reacting with more negative affiliation towards their disorder were less symptomatic. ConclusionsWhen encouraging patients to think about their eating disorder as a relationship, comprehensible relationship patterns between patients and their eating disorders emerged. The idea that this alleged relationship may resemble a real-life relationship could have theoretical implications, and its exploration may be of interest in treatment. Practitioner points Patients were able to conceptualize their eating disorder as a significant other to whom they relate when encouraged to do so. Patients tended to experience their disorder as controlling and domineering. Exploring the hypothetical patient-eating disorder relationship may prove helpful in understanding dysfunctional relational patterns. Helping patients to rebel against their eating disorder could potentially aid in symptom reduction.

  • 10.
    Forsén Mantilla, Emma
    et al.
    Karolinska Inst, Stockholm Cty Council, Ctr Psychiat Res, Dept Clin Neurosci, Norra Stationsgatan 69,7 Tr, S-11364 Stockholm, Sweden..
    Clinton, David
    Karolinska Inst, Stockholm Cty Council, Ctr Psychiat Res, Dept Clin Neurosci, Norra Stationsgatan 69,7 Tr, S-11364 Stockholm, Sweden.;Inst Eating Disorders, Oslo, Norway..
    Birgegard, Andreas
    Karolinska Inst, Stockholm Cty Council, Ctr Psychiat Res, Dept Clin Neurosci, Norra Stationsgatan 69,7 Tr, S-11364 Stockholm, Sweden..
    The unsafe haven: Eating disorders as attachment relationships2019Inngår i: Psychology and Psychotherapy: Theory, Research and Practice, ISSN 1476-0835, E-ISSN 2044-8341, Vol. 92, nr 3, s. 379-393Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objectives Some patients with eating disorders (EDs) seem to experience their illness as an entity, a symbolic other to whom they relate, and which may influence both symptom levels and self-image. Extending previous research, this study investigated whether the patient-ED relationship has attachment qualities. Design Structural Analysis of Social Behaviour was used to operationalize the patient-ED relationship, and the Attachment Style Questionnaire was used to measure attachment. Method We examined ED patients' (N = 148) relationship with their ED, attachment behaviour, symptoms, and self-image. Attachment dimensions of Confidence, Anxious/ambivalence, and Avoidance were found to be significantly correlated with aspects of the patient-ED relationship. Introjection (i.e., whether ED actions were incorporated into patients' self-image) was investigated by examining the match between self-image profiles and the actions of patients' EDs. A double mediation model was tested in which ED control/emancipation and patients' Self-blame mediated the effect of attachment security on ED symptoms. Results Attachment insecurity was associated with greater ED control and patient submission. In 28.5% of patients, there was a high degree of correlation between self-image and ED action profile. Data supported the mediation model. Conclusions Attachment processes appear to be associated with the manner in which ED patients relate to their disorder, at least in some cases. Attempts to maintain psychological proximity to the ED as an introjected attachment figure may help to explain treatment resistance and ambivalence about change. This perspective may be useful in treatment. Practitioner points Attachment behaviours are associated with the patient-ED relationship, in which attachment insecurity is correlated with greater eating disorder control and patient submission. Some patients seem to incorporate the actions of the ED in their self-image, suggesting the presence of introjection. The patient-ED relationship may help explain patients' anxiety and ambivalence about change, seen from an attachment perspective. In treatment, it may be important to explore alternative safe havens and secure bases to the ED, such as interpersonal relationships and activities.

  • 11.
    Forsén Mantilla, Emma
    et al.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Clinton, David
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Monell, Elin
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Levallius, Johanna
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Birgegard, Andreas
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Impulsivity and compulsivity as parallel mediators of emotion dysregulation in eating-related addictive-like behaviors, alcohol use, and compulsive exercise2022Inngår i: Brain and Behavior, ISSN 2162-3279, E-ISSN 2162-3279, Vol. 12, nr 1, artikkel-id e2458Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Introduction Transdiagnostically relevant psychological traits associated with psychiatric disorders are increasingly being researched, notably in substance use and addictive behaviors. We investigated whether emotion dysregulation mediated by impulsivity and/or compulsivity could explain variance in binge eating, food addiction, self-starvation, and compulsive exercise, as well as alcohol use (addictive-like behaviors relevant to the obesity and eating disorder fields). Method A general population sample of adults (N = 500, mean age = 32.5 years), females (n = 376) and males (n = 124), completed the Difficulties in Emotion Regulation Scale-16, the Trait Rash Impulsivity Scale, the Obsessive-Compulsive Inventory-Revised, the Eating Disorders Examination Questionnaire, the Self-Starvation Scale, the Exercise Dependence Scale, the Yale Food Addiction Scale, and the Alcohol Use Disorders Identification Test online. Besides gender comparisons and intercorrelations between measures, we used predefined multiple mediation models with emotion dysregulation as independent variable, impulsivity and compulsivity as parallel mediators, to investigate whether these factors contributed explanatory power to each addictive-like behavior as outcome, also using age and body mass index as covariates. Results Females scored higher than males on emotion dysregulation and the eating-related addictive-like behaviors food addiction, self-starvation, and binge eating. Intercorrelations between measures showed that emotion dysregulation and compulsivity were associated with all outcome variables, impulsivity with all except compulsive exercise, and the eating-related behaviors intercorrelated strongly. Mediation models showed full or partial mediation of emotion dysregulation for all behaviors, especially via compulsivity, suggesting a behavior-specific pattern. Mediation models were not affected by age or gender. Discussion Addictive-like behaviors seemed to be maintained by trait levels of emotion dysregulation, albeit channeled via trait levels of compulsivity and/or impulsivity. The role of emotion dysregulation may help us to understand why addictive-like behaviors can be difficult to change in both clinical and nonclinical groups, and may be informative for treatment-planning in patients where these behaviors are present. Our findings support adopting a more dimensional approach to psychiatric classification by focusing psychological facets such as those studied.

  • 12.
    Forsén Mantilla, Emma
    et al.
    Karolinska Inst, Dept Clin Neurosci, Ctr Psychiat Res, Norra Stationsgatan 69,7 Tr, S-11364 Stockholm, Sweden. Stockholm Cty Council, Stockholm Hlth Care Serv, Norra Stationsgatan 69,7 Tr, S-11364 Stockholm, Sweden..
    Levallius, Johanna
    Monell, Elin
    Birgegard, Andreas
    Exercise Caution: Questions to Ask Adolescents Who May Exercise Too Hard2018Inngår i: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 15, nr 4, artikkel-id 797Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    When the primary goal of exercise is to compensate for food intake and to alter body shape and weight, it is considered compulsive and may be harmful. Compulsive exercise (CE) is important in the pathogenesis of eating disorders (EDs). Many healthy adolescents engage in CE too, and this may indicate a risk for EDs. Our aim was to learn more about ED risk factors tied to CE and to try to isolate questions to ask in order to probe for high ED risk in adolescents engaging in CE. Using two well-established instruments (the Structural Analysis of Social Behavior and the Eating Disorders Examination Questionnaire), we studied associations between ED variables and CE in healthy adolescent boys and girls. We examined gender-specific items to generate the best possible fit for each gender. Individuals with CE displayed significantly greater ED pathology and more self-criticism, and this pattern was stronger in girls than in boys. Risk factors for ED among individuals with CE differed slightly for boys and girls. We put forward a set of gender-specific questions that may be helpful when probing for ED risk among adolescents engaging in CE.

  • 13.
    Forsén Mantilla, Emma
    et al.
    Karolinska Inst, Dept Clin Neurosci, Norra Stn Gatan 69, SE-11364 Stockholm, Sweden.;Stockholm Cty Council, Ctr Psychiat Res, Norra Stn Gatan 69, SE-11364 Stockholm, Sweden..
    Norring, Claes
    Karolinska Inst, Dept Clin Neurosci, Norra Stn Gatan 69, SE-11364 Stockholm, Sweden.;Stockholm Cty Council, Ctr Psychiat Res, Norra Stn Gatan 69, SE-11364 Stockholm, Sweden..
    Birgegard, Andreas
    Karolinska Inst, Dept Clin Neurosci, Norra Stn Gatan 69, SE-11364 Stockholm, Sweden.;Stockholm Cty Council, Ctr Psychiat Res, Norra Stn Gatan 69, SE-11364 Stockholm, Sweden..
    Self-image and 12-month outcome in females with eating disorders: extending previous findings2019Inngår i: Journal of Eating Disorders, E-ISSN 2050-2974, Vol. 7, artikkel-id 15Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BackgroundThe interpersonal Structural Analysis of Social Behavior (SASB) model of self-image has repeatedly proven valuable in relation to eating disorder (ED) symptoms and in predicting ED outcome.ObjectiveWe studied the association between initial self-image according to the SASB and 12-month outcome, in five diagnostic groups of female ED patients. Based on previous findings, we expected autonomy related variables (self-control/autonomy) would strongly predict outcome in anorexia nervosa (AN) groups, whereas variables related to affiliation (self-attack/love) would moderately predict outcome in bulimia nervosa (BN).MethodParticipants were adult female patients, of whom 457 had AN restrictive type, 228 AN binge/purge subtype, 861 BN, 505 other specified ED and 170 binge eating disorder. Data came from the Stepwise clinical database in Sweden. Outcomes were presence/absence of ED diagnosis and self-rated ED symptoms, and we controlled for baseline ED pathology, BMI, age and general psychiatric symptoms.ResultsRegression analyses showed that although the pattern differed somewhat between diagnostic groups, high initial self-love and low self-attack/self-blame predicted a more positive 12-month outcome. In some groups (AN/R in particular), these variables remained important even when baseline pathology and age were included in the analyses.DiscussionSelf-image aspects once again display substantial power in predicting outcome in EDs. In AN/R patients, self-love plays an almost as crucial a role as baseline ED pathology in relation to 12-month outcome.

  • 14.
    Levallius, Johanna
    et al.
    Karolinska Inst, Ctr Eating Disorders Innovat, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Monell, Elin
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Stockholm, Sweden.;Stockholm Cty Council, Stockholm Hlth Care Serv, Stockholm, Sweden..
    Birgegard, Andreas
    Karolinska Inst, Ctr Eating Disorders Innovat, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Clinton, David
    Karolinska Inst, Ctr Eating Disorders Innovat, Dept Med Epidemiol & Biostat, Stockholm, Sweden.;Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Stockholm, Sweden.;Stockholm Cty Council, Stockholm Hlth Care Serv, Stockholm, Sweden.;Inst Eating Disorders, Oslo, Norway..
    Forsén Mantilla, Emma
    Karolinska Inst, Ctr Eating Disorders Innovat, Dept Med Epidemiol & Biostat, Stockholm, Sweden.;Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Stockholm, Sweden.;Stockholm Cty Council, Stockholm Hlth Care Serv, Stockholm, Sweden..
    Binge Eating and Addictive-Like Behaviours in Males and Females2022Inngår i: Psychological Reports, ISSN 0033-2941, E-ISSN 1558-691X, Vol. 125, nr 1, s. 148-166, artikkel-id 0033294120971750Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Introduction Binge eating is a common behaviour that is strongly linked to both obesity and eating disorder. There is evidence that binge eating commonly co-occurs with other problematic and addictive-like behaviours; however, this has not been explored systematically. The present study aimed to examine the relationship between binge eating, body weight, disordered eating behaviours and associated addictive-like behaviours, with particular attention paid to gender differences. Method A community sample (N = 500; 75% female, M-age = 32.5 years) reported disordered eating behaviours (i.e. binge eating, purging, restriction of eating, compulsive exercise), body mass index (BMI), food addiction, starvation addiction, exercise dependence, tobacco use and alcohol consumption. Results 42% of females and 21% of males reported binge eating during the past four weeks. Binge eating was significantly associated with all investigated behaviours in females, and with purging, compulsive exercise and overweight/obesity in males. Controlling for BMI, self-starvation predicted binge eating in males (OR = 1.07), while food addiction (OR = 1.73) and alcohol dependence (OR = 1.11) predicted binge eating in females. Conclusions The multiple associations between binge eating and addictive-like behaviors supports broad screening and generalized prevention efforts. Prevention efforts should reflect gender differences.

  • 15. Monell, Elin
    et al.
    Högdahl, Louise
    Forsén Mantilla, Emma
    Birgegård, Andreas
    Emotion dysregulation, self-image and eating disorder symptoms in University Women2015Inngår i: Journal of Eating Disorders, E-ISSN 2050-2974, Vol. 3, nr 1, artikkel-id 44Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: We studied associations between emotion dysregulation, self-image and eating disorder (ED)symptoms in university women, and contrasted two indirect effect models to examine possible interveningmechanisms to produce ED symptoms.

    Methods: 252 female Swedish university students completed the Difficulties in Emotion Regulation Scale(DERS), the Structural Analysis of Social Behavior (SASB) self-image measure, and the Eating DisorderExamination Questionnaire (EDE-Q). Correlations between scales were followed by five simple mediationanalysis pairs with two possible pathways using five ED symptom variables as outcome. The models positedeither self-image or emotion dysregulation as mediator or independent variable, respectively. ED symptomswere EDE-Q Global score, objective binge eating episodes (OBE), subjective binge eating episodes (SBE), andtwo variants of EDE-Q excessive exercise.

    Results: Emotion dysregulation and self-image were strongly correlated, and both correlated moderately withEDE-Q Global score. There were distinct indirect effects through self-image on the relationship between emotiondysregulation and ED symptoms, but not vice versa. These indirect effects were evident in relation to cognitive EDsymptoms and both OBE and SBE, but not in relation to excessive exercise.

    Conclusions: Results suggest that even if closely related, emotion dysregulation and self-image both contributeunique knowledge in relation to ED symptoms. Self-image as an intervening mechanism between emotiondysregulation and ED symptoms is relevant for models of the development, maintenance and treatment of ED, as wellas treatment focus.

  • 16.
    Monell, Elin
    et al.
    Karolinska Inst, Dept Clin Neurosci, Ctr Psychiat Res, Stockholm, Sweden.;Stockholm Cty Council, Stockholm Hlth Care Serv, Stockholm, Sweden..
    Levallius, Johanna
    Karolinska Inst, Dept Clin Neurosci, Ctr Psychiat Res, Stockholm, Sweden.;Stockholm Cty Council, Stockholm Hlth Care Serv, Stockholm, Sweden..
    Forsén Mantilla, Emma
    Karolinska Inst, Dept Clin Neurosci, Ctr Psychiat Res, Stockholm, Sweden.;Stockholm Cty Council, Stockholm Hlth Care Serv, Stockholm, Sweden..
    Birgegard, Andreas
    Karolinska Inst, Dept Clin Neurosci, Ctr Psychiat Res, Stockholm, Sweden.;Stockholm Cty Council, Stockholm Hlth Care Serv, Stockholm, Sweden..
    Running on empty - a nationwide large-scale examination of compulsive exercise in eating disorders2018Inngår i: Journal of Eating Disorders, E-ISSN 2050-2974, Vol. 6, artikkel-id 11Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Compulsive exercise (CE) has been the neglected "Cinderella" among eating disorder (ED) symptoms, even though it seems to impact severity, treatment and outcome. This prompted a large-scale and systematic examination of the impact of CE in a representative ED sample. Methods: CE was examined in over 9000 female and male patients from a clinical ED database (covering out-patient, day and/or residential treatment) with respect to prevalence, ED diagnosis, ED symptoms, clinical features, patient characteristics, and outcome at 1-year follow-up. Relationships between changes in CE behavior and remission were also examined. Results: CE was a transdiagnostic symptom, present in nearly half of all patients (48%). It was associated with greater overall ED pathology, particularly dietary restraint, and negative perfectionism. Initial CE did not impact remission rate, but patients continuing or starting CE during treatment had considerably lower remission rates compared to patients who never engaged in, or ceased with, CE. Results were comparable for females and males. Conclusions: At baseline, there were few differences between patients with and without CE, except a somewhat higher symptom load for patients with CE, and CE did not predict ED outcome. However, how CE developed during treatment to 1-year follow-up considerably impacted remission rates. We strongly recommend CE to be systematically assessed, addressed, and continuously evaluated in all ED patients seeking treatment.

  • 17.
    Monell, Elin
    et al.
    Karolinska Inst, Dept Med Biostat & Epidemiol, Stockholm, Sweden.;Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Stockholm, Sweden.;Stockholm Hlth Care Serv, Stockholm, Sweden..
    Meyer, Caroline
    Univ Warwick, WMG, Coventry, W Midlands, England.;Univ Warwick, Warwick Med Sch, Coventry, W Midlands, England.;Warwickshire NHS Partnership Trust, Coventry, W Midlands, England..
    Szwajda, Agnieszka
    Karolinska Inst, Dept Med Biostat & Epidemiol, Stockholm, Sweden..
    Forsén Mantilla, Emma
    Karolinska Inst, Dept Med Biostat & Epidemiol, Stockholm, Sweden.;Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Stockholm, Sweden.;Stockholm Hlth Care Serv, Stockholm, Sweden..
    Taking the LEAP: study protocol for a randomized, multicentre, naturalistic, efficacy trial of the compuLsive Exercise Activity theraPy (LEAP) - a cognitive behavioral program specifically targeting compulsive exercise in patients with eating disorders2021Inngår i: BMC Psychiatry, E-ISSN 1471-244X, Vol. 21, nr 1, artikkel-id 369Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background About half of Swedish eating disorder patients report exercising compulsively and compulsive exercise (CE) is prevalent in all diagnoses and both genders. Yet there are no systematic treatments targeting CE in specialist care. This study aims to evaluate the effects of The CompuLsive Exercise Activity TheraPy (LEAP) - a promising group treatment targeting compulsive exercise, in Swedish eating disorder patients. Method One hundred twenty-eight adult females and males suffering from anorexia nervosa, bulimia nervosa or other specified feeding and eating disorders (type 1, 2, or 4) with CE will be recruited via four specialist eating disorder treatment units. Participants will be randomized to receive treatment as usual (control group) or treatment as usual plus LEAP (intervention group). The groups will be assessed on key variables (e.g., BMI, eating disorder symptoms, exercise cognitions and behaviors) at three occasions: initially, after 3 months and after 6 months. Discussion The project takes place in a clinical setting, including both male and female patients with different eating disorder diagnoses with CE, enabling a good indication of the efficacy of LEAP. If our results are positive, LEAP has the potential of benefiting about half of the eating disorder population, with remission and recovery hopefully improving as a result.

  • 18.
    Petersson, Suzanne
    et al.
    Kalmar Reg Council, Dept Rehabil, Hus 13,Plan 7, S-39185 Lanssjukhuset, Kalmar, Sweden.;Linnaeus Univ, Dept Med & Optometry, Kalmar, Sweden..
    Birgegard, Andreas
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Brudin, Lars
    Region Kalmar Cty, Dept Clin Physiol, Kalmar, Sweden.;Linkoping Univ, Dept Med & Hlth Sci, Linkoping, Sweden..
    Forsén Mantilla, Emma
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden.;Karolinska Inst, Stockholm Hlth Care Serv, Ctr Psychiat Res, Stockholm, Sweden.;Karolinska Inst, Dept Clin Neurosci, Stockholm, Sweden..
    Monell, Elin
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Clinton, David
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden.;Inst Eating Disorders, Oslo, Norway..
    Bjorck, Caroline
    Karolinska Inst, Dept Neurobiol Care Sci & Soc NVS, Stockholm, Sweden..
    Initial self-blame predicts eating disorder remission after 9 years2021Inngår i: Journal of Eating Disorders, E-ISSN 2050-2974, Vol. 9, nr 1, artikkel-id 81Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background Research into predictors of outcome in eating disorders (ED) has shown conflicting results, with few studies of long-term predictors and the possible importance of psychological variables that may act as risk- and maintenance factors. Aim To identify baseline predictors of ED remission nine years after initial clinical assessment using self-report measures of ED psychopathology, psychiatric symptoms, and self-image in a sample of adult ED patients (N = 104) treated at specialist units in Stockholm, Sweden. Sixty patients participated in the follow-up, of whom 41 patients (68%) had achieved remission. Results Results suggested that the only significant predictor of diagnostic remission after nine years was initial levels of self-blame. Conclusion In order to ensure long-term recovery in ED it may be important for clinicians to widen their therapeutic repertoire and utilise techniques that reduce self-blame and increase self-compassion. Plain English summary It is difficult to predict how an eating disorder will develop, and research has found varying factors that affect the outcome of the condition. Recovery rates vary from nearly nil to over 90%. This variation could be explained by different research factors, but are more likely due to varying definitions of 'recovery', with less stringent definitions yielding high recovery rates and more stringent definitions yielding lower rates. The present study investigated whether the severity of eating disorder symptoms and other psychiatric symptoms could predict recovery nine years from first admission to specialised eating disorder care. Sixty patients at three eating disorder treatment units participated, and their scores on self-report measures of symptoms were used as predictor variables. Forty-one participants had no eating disorder diagnosis at nine-year follow-up. Most participants with binge-eating disorder had recovered, while the poorest outcome was found for anorexia nervosa with slightly over half of patients recovered after nine years. The only predictor for the nine-year outcome was a higher initial rating of self-blame, measured with the Structural Analysis of the Social Behavior. It was concluded that it may be important for clinicians to detect and address self-blame early in the treatment of eating disorders in order to enhance the possibility of recovery. Treatment should focus on reducing self-blame and increasing self-acceptance.

  • 19.
    Selenius, Sofia
    et al.
    Natl Eating Disorders Patient & Advocacy Org, Frisk & Fri Riksforeningen Mot Atstorningar, Inedalsgatan 5, S-11233 Stockholm, Sweden..
    Birgegard, Andreas
    Karolinska Inst, Dept Med Epidemiol & Biostat MEB, Nobels Vag 12A, S-17177 Stockholm, Sweden..
    Forsén Mantilla, Emma
    Natl Eating Disorders Patient & Advocacy Org, Frisk & Fri Riksforeningen Mot Atstorningar, Inedalsgatan 5, S-11233 Stockholm, Sweden.;Karolinska Inst, Dept Med Epidemiol & Biostat MEB, Nobels Vag 12A, S-17177 Stockholm, Sweden..
    Preliminary evaluation of the online course "I Care" targeting eating disorder knowledge and attitudes among sports coaches and fitness instructors2022Inngår i: Journal of Eating Disorders, E-ISSN 2050-2974, Vol. 10, nr 1, artikkel-id 142Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Plain English summary Fitness instructors, coaches and trainers are often looked up to within their sporting community. They are also likely to meet individuals at risk for developing eating disorders, since excessive or compulsive exercise is a common symptom of these disorders. Coaches therefore need to know more about how to promote healthy ideals and how to detect and approach individuals at risk of developing an eating disorder. We studied if a brief online education called I Care could improve personal compulsive exercise tendencies, knowledge about eating disorders, and readiness to approach individuals seemingly at risk, in 150 coaches, trainers, and fitness instructors. We found that coaches felt more confident and knowledgeable about warning signs and how to approach a person at risk after completing I Care. They also showed increased insight about EDs not being recognizable just by looking at a person and their attitudes about their own exercise behavior changed in a positive way. Although the lack of a comparison group makes conclusions tentative, I Care may have positive effects in terms of a "declaration of intent" toward more positive role-modeling and interactions with clients. Background Fitness instructors, coaches and trainers are often looked up to and seen as role-models within their sporting community. Since problematic exercise is a common symptom of eating disorders, they are also highly likely to meet individuals at risk for developing eating disorders within their profession. Thus, educating coaches about how to promote healthy ideals within their sports/training context and equipping them with knowledge to be able to detect and approach individuals at risk, is of great importance. Method We studied the pre-to-post effects of the I Care online psychoeducational intervention in 150 coaches, trainers, and fitness instructors. Variables included the Compulsive Exercise Test, as well as knowledge of eating disorders, and confidence and awareness regarding approaching, talking to, and referring individuals whose observed behavior raised concerns. Results Results showed significant and large improvements in coaches' confidence and knowledge regarding warning signs and how to approach an at-risk person, and a decrease in their perceived ability to recognize eating disorders by sight, e.g., insight about EDs not being recognizable just by looking at a person. Also, significant positive change in attitudes about their own rule-driven exercise behavior and lack of enjoyment of exercise was observed. Conclusions Although the lack of a control group compels caution, the study suggests that I Care may have positive effects in terms of a "declaration of intent" toward more positive role-modeling and interactions with clients.

  • 20.
    Termorshuizen, Jet D.
    et al.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden.;GGZ Rivierduinen Eating Disorders Ursula, Leiden, South Holland, Netherlands..
    Sun, Quan
    Univ N Carolina, Dept Biostat, Chapel Hill, NC 27599 USA..
    Borg, Stina
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Forsén Mantilla, Emma
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Goode, Rachel W.
    Univ N Carolina, Sch Social Work, Chapel Hill, NC 27599 USA.;Univ N Carolina, Dept Psychiat, CB 7160,101 Manning Dr, Chapel Hill, NC 27599 USA..
    Peat, Christine M.
    Univ N Carolina, Dept Psychiat, CB 7160,101 Manning Dr, Chapel Hill, NC 27599 USA..
    Thornton, Laura M.
    Univ N Carolina, Dept Psychiat, CB 7160,101 Manning Dr, Chapel Hill, NC 27599 USA..
    Watson, Hunna
    Univ N Carolina, Dept Psychiat, CB 7160,101 Manning Dr, Chapel Hill, NC 27599 USA.;Curtin Univ, Sch Populat Hlth, Discipline Psychol, Perth, WA, Australia.;Univ Western Australia, Sch Med, Div Paediat, Perth, WA, Australia..
    van Furth, Eric F.
    GGZ Rivierduinen Eating Disorders Ursula, Leiden, South Holland, Netherlands.;Leiden Univ, Med Ctr, Dept Psychiat, Leiden, South Holland, Netherlands..
    Birgegard, Andreas
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Bulik, Cynthia M.
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden.;Univ N Carolina, Dept Psychiat, CB 7160,101 Manning Dr, Chapel Hill, NC 27599 USA.;Univ N Carolina, Dept Nutr, Chapel Hill, NC 27599 USA..
    Longer-term impact of COVID-19 among individuals with self-reported eating disorders in the United States, the Netherlands, and Sweden2023Inngår i: International Journal of Eating Disorders, ISSN 0276-3478, E-ISSN 1098-108X, Vol. 56, nr 1, s. 80-90Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective We assessed eating disorder (ED) illness status, symptomatology, treatment access, anxiety, and depression in the first year of the COVID-19 pandemic among individuals with a pre-existing ED in the United States (US), the Netherlands (NL), and Sweden (SE). Methods Participants completed online surveys in April-July 2020, at the early stage of the pandemic, and one year later. At one-year follow-up, we added questions addressing retrospective changes in ED symptoms, treatment, and anxiety/depression since the start of the COVID-19 pandemic. We present descriptive statistics and assess change in ED symptomatology, treatment, and anxiety/depression among those with an active or lingering ED. Results Participants (US n = 132; NL n = 219; SE n = 702) were mostly young and female with a history of anorexia nervosa (>60% in all three countries). Across countries, respondents reported impact of COVID-19 on ED symptoms at both time points, with improvement in US and NL at one-year follow-up, and stable but less impact on ED symptoms in SE. Furthermore, at one-year follow-up, roughly half of those in treatment reported reduced treatment access and quality, and the majority of the sample reported increased anxiety and depressive mood since the start of the pandemic. Discussion Our findings suggest that the self-perceived impact of COVID-19 changed over time but remained concerning even one year after the start of the pandemic. Clinicians, community organizations, and policy makers are encouraged to address potentially changing treatment needs in the face of public health emergency events. Public Significance Our findings suggest that the impact of COVID-19 on individuals with eating disorders decreased over time but remained concerning even one year after the start of the pandemic and that the impact differed across countries. Clinicians, community organizations, and policy makers are encouraged to incorporate this knowledge to address potentially changing treatment needs in the face of public health emergency events.

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