Weight reduction in obese adolescents with and without binge eating

Little is known about binge eating (BE) in adolescents. The primary aim of the present study was to examine the relationship between BE and weight loss in adolescents (BMI ≥95th percentile) enrolled in a randomized controlled trial of behavioral and pharmacologic treatment of obesity. Participants were 82 treatment-seeking adolescents (BMI = 37.9 ± 3.8 kg/m(2); age = 14.1 ± 1.2 years; 67% females; 42% African American, 55% white). Participants completed the Children's Depression Inventory (CDI), the Piers Harris Self-Esteem Questionnaire, and the Eating Inventory (including cognitive restraint, disinhibition, and hunger scales). BE was assessed by a questionnaire and a confirmatory interview. At baseline, 24% of participants met criteria for BE (N = 13 met full BE disorder (BED) criteria; N = 7 met subthreshold BE). There were no significant differences in percentage reduction in initial BMI between participants with or without BE at month 6 (-7.0 ± 1.6 vs. -6.9 ± 0.9%) or month 12 (-8.8 ± 2.4 vs. -8.3 ± 1.3%) (omnibus main effect BE P = 0.89, interaction BE × time P = 0.84, interaction BE × drug P = 0.61). The rate of BE declined significantly over time from 24% (n = 20) at baseline to 8% (n = 6) at month 6 and 3% (n = 2) at month 12 (P = 0.003). There were significant decreases in hunger and disinhibition as well as an increase in cognitive restraint over time (all P ≤ 0.0001). Findings suggest a combination of behavioral and pharmacologic therapy may produce both weight loss and improvement in BE.

Outcome of dialectical behaviour therapy for concurrent eating and substance use disorders

AIM

The current study examined the preliminary efficacy of dialectical behaviour therapy (DBT) adapted for concurrent eating disorders (EDs) and substance use disorders (SUDs).

METHOD

A matched randomized controlled trial was carried out with 25 female outpatients diagnosed with concurrent ED and SUD. Participants randomized to the intervention condition received DBT, whereas those randomized to the control condition received treatment as usual (TAU), both for a period of 1 year. A series of measures related to disordered eating, substance use and depression were administered to the participants at the beginning of treatment and at 3, 6, 9 and 12 months into treatment, followed by 3-month and 6-month follow-up assessments.

FINDINGS

Participants randomized to the DBT condition evidenced a superior retention rate relative to their counterparts in the TAU condition at various study time points, including post-treatment (80% versus 20%) and follow-up (60% versus 20%). Due to the unexpected elevated dropout rates and the worsening of ED-SUD symptomatology in the TAU condition, recruitment efforts were terminated early. Results from the DBT condition revealed that the intervention had a significant positive effect on behavioural and attitudinal features of disordered eating, substance use severity and use, negative mood regulation and depressive symptoms. Finally, increases in participants' perceived ability to regulate and cope with negative emotional states were significantly associated with decreases in emotional eating and increases in levels of confidence in ability to resist urges for substance use.

CONCLUSION

Results suggest that the adapted DBT might hold promise for treating individuals with concurrent ED and SUD.

KEY PRACTITIONER MESSAGE

The current study is the first study to report positive effects of DBT on individuals with concurrent eating and substance use disorders. Although the results require replication and extension, they suggest that the DBT may be promising for this population. The results suggest that clinicians treating individuals with concurrent eating and substance use problems should be particularly cautious of poor treatment retention and treatment complications. The results bear upon the highly salient and important issue of whether individuals with concurrent substance use need to be excluded from research studies and treatment programmes.

Clarifying boundaries of binge eating disorder and psychiatric comorbidity: a latent structure analysis

Binge eating disorder (BED) presents with substantial psychiatric comorbidity. This latent structure analysis sought to delineate boundaries of BED given its comorbidity with affective and anxiety disorders. A population-based sample of 151 women with BED, 102 women with affective or anxiety disorders, and 259 women without psychiatric disorders was assessed with clinical interviews and self-report-questionnaires. Taxometric analyses were conducted using DSM-IV criteria of BED and of affective and anxiety disorders. The results showed a taxonic structure of BED and of affective and anxiety disorders. Both taxa co-occurred at an above-chance level, but also presented independently with twice-as-large probabilities. Within the BED taxon, diagnostic co-occurrence indicated greater general psychopathology, lower social adaptation, and greater premorbid exposure to parental mood and substance disorder, but not greater eating disorder psychopathology. Eating disorder psychopathology discriminated individuals in the BED taxon from individuals in the affective and anxiety disorders taxon. Diagnostic criteria of BED were more indicative of the BED taxon than were criteria of affective and anxiety disorders. The results show that at the latent level, BED was co-occurring with, yet distinct from, affective and anxiety disorders and was not characterized by an underlying affective or anxiety disorder.

Factors associated with binge eating disorder in pregnancy

OBJECTIVE

To identify factors associated with incidence and course of broadly defined binge eating disorder (BED) in pregnancy.

METHOD

As a part of the Norwegian Mother and Child Cohort Study (MoBa), 45,644 women completed a questionnaire at approximately 18 weeks of gestation.

RESULTS

Incidence of BED was significantly associated with lifetime sexual abuse, lifetime physical abuse, lifetime major depression, symptoms of anxiety and depression, low life satisfaction, low self-esteem, low partner relationship satisfaction, smoking, alcohol use, lack of social support, and several weight-related factors. Continuation was negatively associated with thoughts of being overweight before pregnancy. Remission was positively associated with thoughts of being overweight before pregnancy and negatively associated with overvaluation of weight.

DISCUSSION

Onset of BED in pregnancy was associated with psychological, social and weight-related factors, as well as health behaviors and adverse life events. In women with prepregnancy BED, thoughts of being overweight before pregnancy and overvaluation of weight were associated with course of BED during pregnancy.

Mindfulness-Action Based Cognitive Behavioral Therapy for concurrent Binge Eating Disorder and Substance Use Disorders

Individuals with Binge Eating Disorder (BED) often evidence comorbid Substance Use Disorders (SUD), resulting in poor outcome. This study is the first to examine treatment outcome for this concurrent disordered population. In this pilot study, 38 individuals diagnosed with BED and SUD participated in a 16-week group Mindfulness-Action Based Cognitive Behavioral Therapy (MACBT). Participants significantly improved on measures of objective binge eating episodes; disordered eating attitudes; alcohol and drug addiction severity; and depression. Taken together, MACBT appears to hold promise in treating individuals with co-existing BED-SUD.

Eating disorders, obesity and addiction

An addiction model of both eating disorders and obesity has received increasing attention in the popular and scientific literature. The addiction is viewed as a brain disease that must be directly targeted if treatment is to succeed. Evidence from laboratory feeding studies, epidemiology, genetic and familial research, psychopathological mechanisms, and treatment outcome research on cognitive behaviour therapy (CBT) is inconsistent with the clinical validity or utility of the addiction model of eating disorders. Neurobiological research has shown commonalities in brain reward processes between obesity and substance abuse disorders. Yet emphasis on apparent similarities overlooks important differences between obesity and drug addiction. Interest in obesity as a brain disease should not detract from a public health focus on the 'toxic food environment' that is arguably responsible for the obesity epidemic and related nutrition-based chronic disease.

Dialectical behaviour therapy and an added cognitive behavioural treatment module for eating disorders in women with borderline personality disorder and anorexia nervosa or bulimia nervosa who failed to respond to previous treatments. An open trial with a 15-month follow-up

There is evidence from case studies suggesting that adapted dialectical behavior therapy (DBT) for borderline personality disorder (BPD) and eating disorders (ED) might improve disorder related complaints. Twenty-four women with BPD (9 with comorbid anorexia nervosa [AN] and 15 with bulimia nervosa [BN]), who already had failed to respond to previous eating-disorder related inpatient treatments were consecutively admitted to an adapted inpatient DBT program. Assessment points were at pre-treatment, post-treatment, and 15-month follow-up. At follow-up, the remission rate was 54% for BN, and 33% for AN. Yet 44% of women with AN crossed over to BN and one woman additionally met the criteria of AN. For women with AN, the mean weight was not significantly increased at post-treatment, but had improved at follow-up. For women with BN, the frequency of binge-eating episodes was reduced at post-treatment as well as at follow-up. Self-rated eating-related complaints and general psychopathology, as well as ratings on global psychosocial functioning, were significantly improved at post-treatment and at follow-up. Although these findings support the assumption that the adapted DBT inpatient program is a potentially efficacious treatment for those who failed to respond to previous eating-disorder related inpatient treatments, remission rates and maintained eating-related psychopathology also suggest that this treatment needs further improvement.

Associations of negative affect and eating behaviour in obese women with and without binge eating disorder

The present study was planned to investigate differences in psychopathological features, eating behaviour and eating habits between obese women with and without BED. It also aimed to identify specific relationships between affective symptoms and eating behaviour in obese women with BED. Eighty-four obese women were studied (40 with BED, 44 non-BED). Psychiatric comorbidities were assessed with the structured diagnostic interview for DSM-IV (SCID). Depressive symptoms were measured with the Beck Depression Inventory (BDI) and anxiety with the state-trait anxiety inventory (STAI). Eating habits (emotional and restrained eating) were assessed by the Dutch eating behaviour questionnaire (DEBQ). Food diaries were used for assessing naturalistic eating behaviour (food intake) and mood before and after food intake. BED subjects exhibited higher levels of comorbidity (in particular mood disorders, anxiety disorders and substance-related disorders), higher depressive symptoms, trait anxiety, external and emotional eating scores than non-BED subjects. Regression analyses revealed that anxiety and emotional eating were significant predictors for BED status. In the BED group, depressive symptoms were significantly related to emotional eating and food intake and negatively related to restraint. Anxiety was significantly related to emotional eating. In general, food intake significantly enhanced mood. Mood was worse on the days with self-reported binge eating episodes than on nonbinge days. These results are discussed with regard to aetiological models for BED and for BED being a distinct diagnostic category separate from obesity.

Psychiatric, behavioral, and attitudinal correlates of avoidant and obsessive-compulsive personality pathology in patients with binge-eating disorder

OBJECTIVE

We examined correlates of avoidant and obsessive-compulsive personality pathology--with respect to psychiatric comorbidity, eating disorder psychopathology, and associated psychologic factors--in patients with binge-eating disorder (BED).

METHOD

Three hundred forty-seven treatment-seeking patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), research criteria for BED were reliably assessed with semistructured interviews to evaluate DSM-IV Axis I disorders, personality disorders, and behavioral and attitudinal features of eating disorder psychopathology.

RESULTS

Fifteen percent of subjects had avoidant personality disorder features, 12% had obsessive-compulsive personality disorder features, 8% had features of both disorders, and 66% had features of neither. These groups differed significantly in the frequencies of depressive and anxiety disorders, as well as on measures of psychologic functioning (negative/depressive affect and self-esteem) and eating disorder attitudes (shape and weight concerns). There were no group differences on measures of eating behaviors. The avoidant and obsessive-compulsive groups had more psychiatric comorbidity than the group without these personality features but less than the combined group. The group without these features scored significantly lower than all other groups on negative/depressive affect and significantly higher than the avoidant and combined groups on self-esteem. The combined group had the greatest severity on shape and weight concerns.

CONCLUSIONS

Avoidant and obsessive-compulsive personality features are common in patients with BED. Among BED patients, these forms of personality psychopathology--separately and in combination--are associated with clinically meaningful diagnostic, psychologic, and attitudinal differences. These findings have implications for the psychopathologic relationship between BED and personality psychopathology and may also have implications for assessment and treatment.

Personality dimensions in bulimia nervosa, binge eating disorder, and obesity

OBJECTIVE

The purpose of this investigation was to examine differences in personality dimensions among individuals with bulimia nervosa, binge eating disorder, non-binge eating obesity, and a normal-weight comparison group as well as to determine the extent to which these differences were independent of self-reported depressive symptoms.

METHOD

Personality dimensions were assessed using the Multidimensional Personality Questionnaire in 36 patients with bulimia nervosa, 54 patients with binge eating disorder, 30 obese individuals who did not binge eat, and 77 normal-weight comparison participants.

RESULTS

Participants with bulimia nervosa reported higher scores on measures of stress reaction and negative emotionality compared to the other 3 groups and lower well-being scores compared to the normal-weight comparison and the obese samples. Patients with binge eating disorder scored lower on well-being and higher on harm avoidance than the normal-weight comparison group. In addition, the bulimia nervosa and binge eating disorder groups scored lower than the normal-weight group on positive emotionality. When personality dimensions were reanalyzed using depression as a covariate, only stress reaction remained higher in the bulimia nervosa group compared to the other 3 groups and harm avoidance remained higher in the binge eating disorder than the normal-weight comparison group.

CONCLUSIONS

The higher levels of stress reaction in the bulimia nervosa sample and harm avoidance in the binge eating disorder sample after controlling for depression indicate that these personality dimensions are potentially important in the etiology, maintenance, and treatment of these eating disorders. Although the extent to which observed group differences in well-being, positive emotionality, and negative emotionality reflect personality traits, mood disorders, or both, is unclear, these features clearly warrant further examination in understanding and treating bulimia nervosa and binge eating disorder.

The validity and clinical utility of binge eating disorder

OBJECTIVE

This review attempted to examine the validity and clinical utility of the DSM-IV binge eating disorder (BED) diagnosis across a wide range of validating strategies.

METHOD

Various electronic databases (Pub Med, Psych Info) were searched for terms relevant to the diagnosis of BED (e.g., binge eating disorder, binge eating) in order to identify papers. Additionally, published papers were reviewed in order to locate additional manuscripts and papers that were presented at meetings.

RESULTS

The validity and utility of BED varied substantially according to the validator chosen. There is reasonable evidence that BED can be differentiated from other existing eating disorders and is associated with significant impairment and clinical levels of eating disorder psychopathology. The relationship of BED to obesity is complex, and in spite of some positive findings, further research examining the predictive power of BED, beyond the simple presence of obesity and associated psychopathology, in relationship to clinically relevant outcomes is needed.

DISCUSSION

Binge eating disorder is being considered for inclusion in the DSM-V and various options regarding this decision are reviewed based upon the empirical findings in the paper.

Prevalence and characteristics of binge eating in an adolescent community sample

The objective of this article was to investigate the prevalence and psychological correlates of binge eating among adolescents. Self-report questionnaires were administered to a community sample of 708 adolescents (M(age) = 14 years). Adolescents reporting loss of control over eating (17% of the sample) reported more eating pathology and more general maladjustment compared to those without loss of control. The combined presence of subjective and objective binge episodes was related to the most severe pattern of eating pathology. The results suggest that loss of control over eating is a relatively frequent experience among adolescents from the general population and it is related to eating pathology and maladjustment.

DSM-IV psychiatric disorder comorbidity and its correlates in binge eating disorder

OBJECTIVE

To assess DSM-IV lifetime and current psychiatric disorder comorbidity in patients with binge eating disorder (BED) and to examine associations of comorbidity with gender, selected historical obesity-related variables, and current eating disorder psychopathology.

METHOD

A consecutive series of 404 patients with BED (310 women, 94 men) were reliably administered semistructured diagnostic and clinical interviews to assess DSM-IV psychiatric disorders and features of eating disorders.

RESULTS

Overall, 73.8% of patients with BED had at least one additional lifetime psychiatric disorder and 43.1% had at least one current psychiatric disorder. Lifetime-wise, mood (54.2%), anxiety (37.1%), and substance use (24.8%) disorders were most common. In terms of current comorbidity, mood (26.0%) and anxiety (24.5%) were most common. Few gender differences were observed; men had higher lifetime rates of substance use disorders and current rates of obsessive compulsive disorder. Patients with BED with current psychiatric comorbidity reported earlier age at first diet and higher "lifetime-high" BMI. Patients with current comorbidity also had significantly higher levels of current eating disorder psychopathology and negative affect and lower self-esteem relative to patients with BED with either lifetime (noncurrent) or no psychiatric histories.

DISCUSSION

Among treatment-seeking patients with BED, the presence of current psychiatric comorbidity is associated with greater eating disorder psychopathology and associated distress.

The role of depression and anxiety in impulsive and obsessive-compulsive behaviors among anorexic and bulimic patients

Eating disorders are believed to range across a spectrum of varying degrees of obsessive-compulsive and impulsive behavior. Sixty anorexic (mean age = 19.8; sd = 5.9) and 109 bulimic (mean age = 26.9; sd = 11.3) female patients completed self-report questionnaires assessing obsessive-compulsiveness, impulsivity, depression and anxiety, as well as two eating disorder scales. Results yielded significantly higher levels of impulsivity and negative body image in the bulimic compared to the anorexic group. Regression analysis predicting impulsivity showed that bulimia and negative body image were the main contributors. Regression analysis for predicting obsessive-compulsive behavior suggested that depression and anxiety obscure the link between anorexia and obsessive-compulsive behavior, and a high BMI intensifies the association between anxiety and obsessive-compulsive behavior. The high rates of both impulsivity and obsessive-compulsiveness found in both groups, and their association with the severity of the eating disorder, may suggest that impulsivity and obsessive-compulsiveness are not mutually exclusive and can both be found among anorexic and bulimic patients.

Structure of diagnostic and statistical manual of mental disorders, fourth edition criteria for obsessive-compulsive personality disorder in patients with binge eating disorder

OBJECTIVE

To examine 1-, 2-, and 3-factor model structures through confirmatory analytic procedures for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) obsessive-compulsive personality disorder (OCPD) criteria in patients with binge eating disorder (BED).

METHOD

Participants were consecutive outpatients (n = 263) with binge eating disorder and were assessed with semi-structured interviews. The 8 OCPD criteria were submitted to confirmatory factor analyses in Mplus Version 4.2 (Los Angeles, CA) in which previously identified factor models of OCPD were compared for fit, theoretical relevance, and parsimony. Nested models were compared for significant improvements in model fit.

RESULTS

Evaluation of indices of fit in combination with theoretical considerations suggest a multifactorial model is a significant improvement in fit over the current DSM-IV single- factor model of OCPD. Though the data support both 2- and 3-factor models, the 3-factor model is hindered by an underspecified third factor.

CONCLUSION

A multifactorial model of OCPD incorporating the factors perfectionism and rigidity represents the best compromise of fit and theory in modelling the structure of OCPD in patients with BED. A third factor representing miserliness may be relevant in BED populations but needs further development. The perfectionism and rigidity factors may represent distinct intrapersonal and interpersonal attempts at control and may have implications for the assessment of OCPD.

Dialectical behavior therapy for clients with binge-eating disorder or bulimia nervosa and borderline personality disorder

OBJECTIVE

This treatment development study provides summary data for standard Dialectical Behavior Therapy (DBT) with minimal adaptation for 8 women with binge-eating disorder (BED) (5) or bulimia nervosa (BN) (3) and Borderline Personality Disorder (BPD).

METHOD

DBT involved 6 months of weekly skills group, individual DBT, therapist consultation team meeting, and 24-hour telephone coaching. Assessments were conducted at pre-, post-treatment, and 6-months follow-up and utilized standardized clinical interviews including the Eating Disorders Examination (EDE), Personality Disorders Exam, and the Structured Clinical Interview for DSM-IV.

RESULTS

From pre- to post-treatment, effect sizes for objective binge eating, total EDE scores and global adjustment were large and for number of non-eating disorder axis I disorders and for suicidal behavior and self-injury were medium. From pre- to 6-months follow-up, effect sizes were large for all these outcomes.

CONCLUSION

This provides promising pilot data for larger studies utilizing DBT for BED or BN and BPD.

Review of controlled psychotherapy treatment trials for binge eating disorder

This paper reviews investigations of psychotherapy outcome studies for binge eating disorder, which has recently been intensively studied as several researchers have undertaken the task of delineating which treatment options are the most effective. Several randomized, controlled clinical trials have provided important findings. A current debate concerns what the initial course of treatment should be, reducing binge eating patterns or reducing weight. Several limitations to this literature are mentioned, including the dearth of studies investigating treatment for men and boys with binge eating disorder.

Eating disorder psychopathology does not predict the overweight severity in subjects seeking weight loss treatment

BACKGROUND

Many obese subjects show relevant psychological distress. The aims of this study were to assess the psychopathological and clinical features of a sample of overweight or obese subjects seeking weight loss treatment and to evaluate the possible, significant associations between the levels of overweight and the specific and general eating disorder psychopathology.

METHODS

A total of 397 consecutive overweight (body mass index > or =25 kg/m(2)) patients seeking treatment for weight loss at the Outpatient Clinic for Obesity of the University of Florence were studied. The prevalence of binge eating disorder was assessed using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. All subjects were assessed through the self-report version of the Eating Disorder Examination Questionnaire, the Beck Depression Inventory, and the State-Trait Anxiety Inventory.

RESULTS

The current prevalence of binge eating disorder was 24.2%; 35% of the subjects were overweight during childhood. High prevalence rates of clinical significant depressive (38%) and anxious (71.5%) symptoms were observed. Binge eating disorder, the severity of specific eating disorder psychopathology, and depressive and anxious symptoms were not associated with the severity of overweight.

CONCLUSIONS

The severity of the specific and general eating disorder psychopathology does not predict the levels of overweight. A positive association between severe eating disorder psychopathology and clinical depression was observed.

A family history study of binge-eating disorder

Family studies of anorexia nervosa and bulimia nervosa have yielded important information about the etiologies of these eating disorders. By contrast, little is known about familial factors of etiologic importance for binge-eating disorder (BED). The purpose of the current family history study was to assess the prevalence of comorbid psychopathology in a non-treatment seeking female sample of 31 probands with BED, 32 control probands without BED, and their 283 first-degree relatives. In-person semistructured clinical interviews were conducted with the probands, who also served as informants for all of their first-degree relatives. Significantly higher lifetime rates of major depressive disorder, dysthymic disorder, and social phobia were found among women with BED compared with control women. Significantly higher lifetime rates of bipolar (I or II) disorder, any depressive disorder, nearly all anxiety disorders, anorexia nervosa, and BED were reported among the first-degree relatives of women with BED compared with the first-degree relatives of control women. Furthermore, female relatives of women with BED were reported to have higher rates of substance use disorders and dysthymic disorder compared with female relatives of control women without BED. Nearly all disorders that were elevated in relatives of women with BED followed a pattern of independent transmission from BED. The primary exception was substance use disorder among female relatives, whose transmission pattern was consistent with that of a shared etiology with BED. Thus, BED and substance use disorder may share a common mechanism of familial transmission among women.

Personality in non-clinical adolescents with eating disorders

OBJECTIVE

The aim of this study was to examine whether personality-related differences also exist in non-clinical adolescents with any given type of eating disorder (ED) and whether personality characteristics are associated with changes in the course of the diagnosis.

METHOD

An initial sample of 1336 boys and girls (mean age: 11.37, SD = 0.62) was assessed in a two-phase long-term study. A total of 258 subjects were selected from the initial sample (T1) and contacted again 2 years later (T2) (n = 200). These subjects comprise the sample group of this study. Of these, 51 were diagnosed with ED (37 with diagnosis type anorexia (DTA) and 14 with diagnosis type bulimia (DTB)). An experimental version of the Junior Temperament and Character Inventory (JTCI) was applied.

RESULTS

Subjects with DTA had significantly higher scores on Reward Dependence and Self-Directedness factors than subjects with no diagnosis or DTB, respectively. Subjects with DTB had higher scores on Novelty Seeking, Harm Avoidance and Spirituality factors than subjects with forms of anorexia or without diagnosed ED. Subjects with ED remission had significantly lower scores on Persistence and Self-Directedness scales. ED incident subjects had significantly higher scores on Harm Avoidance.

CONCLUSIONS

Subjects without full-blown syndromes have similar temperament characteristics to subjects with full eating disorders. These results support the theory that non-full-blown syndromes differ from full syndromes only in pathological severity.

A prospective study of obsessive-compulsive and borderline personality traits, race and disordered eating

Most previous investigations of the relationship between personality and disordered eating have been cross-sectional and have utilised relatively homogeneous samples. The current study sought to prospectively explore two specific putative personality risk factors for disordered eating in an ethnically diverse sample of women (n = 58). During the initial and 2-year follow-up assessments, semi-structured diagnostic interviews were administered. Analyses revealed that borderline personality disorder symptoms, as well as an interaction between obsessive-compulsive personality disorder symptoms and race, significantly predicted disordered eating over a 2-year period. Obsessive-compulsive personality pathology was most strongly predictive of disordered eating for the African American women, specifically. These data supported both borderline and obsessive-compulsive personality pathology as predictors of the development of eating disorder symptoms among women over a 2-year period in college. In addition, race may be an important consideration in understanding the role of personality in the aetiology of disordered eating.

Diagnostic co-morbidity in 2300 psychiatric out-patients presenting for treatment evaluated with a semi-structured diagnostic interview

BACKGROUND

The largest clinical epidemiological surveys of psychiatric disorders have been based on unstructured clinical evaluations. However, several recent studies have questioned the accuracy and thoroughness of clinical diagnostic interviews; consequently, clinical epidemiological studies, like community-based studies, should be based on standardized evaluations. The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project is the largest clinical epidemiological study using semi-structured interviews assessing a wide range of psychiatric disorders conducted in a general clinical out-patient practice. In the present report we examined the frequency of DSM-IV Axis I diagnostic co-morbidity in psychiatric out-patients.

METHOD

A total of 2300 out-patients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) upon presentation for treatment.

RESULTS

The mean number of current and lifetime DSM-IV Axis I disorders in the 2300 patients was 1.9 (s.d.=1.5) and 3.0 (s.d.=1.8) respectively. The majority of patients were diagnosed with two or more current disorders, and more than one-third were diagnosed with three or more current disorders. Examination of the most frequent current disorders in the patients with the 12 most common principal diagnoses indicated that the pattern of co-morbidity differed among the disorders. The highest mean number of current co-morbid disorders was found for patients with a principal diagnosis of post-traumatic stress disorder and bipolar disorder.

CONCLUSIONS

Clinicians should assume that psychiatric patients presenting for treatment have more than one current diagnosis. The pattern of co-morbidity varies according to the principal diagnosis.

The diagnostic validity of the criteria for binge eating disorder

OBJECTIVE

This paper considers whether the criteria currently used to classify the diagnosis of binge eating disorder (BED) are valid and appropriate.

METHOD

We review evidence that reflects on the validity of the current criteria for binge eating episodes and BED, using literature retrieved through major psychology and psychiatry search engines (e.g., PsycInfo, PubMed).

RESULTS

Evidence from experimental research points to the relative importance of episode frequency, the amount of food consumed at episodes, the subjective sense of loss of control over eating, and several additional criteria associated with binge episodes in BED. Evidence on the differences in psychopathology between BED and bulimia nervosa and between BED and obesity without binge eating, as related to diagnostic criteria, is reviewed.

CONCLUSION

Although evidence concerning the diagnostic criteria of BED is mixed, broadening certain diagnostic criteria for binge eating episodes and BED might more accurately reflect the research literature and increase the number of individuals eligible for inclusion in treatment programs.

Psychometric properties of the Eating Disorders in Obesity questionnaire: validating against the Eating Disorder Examination interview

Inconclusive results of how weight-loss treatment (WLT) results are affected by participants' eating disorders and/or binge eating are partly due to the variation caused by the multitude of assessment instruments used. The objective of the present study was to evaluate the psychometric properties of a short DSM-IV-based assessment instrument designed to be used specifically in WLT settings, the Eating Disorders in Obesity (EDO) questionnaire. Participants were 97 patients seeking WLT at four surgical and one non-surgical clinics. Participants were assessed by the EDO and the Eating Disorder Examination (EDE) interview . The validity and reliability of the EDO was measured as concordance with the EDE, and test-retest agreement of the EDO, respectively. Validity as well as reliability was found to be good for both eating disorders diagnoses and binge eating as a distinct symptom. Results suggest that the EDO is a short, easily administered instrument with good psychometric properties which makes it a suitable, economical method of assessing eating disorders and binge eating in clinical WLT settings.

Predictors and mediators of treatment outcome in patients with binge eating disorder

A randomized controlled trial (N=52) was conducted comparing cognitive-behavioral therapy with a waiting list control group to identify mediators and predictors of treatment outcome. Reduction of weight concerns mediated abstinence of binge eating at post-treatment. Abstinence was marginally mediated by changes in eating and shape concerns, depressive symptoms and global severity of general psychopathology. Neither treatment outcome nor status at 1-year follow-up could be predicted by severity of eating disorder, comorbid psychopathology or maladaptive core beliefs at baseline or at post-treatment. The only predictor for abstinence at both post-treatment and 1-year follow-up was the coping style palliative reacting: higher scores predicted less favorable outcomes. Lower expression of emotions at post-treatment predicted more reduction of eating disorder psychopathology at follow-up. No other patient characteristics allowing treatment-patient matching could be identified.

Eating disorders across the lifespan

Eating disorders have traditionally been considered afflictions of adolescents and young women. Recent evidence, however, suggests that eating disorders often occur across the life span. Although the incidence of these disorders among mid-life and older women appears to be on the rise, it is not clear if this reflects a true increase in prevalence, better recognition among clinicians, or both. This paper presents an overview of the etiology and treatment of eating disorders, with particular emphasis on developmental factors impacting older women. Recommendations for the treatment of eating disorders among older women are offered. An emerging clinical literature suggests various lines of research that are needed to explore the development and treatment of eating disorders in older women.

Preventing excessive weight gain in adolescents: interpersonal psychotherapy for binge eating

The most prevalent disordered eating pattern described in overweight youth is loss of control (LOC) eating, during which individuals experience an inability to control the type or amount of food they consume. LOC eating is associated cross-sectionally with greater adiposity in children and adolescents and seems to predispose youth to gain weight or body fat above that expected during normal growth, thus likely contributing to obesity in susceptible individuals. No prior studies have examined whether LOC eating can be decreased by interventions in children or adolescents without full-syndrome eating disorders or whether programs reducing LOC eating prevent inappropriate weight gain attributable to LOC eating. Interpersonal psychotherapy, a form of therapy that was designed to treat depression and has been adapted for the treatment of eating disorders, has shown efficacy in reducing binge eating episodes and inducing weight stabilization among adults diagnosed with binge eating disorder. In this paper, we propose a theoretical model of excessive weight gain in adolescents at high risk for adult obesity who engage in LOC eating and associated overeating patterns. A rationale is provided for interpersonal psychotherapy as an intervention to slow the trajectory of weight gain in at-risk youth, with the aim of preventing or ameliorating obesity in adulthood.

Outcomes of eating disorders: a systematic review of the literature

OBJECTIVE

The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center systematically reviewed evidence on factors associated with outcomes among individuals with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) and whether outcomes differed by sociodemographic characteristics.

METHOD

We searched electronic databases including MEDLINE and reviewed studies published from 1980 to September, 2005, in all languages against a priori inclusion/exclusion criteria and focused on eating, psychiatric or psychological, or biomarker outcomes.

RESULTS

At followup, individuals with AN were more likely than comparisons to be depressed, have Asperger's syndrome and autism spectrum disorders, and suffer from anxiety disorders including obsessive-compulsive disorders. Mortality risk was significantly higher than what would be expected in the population and the risk of suicide was particularly pronounced. The only consistent factor across studies relating to worse BN outcomes was depression. A substantial proportion of individuals continue to suffer from eating disorders over time but BN was not associated with increased mortality risk. Data were insufficient to draw conclusions concerning factors associated with BED outcomes. Across disorders, little to no data were available to compare results based on sociodemographic characteristics.

CONCLUSION

The strength of the bodies of literature was moderate for factors associated with AN and BN outcomes and weak for BED.

Recurrent binge eating (RBE) and its characteristics in a sample of young women in Germany

OBJECTIVE

To examine the characteristics of recurrent binge eating (RBE) in a non-treatment-seeking sample from the general population. RBE individuals are described in terms of socio-economic status, general psychopathology, and comorbidity rates of mental disorders.

METHOD

Participants were 1877 German females aged 18-24 years from a population-based epidemiological study.

RESULTS/DISCUSSION

The point prevalence of RBE in our sample was 0.9% (N = 17). Compared to healthy women, subjects with RBE suffered more often from comorbid mental disorders and also exhibited more general psychopathology: They were similar to women with other mental disorders and other eating disorders (EDs). RBE seems to be a syndrome of clinical significance itself and might be an important risk factor for the development of further EDs, especially binge eating disorder (BED) and other mental disorders.

Self-criticism, low self-esteem, depressive symptoms, and over-evaluation of shape and weight in binge eating disorder patients

Despite the fact that negative self-evaluations are widely considered to be prominent in eating disorders, the role of self-criticism has received little empirical attention. The vast majority of research on the construct of self-criticism has focused on its role as a specific personality vulnerability factor in depression-related phenomena. In this study of 236 patients with binge eating disorder, confirmatory factor analysis supported self-criticism, self-esteem, depressive symptoms, and over-evaluation of shape and weight as distinct, albeit related, constructs. Structural equation modeling demonstrated that the relation between self-criticism and over-evaluation of shape and weight was partly mediated or explained by low self-esteem and depressive symptoms. Continued efforts to understand the role of self-criticism in eating disorders appear warranted.

Binge eating and weight loss in a self-help behavior modification program

OBJECTIVE

To examine the occurrence of binge eating and its impact on weight loss outcomes among obese participants in the Trevose Behavior Modification Program, a lay-administered, lay-directed self-help weight loss program offering continuing care.

RESEARCH METHODS AND PROCEDURES

Participants completed questionnaires, and weight loss data were recorded prospectively.

RESULTS

Although objective bulimic episodes were reported by 41% of the sample, objective bulimic episodes were not associated with worse weight loss outcomes. Mean weight loss after 12 months was 18.2 kg (18.8% of initial body weight) for the treatment completers and 10.3 kg (10.5% of initial body weight) for the full sample (using intent-to-treat analyses, with baseline scores carried forward).

DISCUSSION

Substantial long-term weight loss, resulting from a continuing care treatment program, occurred in individuals both with and without frequent binge eating.

Binge eating in overweight treatment-seeking adolescents

OBJECTIVE

To examine the frequency and recency of binge eating in relation to psychopathology in overweight, treatment-seeking adolescents.

METHODS

We investigated psychological correlates of the frequency and recency of reported loss of control (LOC) eating episodes in 160 overweight (body mass index [BMI]: 40.7 +/- 8.8 kg/m(2)) adolescents. On the basis of the responses to the eating disorder examination (EDE), participants were categorized into one of four groups: full-syndrome binge eating disorder (BED); recent but infrequent binge eating (episodes within the 3 months before interview; RECENT-BINGE); remote and infrequent LOC eating (episodes occurring >3 months before assessment; PAST-LOC), or no history of LOC episodes (NE).

RESULTS

The BED group reported higher EDE scores (global, p < .01), and more negative mood and anxiety than all other groups (p's < .01). Compared with NE, RECENT-BINGE also reported more anxiety and higher EDE scores (p's < .01).

CONCLUSIONS

Overweight, treatment-seeking adolescents with BED are clearly distinguishable from teens without the disorder on measures of eating-related psychopathology, mood, and anxiety. RECENT-BINGE, but not PAST-LOC, is also associated with significantly greater eating-related and general psychopathology.

Comparison of two self-report instruments for assessing binge eating in bariatric surgery candidates

This study compared two self-report methods for assessing binge eating in severely obese bariatric surgery candidates. Participants were 249 gastric bypass candidates who completed the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R) and the Eating Disorder Examination-Questionnaire (EDE-Q) prior to surgery. Participants were classified by binge eating status (i.e., no or recurrent binge eating) with each of the measures. The degree of agreement was examined, as well as the relationship between binge eating and measures of convergent validity. The two measures identified a similar number of patients with recurrent binge eating (i.e., at least 1 binge/week); however, overlap was modest (kappa=.26). Agreement on twice weekly binge eating was poor (kappa=.05). The QEWP-R and EDE-Q both identified clinically meaningful groups of binge eaters. The EDE-Q appeared to differentiate between non/infrequent bingers and recurrent bingers better than the QEWP-R, based on measures of convergent validity. In addition, the EDE-Q demonstrated an advantage because it identified binge eaters with elevated weight and shape overconcern. Using the self-report measures concurrently did not improve identification of binge eating in this study. More work is needed to determine the construct validity and clinical utility of these measures with gastric bypass patients.

Overeating among seriously overweight children seeking treatment: results of the children's eating disorder examination

OBJECTIVE

We sought to examine rates of eating disorder symptoms among seriously overweight children seeking treatment using the Eating Disorder Examination for Children (ChEDE) and to provide initial data about their association with treatment outcome.

METHOD

Overweight children (N = 27) 8-13 years old were interviewed using the ChEDE before participating in a family-based behavioral treatment program. Height and weight were measured pretreatment, posttreatment, and approximately 8 months posttreatment.

RESULTS

Fifteen percent of children reported subjective bulimic episodes (SBE). Weight loss did not differ for children with and without SBEs, but concerns about body shape were related to larger weight losses during treatment.

CONCLUSION

A considerable minority of treatment-seeking overweight children report an episodic sense of loss of control over eating. Loss of control is related to other disordered eating attitudes and behaviors, but does not appear to affect treatment outcome. Future studies are needed to replicate these initial findings.

Eating disorders and disordered eating among patients seeking non-surgical weight-loss treatment in Sweden

The aim of this cross-sectional descriptive study of 194 Swedish men and women seeking non-surgical weight-loss treatment was to investigate the presence of eating disorders and binge eating symptoms and to compare these two groups of patients with a group without eating disorder- or binge eating symptoms. The groups were compared in regard to co-morbid psychopathology, Health Related Quality of Life (HRQL) and anthropometric data. Of the total sample, 9.8% fulfilled criteria for any eating disorder. An additional 7.2% indicated binge eating symptoms without having an eating disorder. The three groups were significantly different in regard to psychopathology scales and most HRQL items. Eating disorders and binge eating symptoms are common among patients seeking non-surgical weight-loss treatments in Sweden and both groups showed elevated levels of co-morbid psychopathology and lower HRQL compared to patients without disordered eating. These findings point to the importance of assessing the full range of eating disorder symptoms and disorders as well as HRQL and co-morbid psychopathology before weight-loss treatment, as these factors might affect treatment outcome.

Adipositas im Kindes- und Jugendalter:

Zusammenfassung. Adipöse Kinder und Jugendliche gelten als Risikogruppe für die Entwicklung von psychosozialen Belastungen, den Einsatz von gesundheitsschädigenden Gewichtskontrollmaßnahmen sowie auffällige Essverhaltensweisen. Dennoch ist relativ wenig über das Auftreten von Heißhungerattacken (“binging“) und Binge Eating Disorder (BED) bei dieser Gruppe bekannt. Die folgende Studie untersuchte bei 156 adipösen Kindern und Jugendlichen (im Alter zwischen 11 und 18 Jahren) die selbstberichtete Verbreitung von “binging“ und BED. Im zweiten Schritt wurde untersucht, inwieweit sich “Binger“ von “non-Bingern“ in der Störbarkeit ihres Essverhaltens, ihrem Selbstkonzept, dem Erleben von Hänseleien und dem Umgang damit unterscheiden, wobei eine erhöhte Auffälligkeit der Binger vermutet wurde. Die Kinder beantworteten ein Fragebogenpaket mit folgenden Instrumenten: QEWP-A (essgestörtes Verhalten), POTS (Hänseleien), Auslöser für Essverhalten, Fragebogen zur Problembewältigung und FSK-K (Selbstkonzept). Die Auftretenshäufigkeit der BED lag bei 3.8%. Insgesamt berichteten jedoch 12.8% der Kinder und Jugendlichen (sog. Binger) von Heißhungerattacken. Diese Gruppe unterschied sich von den non-Bingern weder im Alter, noch im BMI oder in der Geschlechtsverteilung. Erwartungsgemäß berichteten die Binger über eine höhere Auslösbarkeit von Essverhalten sowie ein häufigeres Auftreten von gewichtsbezogenen Hänseleien, unter denen sie auch angaben, vermehrt zu leiden. Beim Umgang mit solchen Hänseleien benutzten Binger darüber hinaus häufiger vermeidende Strategien. Keine Gruppenunterschiede wurden im Selbstwert, der erlebten Attraktivität und schulischen Kompetenz gefunden. Vermeidender Bewältigungsstil sowie hohe Störbarkeit des Essverhaltens erwiesen sich als bedeutsam zur Vorhersage der Gruppenzugehörigkeit. Die Ergebnisse wurden in Bezug auf die Bedeutung von Hänseleien und deren Bewältigung diskutiert.

Eating disorder or disordered eating? Non-normative eating patterns in obese individuals

Binge eating disorder (BED) and night eating syndrome (NES) are putative eating disorders frequently seen in obese individuals. Data suggest that BED fulfills criteria for a mental disorder. Criteria for NES are evolving but at present do not require distress or functional impairment. It remains unclear whether BED and NES, as they are currently defined, are optimally useful for characterizing distinct patient subgroups. We propose that a distinction be made between "eating disorders" and "non-normative" eating patterns without associated distress or impairment. Although non-normative eating patterns may not be considered mental disorders, they may be very important in terms of their impact on body weight and health. More precise behavioral and metabolic characterization of subgroups with eating disorders and non-normative eating behaviors has important implications for understanding the etiology, pathophysiology, and treatment of obesity. Ultimately, better understanding of the many pathways to increased energy intake may lead to targeted strategies for prevention of overweight and obesity in at-risk individuals and populations.

The prevalence of personality disorders among those with eating disorders

The genuine prevalence of personality disorders among those with eating disorders is unknown. However, in this paper, we summarize the existing data, with careful acknowledgment of our approach to interpretation as well as the limitations of previous studies. Our findings indicate that obsessive-compulsive personality is the most common personality disorder in restricting-type anorexia nervosa, while borderline personality is the most common personality disorder in binge-eating/purging type anorexia nervosa. Borderline personality is the most common personality disorder in bulimia nervosa, as well. In those with binge eating disorder, obsessive-compulsive personality is the most common personality disorder although, compared with the preceding eating disorder diagnoses, there are broader clusters of personality disorders represented in this group. We discuss the implications of these findings.

Empirically Supported Psychotherapies: Comment on Westen, Novotny, and Thompson-Brenner (2004)

D. Westen, C. M. Novotny, and H. Thompson-Brenner (2004; see record 2004-15935-005) suggested that efforts to identify empirically supported treatments are misguided because they are based on assumptions that are not appropriate for some types of treatment and patients. The authors of this comment argue that Westen and colleagues are simply incorrect when they assert that empirically supported treatments require that psychopathology must be highly malleable, that treatments must be brief, or that the samples studied are unrepresentative of the kinds of patients typically encountered in clinical practice--comorbidity is common in many clinical trials. Randomized controlled trials remain the most powerful way to test notions of causal agency.

Treatment implications of Axis-II comorbidity in eating disorders

In this article, we review the clinical research on the implications of comorbid personality disorders (PDs), pathological personality traits, and the expression and response to treatment of those with eating disorders (EDs) (i.e., anorexia and bulimia nervosa, and binge eating disorder). Obsessive-compulsive PDs and related traits, such as perfectionism and rigidity, appear to be clear-cut risk and maintenance factors for anorexia nervosa. In bulimia nervosa, trait impulsivity seems to be related to early termination from therapy and, according to at least some indices, poorer responses to treatment. Dramatic-Erratic PD features, generally more characteristic of binge-purge ED variants, clearly predict a protracted course for general psychiatric symptoms, but may have less prognostic value for eating symptoms. Recent guidelines from two influential bodies--the American Psychiatric Association (APA, 2000) and the United Kingdom's National Institute for Clinical Excellence (NICE, 2004)--both include the concept that "trait-oriented" interventions, targeting personality-linked components like perfectionism, affective instability, impulsivity, and interpersonal disturbances, may optimize treatment effects. In general, the literature supports the recommendation that clinicians should apply well-validated, symptom-focused therapies for the EDs; in addition, clinicians may wish to incorporate trait-focused interventions in patients in whom personality pathology contributes to suboptimal response.

A preliminary analysis of binge episodes: comparison of a treatment-seeking sample of Black and White women

OBJECTIVE

This study sought to examine differences in the nutritional composition of binges, both qualitatively and quantitatively, between participants with binge eating disorder (BED) and bulimia nervosa (BN) taken from a sample of treatment-seeking Black and White women. Overall qualitative and quantitative differences between diagnostic categories, regardless of ethnicity, were also explored.

METHOD

Patients seeking treatment for eating disorders were assessed on binge content. Black (n=26) and White (n=26) participants were matched on age and body mass index (BMI).

RESULTS

The binges of individuals with BN were lower in percent protein, but higher in calories, carbohydrates, and sugar, than those individuals with BED. However, there was little difference as a function of ethnicity between treatment-seeking Black and White women.

DISCUSSION

Preliminary data suggest that health professionals are faced with similar binge eating pathology, regardless of ethnicity, despite, probably, etiologic variation. The importance of the role of ethnicity in the expression of eating disorders is discussed.

Factorial structure and diagnostic efficiency of DSM-IV criteria for avoidant personality disorder in patients with binge eating disorder

This study examined the factorial structure and diagnostic efficiency of the DSM-IV criteria for avoidant personality disorder (AVPD). Two hundred and twenty-eight consecutive outpatients (181 females and 47 males) with a primary diagnosis of binge eating disorder were reliably assessed with diagnostic interviews. Internal consistency of AVPD criteria was good, as suggested by coefficient alpha of 0.87, the pattern of inter-item correlations (range 0.41 to 0.64), and the lack of changes in alpha if any criteria are deleted. Exploratory factor analysis revealed a one-factor solution (56% of variance) supporting the unidimensionality of the AVPD criteria. Diagnostic efficiency indices (conditional probabilities, total predictive power, and kappa coefficients) were calculated for each AVPD criterion, for the entire study group and separately by gender. Overall, the best inclusion criterion was 'fears being ridiculed,' which was also the best predictor overall. These psychometric findings did not differ by gender. The findings support certain important aspects of the AVPD diagnosis.

Diagnostic efficiency of DSM-IV criteria for obsessive compulsive personality disorder in patients with binge eating disorder

This study examined the diagnostic efficiency of the DSM-IV criteria for obsessive compulsive personality disorder (OCPD) in patients with binge eating disorder (BED). Two hundred and eleven consecutive adult patients with axis I diagnoses of BED were reliably assessed with semi-structured diagnostic interviews. Conditional probabilities-sensitivity, specificity, positive predictive power (PPP), and negative predictive power (NPP)-were calculated for each of the eight criteria for OCPD, using the 'best-estimate' OCPD diagnosis as the standard. The diagnostic efficiencies of the OCPD criteria were variable, with three criteria failing to have predictive value (PPP<0.50). The best inclusion criterion (highest PPP) was 'Perfectionism,' which was also the overall most predictive criterion. The findings suggest ordering of the DSM-IV criteria for OCPD based on performance and call into question the utility of some criteria.

Factor structure of DSM-IV criteria for obsessive compulsive personality disorder in patients with binge eating disorder

OBJECTIVE

To examine the factor structure of DSM-IV criteria for obsessive compulsive personality disorder (OCPD) in patients with binge eating disorder (BED).

METHOD

Two hundred and eleven consecutive out-patients with axis I diagnoses of BED were reliably assessed with semi-structured diagnostic interviews. The eight criteria for the OCPD diagnosis were examined with reliability and correlational analyses. Exploratory factor analysis was performed to identify potential components.

RESULTS

Cronbach's coefficient alpha for the OCPD criteria was 0.77. Principal components factor analysis with varimax rotation revealed a three-factor solution (rigidity, perfectionism, and miserliness), which accounted for 65% of variance.

CONCLUSION

The DSM-IV criteria for OCPD showed good internal consistency. Exploratory factor analysis, however, revealed three components that may reflect distinct interpersonal, intrapersonal (cognitive), and behavioral features.