Long-term efficacy of psychological treatments for binge eating disorder

A Pilot Study of an Acceptance-based Behavioral Treatment for Binge Eating Disorder

While existing treatments produce remission in a relatively large percentage of individuals with binge eating disorder (BED), room for improvement remains. Interventions designed to increase emotion regulation skills and clarify one's chosen values may be well-suited to address factors known to maintain BED. The current study examined the preliminary efficacy of a group-based treatment, Acceptance-based Behavioral Therapy (ABBT), in a small open trial (n=19), as well as the relationship between changes in hypothesized mechanisms of action and outcomes. ABBT includes the behavioral components of cognitive behavioral treatment for BED and emotion-focused strategies from acceptance and commitment therapy and dialectical behavioral therapy. Results from generalized linear multilevel modeling revealed significant fixed linear effects of time on depression, quality of life, global eating pathology, and binge frequency (all ps < .05). Global eating disorder symptoms appeared to improve rapidly from pre- to mid-treatment, and continued to improve toward post-treatment and follow-up, but at a slower rate. Binge frequency decreased rapidly from pre- to mid-treatment, followed by a slight increase at post-treatment and a reduction again by follow-up. Improvements in experiential acceptance were strongly and consistently related to decreases in overall eating pathology across several measures (rs = .35-.54). Additionally, greater access to emotion regulation strategies was strongly related to decreases in overall eating pathology (r= .67). Preliminary results support the efficacy of this novel treatment approach and indicate that additional research on ABBT for BED is warranted.

Binge abstinence is associated with reduced energy intake after treatment in patients with binge eating disorder and obesity

OBJECTIVE

Binge eating disorder (BED) is strongly associated with obesity and related medical and psychiatric morbidities. Cognitive behavioral therapy (CBT) has consistently been shown to reduce binge eating frequency and improve psychological functioning, as well as to produce abstinence rates of roughly 50%. This study examined the relationship between binge abstinence and dietary and psychological outcomes after CBT for BED.

METHODS

Fifty adult patients with BED received 6-month treatments using a combination of CBT and dietary counseling. Trained interviewers conducted two 24-hour dietary recall interviews on randomly selected days at baseline and at 6 months.

RESULTS

Participants had significant reductions in energy, macronutrient, and sugar intake and an increase in fruit intake. They reported significant reductions in BMI and binge eating frequency (from mean = 14.24 to mean = 1.90 binge eating episodes during the previous 28 days), as well as improvements in psychological functioning. Those who became binge abstinent reported eating roughly 400 fewer calories per day and experienced greater improvements in psychological functioning than those who did not.

CONCLUSIONS

Findings from this study suggest that individuals who achieve complete cessation from binge eating have significantly improved dietary and psychological outcomes that could potentially improve weight status, compared with those who continue to binge eat post-treatment.

Hypothalamic expression of inflammatory mediators in an animal model of binge eating

Binge eating episodes are characterized by uncontrollable, distressing eating of a large amount of highly palatable food and represent a central feature of bingeing related eating disorders. Research suggests that inflammation plays a role in the onset and maintenance of eating-related maladaptive behavior. Markers of inflammation can be selectively altered in discrete brain regions where they can directly or indirectly regulate food intake. In the present study, we measured expression levels of different components of cytokine systems (IL-1, IL-6, IL-18, TNF-α and IFN-ɣ) and related molecules (iNOS and COX2) in the preoptic and anterior-tuberal parts of the hypothalamus of a validated animal model of binge eating. In this animal model, based on the exposure to both food restriction and frustration stress, binge-like eating behavior for highly palatable food is not shown when animals are exposed to the frustration stress during the estrus phase. We found a characteristic down-regulation of the IL-18/IL-18 receptor system (with increased expression of the inhibitor of the pro-inflammatory cytokine IL-18, IL-18BP, together with a decreased expression of the binding chain of the IL-18 receptor) and a three-fold increase in the expression of iNOS specifically in the anterior-tuberal region of the hypothalamus of animals that develop a binge-like eating behavior. Differently, when food restricted animals were stressed during the estrus phase, IL-18 expression increased, while iNOS expression was not significantly affected. Considering the role of this region of the hypothalamus in controlling feeding related behavior, this can be relevant in eating disorders and obesity. Our data suggest that by targeting centrally selected inflammatory markers, we may prevent that disordered eating turns into a full blown eating disorder.

[Interpersonal therapy (IPT) in child psychiatry and adolescent]

INTRODUCTION

Depression disorder may become the first cause of morbidity by 2030, according to the World Health Organization. It is actually one of the main causes of disease and handicap in children aged from 10 to 19. The major risk is suicide, whose prevalence is estimated, in France, around 6.7 for 100,000, which is probably underestimated. At present, the discussions about prescription of antidepressants in an adolescent's depression remain intense which is why psychotherapy becomes the first choice of treatment. We propose here to present one of them, Interpersonal PsychoTherapy (IPT), which remains largely unknown in France, and its adaptations in the adolescent population.

PRESENTATION OF IPT

IPT is a brief psychotherapy, structured in twelve to sixteen sessions, which was created by Klerman and Weissman in the seventies inspired by the biopsychosocial model of Meyer, interpersonal theory of Sullivan, and attachment theory of Bowlby. It is divided into three parts: the initial phase, the intermediate phase, and the termination phase.

ADAPTATION FOR ADOLESCENTS

IPT was adapted for adolescents by Mufson in 1993, but a few modifications must be considered. Parental implication is the first. Indeed, parents, rather than the adolescent, often ask for the consultation; but it is the latter who benefits from the therapy. Parents may be met at some point in the therapy, for example between each phase and at the end. The initial phase is very close for the adolescent as for the adult; but the therapist must be careful about employing the "sick role" which can be used by the adolescent to avoid school, and as a consequence, to exacerbate the interpersonal deficit. The intermediate phase focuses on one of the four interpersonal issues: complicated bereavement, role transition, interpersonal role disputes, and interpersonal deficit. Complicated bereavement may become problematic when prolonged or when the adolescent had complicated relations with the deceased. The therapist essentially works on emotion verbalization. The role of transition is very common during adolescence: children become adults, they pass from high school to college, or their parents get divorced, etc. The patient and the therapist work on giving up the old role with its emotional expression (guilt, anger, and loss), and acquiring new skills, and identifying positive aspects of the new role. Interpersonal role disputes are common during adolescence, with parents or teachers for example. To determine a treatment plan, the therapist may first determine the stage of the role dispute, among impasse, renegotiation, or dissolution, and then work on the communication mode of the patient. At the least, the interpersonal deficit may be the most difficult area to work on because of the risk of psychiatric comorbidity. The therapist must be especially careful about anxious disorder which may complicate the psychotherapy and for which IPT is not the best therapy. The termination phase focuses on the new skills and abilities and works on the future without therapy. IPT is one of the psychotherapies recommended in the treatment of depression disorder in the international recommendations. But in France, all psychotherapies are considered equally. This may be a consensual approach, but the authors wonder if it is the best, especially to motivate research in the psychotherapy field.

OTHER INDICATIONS

Finally, IPT has been developed in other indications in the past years, and many others are presently in research projects: depression during pregnancy, prevention of depression relapse, eating disorders, attention deficit and hyperactivity disorder, self-harm for example.

CONCLUSION

Its validity, simplicity and efficacy should stimulate psychiatrists and residents to train themselves to IPT.

Predictors of psychological outcome in patients with eating disorders: A routine outcome monitoring study

BACKGROUND

Identifying predictors of psychological outcome for patients with eating disorders may improve the effectiveness of treatment. Patients with different pre-treatment characteristics and symptoms may benefit from different therapies. This study aimed to identify potential predictors of treatment outcome in a large naturalistic cohort of patients with an eating disorder.

METHOD

The study sample included patients (N = 1153) with all types of eating disorders who were receiving residential, day, or outpatient treatment. Remission was defined by means of four different indicators based on the Eating Disorder Examination-Questionnaire global score: 1. achieving reliable change; 2. showing a 50% reduction in baseline symptom severity; 3. reaching the clinical significance cut-off point; and 4. a combination of indicators 2 and 3. Potential predictor variables were investigated in univariate and multivariate Cox regression models.

RESULTS

Different predictors were found for the four outcome criteria. Patients with high levels of interpersonal distrust at baseline were less likely to have achieved reliable change in eating disorder psychopathology. Higher self-esteem and less body dissatisfaction at baseline was independently associated with a symptom reduction of more than 50% and/or reaching the clinical significance cut-off point. Contrary to our expectations, no differences in outcome were found between the eating disorder subtypes.

DISCUSSION

Clinically, it is important to reduce the risk of poor outcome and to achieve a rapid response in treatment using an intervention designed for this purpose, such as shared decision making or an intervention directed at self-esteem or body image, which may act as a catalyst for change. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:863-873).

Randomized Controlled Trial of an Internet-Based Cognitive-Behavioral Treatment Program for Binge-Eating Disorder

Binge-eating disorder (BED) is a prevalent health condition associated with obesity. Few people with BED receive appropriate treatment. Personal barriers include shame, fear of stigma, geographic distance to mental health services, and long wait-lists. The aims of this study were to examine the efficacy of an Internet-based cognitive-behavioral intervention for adults with threshold BED (DSM-IV) and to examine the stability of treatment effects over 12months. Participants were randomly assigned to a 16-week Internet-based cognitive-behavioral intervention (n=69) or a wait-list condition (n=70). Binge-eating frequency and eating disorder psychopathology were measured with the Eating Disorder Examination-Questionnaire and the Eating Disorder Examination administered over the telephone. Additionally, body weight and body mass index, depression, and anxiety were assessed before and immediately after treatment. Three-, 6-, and 12-month follow-up data were recorded in the treatment group. Immediately after the treatment the number of binge-eating episodes showed significant improvement (d=1.02, between group) in the treatment group relative to the wait-list condition. The treatment group had also significantly reduced symptoms of all eating psychopathology outcomes relative to the wait-list condition (0.82≤d≤1.11). In the treatment group significant improvement was still observed for all measures 1year after the intervention relative to pretreatment levels. The Internet-based intervention proved to be efficacious, significantly reducing the number of binge-eating episodes and eating disorder pathology long term. Low-threshold e-health interventions should be further evaluated to improve treatment access for patients suffering from BED.

Combined therapy with interpersonal psychotherapy adapted for borderline personality disorder: A two-years follow-up

Few investigations evaluated the long-term effects of psychotherapies in borderline personality disorder (BPD). In a previous study, we compared efficacy of combination of fluoxetine and interpersonal psychotherapy adapted to BPD (IPT-BPD) versus single fluoxetine administered for 32 weeks. This study is aimed to investigate whether the results obtained with the addition of IPT-BPD persist during a follow-up period. Forty-four patients who completed the 32 weeks trial underwent 24 months of follow-up receiving fluoxetine 20-40 mg/day. Clinical Global Impression Severity (CGI-S), Hamilton Rating Scales for Depression and Anxiety (HDRS, HARS), Social and Occupational Functioning Assessment Scale (SOFAS), Satisfaction Profile (SAT-P), and Borderline Personality Disorder Severity Index (BPDSI) were repeated at 6, 12, and 24 months. Statistical analysis was performed with the general linear model. Results showed that most of the differences between combined therapy and single pharmacotherapy at the end of the 32 weeks trial were maintained after 24 months follow-up. The addition of IPT-BPD to medication produced greater effects on BPD symptoms (impulsivity and interpersonal relationships) and quality of life (perception of psychological and social functioning) that endured after termination of psychotherapy. On the contrary, different effects on anxiety symptoms and affective instability were lost after 6 months.

Combining Pharmacological and Psychological Treatments for Binge Eating Disorder: Current Status, Limitations, and Future Directions

Binge eating disorder (BED) is characterized by recurrent binge eating and marked distress about binge eating without the extreme compensatory behaviors for weight control that characterize other eating disorders. BED is prevalent, associated strongly with obesity, and is associated with heightened levels of psychological, psychiatric, and medical concerns. This article provides an overview of randomized controlled treatments for combined psychological and pharmacological treatment of BED to inform current clinical practice and future treatment research. In contrast to the prevalence and significance of BED, to date, limited research has been performed on combining psychological and pharmacological treatments for BED to enhance outcomes. Our review here found that combining certain medications with cognitive behavioral therapy (CBT) or behavioral weight loss (BWL) interventions produces superior outcomes to pharmacotherapy only but does not substantially improve outcomes achieved with CBT/BWL only. One medication (orlistat) has improved weight losses with CBT/BWL albeit minimally, and only one medication (topiramate) has enhanced reductions achieved with CBT in both binge eating and weight. Implications for future research are discussed.

Effect of adapted interpersonal psychotherapy versus health education on mood and eating in the laboratory among adolescent girls with loss of control eating

OBJECTIVE

Interpersonal psychotherapy (IPT) is aimed at improving negative affect that is purported to contribute to the development and maintenance of loss-of-control (LOC) eating. Although youth who report LOC over eating tend to consume more snack-foods than those without LOC, it is unknown if IPT impacts objective energy intake.

METHODS

To test if IPT improves mood and eating in the laboratory, we examined a sample of 88 girls with LOC eating who were randomized to either IPT (n = 46) or a standard-of-care health education (HE) group program. At baseline, and 6-month (follow-up 1) and 1-year (follow-up 2) following the initiation of the groups, girls consumed lunch from a multi-item meal with an instruction designed to model a LOC episode. Girls also reported mood state immediately before each meal.

RESULTS

Girls in IPT experienced no significant changes in pre-meal state depressive affect, while girls in HE experienced a non-significant improvement by follow-up 1 and then returned to baseline by follow-up 2 (p < .04). We found no significant group difference for changes in total intake relative to girls' daily energy needs (p's ≥ .25). However, IPT reduced, while HE increased, the percentage of daily energy needs consumed from snack-foods by follow-up 2 (p = .04). Within-groups, HE increased their snack food intake from follow-up 1 to follow-up 2 (p = .01).

CONCLUSIONS

In adolescent girls with LOC, IPT did not change total intake at the test meal and was associated with reduced snack-food intake. Data are required to determine if IPT effectively prevents excess weight gain in the longer-term. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:490-498).

Effectiveness of individualized, integrative outpatient treatment for females with anorexia nervosa and bulimia nervosa

The effectiveness of an individualized outpatient program was investigated in the treatment of bulimia nervosa (BN) and anorexia nervosa (AN). Participants included 151 females who received outpatient eating disorder treatment in the partial hospitalization program, the intensive outpatient program, or a combination of the two programs. Outcome measures included the Eating Disorder Inventory (EDI-2), Beck Depression Inventory (BDI-II), frequency of binge eating and purging, and mean body weight. Findings included significant increases in weight for the AN group, reductions in binge eating frequency for the BN group, and reductions in EDI-2 and BDI-II scores and purging frequency for both groups. This study provides preliminary support for the efficacy of a multimodal program for the treatment of both anorexia nervosa and bulimia nervosa.

Targeting Neural Endophenotypes of Eating Disorders with Non-invasive Brain Stimulation

The term "eating disorders" (ED) encompasses a wide variety of disordered eating and compensatory behaviors, and so the term is associated with considerable clinical and phenotypic heterogeneity. This heterogeneity makes optimizing treatment techniques difficult. One class of treatments is non-invasive brain stimulation (NIBS). NIBS, including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), are accessible forms of neuromodulation that alter the cortical excitability of a target brain region. It is crucial for NIBS to be successful that the target is well selected for the patient population in question. Targets may best be selected by stepping back from conventional DSM-5 diagnostic criteria to identify neural substrates of more basic phenotypes, including behavior related to rewards and punishment, cognitive control, and social processes. These phenotypic dimensions have been recently laid out by the Research Domain Criteria (RDoC) initiative. Consequently, this review is intended to identify potential dimensions as outlined by the RDoC and the underlying behavioral and neurobiological targets associated with ED. This review will also identify candidate targets for NIBS based on these dimensions and review the available literature on rTMS and tDCS in ED. This review systematically reviews abnormal neural circuitry in ED within the RDoC framework, and also systematically reviews the available literature investigating NIBS as a treatment for ED.

Overview of the treatment of binge eating disorder

We performed a qualitative review of treatment studies of binge eating disorder (BED), focusing on randomized clinical trials (RCTs). Limited effectiveness has been demonstrated for self-help strategies, and substantial effectiveness has been shown for cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). CBT and IPT may each be more effective than behavior weight loss therapy (BWLT) for reducing binge eating over the long term. The stimulant pro-drug lisdexamfetamine dimesylate (LDX) is the only drug approved by the FDA for the treatment of BED in adults based on 2 pivotal RCTs. Topiramate also decreases binge eating behavior, but its use is limited by its adverse event profile. Antidepressants may be modestly effective over the short term for reducing binge eating behavior and comorbid depressive symptoms, but are not associated with clinically significant weight loss. A RCT presented in abstract form suggests that intranasal naloxone may decrease time spent binge eating. There is no RCT of obesity surgery in BED, but many patients with BED seek and receive such surgery. While some studies suggest patients with BED and obesity do just as well as patients with obesity alone, other studies suggest that patients with BED have more post-operative complications, less weight loss, and more weight regain. This evidence suggests that patients with BED would benefit from receiving highly individualized treatment.

Examination of early group dynamics and treatment outcome in a randomized controlled trial of group cognitive behavior therapy for binge eating disorder

This study examined whether perceptions of group dynamics early in treatment predicted eating disorder outcomes in a sample of adults (N = 190) with binge eating disorder (BED) who participated in a 15-session group cognitive behavior therapy (gCBT) treatment with differing levels of therapist involvement (therapist led, therapist assisted, and self-help). The group dynamic variables included the Engaged subscale of the Group Climate Questionnaire--Short Form and the Group Attitude Scale, measured at session 2 and session 6. Treatment outcome was assessed in terms of global eating disorder severity and frequency of binge eating at end of treatment, 6-month, and 12-month follow-up. Session 2 engagement and group attitudes were associated with improved outcome at 12-month follow-up. No other group dynamic variables were significantly associated with treatment outcome. Group dynamic variables did not differ by levels of therapist involvement. Results indicate that early engagement and attitudes may be predictive of improved eating disorder psychopathology at 12 month follow-up. However, the pattern of mostly insignificant findings indicates that in gCBT, group process variables may be less influential on outcomes relative to other treatment components. Additionally, participants were able to engage in group treatment regardless of level of therapist involvement.

Rapid response in psychological treatments for binge eating disorder

OBJECTIVE

Analysis of short- and long-term effects of rapid response across 3 different treatments for binge eating disorder (BED).

METHOD

In a randomized clinical study comparing interpersonal psychotherapy (IPT), cognitive-behavioral therapy guided self-help (CBTgsh), and behavioral weight loss (BWL) treatment in 205 adults meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994) criteria for BED, the predictive value of rapid response, defined as ≥70% reduction in binge eating by Week 4, was determined for remission from binge eating and global eating disorder psychopathology at posttreatment, 6-, 12-, 18-, and 24-month follow-ups.

RESULTS

Rapid responders in CBTgsh, but not in IPT or BWL, showed significantly greater rates of remission from binge eating than nonrapid responders, which was sustained over the long term. Rapid and nonrapid responders in IPT and rapid responders in CBTgsh showed a greater remission from binge eating than nonrapid responders in CBTgsh and BWL. Rapid responders in CBTgsh showed greater remission from binge eating than rapid responders in BWL. Although rapid responders in all treatments had lower global eating disorder psychopathology than nonrapid responders in the short term, rapid responders in CBTgsh and IPT were more improved than those in BWL and nonrapid responders in each treatment. Rapid responders in BWL did not differ from nonrapid responders in CBTgsh and IPT.

CONCLUSION

Rapid response is a treatment-specific positive prognostic indicator of sustained remission from binge eating in CBTgsh. Regarding an evidence-based, stepped-care model, IPT, equally efficacious for rapid and nonrapid responders, could be investigated as a second-line treatment in case of nonrapid response to first-line CBTgsh.

Binge-eating disorder diagnosis and treatment: a recap in front of DSM-5

INTRODUCTION

Binge Eating Disorders is a clinical syndrome recently coded as an autonomous diagnosis in DSM-5. Individuals affected by Binge Eating Disorder (BED) show significantly lower quality of life and perceived health and higher psychological distress compared to the non-BED obese population. BED treatment is complex due to clinical and psychological reasons but also to high drop-out and poor stability of achieved goals. The purpose of this review is to explore the available data on this topic, outlining the state-of-the-art on both diagnostic issues and most effective treatment strategies.

METHODS

We identified studies published in the last 6 years searching the MeSH Term "binge eating disorder", with specific regard to classification, diagnosis and treatment, in major computerized literature databases including: Medline, PubMed, PsychINFO and Science Direct.

RESULTS

A total of 233 studies were found and, among them, 71 were selected and included in the review.

REVIEW

Although Binge Eating Disorder diagnostic criteria showed empirical consistency, core psychopathology traits should be taken into account to address treatment strategies. The available body of evidence shows psychological treatments as first line interventions, even if their efficacy on weight loss needs further exploration. Behavioral and self-help interventions evidenced some efficacy in patients with lower psychopathological features. Pharmacological treatment plays an important role, but data are still limited by small samples and short follow-up times. The role of bariatric surgery, a recommended treatment for obesity that is often required also by patients with Binge Eating Disorder, deserves more specific studies. Combining different interventions at the same time does not add significant advantages, planning sequential treatments, with more specific interventions for non-responders, seems to be a more promising strategy.

CONCLUSIONS

Despite its recent inclusion in DSM-5 as an autonomous disease, BED diagnosis and treatment strategies deserve further deepening. A multidisciplinary and stepped-care treatment appears as a promising management strategy. Longer and more structured follow-up studies are required, in order to enlighten long term outcomes and to overcome the high dropout rates affecting current studies.

A test of an interactive model of binge eating among undergraduate men

Past research has shown that a combination of high perfectionism, high body dissatisfaction, and low self-esteem is predictive of binge eating in college women (Bardone-Cone et al., 2006). In the current study, we examined whether this triple interaction model is applicable to men. Male undergraduate college students from a large Midwestern university (n=302) completed self-report measures online at two different time points, a minimum of eight weeks apart. Analyses revealed a significant interaction between the three risk factors, such that high perfectionism, high body dissatisfaction, and low self-esteem at Time 1 were associated with higher levels of Time 2 binge eating symptoms. The triple interaction model did not predict Time 2 anxiety or depressive symptoms, which suggests model specificity. These findings offer a greater understanding of the interactive nature of risk factors in predicting binge eating symptoms among men.

Development of a novel mindfulness and cognitive behavioral intervention for stress-eating: a comparative pilot study

Stress-related eating is increasingly cited as a difficulty in managing healthy eating behaviors and weight. However few interventions have been designed to specifically target stress-related eating. In addition, the optimal target of such an intervention is unclear, as the target might be conceptualized as overall stress reduction or changing emotional eating-related thoughts and behaviors. This pilot study compared the effects of three interventions targeting those components individually and in combination on stress-related eating, perceived stress, and weight loss to determine whether the two intervention components are effective alone or are more effective when combined. Fifty-three overweight participants (98% female) who reported elevated levels of stress and stress-eating and were at risk for obesity were randomly assigned to one of three six-week interventions: a modified mindfulness-based stress reduction (MBSR) intervention, a cognitive behavioral stress-eating intervention (SEI), and a combined intervention that included all MBSR and SEI components. All three interventions significantly reduced perceived stress and stress-eating, but the combination intervention resulted in greater reductions and also produced a moderate effect on short term weight loss. Benefits persisted at six week follow-up.The pattern of results preliminarily suggests that the combination intervention (MBSR+SEI) may yield promise in the treatment of stress-related eating.

Targeted prevention of excess weight gain and eating disorders in high-risk adolescent girls: a randomized controlled trial

BACKGROUND

The high prevalence and incidence of obesity and eating disorders in US adolescent girls are serious health problems. Because of the shared risk factors for obesity and eating disorders, a targeted prevention of both conditions is a priority.

OBJECTIVE

We determined whether an adapted interpersonal psychotherapy prevention program is more efficacious for reducing excess weight gain and worsening disordered eating than health education in adolescent girls at high risk of obesity and eating disorders.

DESIGN

A parallel-group, randomized controlled trial was conducted between September 2008 and January 2013 in a university-based laboratory and a federal research hospital. The study included 113 adolescent (12-17-y-old) girls deemed at high risk of adult obesity and eating disorders because of a body mass index (BMI) between the 75th and 97th percentiles and reports of episodes of a loss of control over their eating. Girls were randomly assigned to participate in an adapted interpersonal psychotherapy or a health-education group program for 12 weekly 90-min group sessions. Follow-up assessments occurred immediately after group programs and at 6 and 12 mo.

RESULTS

Participation in both conditions was associated with decreases in expected BMI gain, age-adjusted BMI metrics, the percentage of fat by using dual-energy X-ray absorptiometry, symptoms of depression and anxiety, and the frequency of loss-of-control eating over 12 mo of follow-up (Ps < 0.001) with no group difference. In follow-up analyses, interpersonal psychotherapy was more efficacious than health education at reducing objective binge eating at the 12-mo follow-up (P < 0.05).

CONCLUSIONS

The intervention with adolescent girls with loss-of-control eating is associated with lower age-adjusted BMI and percentage of adiposity as well as improved mood symptoms over 1 y. Interpersonal psychotherapy further reduced objective binge eating. Additional research is needed to elucidate the mechanisms by which physical and psychological improvements were observed. This trial was registered at clinicaltrials.gov as NCT00680979.

Food addiction in the light of DSM-5

The idea that specific kind of foods may have an addiction potential and that some forms of overeating may represent an addicted behavior has been discussed for decades. In recent years, the interest in food addiction is growing and research on this topic lead to more precise definitions and assessment methods. For example, the Yale Food Addiction Scale has been developed for the measurement of addiction-like eating behavior based on the diagnostic criteria for substance dependence of the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In 2013, diagnostic criteria for substance abuse and-dependence were merged, thereby increasing the number of symptoms for substance use disorders (SUDs) in the DSM-5. Moreover, gambling disorder is now included along SUDs as a behavioral addiction. Although a plethora of review articles exist that discuss the applicability of the DSM-IV substance dependence criteria to eating behavior, the transferability of the newly added criteria to eating is unknown. Thus, the current article discusses if and how these new criteria may be translated to overeating. Furthermore, it is examined if the new SUD criteria will impact future research on food addiction, for example, if "diagnosing" food addiction should also be adapted by considering all of the new symptoms. Given the critical response to the revisions in DSM-5, we also discuss if the recent approach of Research Domain Criteria can be helpful in evaluating the concept of food addiction.

Treatment of binge eating disorder in racially and ethnically diverse obese patients in primary care: randomized placebo-controlled clinical trial of self-help and medication

The objective was to determine whether treatments with demonstrated efficacy for binge eating disorder (BED) in specialist treatment centers can be delivered effectively in primary care settings to racially/ethnically diverse obese patients with BED. This study compared the effectiveness of self-help cognitive-behavioral therapy (shCBT) and an anti-obesity medication (sibutramine), alone and in combination, and it is only the second placebo-controlled trial of any medication for BED to evaluate longer-term effects after treatment discontinuation. 104 obese patients with BED (73% female, 55% non-white) were randomly assigned to one of four 16-week treatments (balanced 2-by-2 factorial design): sibutramine (N = 26), placebo (N = 27), shCBT + sibutramine (N = 26), or shCBT + placebo (N = 25). Medications were administered in double-blind fashion. Independent assessments were performed monthly throughout treatment, post-treatment, and at 6- and 12-month follow-ups (16 months after randomization). Mixed-models analyses revealed significant time and medication-by-time interaction effects for percent weight loss, with sibutramine but not placebo associated with significant change over time. Percent weight loss differed significantly between sibutramine and placebo by the third month of treatment and at post-treatment. After the medication was discontinued at post-treatment, weight re-gain occurred in sibutramine groups and percent weight loss no longer differed among the four treatments at 6- and 12-month follow-ups. For binge-eating, mixed-models revealed significant time and shCBT-by-time interaction effects: shCBT had significantly lower binge-eating frequency at 6-month follow-up but the treatments did not differ significantly at any other time point. Demographic factors did not significantly predict or moderate clinical outcomes. Our findings suggest that pure self-help CBT and sibutramine did not show long-term effectiveness relative to placebo for treating BED in racially/ethnically diverse obese patients in primary care. Overall, the treatments differed little with respect to binge-eating and associated outcomes. Sibutramine was associated with significantly greater acute weight loss than placebo and the observed weight-regain following discontinuation of medication suggests that anti-obesity medications need to be continued for weight loss maintenance. Demographic factors did not predict/moderate clinical outcomes in this diverse patient group.

Current and emerging drug treatments for binge eating disorder

INTRODUCTION

This study evaluated controlled treatment studies of pharmacotherapy for binge eating disorder (BED).

AREAS COVERED

The primary focus of the review was on Phase II and III controlled trials testing medications for BED. A total of 46 studies were considered and 26 were reviewed in detail. BED outcomes included binge eating remission, binge eating frequency, associated eating disorder psychopathology, associated depression and weight loss.

EXPERT OPINION

Data from controlled trials suggest that certain medications are superior to placebo for stopping binge eating and for producing faster reductions in binge eating, and - to varying degrees - for reducing associated eating disorder psychopathology, depression and weight loss over the short term. Almost no data exist regarding longer-term effects of medication for BED. Except for topiramate, which reduces both binge eating and weight, weight loss is minimal with medications tested for BED. Psychological interventions and the combination of medication with psychological interventions produce binge eating outcomes that are superior to medication-only approaches. Combining medications with psychological interventions does not significantly enhance binge eating outcomes, although the addition of certain medications enhances weight losses achieved with cognitive-behavioral therapy and behavioral weight loss, albeit modestly.

Psychological treatments for eating disorders

PURPOSE OF REVIEW

This review summarizes recent evidence on psychological treatments for eating disorders.

RECENT FINDINGS

Eating disorders are serious psychiatric conditions requiring evidence-based intervention. Treatments have been evaluated within each eating disorder diagnosis and across diagnoses. For adults with anorexia nervosa, no one specialist treatment has been shown to be superior. Cognitive behavioral therapy and interpersonal psychotherapy remain the most established treatments for bulimia nervosa and binge eating disorder, with stepped-care approaches showing promise and new behavioral treatments under study. Enhanced cognitive behavioral therapy has improved symptoms in adults and youth. Maudsley family-based therapy is the most established treatment for youth with anorexia nervosa and may be efficacious for youth with bulimia nervosa. Interpersonal psychotherapy for the prevention of excess weight gain may be efficacious for reducing loss of control eating and weight gain in overweight youth.

SUMMARY

Significant advances in treatments have been made, including evaluation of long-term outcomes, novel approaches, and tailored extension for specific patient profiles. However, widespread access to effective eating disorder treatments remains limited. Increasing the potency and expanding the implementation of psychological treatments beyond research settings into clinical practice has strong potential to increase access to care, thereby reducing the burden of eating disorders.

Epidemiology, course, and outcome of eating disorders

PURPOSE OF REVIEW

To review the recent literature about the epidemiology, course, and outcome of eating disorders in accordance with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

RECENT FINDINGS

The residual category 'eating disorder not otherwise specified' (EDNOS) was the most common DSM-IV eating disorder diagnosis in both clinical and community samples. Several studies have confirmed that the DSM-5 criteria for eating disorders effectively reduce the proportion of EDNOS diagnoses. The lifetime prevalence of DSM-5 anorexia nervosa among women might be up to 4%, and of bulimia nervosa 2%. In a cross-national survey, the average lifetime prevalence of binge eating disorder (BED) was 2%. Both anorexia nervosa and bulimia nervosa are associated with increased mortality. Data on long-term outcome, including mortality, are limited for BED. Follow-up studies of BED are scarce; remission rates in randomized controlled trials ranged from 19 to 65% across studies. On a community level, 5-year recovery rates for DSM-5 anorexia nervosa and bulimia nervosa are 69 and 55%, respectively; little is known about the course and outcome of BED in the community.

SUMMARY

Applying the DSM-5 criteria effectively reduces the frequency of the residual diagnosis EDNOS, by lowering the threshold for anorexia nervosa and bulimia nervosa, and adding BED as a specified eating disorder. Course and outcome studies of both anorexia nervosa and bulimia nervosa show that no significant differences exist between DSM-5 and DSM-IV definitions.

Self-help for binge eating disorder in primary care: a randomized controlled trial with ethnically and racially diverse obese patients

OBJECTIVE

The objective was to examine the effectiveness of a self-help treatment as a first line primary care intervention for binge eating disorder (BED) in obese patients. This study compared the effectiveness of a usual care plus self-help version of cognitive behavioral therapy (shCBT) to usual care (UC) only in ethnically/racially diverse obese patients with BED in primary care settings in an urban center.

METHOD

48 obese patients with BED were randomly assigned to either shCBT (N = 24) or UC (N = 24) for four months. Independent assessments were performed monthly throughout treatment and at post-treatment.

RESULTS

Binge-eating remission rates did not differ significantly between shCBT (25%) and UC (8.3%) at post-treatment. Mixed models of binge eating frequency determined using the Eating Disorder Examination (EDE) revealed significant decreases for both conditions but that shCBT and UC did not differ. Mixed models of binge eating frequency from repeated monthly EDE-questionnaire assessments revealed a significant treatment-by-time interaction indicating that shCBT had significant reductions whereas UC did not during the four-month treatments. Mixed models revealed no differences between groups on associated eating disorder psychopathology or depression. No weight loss was observed in either condition.

CONCLUSIONS

Our findings suggest that pure self-help CBT did not show effectiveness relative to usual care for treating BED in obese patients in primary care. Thus, self-help CBT may not have utility as a front-line intervention for BED for obese patients in primary care and future studies should test guided-self-help methods for delivering CBT in primary care generalist settings.

Cognitive-behavioral therapy for binge eating disorder in adolescents: study protocol for a randomized controlled trial

BACKGROUND

Binge eating disorder is a prevalent adolescent disorder, associated with increased eating disorder and general psychopathology as well as an increased risk for overweight and obesity. As opposed to binge eating disorder in adults, there is a lack of validated psychological treatments for this condition in adolescents. The goal of this research project is therefore to determine the efficacy of age-adapted cognitive-behavioral therapy in adolescents with binge eating disorder - the gold standard treatment for adults with binge eating disorder.

METHODS/DESIGN

In a single-center efficacy trial, 60 12- to 20-year-old adolescents meeting diagnostic criteria of binge eating disorder (full-syndrome or subthreshold) according to the Diagnostic and Statistical Manual of Mental Disorders 4th or 5th Edition, will be centrally randomized to 4 months of cognitive-behavioral therapy (n = 30) or a waiting-list control condition (n = 30). Using an observer-blind design, patients are assessed at baseline, mid-treatment, post-treatment, and at 6- and 12-month follow-ups after the end of treatment. In 20 individual outpatient sessions, cognitive-behavioral therapy for adolescents focuses on eating behavior, body image, and stress; parents receive psychoeducation on these topics. Primary endpoint is the number of episodes with binge eating over the previous 28 days at post-treatment using a state-of-the art clinical interview. Secondary outcome measures address the specific eating disorder psychopathology, general psychopathology, mental comorbidity, self-esteem, quality of life, and body weight.

DISCUSSION

This trial will allow us to determine the short- and long-term efficacy of cognitive-behavioral therapy in adolescent binge eating disorder, to determine cost-effectiveness, and to identify predictors of treatment outcome. Evidence will be gathered regarding whether this treatment will help to prevent excessive weight gain. If efficacy can be demonstrated, the results from this trial will enhance availability of evidence-based treatment of adolescent binge eating disorder.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00000542.

The dissemination and implementation of psychological treatments: problems and solutions

Treatment researchers expend their efforts identifying effective treatments, and for whom and how they work, but there are matters over and above these that are of concern when it comes to dissemination and implementation. These include the clinical range of the interventions concerned, the ease with which they can be learned, and their mode of delivery. It is these three topics, as they apply to the psychological treatment of eating disorders, that form the focus of this article. Alongside these considerations, we discuss how modern technology has the potential to transform both treatment and training.

A systematic review of evidence for psychological treatments in eating disorders: 2005-2012

OBJECTIVE

To update new evidence for psychotherapies in eating disorders (EDs) since 2005-September 2012.

METHOD

Completed and published in the English language randomized controlled trials (RCTs) were identified by SCOPUS search using terms "bulimia" or "binge eating disorder" (BED) or "anorexia nervosa" (AN) or "eating disorder" and "treatment," and 36 new RCTs met inclusion criteria.

RESULTS

There has been progress in the evidence for family based treatment in adolescents with AN, for cognitive behavior therapy (CBT) in full and guided forms, and new modes of delivery for bulimia nervosa (BN), BED, and eating disorder not otherwise specified with binge eating. Risk of bias was low to moderate in 22 (61%) of RCTs.

DISCUSSION

The evidence base for AN has improved and CBT has retained and extended its status as first-line therapy for BN. However, further research is needed, in particular noninferiority trials of active therapies and the best approach to addressing ED features and weight management in co-morbid BED and obesity.

Secretive food concocting in binge eating: test of a famine hypothesis

OBJECTIVE

Food concocting, or making strange food mixtures, is well documented in the famine and experimental semistarvation literature and appears anecdotally in rare descriptions of eating disorder (ED) patients but has never been scientifically investigated. Here we do so in the context of binge-eating using a "famine hypothesis of concocting."

METHOD

A sample of 552 adults varying in binge eating and dieting traits completed a Concocting Survey created for this study. Exploratory ED groups were created to obtain predictions as to the nature of concocting in clinical populations.

RESULTS

Binge eating predicted the 24.6% of participants who reported having ever concocted but dietary restraint, independently, even after controlling for binge eating, predicted its frequency and salience. Craving was the main motive. Emotions while concocting mirrored classic high-arousal symptoms associated with drug use; while eating the concoctions were associated with intensely negative/self-deprecating emotions. Concocting prevalence and salience was greater in the anorexia > bulimia > BED > no ED groups, consistent with their respectively incrementing dieting scores.

DISCUSSION

Concocting distinguishes binge eating from other overeating and, consistent with the famine hypothesis, is accounted for by dietary restraint. Unlike its adaptive function in famine, concocting could worsen binge-eating disorders by increasing negative effect, shame, and secrecy. Its assessment in these disorders may prove therapeutically valuable.

INTERBED: internet-based guided self-help for overweight and obese patients with full or subsyndromal binge eating disorder. A multicenter randomized controlled trial

Background

Binge eating disorder (BED) is a prevalent clinical eating disorder associated with increased psychopathology, psychiatric comorbidity, overweight and obesity, and increased health care costs. Since its inclusion in the DSM-IV, a few randomized controlled trials (RCTs) have suggested efficacy of book-based self-help interventions in the treatment of this disorder. However, evidence from larger RCTs is needed. Delivery of self-help through new technologies such as the internet should be investigated in particular, as these approaches have the potential to be more interactive and thus more attractive to patients than book-based approaches. This study will evaluate the efficacy of an internet-based guided self-help program (GSH-I) and cognitive-behavioral therapy (CBT), which has been proven in several studies to be the gold standard treatment for BED, in a prospective multicenter randomized trial.

Methods

The study assumes the noninferiority of GSH-I compared to CBT. Both treatments lasted 4 months, and maintenance of outcome will be assessed 6 and 18 months after the end of treatment. A total of 175 patients with BED and a body mass index between 27 and 40 kg/m² were randomized at 7 centers in Germany and Switzerland. A 20% attrition rate was assumed. As in most BED treatment trials, the difference in the number of binge eating days over the past 28 days is the primary outcome variable. Secondary outcome measures include the specific eating disorder psychopathology, general psychopathology, body weight, quality of life, and self-esteem. Predictors and moderators of treatment outcome will be determined, and the cost-effectiveness of both treatment conditions will be evaluated.

Results

The methodology for the INTERBED study has been detailed.

Conclusions

Although there is evidence that CBT is the first-line treatment for BED, it is not widely available. As BED is still a recent diagnostic category, many cases likely remain undiagnosed, and a large number of patients either receive delayed treatment or never get adequate treatment. A multicenter efficacy trial will give insight into the efficacy of a new internet-based guided self-help program and will allow a direct comparison to the evidence-based gold standard treatment of CBT in Germany.

Trial Registration

Current Controlled Trials ISRCTN40484777

German Clinical Trial Register DRKS00000409

12-month follow-up of fluoxetine and cognitive behavioral therapy for binge eating disorder

OBJECTIVE

The longer term efficacy of medication treatments for binge-eating disorder (BED) remains unknown. This study examined the longer term effects of fluoxetine and cognitive behavioral therapy (CBT) either with fluoxetine (CBT + fluoxetine) or with placebo (CBT + placebo) for BED through 12-month follow-up after completing treatments.

METHOD

81 overweight patients with BED within a randomized double-blind placebo-controlled acute treatment trial allocated to fluoxetine-only, CBT + fluoxetine, and CBT + placebo were assessed before treatment, during treatment, posttreatment, and 6 and 12 months after completing treatments. Outcome variables comprised remission from binge eating (0 binge-eating episodes for 28 days) and continuous measures of binge-eating frequency, eating disorder psychopathology, depression, and weight.

RESULTS

Intent-to-treat remission rates (missing data coded as nonremission) differed significantly across treatments at posttreatment and at 6- and 12-month follow-ups. At 12-month follow-up remission rates were 3.7% for fluoxetine-only, 26.9% for CBT + fluoxetine, and 35.7% for CBT + placebo. Mixed-effects models of all available continuous data (without imputation) at posttreatment and at 6- and 12-month follow-ups (controlling for baseline scores) revealed the treatments differed on all clinical outcome variables, except for weight, across time. CBT + fluoxetine and CBT + placebo did not differ and both were significantly superior to fluoxetine-only on the majority of clinical outcomes.

CONCLUSIONS

This represents the first report from any randomized placebo-controlled trial for BED that has reported follow-up data after completing a course of medication-only treatment. CBT + placebo was superior to fluoxetine-only, and adding fluoxetine to CBT did not enhance findings compared to adding placebo to CBT. The findings document the longer term effectiveness of CBT, but not fluoxetine, through 12 months after treatment completion.

Psychological treatments for binge eating disorder

Binge eating disorder (BED) is the most prevalent eating disorder in adults, and individuals with BED report greater general and specific psychopathology than non-eating disordered individuals. The current paper reviews research on psychological treatments for BED, including the rationale and empirical support for cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), dialectical behavior therapy (DBT), behavioral weight loss (BWL), and other treatments warranting further study. Research supports the effectiveness of CBT and IPT for the treatment of BED, particularly for those with higher eating disorder and general psychopathology. Guided self-help CBT has shown efficacy for BED without additional pathology. DBT has shown some promise as a treatment for BED, but requires further study to determine its long-term efficacy. Predictors and moderators of treatment response, such as weight and shape concerns, are highlighted and a stepped-care model proposed. Future directions include expanding the adoption of efficacious treatments in clinical practice, testing adapted treatments in diverse samples (e.g., minorities and youth), improving treatment outcomes for nonresponders, and developing efficient and cost-effective stepped-care models.