Classifying Adults with Binge Eating Disorder Based on Severity Levels

Predictors of neurofeedback treatment outcome in binge-eating disorder: An exploratory study

OBJECTIVE

Knowledge on predictors for treatment response to psychotherapy in binge-eating disorder (BED) is mixed and not yet available for increasingly popular neurofeedback (NF) treatment targeting self-regulation of aberrant brain activity. This study examined eating disorder- and psychopathology-related predictors for NF treatment success in BED.

METHOD

Patients with BED (N = 78) were randomized to 12 sessions of real-time functional near-infrared spectroscopy (rtfNIRS)-NF, targeting individual prefrontal cortex signal up-regulation, electroencephalography (EEG)-NF, targeting down-regulation of fronto-central beta activity, or waitlist (WL). The few studies assessing predictors for clinical outcomes after NF and evidenced predictors for psychotherapy guided the selection of baseline eating disorder-related predictors, including objective binge-eating (OBE) frequency, eating disorder psychopathology (EDP), food cravings, and body mass index (BMI), and general psychopathology-related predictors, including depressive and anxiety symptoms, impulsivity, emotion dysregulation, and self-efficacy. These questionnaire-based or objectively assessed (BMI) predictors were regressed on outcomes OBE frequency and EDP as key features of BED at post-treatment (t1) and 6-month follow-up (t2) in preregistered generalized mixed models (https://osf.io/4aktp).

RESULTS

Higher EDP, food cravings, and BMI predicted worse outcomes across all groups at t1 and t2. General psychopathology-related predictors did not predict outcomes at t1 and t2. Explorative analyses indicated that lower OBE frequency and higher self-efficacy predicted lower OBE frequency, and lower EDP predicted lower EDP after the waiting period in WL.

DISCUSSION

Consistent with findings for psychotherapy, higher eating disorder-related predictors were associated with higher EDP and OBE frequency. The specificity of psychopathological predictors for NF treatment success warrants further examination.

PUBLIC SIGNIFICANCE

This exploratory study firstly assessed eating disorder- and psychopathology-related predictors for neurofeedback treatment outcome in binge-eating disorder and overweight. Findings showed an association between higher eating disorder symptoms and worse neurofeedback outcomes, indicating special needs to be considered in neurofeedback treatment for patients with a higher binge-eating disorder symptom burden. In general, outcomes and assignment to neurofeedback treatment may be improved upon consideration of baseline psychological variables.

Cognitive flexibility and DSM-5 severity criteria for eating disorders: assessing drive for thinness and duration of illness as alternative severity variables

BACKGROUND

The severity criteria for eating disorders (EDs) proposed in the DSM-5 have been established without sufficient empirical support. Drive for thinness (DT) and duration of illness have been proposed as two alternative severity measures, however their empirical evidence is also limited. To date, no research has assessed the validity of current eating disorder (ED) severity criteria regarding cognitive flexibility factors. Cognitive flexibility is often impaired in EDs, becoming a possible severity symptom. The current study assessed for the first time (1) whether the severity indexes for EDs proposed in the DSM-5 were associated with deficits in cognitive flexibility and, (2) whether drive for thinness and illness duration, acted as an alternative, more meaningful severity indices for deficiencies in cognitive flexibility.

METHODS

Participants were 161 patients diagnosed with an ED, who were categorized according to DSM-5 severity categories, DT and duration of illness. Discriminative capacity of each classification was assessed for cognitive flexibility measured by Wisconsin card sorting test (WCST).

RESULTS

The findings for the DSM-5 classification comprised: (a) In the anorexia nervosa (AN) group, patients with moderate severity showed better scores in WCST than patients with mild and severe/extreme severity. Also, patients with moderate severity showed lower percentage of cognitive flexibility deficits than the other two severity categories; (b) For the binge spectrum disorders (BSD) group, the patients with mild severity showed a higher percentage of cognitive flexibility deficits than did the moderate and severe/extreme categories. When assessing the alternative severity index of DT, no differences were found in cognitive flexibility in any of the groups. Regarding illness duration, in the AN group the task performance of the patients with longer illness duration was worse than the performance of the short duration group and, in the BSD group, patients with longer duration also showed more deficits in cognitive flexibility than the patients with shorter duration of illness.

CONCLUSIONS

Our findings point out the limitations of the DSM-5 severity criteria to categorize cognitive flexibility in EDs and support illness duration as an alternative severity approach for EDs.

Empirically determined severity levels for binge-eating disorder outperform existing severity classification schemes

BACKGROUND

Eating-disorder severity indicators should theoretically index symptom intensity, impairment, and level of needed treatment. Two severity indicators for binge-eating disorder (BED) have been proposed (categories of binge-eating frequency and shape/weight overvaluation) but have mixed empirical support including modest clinical utility. This project uses structural equation model (SEM) trees - a form of exploratory data mining - to empirically determine the precise levels of binge-eating frequency and/or shape/weight overvaluation that most significantly differentiate BED severities.

METHODS

Participants were 788 adults with BED enrolled in BED treatment studies. Participants completed interviews and self-report measures assessing eating-disorder and comorbid symptoms. SEM Tree analyses were performed by specifying an outcome model of BED severity and then recursively partitioning the outcome model into subgroups. Subgroups were split based on empirically determined values of binge-eating frequency and/or shape/weight overvaluation. SEM Forests also quantified which variable contributed more improvement in model fit.

RESULTS

SEM Tree analyses yielded five subgroups, presented in ascending order of severity: overvaluation <1.25, overvaluation = 1.25-2.74, overvaluation = 2.75-4.24, overvaluation ⩾4.25 with weekly binge-eating frequency <4.875, and overvaluation ⩾4.25 with weekly binge-eating frequency ⩾4.875. SEM Forest analyses revealed that splits that occurred on shape/weight overvaluation resulted in much more improvement in model fit than splits that occurred on binge-eating frequency.

CONCLUSIONS

Shape/weight overvaluation differentiated BED severity more strongly than binge-eating frequency. Findings indicate a nuanced potential BED severity indicator scheme, based on a combination of cognitive and behavioral eating-disorder symptoms. These results inform BED classification and may allow for the provision of more specific and need-matched treatment formulations.

Naturalistic and Uncontrolled Pilot Study on the Efficacy of Vortioxetine in Binge Eating Disorder With Comorbid Depression

Background: Binge eating disorder (BED) is clinically relevant by virtue of the global impairment, poor quality of life, and increased overall medical morbidity. The high comorbidity with psychiatric disorders, particularly depression, has received attention as a possible mediator of the poor outcome. Further, BED and depression share cognitive dysfunctions. This naturalistic and uncontrolled pilot study aimed at evaluating the efficacy of vortioxetine (VTX) on depressive symptoms in patients with BED, secondly the efficacy in improving a broad array of executive functions, and third to explore the effect on eating behavior and body weight. Methods: This pilot study involved 30 patients with BED and comorbid MDD, treated with VTX for 24 weeks. Assessments were run at baseline (t 0), 4 (t 1), 8 (t 2), 12 (t 3), and 24 (t 4) weeks. Changes in depressive symptoms (HDRS and BDI), executive functions, eating behaviors (binge frequency and severity, night eating, food addiction), and body weight were estimated after treatment with VTX through GLM. Results: Significant improvements emerged after treatment with VTX in: depression (HDRS p < 0.001; BDI p = 0.002) regardless the dose of VTX and first diagnosis (BED/MDD), working memory (RAVLT acquisition p = 0.01, delay recall p < 0.001, RCFT percentage of recall p = 0.01, and Attentional Matrices p = 0.05), binge days frequency (p < 0.001), binge eating severity (BES p < 0.001), night eating (p = 0.001), food addiction (YFAS 2.0 p = 0.039), and body weight (p = 0.039). The improvement in depressive symptoms was associated with the concurrent improvement in night eating as assessed by the I-NEQ. Conclusions: VTX can be a valid therapeutic choice for patients with BED with comorbid depression in controlling the depressive symptoms, working memory, and eating behavior. Indeed, by acting on affective symptoms, neurocognitive functioning, and eating behaviors, it confirms the results already obtained with VTX in other disorders, expanding them to BED.

Drive for thinness provides an alternative, more meaningful, severity indicator than the DSM-5 severity indices for eating disorders

OBJECTIVE

To assess an alternative trans-diagnostic indicator for severity based on drive for thinness (DT) for anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and other specified feeding or eating disorder (OSFED), and to compare this new approach to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) severity categories for EDs.

METHOD

A total of 2,811 ED [428 AN-restrictive (AN-R), 313 AN-binge purging (AN-BP), 1,340 BN, 329 BED, 154 OSFED/atypical AN (AT), and 223 OSFED/purging disorder (PD)] patients were classified using: (a) The DSM-5 severity categories and (b) a DT categorisation. These severity classifications were then compared based on ED symptoms, general psychopathology, personality, and impulsive behaviours.

RESULTS

For the DSM-5 categories, most ED patients fell into the 'mild' to 'moderate' categories. Using the DT categories, AN patients were mainly represented in the 'low' DT category, and BN, OSFED/AT, and PD in the 'high' DT category. The clinically significant findings were stronger for the DT than the DSM-5 severity approach (medium-to-large effect sizes). AN-BP and AN-R provided the most pronounced effects.

CONCLUSION

Our findings question the clinical value of the DSM-5 severity categorisation, and provide initial support for an alternative DT severity approach for AN. HIGHLIGHTS : This study assessed an alternative trans-diagnostic drive for thinness (DT) severity. Category for all eating disorder (ED) sub-types, and then compared this to the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) severity indices for EDs. ED symptoms, general psychopathology, personality, and impulsive behaviours were assessed using both classifications in a total of 2,811 female patients diagnosed with EDs. Clinically significant findings were stronger for the DT than the DSM-5 severity category (medium-to-large effect sizes); there was differentiation of the anorexia nervosa (AN) patients into mainly 'low' DT, and bulimia nervosa (BN) spectrum patients into mainly 'high' DT, vs. most patients were clustered in the 'mild-to-moderate' DSM-5 categories. Our findings provide initial support for an alternative trans-diagnostic DT severity category that may be more clinically meaningful than the DSM-5 severity indices for EDs.

Prevalence of eating disorders over the 2000-2018 period: a systematic literature review

BACKGROUND

Eating disorders (EDs) lead to multiple psychiatric and somatic complications and thus constitute a major public health concern.

OBJECTIVES

The aim of this study was to give an exhaustive view of the studies reporting the prevalence of the different EDs or total EDs and to study their evolution.

METHODS

A literature search following PRISMA Guidelines and limited to studies in English or French published between 2000 and 2018 was performed and relevant studies were included in this systematic review on the prevalence of EDs. The literature search revealed 94 studies with accurate ED diagnosis and 27 with broad ED diagnosis.

RESULTS

In 94 studies with accurate ED diagnosis, the weighted means (ranges) of lifetime ED were 8.4% (3.3-18.6%) for women and 2.2% (0.8-6.5%) for men. The weighted means (ranges) of 12-month ED prevalence were 2.2% (0.8-13.1%) for women and 0.7% (0.3-0.9%) for men. The weighted means (ranges) of point prevalence were 5.7% (0.9-13.5%) for women and 2.2% (0.2-7.3%) for men. According to continents, the weighted means (ranges) of point prevalence were 4.6% (2.0-13.5%) in America, 2.2% (0.2-13.1%) in Europe, and 3.5% (0.6-7.8%) in Asia.In addition to the former, 27 other studies reported the prevalence of EDs as broad categories resulting in weighted means (ranges) of total point prevalence of any EDs of 19.4% (6.5-36.0%) for women and 13.8% (3.6-27.1%) for men.

CONCLUSIONS

Despite the complexity of integrating all ED prevalence data, the most recent studies confirm that EDs are highly prevalent worldwide, especially in women. Moreover, the weighted means of point ED prevalence increased over the study period from 3.5% for the 2000-2006 period to 7.8% for the 2013-2018 period. This highlights a real challenge for public health and healthcare providers.

Uncontrolled eating: a unifying heritable trait linked with obesity, overeating, personality and the brain

Many eating-related psychological constructs have been proposed to explain obesity and overeating. However, these constructs, including food addiction, disinhibition, hedonic hunger, emotional eating, binge eating and the like all have similar definitions, emphasizing loss of control over intake. As questionnaires measuring the constructs correlate strongly (r > 0.5) with each other, we propose that these constructs should be reconsidered to be part of a single broad phenotype: uncontrolled eating. Such an approach enables reviewing and meta-analysing evidence obtained with each individual questionnaire. Here, we describe robust associations between uncontrolled eating, body mass index (BMI), food intake, personality traits and brain systems. Reviewing cross-sectional and longitudinal data, we show that uncontrolled eating is phenotypically and genetically intertwined with BMI and food intake. We also review evidence on how three psychological constructs are linked with uncontrolled eating: lower cognitive control, higher negative affect and a curvilinear association with reward sensitivity. Uncontrolled eating mediates all three constructs' associations with BMI and food intake. Finally, we review and meta-analyse brain systems possibly subserving uncontrolled eating: namely, (i) the dopamine mesolimbic circuit associated with reward sensitivity, (ii) frontal cognitive networks sustaining dietary self-control and (iii) the hypothalamus-pituitary-adrenal axis, amygdala and hippocampus supporting stress reactivity. While there are limits to the explanatory and predictive power of the uncontrolled eating phenotype, we conclude that treating different eating-related constructs as a single concept, uncontrolled eating, enables drawing robust conclusions on the relationship between food intake and BMI, psychological variables and brain structure and function.

A new approach to eating-disorder classification: Using empirical methods to delineate diagnostic dimensions and inform care

OBJECTIVE

Despite changes to the diagnostic criteria for eating disorders (EDs) in the DSM-5, the current diagnostic system for EDs has limited ability to inform treatment planning and predict outcomes. Our objective was to test the clinical utility of a novel dimensional approach to understanding the structure of ED psychopathology.

METHOD

Participants (N = 243; 82.2% women) were community-recruited adults with a DSM-5 ED assessed at baseline, 6-month, and 1-year follow-up. Hierarchical factor analysis was used to identify a joint hierarchical-dimensional structure of eating, mood, and anxiety symptoms. Exploratory structural equation modeling was used to test the ability of the dimensional model to predict outcomes.

RESULTS

At the top of the hierarchy, we identified a broad Internalizing factor that reflected diffuse symptoms of eating, mood, and anxiety disorders. Internalizing branched into three subfactors: distress, fear-avoidance (fears of certain stimuli and behaviors to neutralize fears, including ED behaviors designed to reduce fear of weight gain), and body dissatisfaction, which was nested within distress. The lowest level of the hierarchy was characterized by 15 factors. The hierarchical model predicted 60.1% of the variance in outcomes at 6-month follow-up, whereas all DSM eating, mood, and anxiety disorders combined predicted 35.8% of the variance in outcomes.

DISCUSSION

A dimensional approach to understanding and diagnosing EDs improved the ability to prospectively predict clinical course above-and-beyond the traditional categorical (DSM-based) approach. Our findings have implications for endeavors to improve the prediction of ED prognosis and course, and to develop more effective trans-diagnostic treatments.

Evaluation of the DSM-5 Severity Specifier for Bulimia Nervosa in Treatment-Seeking Youth

A new severity specifier for bulimia nervosa (BN), based on the frequency of inappropriate weight compensatory behaviours (e.g., laxative misuse, self-induced vomiting, fasting, diuretic misuse, and excessive exercise), has been added to the most recent (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a means of addressing variability and heterogeneity in the severity of the disorder. While existing research provides support for the DSM-5 severity specifier for BN in adult patients, evidence for its validity and clinical utility in youth is currently lacking. To address this gap, data from 272 treatment-seeking adolescents with DSM-5 BN (94.2% female, M _age = 15.3 years, SD 1.7) were analysed to examine whether these patients, sub-grouped based on the DSM-5 severity definitions, would show meaningful differences in a broad range of clinical variables and demographic and physical characteristics. Analyses revealed that participants categorized with mild, moderate, severe, and extreme severity of BN significantly differed from each other in 15 variables regarding eating disorder pathological features and putative maintenance factors (i.e., core low self-esteem, perfectionism, social appearance anxiety, body surveillance, and mood intolerance), health-related quality of life and comorbid psychiatric (i.e., affective and anxiety) disorders (large effect sizes). Between-group differences in demographics, body mass index, or age-of-BN onset were not observed. Collectively, our findings provide support for the utility of the frequency of inappropriate weight compensatory behaviours as a severity indicator for BN and suggest that age-at-onset of BN is probably more disorder- than severity-dependent. Implications for future research are outlined.

Lisdexamfetamine: A Review in Binge Eating Disorder

Oral lisdexamfetamine dimesylate (Vyvanse^®; lisdexamfetamine), a prodrug of dextroamfetamine, is currently the only drug to be approved in the USA for the treatment of moderate to severe binge eating disorder (BED) in adult patients. Its approval was based on the results of two pivotal short-term (12 weeks) phase III studies, which showed a significantly greater reduction in binge eating days/week at the end of the study with lisdexamfetamine 50-70 mg/day than with placebo. The findings of these studies have been supported and extended by the results of longer-term (≤ 52 weeks) phase III studies, including one with a randomized 26-week withdrawal phase, which showed that lisdexamfetamine markedly reduced the risk of BED relapse relative to placebo. Lisdexamfetamine was generally well tolerated in clinical trials in patients with moderate to severe BED, with a tolerability profile similar to that observed in ADHD patients; most treatment-emergent adverse events (TEAEs) were of mild or moderate intensity. The most common TEAEs in phase III trials included dry mouth, headache and insomnia; TEAEs infrequently led to study drug discontinuation. In conclusion, lisdexamfetamine 50-70 mg/day is an effective and generally well tolerated option for treating moderate to severe BED in adults.

The impact of DSM-5 on the diagnosis and severity indicator of eating disorders in a treatment-seeking sample

OBJECTIVE

To examine the impact of the DSM-5 on the diagnoses and severity indicators of eating disorders, we conducted a comparative study on the classification of eating disorders including subtypes of anorexia nervosa (AN) between the DSM-IV and DSM-5 criteria. In addition, we studied the association of the DSM-5 severity criteria and clinical variables.

METHOD

Participants were 304 outpatients, aged 16-45 years, with eating disorders, diagnosed using semi-structured clinical interviews and the eating disorder examination questionnaire (EDE-Q). The severity of AN, bulimia nervosa (BN), and binge-eating disorder (BED) was rated from mild to extreme using the DSM-5 severity criteria.

RESULTS

The DSM-5 remarkably reduced the number of diagnoses in the residual category from 37.5% to 9.2% and effectively differentiated the diagnostic groups in eating disorder psychopathology. Unexpectedly, however, the scores of all the EDE-Q subscales significantly decreased as severity ratings increased in the DSM-5 AN. Furthermore, while the AN binge-eating/purging group reported significantly lower severity ratings than the AN restricting group, the former displayed more severe eating disorder psychopathology than the latter. In the BN and BED groups, the level of eating concern increased as severity ratings increased, but the severity groups did not differ on other eating pathology variables.

DISCUSSION

The DSM-5 effectively reduced the reliance on residual categories and differentiated the diagnostic groups in eating disorder psychopathology. However, our findings show limited support for the DSM-5 severity specifiers for eating disorders. It is necessary to test additional clinical or functional variables for severity specifiers across eating disorders.

A Randomised Controlled Comparison of Second-Level Treatment Approaches for Treatment-Resistant Adults with Bulimia Nervosa and Binge Eating Disorder: Assessing the Benefits of Virtual Reality Cue Exposure Therapy

A question that arises from the literature on therapy is whether second-level treatment is effective for patients with recurrent binge eating who fail first-level treatment. It has been shown that subjects who do not stop binge eating after an initial structured cognitive-behavioural treatment (CBT) programme benefit from additional CBT (A-CBT) sessions; however, it has been suggested that these resistant patients would benefit even more from cue exposure therapy (CET) targeting features associated with poor response (e.g. urge to binge in response to a cue and anxiety experienced in the presence of binge-related cues). We assessed the effectiveness of virtual reality-CET as a second-level treatment strategy for 64 patients with bulimia nervosa and binge eating disorder who had been treated with limited results after using a structured CBT programme, in comparison with A-CBT. The significant differences observed between the two groups at post-treatment in dimensional (behavioural and attitudinal features, anxiety, food craving) and categorical (abstinence rates) outcomes highlighted the superiority of virtual reality-CET over A-CBT. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.