Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States

T-wave morphology among medically treated patients with Anorexia Nervosa

Anorexia nervosa (AN) has the highest rate of mortality of any psychiatric disorder, and cardiovascular complications occur in up to 80% of patients with AN and account for up to 30% of mortality. A controversy exists as to whether patients with AN are prone to develop electrocardiographic abnormalities related to repolarization. We aim to study previously unexplored T wave morphology markers in medically-treated patients with AN. Fifty-eight patients with AN (32 with restricting type and 26 with binge-eating/purging type) and 82 healthy controls were included in the study. ECGs were conducted under strict conditions and total cosine R-to-T (TCRT) and T-wave morphology dispersion (TMD) were computed according to accepted standards for a random beat and for an averaged beat. Forty-six AN patients were hospitalized (79.3%) during the study for a mean duration of 1.5 ± 1.1 months. AN patients had comparable QTc, TCRT, mean TMD, TMDpre, TMDpost and TCRTc values to those of healthy adults. Flattened T wave occurred slightly more often among AN patients than in controls (1.57 ± 1.23 leads affected compared with 1.11 ± 0.80 leads, respectively, p = 0.017). QTc, TCRT and TMD parameters' values were unaffected by the clinical type of AN. In conclusion, weight-restored AN patients are characterized by T wave flattening, but normal other T wave morphology parameters, which seemingly reflects an overall low risk of repolarization-associated ventricular arrhythmias. Long-term follow-up studies should be conducted to evaluate the prognostic significance of these novel repolarization markers in untreated patients or early in the refeeding phase.

Examining heterogeneity of binge-eating disorder using latent class analysis

There is significant variability in the type and severity of symptoms reported by individuals diagnosed with binge-eating disorder (BED). Using latent class analysis (LCA), the current study aimed to investigate potential sources of heterogeneity among individuals with BED. Participants were 775 treatment-seeking adults with DSM-IV-defined BED. Doctoral research clinicians reliably assessed participants for BED and associated eating-disorder psychopathology using the Structured Clinical Interview for DSM-IV Disorders and the Eating Disorder Examination (EDE) interview, measured weight and height, and participants completed a battery of self-report measures. Based on fit statistics and class interpretability, a 2-class model yielded the best overall fit to the data. The two classes were most distinct with respect to differences in body image concerns, distress about binge-eating, and depressive symptomology. Number of binge episodes were significantly different between classes, though the effect was much smaller. Body mass index was not a significant covariate in the majority of models. The results show that many of the features currently used to define BED (e.g., binge-eating frequency) are not helpful in explaining heterogeneity among individuals with BED. Instead, body image disturbances, which are not currently included as a part of the diagnostic classification system, appear to differentiate distinct subgroups of individuals with BED. Future research examining subgroups based on body image could be integral to resolving ongoing conflicting evidence related to the etiology and maintenance of BED.

Cognitive flexibility in acute anorexia nervosa and after recovery: A systematic review

Difficulties in cognitive flexibility-the ability to adapt effectively to changes in the environment and/or changing task demands-have been reported in anorexia nervosa (AN). However, findings are inconsistent across studies and it remains unclear which specific aspects of cognitive flexibility patients with AN may struggle with. This systematic review aimed to synthesise existing research on cognitive flexibility in AN and clarify differences between patients with acute AN, patients who are weight-restored and patients who are fully recovered from AN. Electronic databases were searched through to January 2020. 3,310 papers were screened and 70 papers were included in the final review. Although adults with acute AN performed worse in perceptual flexibility tasks and self-report measures compared to HCs, they did not exhibit deficits across all domains of cognitive flexibility. Adolescents with acute AN did not differ to HCs in performance on neurocognitive tasks despite self-reporting poorer cognitive flexibility. Overall, significant differences in cognitive flexibility between acute and recovered participants was not evident, though, the findings are limited by a modest number of studies. Recovered participants performed poorer than HCs in some neurocognitive measures, however, results were inconsistent across studies. These results have implications for the assessment of cognitive flexibility in AN and targeted treatment approaches.

Randomized Controlled Trial of Behavioral Weight Loss and Stepped Care for Binge-Eating Disorder: 12-Month Follow-up

OBJECTIVE

This study aimed to examine longer-term effects of behavioral weight loss (BWL) and Stepped Care for binge-eating disorder and obesity through 12-month follow-up after completing treatments.

METHODS

A total of 191 patients with binge-eating disorder/obesity were randomized to 6 months of BWL (n = 39) or Stepped Care (n = 152). Within Stepped Care, patients began BWL (1 month), treatment responders continued BWL, nonresponders switched to cognitive behavioral therapy, and all were randomized (double-blind) to weight-loss medication or placebo (5 months). Patients were independently assessed throughout/after treatment and at 6- and 12-month follow-ups.

RESULTS

Intent-to-treat analyses of remission rates revealed that BWL and Stepped Care did not differ significantly at posttreatment (74.4% vs. 66.5%), 6-month follow-up (38.2% vs. 33.3%), or 12-month follow-up (44.7% vs. 41.0%). Mixed models of binge-eating frequency indicated significant reductions through posttreatment but no significant changes or differences between BWL and Stepped Care during follow-up. Mixed models revealed significant weight loss with no differences between BWL and Stepped Care (5.1% vs. 5.8%) at posttreatment and significant time effects (larger percent weight loss at 6-month than at 12-month follow-up) with no differences between BWL and Stepped Care (-5.1% vs. -5.2% and -3.4% vs. -5.0%, respectively).

CONCLUSIONS

Binge-eating improvements and weight loss produced by BWL and adaptive Stepped Care did not differ significantly 12 months after completing treatments.

Medical management of eating disorders: an update

PURPOSE OF REVIEW

Eating disorders are associated with numerous medical complications. The aim of this study was to review recent progress in improving the medical management of patients with eating disorders.

RECENT FINDINGS

With close medical monitoring and electrolyte supplementation, accelerated refeeding protocols improve weight restoration without increasing the risk of refeeding syndrome. Olanzapine improves weight restoration better than placebo, without leading to adverse metabolic effects seen in individuals not in starvation. Alterations of the gut microbiome in anorexia nervosa have been demonstrated, but their clinical relevance remains unclear.

SUMMARY

Medical complications of eating disorders may facilitate the first contact with health professionals and treatment initiation. Medical complications of anorexia nervosa generally occur due to starvation, malnutrition and their associated physiological effects, whereas medical complications of bulimia nervosa are generally due to purging behaviors. Most medical complications in patients with binge eating disorder are secondary to obesity. Most medical complications of eating disorders can be effectively treated with nutritional management, weight normalization and the termination of purging behaviors. In summary, eating disorders are associated with many medical complications that have to be carefully assessed and managed as early as possible to improve long-term outcomes.

Self-esteem and binge eating: Do patients with binge eating disorder endorse more negatively worded items of the Rosenberg Self-Esteem Scale?

OBJECTIVE

Self-esteem is a core aspect of eating disorder symptomatology. This study aims to examine whether method effects associated with negatively worded items of the Rosenberg Self-Esteem Scale (RSES) may interact the negative self-evaluations experienced by patients with obesity and binge eating disorder (BED). We also examined whether negatively worded items were associated with psychological distress and eating symptoms.

METHOD

Five hundred thirty three female outpatients (mean age: 42.59) with BED (n = 160) or obesity without BED (n = 373) completed the RSES and measures of interpersonal problems, psychological distress, and eating symptoms.

RESULTS

Patients with BED responded more strongly to the negatively worded items of the RSES than those with obesity. The RSES negatively worded item factor was negatively associated with higher interpersonal problems, psychological distress, and binge eating.

CONCLUSIONS

Patients with BED may be more responsive to negatively phrased items on the RSES consistent with their negative self-evaluations and self-perceptions.

Development and Validation of the Eating Disorders Screen for Athletes (EDSA): A Brief Screening Tool for Male and Female Athletes

OBJECTIVES

To develop and validate the Eating Disorders Screen for Athletes (EDSA), a brief eating disorders screening tool for use in both male and female athletes.

METHODS

Data from Division I athletes at a Midwestern university (N=434) were used to conduct exploratory factor analysis (EFA) by gender. Data from athletes competing at various levels at universities across the United States (N=862) were then used to conduct confirmatory factor analysis (CFA) and receiver operator characteristic (ROC) curve analysis by gender. Athletes from a range of lean and non-lean sports were included. Gender-specific empirically derived cut-offs on the Eating Disorder Examination-Questionnaire were used to classify high eating disorder risk for ROC curve analysis. Measurement invariance by gender, level of competition, and sport type was also examined.

RESULTS

A six-item, one-factor structure for the EDSA was supported by EFA and CFA in both genders, and internal consistency was good for both male (α=. 80) and female athletes (α=.86). ROC curve analyses indicated that the EDSA was highly accurate in predicting eating disorder risk status and identified a score of 3.33 as the optimal cut-off for both male (sensitivity=.96, specificity=.80) and female athletes (sensitivity=.96, specificity=.64). Results also supported strong measurement invariance for the EDSA by gender, level of competition (Division I versus club), and sport type (lean versus non-lean).

CONCLUSIONS

The EDSA shows promise as a brief screening tool to identify male and female athletes at risk for eating disorders.

Lifetime patterns of comorbidity in eating disorders: An approach using sequence analysis

OBJECTIVE

Eating disorders (EDs) have high rates of psychiatric comorbidity. This study aimed to characterize longitudinal patterns of comorbidities in adults with EDs.

METHODS

Sequence analysis and hierarchical clustering were applied to ages of onset and recency for select eating, substance, mood, and anxiety disorders from the 479 participants in the Collaborative Psychiatric Epidemiology Surveys with lifetime DSM-IV bulimia nervosa, binge eating disorder, or anorexia nervosa. External validators were compared across clusters using chi-square tests.

RESULTS

Five clusters were identified among individuals with any lifetime ED based on longitudinal sequence of psychiatric disorder onset and remission, characterized as: (1) multi-comorbid with early onset of comorbid disorder (46%); (2) moderate preeminent anxiety with moderate comorbidity and low ED persistence (20%); (3) late ED onset with low comorbidity (15%); (4) early onset, persistent ED with low comorbidity (14%); and (5) chronic, early onset depression (5%). Clusters were well differentiated by significant differences in age, body mass index, race, and psychiatric indicators.

CONCLUSIONS

This study demonstrates a new method to assess clustering of comorbidity among individuals with lifetime EDs. Having a psychiatric diagnosis prior to an ED was associated with greater psychopathology and illness duration. Information on timing of diagnoses may allow for more refined comorbidity classification.

Childhood food neglect and adverse experiences associated with DSM-5 eating disorders in U.S. National Sample

OBJECTIVE

Adverse childhood experiences (ACEs) and restricted food access have been associated with risk for eating disorders (EDs). This study examined the relationship between childhood food neglect, an ACE specifically involving restricted food access, and DSM-5-defined EDs in a nationally representative sample of U.S. adults, with a particular focus on whether the relationship persists after adjusting for other ACEs and family financial difficulties.

METHODS

Participants were 36,145 respondents from the National Epidemiological Survey on Alcohol and Related Conditions III (NESARC-III) who provided data regarding childhood food neglect. Prevalence rates of lifetime anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) were determined for those who reported versus denied childhood food neglect. Analyses compared the odds of each ED diagnosis after adjusting for sociodemographic characteristics (Model 1) and further adjusting for other ACEs and governmental-financial support during childhood (Model 2).

RESULTS

Prevalence estimates for AN, BN, and BED with a history of childhood food neglect were 2.80% (SE = 0.81), 0.60% (SE = 0.21), and 3.50% (SE = 0.82), respectively and 0.80% (SE = 0.07), 0.30% (SE = 0.03), and 0.80% (SE = 0.05) for those without a history (all significantly different, p < .05). In the fully-adjusted model, odds of having an ED diagnosis were significantly higher for AN (AOR = 2.98 [95% CI = 1.56-5.71]) and BED (AOR = 2.95 [95% CI = 1.73-5.03]) in respondents with a history of childhood food neglect compared with those without.

CONCLUSION

Individuals who experience childhood food neglect may be at increased risk for AN and BED and the elevated risk exists after adjusting for other adverse experiences and financial difficulties during childhood.

Somatic symptoms and binge eating in women's daily lives

OBJECTIVE

The present study aimed to determine whether the momentary severity of women's somatic symptoms was concurrently and prospectively associated with their engagement in binge eating in naturalistic settings.

METHOD

Thirty women (M_age = 34.13, SD = 13.92) who had engaged in binge eating at least once over the month prior to study entry completed a 14-day ecological momentary assessment (EMA) protocol. During each of the 14 days, participants received five semi-random surveys via text message that assessed momentary somatic symptom severity (i.e., headaches, stomachaches/pain, chest/heart pain, faintness/dizziness, shortness of breath, fatigue) and disordered eating behaviors. Generalized estimating equations were used to determine whether momentary somatic symptoms were concurrently and prospectively (i.e., by participants' next assessment) associated with the occurrence of binge eating behavior, while controlling for age and body mass index.

RESULTS

At the within-person level, more severe stomachaches/pain, faintness/dizziness, shortness of breath, and fatigue were concurrently associated with an increased likelihood of engaging in binge eating. Further, at the between-person level, more severe stomachaches/pain, chest/heart pain, shortness of breath, and fatigue in general were associated with binge eating across the EMA protocol. Momentary stomachache/pain severity also prospectively predicted women's engagement in binge eating behavior at the next assessment.

CONCLUSIONS

The present results provide initial evidence that multiple somatic symptoms may serve as momentary correlates or proximal antecedents of binge eating behavior in women's daily lives. Somatic symptoms may consequently prove useful to target in eating disorder treatments, perhaps via interoceptive exposure interventions.

Treating Eating: A Dynamical Systems Model of Eating Disorders

Mainstream forms of psychiatric talk therapy and cognitive behavioral therapy (CBT) do not reliably generate lasting recovery for eating disorders. We discuss widespread assumptions regarding the nature of eating disorders as fundamentally psychological disorders and highlight the problems that underlie these notions, as well as related practical problems in the implementation of mainstream treatments. We then offer a theoretical and practical alternative: a dynamical systems model of eating disorders in which behavioral interventions are foregrounded as powerful mediators between psychological and physical states. We go on to present empirical evidence for behavioral modification specifically of eating speed in the treatment of eating disorders, and a hypothesis accounting for the etiology and progression, as well as the effective treatment, of the full spectrum of eating problems. A dynamical systems approach mandates that in any dietary and lifestyle change as profound as recovery from an eating disorder, acknowledgment must be made of the full range of pragmatic (psychological, cultural, social, etc.) factors involved. However, normalizing eating speed may be necessary if not sufficient for the development of a reliable treatment for the full spectrum of eating disorders, in its role as a mediator in the complex feedback loops that connect the biology and the psychology with the behaviors of eating.

Changes in disordered eating behaviors over 10 or more years: A meta-analysis

OBJECTIVE

The present meta-analysis evaluated changes in individuals' risk of engaging in distinct disordered eating behaviors (DEBs) in the long-term.

METHOD

Longitudinal studies assessing changes in DEBs via ≥2 assessments with a time lag of ≥10 years were included. Risk ratios were calculated for baseline to 10-14.9-year (M = 11.04) follow-up and baseline to ≥15-year (M = 18.62) follow-up changes in the use of binge eating, multiple purging, self-induced vomiting, laxatives, diuretics, diet pills, compensatory exercising, fasting/dieting, and multiple DEBs; Cohen's d was used for continuous binge-eating plus purging variable changes. Subgroup and meta-regression analyses tested whether eating disorder (ED) clinical sample versus nonclinical sample status, female versus male sex/gender, higher versus lower study bias, and baseline mean age and body mass index influenced overall effect magnitude for analyses with sufficient data.

RESULTS

Seventeen studies (26 [sub]samples) were included. Overall, individuals' risk of engaging in various restrictive eating and other compensatory behaviors decreased over time and the magnitudes of risk reductions for the use of certain compensatory DEBs were larger over longer follow-up durations. Specifically, for significant DEB change models, risk reductions spanned from 20.0-39.8% for 10-year follow-up and 24.7-74.8% for ≥15-year follow-up. However, nuances were found in the nature of these DEB changes as a function of DEB type, follow-up length, ED versus nonclinical sample composition, and baseline mean age.

CONCLUSIONS

These findings provide important information that can help identify treatment priorities and suggest that targeted and tailored preventative ED treatments warrant consistent implementation at the community-level, particularly for youth.

Reduced alcohol drinking following patterned feeding: Role of palatability and acute contingent availability

Recent studies from our lab have demonstrated that intermittent high-fat diet access reduces alcohol drinking in rats. However, it was unclear if caloric overload, palatability, or diet itself triggered reduced alcohol drinking. It is also unknown if a similar paradigm could reduce relapse-like alcohol drinking. The presented study tested the hypothesis that acute intermittent palatable diet (PD) access would rescue relapse-like drinking and palatability, but not diet itself contributes to reduced drinking. Male Long Evans rats received six-weeks intermittent or chronic chow (controls) or PDs (high-fat diet, high-sugar diet) exposure, and alcohol testing occurred following PDs suspension. Alcohol intake was not significantly different among groups in either condition, suggesting that diet itself did not impact alcohol drinking. A subset of these rats received two-weeks intermittent PDs (Int-PDs) exposure and alcohol testing reinitiated while Int-PDs access continued. Alcohol intake significantly escalated (~137% compared to baseline; alcohol deprivation effect) in the chow controls, whereas it remained unchanged in PD groups. These data demonstrate the critical importance of acute intermittent PDs availability and its protective effect in relapse-like drinking. To assess the contribution of palatability in reduced alcohol drinking, a separate group of rats received two-weeks intermittent high-sugar diet (Int-HSD) or saccharin (Int-SAC) access and tested for alcohol drinking while Int-HSD/SAC continued. Alcohol drinking significantly decreased (~30%) in both HSD and SAC groups compared to the controls. These data identify the critical parameters by which acute intermittent PD access reduces alcohol drinking and could have important therapeutic implications in the management of alcoholism.

Cocreating research priorities for anorexia nervosa: The Canadian Eating Disorder Priority Setting Partnership

OBJECTIVE

The Canadian Eating Disorder Priority Setting Partnership was established to identify and prioritize the top 10 research priorities for females, 15 years or older, with anorexia nervosa, by incorporating equal input from those with lived experience, families, and healthcare professionals.

METHOD

This project, which closely followed the James Lind Alliance guidelines, solicited research priorities from the Canadian eating disorder community by means of a five-step process including use of a survey, response collation, literature checking, interim ranking survey, and in-person prioritization workshop.

RESULTS

The initial survey elicited 897 priorities from 147 individuals, with almost equal representation from all three stakeholder groups. From this, 603 responses aligned with the project objectives and were collapsed into 71 broader indicative questions. Based on available systematic reviews, 18 indicative questions were removed as they were considered answered by existing literature while 8 indicative questions were added from the recommendations of the reviews. In total, 61 indicative questions were ranked in an interim ranking survey, where 21 questions were prioritized as important by at least 20% of respondents. As a final step, 28 individuals from across Canada attended the prioritization workshop to coestablish the top 10 research priorities.

DISCUSSION

Top priorities were related to treatment gaps and the need for more surveillance data. This systematic methodology allowed for a transparent and collaborative approach to identifying current priorities from both the service user and provider perspective. Wide dissemination is anticipated to promote work that is of high relevance to patients, families, and clinicians.

Access to evidence-based care for eating disorders during the COVID-19 crisis

The COVID-19 pandemic has forced an abrupt change in the delivery of clinical services, including for individuals with an eating disorder. We present this Virtual Issue as a resource for the eating disorder community to showcase research published in the International Journal of Eating Disorders that provides information on effective strategies to help address the challenges arising from COVID-19-related disruptions. Articles included describe original research or systematic reviews on obstacles to health services use and strategies to improve access to care; technological tools to provide or enhance interventions; patients' and clinicians' attitudes or perspectives on using digital tools for clinical care; factors influencing therapeutic alliance; and ideas for improving reach and uptake of digital interventions. We hope that readers will find ways to observe and record their own experiences during this global crisis; the experiences of people at risk for developing or exhibiting an eating disorder; and the experiences of those who care for people with an eating disorder. These lived experiences will be invaluable in formulating hypotheses for future studies in service of advancing the understanding of eating disorders and improving interventions and policies for reducing the burden of suffering attributable to eating disorders.

Managing Patients With Severe and Enduring Anorexia Nervosa: When Is Enough, Enough?

OBJECTIVE

Approximately 20% of patients with anorexia nervosa develop severe and enduring anorexia nervosa (SE-AN), manifest by decades-long illnesses. At certain points, demoralized and/or based on judicious appraisals of the seeming futility of further professional treatment to radically alter their course, some SE-AN patients decide that "enough is enough" and opt out of intensive treatment. This article considers courses and treatment options available at these stages for patients, families, and clinicians.

METHODS

The author uses clinical illustrations, Socratic questioning, and available literature to explore questions of treatment strategies with patients struggling with SE-AN.

RESULTS

SE-AN patients have frequently received care in varieties of medical, psychiatric, and specialized eating disorders inpatient, residential, partial hospital, and outpatient treatment settings. Patients may reject further high-intensity treatment for judicious or capricious reasons, but may still accept lower intensity treatments. Some may reject any and all offers of treatment. Clinicians' treatment recommendations, not always coinciding with patients' wishes, are influenced by numbers of clinical, social, and professional pressures, including those from families, treatment settings, regulatory bodies, and payors.

CONCLUSIONS

When managing patients with decades-long disease and multiple comorbidities, clinicians must be realistic about the low odds of effecting cure and adjust treatment expectations accordingly. For patients with SE-AN, a variety of low-intensity treatment approaches, at times extending to palliative and hospice care, may be useful. Clinicians should always strive to provide humane comfort and support, as closely aligned to patients' judicious wishes as realistically possible.

Eating disorders

Eating disorders are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning. Disturbed attitudes towards weight, body shape, and eating play a key role in the origin and maintenance of eating disorders. Eating disorders have been increasing over the past 50 years and changes in the food environment have been implicated. All health-care providers should routinely enquire about eating habits as a component of overall health assessment. Six main feeding and eating disorders are now recognised in diagnostic systems: anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant-restrictive food intake disorder, pica, and rumination disorder. The presentation form of eating disorders might vary for men versus women, for example. As eating disorders are under-researched, there is a great deal of uncertainty as to their pathophysiology, treatment, and management. Future challenges, emerging treatments, and outstanding research questions are addressed.

Treating Individuals With Eating Disorders: Part 1

According to the American Psychiatric Association, eating disorders (EDs) are characterized by a persistent disturbance of eating or eating-related behaviors that result in altered consumption or absorption of food and that significantly impair physical health and/or psychosocial functioning. EDs are chronic psychiatric illnesses and are notoriously difficult to treat. The etiology of eating disorders is unknown and thought to be a complex interplay among biological predisposition, environmental and sociocultural factors, neurobiological influences, and psychological factors. Moreover, prevalence of eating disorders is increasing despite variation in prevalence estimates across studies. Nurses are well-positioned to implement appropriate screening for and comprehensive assessment of EDs as well as offer patient-centered treatment options including referrals when indicated. As the first in a two-part series, this article provides an overview of the clinical characteristics of EDs and key areas for assessment and diagnostic considerations. The follow-up article in this series will focus on pharmacological treatment strategies. [Journal of Psychosocial Nursing and Mental Health Services, 58(3), 7-13.].

Randomized controlled trial testing the effectiveness of adaptive "SMART" stepped-care treatment for adults with binge-eating disorder comorbid with obesity

This randomized controlled trial (RCT) tested effectiveness of adaptive SMART stepped-care treatment to "standard" behavioral weight loss (BWL [standard]) for patients with binge-eating disorder (BED) and obesity. One hundred ninety-one patients were randomly assigned to 6 months of BWL (standard; n = 39) or stepped care (n = 152). Within stepped care, patients started with BWL for 1 month; treatment responders continued BWL, whereas nonresponders switched to cognitive-behavioral therapy (CBT), and patients receiving stepped care were additionally randomized to weight-loss medication or placebo (double-blind) for the remaining 5 months. Independent assessments were performed reliably at baseline, throughout treatment, and posttreatment. Intent-to-treat (ITT) analyses of remission rates (zero binges/month) revealed that BWL (standard) and stepped care did not differ (74.4% vs. 66.5%); within stepped care, remission rates ranged 40.0% to 83.3%, with medication significantly superior to placebo (overall) and among nonresponders switched to CBT. Mixed-models analyses of binge-eating frequency revealed significant time effects, but BWL (standard) and stepped care did not differ; within stepped care, medication was significantly superior to placebo and among nonresponders switched to CBT. Mixed models revealed significant weight loss, but BWL (standard; 5.1% weight-loss) and stepped care (5.8% weight-loss) did not differ; within stepped care (range = 0.4% to 8.8% weight-loss), medication was significantly superior to placebo and among both responders continued on BWL and nonresponders switched to CBT. In summary, BWL (standard) and adaptive stepped-care treatments produced robust improvements in binge eating and weight loss in patients with BED/obesity. Within adaptive stepped care, weight-loss medication enhanced outcomes for BED/obesity. Implications for clinical practice and future adaptive designs are offered. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Disparities in DSM-5 defined eating disorders by sexual orientation among U.S. adults

OBJECTIVE

The increased occurrence of disordered eating behaviors among sexual minorities is well established; however, few studies have examined disparities in eating disorder diagnoses among this population. This study sought to examine lifetime prevalence estimates of DSM-5 defined EDs, including anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) as a function of sexual orientation. We then compared prevalence of EDs based on experiences with perceived discrimination.

METHOD

A nationally representative sample of U.S. adults (N = 35,995) participating in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III completed structured diagnostic interviews.

RESULTS

Prevalence rates were significantly higher among sexual minorities than heterosexual respondents for all EDs: AN = 1.71% (SE = 0.50) versus 0.77% (SE = 0.07), BN = 1.25% (SE = 0.37) versus 0.24% (SE = 0.03), BED = 2.17% (SE = 0.52) versus 0.81% (SE = 0.05). Odds of lifetime diagnosis were significantly greater among sexual minorities for AN (adjusted odds ratio [AOR] = 1.93), BN (AOR = 3.69), and BED (AOR = 2.32), after adjusting for sociodemographic variables. Sexual minorities reporting experiences with perceived discrimination had significantly higher prevalence of AN than those not endorsing perceived discrimination: 3.78% (SE = 1.43) versus 0.82% (SE = 0.33); AOR = 5.06. There were no significant differences in prevalence of BN or BED by perceived discrimination.

DISCUSSION

Findings indicate that sexual minorities are disproportionately affected by EDs. Further research is needed to better understand mechanisms contributing to these disparities and heightened risk for EDs.

A developmental framework of binge-eating disorder based on pediatric loss of control eating

Although binge-eating disorder may manifest in childhood, a significantly larger proportion of youth report episodes involving a loss of control while eating, the hallmark feature of binge eating that predicts excess weight gain and obesity. Adults with binge-eating disorder often report that symptoms emerged during childhood or adolescence, suggesting that a developmental perspective of binge eating may be warranted. Thus, loss of control eating may be a marker of prodromal binge-eating disorder among certain susceptible youth. The present article offers a broad developmental framework of binge-eating disorder and proposes areas of future research to determine which youths with loss of control eating are at risk for persistent and exacerbated behavior that may develop into binge-eating disorder and adult obesity. To this end, this article provides an overview of loss of control eating in childhood and adolescence, including its characterization, etiology, and clinical significance, with a particular focus on associations with metabolic risk, weight gain, and obesity. A conceptual model is proposed to further elucidate the mechanisms that may play a role in determining which youths with loss of control are at greatest risk for binge-eating disorder and obesity. Ways in which treatments for adult binge-eating disorder may inform approaches to reduce loss of control eating and prevent excess weight gain in youth are discussed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Testing the validity and clinical utility of the severity specifiers for binge-eating disorder for predicting treatment outcomes

OBJECTIVE

To test the validity and clinical utility of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) severity specifiers for binge-eating disorder (BED) in predicting treatment outcomes.

METHOD

Participants (N = 521) were patients in randomized controlled trials (RCTs) at 1 medical center testing treatments for BED; data were aggregated from RCTs testing cognitive-behavioral therapy (CBT), behavioral weight loss (BWL), and/or multimodal (i.e., CBT or BWL plus pharmacotherapy) treatment. Participants were categorized according to DSM-5 severity specifiers for BED: "mild" (n = 273; 52.5%), "moderate" (n = 182; 34.9%), and "severe/extreme" (n = 58; 11.1%). Participants had their weight and height measured and were assessed using established interviews and self-report measures at baseline, throughout treatment, and post treatment.

RESULTS

Mixed models revealed that severity category did not significantly predict treatment response. However, there were main effects of BED severity category: "Severe/extreme" BED had greater binge-eating frequency and had greater global eating-disorder psychopathology than did "mild" BED across all time points. "Severe/extreme" BED was less likely to have remission from binge eating than was "mild" BED. Weight loss and depression scores did not significantly differ by severity category.

CONCLUSION

In a large series of treatment-seeking individuals with BED aggregated across RCTs at 1 medical center testing psychological and pharmacological treatments for BED, DSM-5 severity specifiers for BED had limited validity and utility predicting response to treatments. Future research is needed to identify more robust severity indicators with clinical utility to inform future DSM revisions and clinical practice. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Examining sex as a predictor and moderator of treatment outcomes for binge-eating disorder: Analysis of aggregated randomized controlled trials

OBJECTIVE

This study examined whether sex predicted and/or moderated treatment outcomes among men and women who participated in binge-eating disorder (BED) randomized controlled trials (RCTs).

METHOD

Data were aggregated from RCTs performed at one medical center. RCTs tested cognitive-behavioral therapy, behavioral weight loss, multimodal treatment, and/or control conditions. Participants were 660 adults, both men (n = 170) and women (n = 490), with Diagnostic and Statistical Manual-fourth edition (DSM-IV)-defined BED. Doctoral-level research-clinicians assessed participants using structured interviews and established self-report measures of eating-disorder psychopathology and depression, and measured height and weight. Assessments occurred at baseline, throughout treatment, and at post-treatment.

RESULTS

Sex was not a significant moderator of any treatment outcomes. Mixed models revealed sex had a main effect: men had lower eating-disorder psychopathology and lost more weight than women over the course of treatment.

DISCUSSION

Both epidemiological and RCT studies report disparities in treatment-seeking between men and women with BED. Despite this, men have comparable or better treatment outcomes compared with women, including significantly greater weight loss. Thus, disseminating evidence-based BED treatments is promising for both men and women. Additional research is necessary, however, to understand treatment effects-including other predictors and moderators of outcomes-across diverse providers, treatment settings, and patient groups.

Non-Suicidal Self-Injury and Eating Disordered Behaviors: An Update on What We Do and Do Not Know

PURPOSE OF REVIEW

The current report aims to summarize recent advances about the relationship between non-suicidal self-injury (NSSI) and eating disordered (ED) behaviors and highlights meaningful directions for future research.

RECENT FINDINGS

While there is solid evidence indicating a robust cross-sectional association between NSSI and ED behaviors, emerging evidence suggests that the temporal relationship between these behaviors may be bidirectional. Shared functions and risk factors may explain why these behaviors often co-develop. At the same time, little is still known about the psychosocial consequences of comorbid NSSI and ED engagement, and there is a lack of intervention studies that target these behaviors simultaneously. It is well-established that NSSI and ED behaviors frequently co-occur. The field should now turn to longitudinal designs to advance our understanding of the longer-term developmental and the shorter-term momentary relationship of these behaviors in daily life. Providing insight into these areas will help guide the deployment of evidence-based interventions that match the needs of clients who report comorbid NSSI and ED behaviors.

Behavioral and Neurobiological Consequences of Hedonic Feeding on Alcohol Drinking

A complex interplay of peripheral and central signaling mechanisms within the body of an organism maintains energy homeostasis. In addition, energy/food intake is modified by various external factors (e.g., palatability, food availability, social and environmental triggers). Highly palatable foods can provoke maladaptive feeding behavior, which in turn disrupts normal homeostatic regulation resulting in numerous health consequences. Furthermore, neuroendocrine peptides, traditionally considered to regulate appetite and energy homeostasis, also control the intake and reinforcing properties of alcohol and drugs of abuse. Therefore, dysregulated eating as a result of a hedonic/binge-like intake of hyper-palatable food may impact alcohol drinking behavior. Relevant in this case is the fact that eating disorders are highly comorbid with several neuropsychiatric conditions, including alcohol use disorder. The present review is intended to summarize the neurobiological and functional consequences of hedonic feeding on alcohol intake.

Physical activity levels and correlates in nationally representative sample of U.S. adults with healthy weight, obesity, and binge-eating disorder

OBJECTIVES

This study compared the patterns of moderate and vigorous physical activity (PA) and health conditions in a nationally representative sample of adults categorized with healthy weight (HW) without eating disorder history, obesity without eating disorder history (OB), or current binge-eating disorder (BED) with obesity (BED+OB).

METHOD

We used the third National Epidemiological Survey on Alcohol and Related Conditions to compare PA intensity, duration, and their relationships with health indicators in the three groups: HW (n = 11,635), OB (n = 11,056), and BED+OB (n = 110).

RESULTS

Prevalence of physical inactivity was significantly greater in OB (38.1%) and BED (51.4%) than HW (30.3%). Prevalence of vigorous PA was significantly lower in OB (45.5%) and BED (31.7%) than HW (54.0%). Duration of moderate and vigorous activity per week was significantly shorter in BED+OB than HW and duration of vigorous activity was shorter in OB than HW. Regardless of PA intensity, BED+OB reported poorer physical and mental health than OB and HW. Greater PA intensity and duration were associated with better physical health, particularly in OB.

DISCUSSION

In this nationally representative study of U.S. adults, obesity was associated with physical inactivity. Comorbid obesity and BED was associated with lower PA levels and poorer health. Particularly among adults with obesity, greater PA intensity was associated with better physical health, and greater duration of PA was associated with better physical and mental health. The findings highlight the importance of screening for BED in addition to obesity status and for promoting PA to improve health in U.S. adults.

Investigational drugs for the treatment of binge eating disorder (BED): an update

Introduction: Binge eating disorder (BED) is the most common eating disorder and is frequently associated with psychiatric and medical comorbidities and functional impairment. Although psychological treatments have been the cornerstones of BED treatment, pharmacologic interventions also play an important part of the multimodal management of this condition.Areas covered: This review examines investigational, approved and other pharmacological agents for the treatment of BED. We searched PubMed and clinicaltrials.gov to identify pharmacological interventions for the management of this condition.Expert opinion: BED pharmacological studies have incorporated new drug targets based on our enhanced understanding of the pathophysiology of BED. Neurobiological dysregulation in the reward center and impulse control circuitry and related disturbances in dopamine neurotransmission are among the neurobiological explanations that have been suggested for BED. These mechanisms serve as a pharmacodynamic foundation for the development of new compounds such as lisdexamfetamine (LDX) and dasotraline. Despite these advances, pharmacological trials in BED have numerous challenges that must be overcome. For most compounds studied, larger and more definitive trials is a high priority.

Associations between physical activity and eating-disorder psychopathology among individuals categorised with binge-eating disorder and bulimia nervosa

OBJECTIVE

While physical activity (PA) is known to have positive effects on psychological and physical health, little is understood about the association between non-compensatory PA (ie, not compulsive or intended to control weight or shape) and psychopathology among individuals with eating-disorder features. The present study explored associations between non-compensatory PA and psychopathology among adults categorised with bulimia nervosa (BN) and binge-eating disorder (BED). We further explored the association between compensatory PA and psychopathology among those who engaged in that form of "purging."

METHOD

Participants were recruited through Mechanical Turk, an online recruitment platform. Individuals categorised with core features of BED (N = 138) and BN (N = 138) completed measures of eating-disorder psychopathology (Eating Disorder Examination - Questionnaire [EDE-Q] and Questionnaire on Eating and Weight Patterns - 5), depression (Patient Health Questionnaire - 2) and PA (both non-compensatory and compensatory, measured using the EDE-Q and Godin Leisure-Time Exercise Questionnaire).

RESULTS

Engagement in non-compensatory PA was associated with lower frequency of binge-eating episodes, lower overvaluation of shape/weight and lower dissatisfaction with shape/weight (Ps < .05). Engagement in compensatory PA was related to greater frequency of binge-eating episodes and greater restraint (Ps < .05).

DISCUSSION

Non-compensatory PA was associated with lower eating-disorder psychopathology. This suggests that PA is an important, though understudied, health behaviour among persons with features of BED and BN. Future research should examine the potential role of non-compensatory PA in interventions for individuals with core features of these eating disorders.

Binge eating disorder revisited: what's new, what's different, what's next

Binge eating disorder (BED) is the most common type of eating disorder. According to the most recent data available, the estimated lifetime prevalence of BED among US adults in the general population is 0.85% (men 0.42% and women 1.25%). Among psychiatric treatment populations, prevalence is several-fold higher. Although many people with BED are obese (BMI ≥ 30 kg/m2), roughly half are not. In the DSM-5, BED is defined by recurrent episodes of binge eating (eating in a discrete period of time, an amount of food larger than most people would eat in a similar amount of time under similar circumstances and a sense of lack of control over eating during the episode), occurring on average at least once a week for 3 months, and associated with marked distress. BED often goes unrecognized and thus untreated; in one study, 344 of 22,387 (1.5%) survey respondents met DSM-5 criteria for BED, but only 11 out of the 344 had ever been diagnosed with BED by a health-care provider. Psychiatric comorbidities are very common, with most adults with BED also experiencing anxiety disorders, mood disorders, impulse control disorders, or substance use disorders, suggesting that clinicians have patients in their practice with unrecognized BED. Multiple neurobiological explanations have been suggested for BED, including dysregulation in reward center and impulse control circuitry. Additionally, there is interplay between genetic influences and environmental stressors. Psychological treatments such as cognitive behavioral interventions have been recommended as first line and are supported by meta-analytic reviews; however, access to such treatments may be limited because of local availability and/or cost, and these treatments generally lead to little to no weight loss, although successfully eliminating binge eating can protect against future weight gain. Routine medication treatments for anxiety and depression do not necessarily ameliorate the symptoms of BED, but there are approved and emerging medication options, lisdexamfetamine and dasotraline, respectively, that specifically address the core drivers behind binge eating, namely obsessive thoughts and compulsive behaviors regarding food, resulting in marked decreases in binge eating behaviors as well as weight loss.

Rates of Help-Seeking in US Adults With Lifetime DSM-5 Eating Disorders: Prevalence Across Diagnoses and Differences by Sex and Ethnicity/Race

OBJECTIVE

To investigate, in a nationally representative sample of US adults, the prevalence of help-seeking in individuals with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) eating disorders (EDs) and to examine sex and ethnic/racial differences.

PATIENTS AND METHODS

The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (N=36,309) included respondents who met the criteria for specific lifetime DSM-5 EDs and answered questions regarding help-seeking for their ED symptoms (anorexia nervosa [AN]: n=275; bulimia nervosa [BN]: n=91; and binge-eating disorder [BED]: n=256).

RESULTS

The prevalence (standard error) estimates of ever seeking any help for AN, BN, and BED were 34.5% (2.80%), 62.6% (5.36%), and 49.0% (3.74%), respectively. Adjusting for sociodemographic characteristics, men and ethnic/racial minorities (non-Hispanic blacks and Hispanics) were statistically significantly less likely to ever seek help for BED than were women or non-Hispanic whites, respectively. Hispanics also were significantly less likely to seek help for AN relative to non-Hispanic whites.

CONCLUSION

This was the first study in a nationally representative sample of US adults to examine rates of help-seeking, including by sex and ethnic/racial differences, across DSM-5-defined EDs. These findings emphasize the need to develop strategies to encourage help-seeking among individuals with EDs, particularly among men and ethnic/racial minorities.

Prevalence of Neoplasms among Former Adolescent Psychiatric Inpatients

OBJECTIVE

To examine the association between psychiatric disorders and neoplasms.

METHODS

A follow-up study of a population-based cohort of patients admitted for psychiatric care between the ages 13-17 years. The cases were patients with a follow-up diagnosis of neoplasm. The K-SADS-PL interview was used to assess DSM-IV based psychiatric diagnoses at adolescence. The treatment episodes due to neoplasms and related psychiatric disorders were extracted from the National Health Care Registers.

RESULTS

Of the original cohort, 6.3% of subjects had a neoplasm diagnosis. Male cases were characterized as taking snuff and females as having a fear of becoming obese. 75% of cases had smoked regularly and 47% suffered from substance misuse disorder already in adolescence. At a mean age of 22 years, the diagnoses of skin or soft tissue neoplasms were prevailing, three being malignant neoplasms of the skin, mouth or colon. Non-psychotic disorders were comorbid both two years before (26%) and after (33%) the neoplasm diagnosis.

CONCLUSION

Focus on psychiatric symptoms of patients with neoplasms may enhance their treatment outcome and quality of life.

Clinical phenotype and genetic risk factors for bipolar disorder with binge eating: an update

Introduction: Clinical and genetic study of psychiatric conditions has underscored the co-occurrence of complex phenotypes and the need to refine them. Bipolar Disorder (BD) and Binge Eating (BE) behavior are common psychiatric conditions that have high heritability and high co-occurrence, such that at least one quarter of BD patients have BE (BD + BE). Genetic studies of BD alone and of BE alone suggest complex polygenic risk models, with many genetic risk loci yet to be identified. Areas covered: We review studies of the epidemiology of BD+BE, its clinical features (cognitive traits, psychiatric comorbidity, and role of obesity), genomic studies (of BD, eating disorders (ED) defined by BE, and BD + BE), and therapeutic implications of BD + BE. Expert opinion: Subphenotyping of complex psychiatric disorders reduces heterogeneity and increases statistical power and effect size; thus, it enhances our capacity to find missing genetic (and other) risk factors. BD + BE has a severe clinical picture and genetic studies suggests a distinct genetic architecture. Differential therapeutic interventions may be needed for patients with BD + BE compared with BD patients without BE. Recognizing the BD + BE subphenotype is an example of moving towards more precise clinical and genetic entities.

Suicide attempts in US adults with lifetime DSM-5 eating disorders

BACKGROUND

Rates of suicide are increasing in the US. Although psychiatric disorders are associated with suicide risk, there is a dearth of epidemiological research on the relationship between suicide attempts (SAs) and eating disorders (EDs). The study therefore aimed to examine prevalence and correlates of SAs in DSM-5 EDs-anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED)-in a nationally representative sample of US adults. In addition, prevalence and correlates of SAs were examined in the two subtypes of AN-restricting (AN-R) and binge/purge (AN-BP) types.

METHODS

The study included 36,171 respondents in the Third National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III) who completed structured diagnostic interviews (AUDADIS-5) and answered questions regarding SA histories and psychosocial impairment associated with EDs. We evaluated lifetime prevalence of SA, psychosocial impairment, clinical profiles, and psychiatric comorbidity in adults with EDs with and without SA histories, and temporal relationships between age onset of SA and EDs.

RESULTS

Prevalence estimates of suicide attempts were 24.9% (for AN), 15.7% (for AN-R), 44.1% (for AN-BP), 31.4% (for BN), and 22.9% (for BED). Relative to respondents without specific EDs, adjusted odds ratios (AORs) of SAs were significantly greater in all EDs: AN = 5.40 (95% confidence intervals [CIs] = 3.80-7.67), AN-R = 3.16 (95% CIs = 1.82-5.42), AN-BP = 12.09 (95% CIs = 6.29-23.24), BN = 6.33 (95% CIs = 3.39-11.81), and BED = 4.83 (95% CIs = 3.54-6.60). Among those with SA history, mean age at first SA and number of SAs were not significantly different across the specific EDs. SA was associated with significantly earlier ED onset in BN and BED, longer duration of AN but shorter duration of BN, greater psychosocial impairment in AN and BN, and with significantly increased risk for psychiatric disorder comorbidity across EDs. Onset of BED was significantly more likely to precede SA (71.2%) but onsets of AN (50.4%) and BN (47.6%) were not.

CONCLUSIONS

US adults with lifetime DSM-5 EDs have significantly elevated risk of SA history. Even after adjusting for sociodemographic factors, those with lifetime EDs had a roughly 5-to-6-fold risk of SAs relative to those without specific EDs; the AN binge/purge type had an especially elevated risk of SAs. SA history was associated with distinctively different clinical profiles including greater risk for psychosocial impairment and psychiatric comorbidity. These findings highlight the importance of improving screening for EDs and for suicide histories.