Self-report versus interview assessment of purging in a community sample of women

Analysis of symptom clusters amongst adults with anorexia nervosa: Key severity indicators

This study used cluster analysis to explore clinically relevant subgroups of adult patients with anorexia nervosa (AN). Patients were clustered based on their body mass index (BMI), eating disorder symptomatology, anxiety and depression symptoms and autistic characteristics. The difference between clusters in work and social functioning, duration of illness, bingeing and purging behaviour, previous hospitalisations and number of comorbidities was also investigated. Two meaningful clusters emerged: a higher symptoms cluster with more severe eating pathology, anxiety, depression, and more autistic traits, and a second cluster with lower symptoms. BMI did not make major contributions to cluster formation. The higher symptoms cluster also reported lower self-efficacy to change, more previous hospitalisations, comorbid diagnoses, binge eating and purging behaviours and use of psychotropic medication. Our findings suggest that weight alone may not be a significant severity indicator amongst inpatients with AN, and targeted treatment of AN should consider a broader range of symptom severity indicators.

Using clinical cutoff scores on the eating disorder examination-questionnaire to evaluate eating disorder symptoms during and after naturalistic intensive treatment

Clinical cutoff scores for self-report measures provide a means of evaluating clinically significant pathology during and after treatment. A cutoff of 2.8 on the Eating Disorder Examination-Questionnaire (EDE-Q) has been recommended to screen for eating disorders (ED). We used this cutoff to assess ED symptoms in adolescents (n = 444) and adults (n = 592) through ED treatment and follow-up. Most patients scored above 2.8 at intake (adolescents 67%, M = 3.21; adults 78%, M = 4.20) and below 2.8 at discharge (adolescents 65%, M = 1.87; adults 66%, M = 2.67), with gains often maintained through follow-up (40% of adolescents and 35% of adults at 12-month follow-up). EDE-Q scores were higher in adults than adolescents and in patients with binge/purge disorders. Results suggest a cutoff of 2.8 on the EDE-Q effectively tracks ED symptom improvement through treatment and discharge. This supports the need for the development of culture-specific and empirically developed clinical cutoffs and their widespread use to evaluate program effectiveness.

Transitioning to digital first line intervention - validation of a brief online screener for early identification of a suspected eating disorder: study protocol

BACKGROUND

Only one in four people with eating disorders seeks treatment, and of those who do seek treatment, 20% go on to experience a chronic course. Early intervention has been associated with better prognosis, with those seeking specialised intervention in the early stages of their illness more than twice as likely to achieve remission. Current screening measures typically require expert administration and are rarely validated across a spectrum of DSM-5 eating disorder presentations or for online use. In light of COVID-19 and increasing reliance on telehealth technologies in the intervention and delivery of mental health services, online assessments suitable for self-referral are likely to be the first step to seeking care. InsideOut Institute has developed a 6-item online screening tool for the purposes of identifying eating disorder risk and symptomatology, aimed specifically at increasing help-seeking behaviour in subsyndromal and early presentations.

METHODS

This study investigates the reliability and validity of the InsideOut Institute Screener (IOI-S), using a cross-sectional survey research design. Participants aged 14 and over will complete an extensive baseline survey battery for evaluation. 50% of participants will be randomly selected for one follow-up re-test of the IOI-S only, 2 weeks post initial testing. The IOI-S will be analysed for statistical reliability on two parameters: internal consistency and test re-test reliability, and for statistical validity on four parameters: concurrent validity, sensitivity and specificity, convergent and discriminant validity.

DISCUSSION

The rapid and ongoing shift to digital intervention has highlighted gaps and opportunities in our pathways to care. Adequate screening for eating disorders is a major gap. This study aims to validate an online screening tool for use in telehealth early intervention, designed for users seeking information for a suspected eating disorder. The screener meets those at risk 'where they are' (i.e. online) and may improve timely referrals to relevant services. This is of particular salience as face-to-face healthcare and traditional frontline interventions are disrupted, and we are challenged to re-design our practices to deliver diagnostic and treatment services in highly adaptive digital contexts.

Toward an understanding of the distinctiveness of body-image constructs in persons categorized with overweight/obesity, bulimia nervosa, and binge-eating disorder

OBJECTIVE

We examined distinctiveness of different aspects of body-image disturbance in persons categorized with eating/weight disorders. We compared dissatisfaction with weight/shape, overvaluation of weight/shape, preoccupation with weight/shape, and fear of weight gain - in three study groups of persons categorized with overweight/obesity [O/O], bulimia nervosa [BN], and binge-eating disorder [BED] and examined how each body-image construct relates to clinical measures within and between the study groups.

METHOD

1017 community volunteers completed measures of body-image, eating-disorder psychopathology, and depression. Participants were categorized into three study groups: O/O (N = 511), BN-purging type (N = 167), and BED (N = 339).

RESULTS

Groups differed significantly on the four body-image constructs (medium-to-large effect sizes) with a consistent severity gradient with BN greater than BED greater than O/O. Both within and between groups, the four body-image constructs varied in strengths of association among themselves and with clinical measures. Analyses revealed considerable variability in variance accounted for in the clinical measures; distinctive significant patterns observed across the groups included: dissatisfaction with BMI, preoccupation and fear with eating concerns and restraint, and overvaluation with depression.

CONCLUSION

Clinical manifestations of body-image disturbances are complex and show important differences across study groups defined as overweight/obesity, BN, and BED. Improved understanding of distinctions between different body-image constructs and their differential salience across different eating/weight disorders is needed to improve case conceptualization and treatment formulation.

Gender differences in disordered eating behaviors and body dissatisfaction among adolescents with type 1 diabetes: Results from diabetes MILES youth-Australia

OBJECTIVE

To examine gender differences in disordered eating behaviors (DEB) and body dissatisfaction in adolescents with type 1 diabetes. While evidence shows that female youth with type 1 diabetes are more prone to DEB compared to their peers without diabetes, little is known about male adolescents.

METHOD

In a national online survey, adolescents (13-19 years) with type 1 diabetes for ≥1 year completed the Diabetes Eating Problem Survey-Revised (DEPS-R), and the Body Mass Index Silhouette Matching Test (BMI-SMT) and items on binge eating and insulin omission.

RESULTS

About 477 adolescents (mean age 16 years; 62% females) completed the DEPS-R and 431 the BMI-SMT. The DEPS-R total score was higher for females than males, with scores for females increasing with age. BMI, HbA_1c , insulin omission, and binge-eating frequency were associated moderately with DEPS-R for both genders. On the BMI-SMT, 88% of females wanted to be thinner. Of the males, 76% reported body dissatisfaction; however, only 43% expressed a desire for thinness with the remainder desiring a larger body size. DEPS-R was positively associated with the discrepancy between perceived actual and ideal body size for both genders.

DISCUSSION

A large proportion of adolescents with type 1 diabetes, particularly females reported engaging in DEB. Similarly, high rates of body dissatisfaction were reported, though ideal body shape preferences differed by gender. Given the high levels of self-reported DEB and gender-based patterns of body dissatisfaction, future research needs to examine the effectiveness of routine screening of DEB and consider implementation of stepped care approaches.

An exploratory examination of At-Risk/Problematic Internet Use and disordered eating in adults

PURPOSE

At-Risk/Problematic Internet Use (ARPIU) has been associated with impairment in multiple domains including psychopathology. The present study examined the relationship between ARPIU and disordered eating in a large community sample.

METHODS

Participants (n=1000) completed an online survey about health behaviors. Two thresholds of ARPIU and disordered eating each were examined.

RESULTS

The ARPIU and Sub-ED (subthreshold eating disorders) groups reported greater depressive symptoms and poorer self-control than the Control group; the Sub-ED group reported greater impulsivity than the Control group. The ARPIU and Sub-ED groups significantly differed in key features related to each condition. Finally, the co-occurrence of ARPIU and Sub-ED was associated with greater depression. In the second set of analyses based on more stringent thresholds, the Problematic Internet Use (PIU) and ED groups differed on all measures compared to the Control group. The PIU and ED groups also differed on key features related to each condition, but did not differ on measures of impulsivity or self-control. The co-occurrence of PIU and ED was associated with greater depressive symptoms than either PIU or ED independently.

CONCLUSIONS

ARPIU and Sub-ED share links to depression and poor self-control and these may represent possible therapeutic targets across Internet-use and disordered-eating behaviors. Co-occurring PIU and ED at either lenient or stringent thresholds is associated with greater depression. Future studies should examine the temporal nature of these associations and the extent to which targeting depression, Internet use, or disordered eating may lead to improvements across domains.

Transitioning from DSM-IV to DSM-5: A systematic review of eating disorder prevalence assessment

OBJECTIVE

The objective of this study was to systematically review the literature on assessment of eating disorder prevalence during the DSM-IV era (1994-2015).

METHOD

A PubMed search was conducted targeting articles on prevalence, incidence and epidemiology of eating disorders. The review was performed in accordance with PRISMA guidelines, and was limited to DSM-IV based eating disorder diagnoses published between 1994 and 2015.

RESULTS

A total of 74 studies fulfilled inclusion criteria and were included in the study. Results yielded evidence of over 40 different assessment instruments used to assess eating disorder prevalence, with the EAT-40 being the most commonly used screening instrument, and the SCID being the most frequently used interview. The vast majority of studies employed two-stage designs, closely followed by clinical interviews. Observations of higher prevalence rates were found in studies employing self-reports compared to two-stage designs and interviews.

DISCUSSION

Eating disorder prevalence rates have varied significantly during the DSM-IV era, and are dependent on assessment methods used and samples investigated. Following the transition to the DSM-5, eating disorder prevalence will change, warranting novel approaches to assessment and treatment planning. © 2016 Wiley Periodicals, Inc.

Examining binge-eating disorder and food addiction in adults with overweight and obesity

OBJECTIVE

To compare four subgroups of adults with overweight/obesity: those with binge-eating disorder (BED) only, food addiction (FA) only, both BED + FA, and neither.

METHODS

For this study, 502 individuals with overweight/obesity (body mass index >25 kg/m(2) ) completed a Web-based survey with established measures of eating and health-related behaviors. Most were female (n = 415; 83.2%) and White (n = 404; 80.8%); mean age and body mass index were 38.0 (SD = 13.1) years and 33.6 (SD = 6.9) kg/m(2) , respectively.

RESULTS

Among 502 participants with overweight/obesity, 43 (8.5%) met BED criteria, 84 (16.6%) met FA criteria, 51 (10.1%) met both BED + FA criteria, and 328 (64.8%) met neither (control). The three groups with eating pathology (BED, FA, and BED + FA) had significantly greater disturbances on most measures (eating disorder psychopathology, impulsivity, and self-control) than the control group, while the FA and BED + FA groups reported significantly higher depression scores relative to the control group. The three eating groups did not differ significantly from each other.

CONCLUSIONS

In this online survey, of those with overweight/obesity, nearly one third met criteria for BED, FA, or BED + FA, and these forms of disordered eating were associated with greater pathology relative to individuals with overweight/obesity without BED and FA. Future research should examine whether the presence of BED, FA, or co-occurring BED + FA requires tailored interventions in individuals with overweight or obesity.

Smoking status and psychosocial factors in binge eating disorder and bulimia nervosa

OBJECTIVE

To examine eating-disorder psychopathology and depressive symptoms by smoking status (never, former, or current smoker) in persons with binge eating disorder (BED) and bulimia nervosa (BN).

METHODS

Participants were 575 adult volunteers from the community (mean age=36.0±12years and BMI=32.9±9.5kg/m(2); 80% white; 88% female) who were classified with BED (n=410) or BN (n=165). Participants completed a battery of questionnaires, including items about current and historical cigarette smoking, the Eating Disorder Examination -Questionnaire, and the Beck Depression Inventory.

RESULTS

Among those with BED, depressive symptoms were significantly higher in current smokers than former or never smokers (p=.001). There were no significant differences in depressive symptoms by smoking status in participants with BN and no differences in eating-disorder psychopathology by smoking status in either the BED or BN groups.

DISCUSSION

In this non-clinical group of community volunteers, we found that smoking history or status was not associated with eating disorder psychopathology in participants classified with BED and BN but was significantly associated with depressive symptoms in participants with BED.

Psychometric evaluation of self-report measures of binge-eating symptoms and related psychopathology: A systematic review of the literature

OBJECTIVE

Binge eating is a symptom common to bulimia nervosa, anorexia nervosa (binge/purge subtype), and binge eating disorder. There are many self-report measures available to aid the assessment of eating disorders symptoms, but there has not yet been a systematic review of the literature to identify the most valid and reliable measures for use in assessment and treatment of binge eating.

METHOD

A systematic review of the psychometric properties of self-report measures that assess binge eating symptoms and psychopathology was conducted. Two independent raters assessed the psychometric properties of each measure using a standardized quality analysis tool.

RESULTS

Of the 2,927 studies identified, 72 studies met the inclusion criteria and described the psychometric properties of 29 different self-report measures, and nine specific subscales within these. Results from the quality analysis tool utilized in this study indicated that none of the included measures currently meet all nine criteria of adequate psychometric properties.

DISCUSSION

Most of the included measures had evidence for some adequate psychometric properties. Two measures received six out of nine positive ratings for the assessed psychometric properties, the BITE and the BULIT-R, and thus appear to be the measures with the most evidence of their validity and reliability. Overall, our findings implicate a need for further investigation of the psychometric properties of the available self-report questionnaires in this field.

Medication Use before, during, and after Pregnancy among Women with Eating Disorders: A Study from the Norwegian Mother and Child Cohort Study

INTRODUCTION

Little is known about medication use among women with eating disorders in relation to pregnancy.

AIMS

To explore patterns of and associations between use of psychotropic, gastrointestinal and analgesic medications and eating disorders in the period before, during and after pregnancy.

METHOD

This study is based on the Norwegian Mother and Child Cohort Study (MoBa). A total of 62,019 women, enrolled at approximately 17 weeks' gestation, had valid data from the Norwegian Medical Birth Registry and completed three MoBa questionnaires. The questionnaires provided diagnostic information on broadly defined anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and recurrent self-induced purging in the absence of binge eating (EDNOS-P), along with self-reported use of medication six months before, during, and 0-6 months after pregnancy.

RESULTS

The prevalence of eating disorder subtypes before and/or during pregnancy was: 0.09% AN (n = 54), 0.94% BN (n = 585), 0.10% EDNOS-P (n = 61) and 5.00% BED (n = 3104). The highest over-time prevalence of psychotropic use was within the AN (3.7-22.2%) and EDNOS-P (3.3-9.8%) groups. Compared to controls, BN was directly associated with incident use of psychotropics in pregnancy (adjusted RR: 2.25, 99% CI: 1.17-4.32). Having AN (adjusted RR: 5.11, 99% CI: 1.53-17.01) or EDNOS-P (adjusted RR: 6.77, 99% CI: 1.41-32.53) was directly associated with use of anxiolytics/sedatives postpartum. The estimates of use of analgesics (BED) and laxatives (all eating disorders subtypes) were high at all time periods investigated.

CONCLUSIONS

Use of psychotropic, gastrointestinal, and analgesic medications is extensive among women with eating disorders in the period around pregnancy. Female patients with eating disorders should receive evidence-based counseling about the risk of medication exposure versus the risk of untreated psychiatric illness during pregnancy and postpartum.

Evaluation of the DSM-5 severity indicator for bulimia nervosa

This study examined the DSM-5 severity criterion for bulimia nervosa (BN) based on the frequency of inappropriate weight compensatory behaviors. 199 community volunteers classified with BN were categorized using DSM-5 severity levels and compared on demographic and clinical variables. 77 (39%) participants were categorized as mild, 68 (34%) as moderate, 32 (16%) as severe, and 22 (11%) as extreme. The severity groups did not differ significantly in demographic variables or body mass index. Shape and Weight concerns did not differ significantly across severity groups. Binge eating differed with the extreme group having significantly higher frequency than the severe, moderate, and mild groups, which did not differ from each other. Restraint differed with the extreme group having significantly higher levels than the mild group. Eating concerns differed with the extreme group having significantly higher levels than moderate and mild groups. Depression differed with the extreme group having significantly higher levels than severe, moderate, and mild groups, which did not differ from each other. Findings from this non-clinical group provide new, albeit modest, support for DSM-5 severity rating for BN based on frequency of inappropriate weight compensatory behaviors. Statistical findings indicate that differences in collateral clinical variables associated with the DSM-5 severity ratings reflect small effect sizes. Further research is needed with treatment-seeking patient groups with BN to establish the validity of the DSM-5 severity specifier and should include broader clinical and functional validators.

Evaluation of the DSM-5 severity indicator for binge eating disorder in a community sample

Research has examined various aspects of the diagnostic criteria for binge-eating disorder (BED) but has yet to evaluate the DSM-5 severity criterion. This study examined the DSM-5 severity criterion for BED based on binge-eating frequency and tested an alternative severity specifier based on overvaluation of shape/weight. 338 community volunteers categorized with DSM-5 BED completed a battery of self-report instruments. Participants were categorized first using DSM-5 severity levels and second by shape/weight overvaluation and were compared on clinical variables. 264 (78.1%) participants were categorized as mild, 67 (19.8%) as moderate, 6 (1.8%) as severe, and 1 (0.3%) as extreme. Analyses comparing mild and moderate severity groups revealed no significant differences in demographic variables or BMI; the moderate severity group had greater eating-disorder psychopathology (small effect-sizes) but not depression than the mild group. Participants with overvaluation (N = 196; 60.1%) versus without (N = 130; 39.9%) did not differ significantly in age, sex, BMI, or binge-eating frequency. The overvaluation group had significantly greater eating-disorder psychopathology and depression than the non-overvaluation group. The greater eating-disorder and depression levels (medium-to-large effect-sizes) persisted after adjusting for ethnicity/race and binge-eating severity/frequency, without attenuation of effect-sizes. Findings from this non-clinical community sample provide support for overvaluation of shape/weight as a specifier for BED as it provides stronger information about severity than the DSM-5 rating based on binge-eating. Future research should include treatment-seeking patients with BED to test the utility of DSM-5 severity specifiers and include broader clinical validators.

Screening for DSM-5 Other Specified Feeding or Eating Disorder in a Weight-Loss Treatment-Seeking Obese Sample

OBJECTIVE

To evaluate the effectiveness of specific self-report questionnaires in detecting DSM-5 eating disorders identified via structured clinical interview in a weight-loss treatment-seeking obese sample, to improve eating disorder recognition in general clinical settings.

METHOD

Individuals were recruited over a 3-month period (November 2, 2011, to January 10, 2012) when initially presenting to a hospital-based weight-management center in the northeastern United States, which offers evaluation and treatment for outpatients who are overweight or obese. Participants (N = 100) completed the Structured Clinical Interview for DSM-IV eating disorder module, a DSM-5 feeding and eating disorders interview, and a battery of self-report questionnaires.

RESULTS

Self-reports and interviews agreed substantially in the identification of bulimia nervosa (DSM-IV and DSM-5: tau-b = 0.71, P < .001) and binge-eating disorder (DSM-IV and DSM-5: tau-b = 0.60, P < .001), modestly for subthreshold binge-eating disorder (tau-b = 0.44, P < .001), and poorly for other subthreshold conditions (night-eating syndrome: tau-b = -0.04, P = .72, r = 0.06 [DSM-5]).

DISCUSSION

Current self-report assessments are likely to identify full syndrome DSM-5 eating disorders in treatment-seeking obese samples, but unlikely to detect DSM-5 other specified feeding or eating disorders. We propose specific content changes that might enhance clinical utility as suggestions for future evaluation.

Self-image and eating disorder symptoms in normal and clinical adolescents

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

Calorie estimation accuracy and menu labeling perceptions among individuals with and without binge eating and/or purging disorders

Menu labeling is a public health policy that requires chain restaurants in the USA to post kilocalorie information on their menus to help consumers make informed choices. However, there is concern that such a policy might promote disordered eating. This web-based study compared individuals with self-reported binge eating disorder (N = 52), bulimia nervosa (N = 25), and purging disorder (N = 17) and those without eating disorders (No ED) (N = 277) on restaurant calorie information knowledge and perceptions of menu labeling legislation. On average, people answered 1.46 ± 1.08 questions correctly (out of 6) (25%) on a calorie information quiz and 92% of the sample was in favor of menu labeling. The findings did not differ based on eating disorder, dieting, or weight status, or race/ethnicity. The results indicated that people have difficulty estimating the calories in restaurant meals and individuals with and without eating disorders are largely in favor of menu labeling laws.

Course and predictors of maternal eating disorders in the postpartum period

OBJECTIVE

To investigate course and predictors of eating disorders in the postpartum period.

METHOD

A total of 77,807 women, participating in the Norwegian Mother and Child Cohort Study (MoBa), completed questionnaires during pregnancy including items covering DSM-IV criteria for prepregnancy anorexia nervosa (AN), bulimia nervosa (BN), eating disorder not otherwise specified (EDNOS-P), and binge eating disorder (BED). Additional questionnaires were completed at 18 and 36 months postpartum.

RESULTS

Proportions of women remitting at 18 months and 36 months postpartum were 50% and 59% for AN, 39% and 30% for BN, 46% and 57% for EDNOS-P, and 45% and 42% for BED, respectively. However, disordered eating persisted in a substantial proportion of women meeting criteria for either full or subthreshold eating disorders. BN during pregnancy increased the risk for continuation of BN. BMI and psychological distress were significantly associated with course of BED.

DISCUSSION

This is the first large-scale population-based study on course of eating disorders in the postpartum period. The results indicated that disordered eating persists in a substantial proportion of women with prepregnancy eating disorders. Health care professionals working with women in this phase of life need to pay specific attention to eating disorder symptoms and behaviors.

Health-related quality of life in obese presurgery patients with and without binge eating disorder, and subdiagnostic binge eating disorders

OBJECTIVE

To study health-related quality of life (HRQoL) in obese presurgery patients with binge eating disorder (BED) and with subdiagnostic binge eating disorder (SBED) compared to patients without eating disorders or SBED.

METHOD

Participants were patients referred to St. Olavs University Hospital, Norway, for bariatric surgery. Eating Disorders in Obesity (EDO) questionnaire was used to diagnose BED and SBED. Short-Form Health Survey (SF-12) assessed health-related quality of life. Questionnaires were returned by 160 of 209 patients. The present study sample consisted of 143 patients (103 women and 40 men) as 17 patients did not complete the SF-12.

RESULTS

Patients with BED and patients with SBED both had significantly lower mental HRQoL, but not physical HRQoL, compared to patients without eating disorders.

DISCUSSION

The findings indicate that obese presurgery patients with BED, and also SBED, may have special treatment needs in regard to their mental health.

Clinical characteristics and distinctiveness of DSM-5 eating disorder diagnoses: findings from a large naturalistic clinical database

BACKGROUND

DSM-IV eating disorder (ED) diagnoses have been criticized for lack of clinical utility, diagnostic instability, and over-inclusiveness of the residual category "ED not otherwise specified" (EDNOS). Revisions made in DSM-5 attempt to generate a more scientifically valid and clinically relevant system of ED classification. The aim with the present study was to examine clinical characteristics and distinctiveness of the new DSM-5 ED diagnoses, especially concerning purging disorder (PD).

METHODS

Using a large naturalistic Swedish ED database, 2233 adult women were diagnosed using DSM-5. Initial and 1-year follow-up psychopathology data were analyzed. Measures included the Eating Disorder Examination Questionnaire, Structural Eating Disorder Interview, Clinical Impairment Assessment, Structural Analysis of Social Behavior, Comprehensive Psychiatric Rating Scale, and Structured Clinical Interview for DSM-IV Axis I Disorders.

RESULTS

Few meaningful differences emerged between anorexia nervosa binge/purge subtype (ANB/P), PD, and bulimia nervosa (BN). Unspecified Feeding and Eating Disorders (UFED) showed significantly less severity compared to other groups.

CONCLUSIONS

PD does not appear to constitute a distinct diagnosis, the distinction between atypical AN and PD requires clarification, and minimum inclusion criteria for UFED are needed. Further sub-classification is unlikely to improve clinical utility. Instead, better delineation of commonalities is important.

Clinical correlates of the weight bias internalization scale in a sample of obese adolescents seeking bariatric surgery

The aim of this study was to evaluate psychometric properties and clinical correlates of the Weight Bias Internalization Scale (WBIS) in a sample of obese adolescents seeking bariatric surgery. Sixty five adolescents enrolled in a bariatric surgery program at a large, urban medical center completed psychiatric evaluations, self-report questionnaires including the WBIS and other measures of psychopathology and physical assessments. The WBIS had high internal consistency (Cronbach's α = 0.92). As in previous research with adults, the one underlying factor structure was replicated and 10 of the original 11 items were retained. The scale had significant partial correlations with depression (r = 0.19), anxiety (r = 0.465), social, and behavioral problems (r = 0.364), quality of life (r = -0.480), and eating (r = 0.579), shape (r = 0.815), and weight concerns (r = 0.545), controlling for BMI. However, WBIS scores did not predict current or past psychiatric diagnosis or treatment or past suicidal ideation. Overall, the WBIS had excellent psychometric properties in a sample of obese treatment-seeking adolescents and correlated significantly with levels of psychopathology. These findings suggest that the WBIS could be a useful tool for healthcare providers to assess internalized weight bias among treatment-seeking obese youth. Assessment of internalized weight bias among this clinical population has the potential to identify adolescents who might benefit from information on coping with weight stigma, which in turn may augment weight loss efforts.

How frequent are eating disturbances in the population? Norms of the eating disorder examination-questionnaire

OBJECTIVE

The Eating Disorder Examination-Questionnaire (EDE-Q) is a self-report instrument assessing the specific psychopathology and key behaviors of eating disorders. This study sought to determine the prevalence of eating disturbances, and to provide psychometric properties and norms of the EDE-Q, in a representative German population sample.

METHODS

A total of 2520 individuals (1166 men, 1354 women) were assessed with the EDE-Q.

RESULTS

Eating disorder psychopathology was higher and most key behaviors were more prevalent in women than in men. Psychopathology declined with age ≥65 in both sexes, and showed a peak at age 55-64 in men. Overall, 5.9% of the women and 1.5% of the men revealed eating disturbances. The prevalence of eating disturbances decreased with age in women and was significantly higher in obese than in normal-weight individuals. Psychometric analyses showed favorable item characteristics. Internal consistencies of EDE-Q composite scores were ≥.80 for women and ≥.70 for men. The factor structure of the EDE-Q was partially reproduced. Sex- and age-specific population norms are reported.

DISCUSSION

This study provides population norms of the EDE-Q for both sexes and across the age range, demonstrates demographic variations in symptomatology, and reveals satisfactory psychometric properties. Further research is warranted on eating disturbances in older adults.

Convergence of scores on the interview and questionnaire versions of the Eating Disorder Examination: a meta-analytic review

Significant discrepancies have been found between interview- and questionnaire-based assessments of psychopathology; however, these studies have typically compared instruments with unmatched item content. The Eating Disorder Examination (EDE), a structured interview, and the questionnaire version of the EDE (EDE-Q) are considered the preeminent assessments of eating disorder symptoms and provide a unique opportunity to examine the concordance of interview- and questionnaire-based instruments with matched item content. The convergence of EDE and EDE-Q scores has been examined previously; however, past studies have been limited by small sample sizes and have not compared the convergence of scores across diagnostic groups. A meta-analysis of 16 studies was conducted to compare the convergence of EDE and EDE-Q scores across studies and diagnostic groups. With regard to the EDE and EDE-Q subscale scores, the overall correlation coefficient effect sizes ranged from .68 to .76. The overall Cohen's d effect sizes ranged from .31 to .62, with participants consistently scoring higher on the questionnaire. For the items measuring behavior frequency, the overall correlation coefficient effect sizes ranged from .37 to .55 for binge eating and .90 to .92 for compensatory behaviors. The overall Cohen's d effect sizes ranged from -0.16 to -0.22, with participants reporting more binge eating on the interview than in the questionnaire in 70% of the studies. These results suggest the interview and questionnaire assess similar constructs but should not be used interchangeably. Additional research is needed to examine the inconsistencies between binge frequency scores on the 2 instruments.

A controlled evaluation of the distress criterion for binge eating disorder

OBJECTIVE

Research has examined various aspects of the validity of the research criteria for binge eating disorder (BED) but has yet to evaluate the utility of Criterion C, "marked distress about binge eating." This study examined the significance of the marked distress criterion for BED using 2 complementary comparison groups.

METHOD

A total of 1,075 community volunteers completed a battery of self-report instruments as part of an Internet study. Analyses compared body mass index (BMI), eating-disorder psychopathology, and depressive levels in 4 groups: 97 participants with BED except for the distress criterion (BED-ND), 221 participants with BED including the distress criterion (BED), 79 participants with bulimia nervosa (BN), and 489 obese participants without binge eating or purging (NBPO). Parallel analyses compared these study groups using the broadened frequency criterion (i.e., once weekly for binge/purge behaviors) proposed for the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the 4th edition (DSM-IV) twice-weekly frequency criterion.

RESULTS

The BED group had significantly greater eating-disorder psychopathology and depressive levels than the BED-ND group. The BED group, but not the BED-ND group, had significantly greater eating-disorder psychopathology than the NBPO comparison group. The BN group had significantly greater eating-disorder psychopathology and depressive levels than all 3 other groups. The group differences in eating-disorder psychopathology existed even after controlling for depression levels, BMI, and demographic variables, although some differences between the BN and BED groups were attenuated when controlling for depression levels.

CONCLUSIONS

These findings provide support for the validity of the "marked distress" criterion for the diagnosis of BED.

Beliefs about excessive exercise in eating disorders: the role of obsessions and compulsions

OBJECTIVE

This study aimed to develop an understanding of excessive exercise in eating disorders by exploring the role of exercise beliefs, obsessive beliefs and obsessive-compulsive behaviours.

METHOD

Sixty-four women were recruited from eating disorder services and 75 non-clinical women were recruited from a university. Exercise beliefs and behaviours, obsessive beliefs and behaviours and eating disorder psychopathology were assessed using self-report questionnaires.

RESULTS

There was an association between exercise beliefs, obsessive beliefs and obsessive-compulsive behaviours in the eating-disordered group, but not in the non-eating-disordered group. In the eating-disordered group obsessive beliefs and obsessive-compulsive behaviours were associated with a significant proportion of variance in exercise beliefs after controlling for eating disorder psychopathology and BMI. In the non-eating-disordered group obsessive beliefs and behaviours were associated with beliefs about exercise as a method of affect regulation after controlling for BMI.

CONCLUSION

The results are compatible with a model in which obsessive beliefs and exercise beliefs could maintain exercise in eating disorders. This has implications for the assessment and treatment of excessive exercise. Further research is necessary to determine the causality of these relationships.

Birth characteristics and schizotypy: evidence of a potential "second hit"

Schizophrenia is associated with a modest increase in winter births as well as increased odds of being born in more densely populated and midrange latitude regions. It is unclear the degree to which these findings hold for individuals with schizotypy, defined in terms of the personality organization that is a potential precursor to schizophrenia-spectrum disorders. This issue is important for understanding whether birth factors contribute to general schizophrenia vulnerability or whether they reflect a secondary "hit" that increases the likelihood of psychosis onset in vulnerable individuals. The present project examined season of birth, birthplace population and birth location in a large group of young adults from the southeastern United States. Individuals with extreme schizotypy scores did not differ from those without schizotypy in season of birth, birthplace latitude or population. However, 60% of individuals within the schizotypy group who reported a diagnosis of schizophrenia or prior hospitalization were born during winter months; a dramatic difference from other individuals within the schizotypy group. We also found that individuals with negative/schizoid traits showed a birthplace population less than half that of other individuals with schizotypy. Season of birth appears to be a "second hit" that is related to expression of psychopathology onset in vulnerable individuals. This finding, and the unexpected inverse relationship between birthplace population and negative/schizoid traits, is discussed.

Diagnostic efficiency of DSM-IV indicators for binge eating episodes

OBJECTIVE

Research has examined various aspects of the validity of the research criteria for binge eating disorder (BED) but has yet to evaluate the utility of the 5 Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) "indicators for impaired control" specified to help determine loss of control while overeating (i.e., binge eating). We examined the diagnostic efficiency of these indicators proposed as part of the research criteria for BED (eating until uncomfortably full; eating when not hungry; eating more rapidly than usual; eating in secret; and feeling disgust, shame, or depression after the episode).

METHOD

A total of 916 community volunteers completed a battery of measures including questions about each of the indicators. Participants were categorized into 3 groups: BED (N = 164), bulimia nervosa (BN; N = 83), and non-binge-eating controls (N = 669). Four conditional probabilities (sensitivity, specificity, positive predictive power [PPP], and negative predictive power [NPP]) as well as total predictive value (TPV) and kappa coefficients were calculated for each indicator criterion in separate analyses comparing BED, BN, and combined BED + BN groups relative to controls.

RESULTS

PPPs and NPPs suggest all of the indicators have predictive value, with eating alone because embarrassed (PPP = .80) and feeling disgusted (NPP = .93) performing as the best inclusion and exclusion criteria, respectively. The best overall indicators for correctly identifying binge eating (based on TPV and kappa) were eating when not hungry and eating alone because embarrassed.

CONCLUSIONS

All 5 proposed indicators for impaired control for determining binge eating have utility, and the diagnostic efficiency statistics provide guidance for clinicians and the DSM-5 regarding their usefulness for inclusion or exclusion.

Association between obesity and adult attention-deficit/hyperactivity disorder in a German community-based sample

OBJECTIVE

The goal of the present study was to examine the association between attention-deficit/hyperactivity disorder (ADHD) and obesity in a representative community based sample of the German population.

METHOD

Participants were 1,633 German residents (53.6% female) aged 18-64 years. A retrospective assessment of childhood ADHD and a self-report assessment of adult ADHD were administered for diagnosis of adult ADHD. In addition, binge eating and purging behaviors as well as depression and anxiety were assessed using self-rating instruments.

RESULTS

The estimated prevalence of ADHD in obese participants was 9.7% compared to 3.8% in overweight and 4.3% in under-/normal-weight participants. The prevalence of obesity was 22.1% among adults with ADHD and 10.2% among persons without ADHD. Adult ADHD was significantly associated with a greater likelihood of being obese but not overweight even after adjusting for sociodemographic characteristics. Results were similar when adjusting for depression and anxiety symptoms and for purging behaviors. Odds ratios decreased after adjusting for binge eating; however, the results were still significant which shows that the relationship between obesity and ADHD in adulthood is not fully explained by binge eating.

CONCLUSION

Overall, the results indicate that adult ADHD is associated with obesity in a community-based sample of the adult German population.

A latent profile analysis of the typology of bulimic symptoms in an indigenous Pacific population: evidence of cross-cultural variation in phenomenology

BACKGROUND

Previous efforts to derive empirically based eating disorder (ED) typologies through latent structure modeling have been limited by the ethnic and cultural homogeneity of their study populations and their reliance on DSM-IV ED signs and symptoms as indicator variables.

METHOD

Ethnic Fijian schoolgirls (n=523) responded to a self-report battery assessing ED symptoms, herbal purgative use, co-morbid psychopathology, clinical impairment, cultural orientation, and peer influences. Participants who endorsed self-induced vomiting or herbal purgative use in the past 28 days (n=222) were included in a latent profile analysis (LPA) to identify unique subgroups of bulimic symptomatology.

RESULTS

LPA identified a bulimia nervosa (BN)-like class (n=86) characterized by high rates of binge eating and self-induced vomiting, and a herbal purgative class (n=136) characterized primarily by the use of indigenous Fijian herbal purgatives. Both ED classes endorsed greater eating pathology and general psychopathology than non-purging participants, and the herbal purgative class endorsed greater clinical impairment than either the BN-like or non-purging participants. Cultural orientation did not differ between the two ED classes.

CONCLUSIONS

Including study populations typically under-represented in mental health research and broadening the scope of relevant signs and symptoms in latent structure models may increase the generalizability of ED nosological schemes to encompass greater cultural diversity.

Eating-disordered behavior in Australian and Singaporean women: a comparative study

OBJECTIVE AND METHOD

We used the Eating Disorder Examination Questionnaire (EDE-Q) to compare the specific eating disorder psychopathology of young adult women in Australia (n = 339) and Singapore (n = 164). All participants completed a brief questionnaire that included the EDE-Q, basic socio-demographic information, and self-reported height and weight.

RESULTS

Overall levels of eating disorder psychopathology, as measured by the EDE-Q global score, were very similar. There were also no differences between groups on the EDE-Q subscales. However, analysis at the item level indicated that Singaporean women were more fearful of losing control over their eating, more fearful of gaining weight or becoming fat, and more anxious at the prospect of regularly weighing themselves, than Australian women. Singaporean women were also more likely to report binge eating and laxative misuse, whereas excessive exercise was more common among Australian women. The findings were unaltered when between-group differences in body weight were statistically controlled.

DISCUSSION

The findings provide further evidence that levels of eating disorder psychopathology in some Asian countries may be as high as, if not higher than, those of Western nations. Potentially important differences between different cultural groups may be obscured when the assessment of eating disorder psychopathology is confined to summary-type measures.

Norms for the Eating Disorder Examination Questionnaire among female university students in Norway

BACKGROUND

The Eating Disorder Examination (EDE) is a semi-structured interview used worldwide for diagnostic purposes and to assess the core psychopathology of an eating disorder. The Eating Disorder Examination Questionnaire 6.0 (EDE-Q) has been developed as a self-report questionnaire version of the full-length interview.

AIM

This study was conducted to establish norms among female university students in Norway and to test the reliability of the Norwegian version of the EDE-Q.

METHOD

The questionnaire was administered to 670 young adult women with a mean age (±standard deviation) of 24.8±6.9 years.

RESULT

Participants' mean global EDE-Q score was 1.42±1.07 and subscales means were as follows: 1.44±1.23 for restraint, 0.63±0.88 for eating concern, 2.00±1.42 for shape concern, and 1.63±1.36 for weight concern. Acceptable levels of internal consistency were observed; Cronbach's alpha coefficients were 0.94 for the global EDE-Q score and 0.75-0.90 for the subscales. To evaluate the temporal stability of the EDE-Q, a total of 159 participants completed the measure 1 week later. Spearman's correlation coefficients were 0.93 for global EDE-Q and for the subscales 0.82-0.91, indicating a satisfactory level of test-retest reliability.

CONCLUSION

The EDE-Q was easily administered and required only a few minutes to complete. This brief questionnaire provides a psychometrically established and cost-savings method of quickly assessing the core psychopathology of an eating disorder.

Binge eating, purging, or both: eating disorder psychopathology findings from an internet community survey

OBJECTIVE

This study aimed to compare bulimia nervosa (BN), binge eating disorder (BED), and purging disorder (PD) on clinically significant variables and examine the utility of once versus twice-weekly diagnostic thresholds for disturbed eating behaviors.

METHOD

234 women with BN, BED, or PD were identified through self-report measures via an online survey and categorized based on either once-weekly or twice-weekly disturbed eating behaviors.

RESULTS

BN emerged as a more severe disorder than BED and PD. The three groups differed significantly in self-reported restraint and disinhibition and the BN and BED groups reported higher levels of depression than PD. For BN, those engaging in behaviors twice-weekly versus once-weekly were more symptomatic.

DISCUSSION

The BN, BED, and PD groups differed in clinically meaningful ways. Future research need to clarify the relationship between mood disturbances and eating behaviors. Reducing the twice-weekly behavior threshold for BN would capture individuals with clinically significant eating disorders, though the twice-weekly threshold may provide important information about disorder severity for both BN and BED.

A randomized controlled two-stage trial in the treatment of bulimia nervosa, comparing CBT versus motivational enhancement in Phase 1 followed by group versus individual CBT in Phase 2

OBJECTIVE

To conduct a randomized, controlled, two-stage trial in the treatment of bulimia nervosa, comparing cognitive-behavioral therapy (CBT) versus motivational enhancement in Phase 1 followed by group versus individual CBT in Phase 2.

METHODS

A total of 225 patients with bulimia nervosa or eating disorder not otherwise specified (EDNOS) were recruited into a randomized controlled trial lasting 12 weeks with follow-ups at 1 year and 2.5 years.

RESULTS

Patients improved significantly across all of the interventions with no differences in outcome or treatment adherence. Including motivational enhancement therapy rather than a CBT first phase of treatment did not affect outcome.

CONCLUSIONS

Outcome differences between individual and group CBT were minor, suggesting that group treatment prefaced by a short individual intervention may be a cost-effective alternative to purely individual treatment.

Eating disorders "mental health literacy" in low risk, high risk and symptomatic women: implications for health promotion programs

Attitudes and beliefs concerning the nature and treatment of bulimia nervosa (BN) were compared among young adult women at low risk of an eating disorder (n = 332), at high risk (n = 83), or already showing symptoms (n = 94). Participants completed a self-report questionnaire that included a measure of eating disorder symptoms. A vignette of a fictional person suffering from BN was presented, followed by a series of questions addressing the nature and treatment of the problem described. High-risk and symptomatic participants were more likely than low-risk participants to report that they would not approach anyone for advice or help, were they to have BN or a similar problem, because they would not want anyone to know. Symptomatic participants were more likely to believe that someone with BN would be discriminated against, more likely to consider bulimic behaviors to be acceptable, and more likely to view BN as being common among women in the community, than low-risk participants, participants in the high-risk group being intermediate on each of these questions. The findings suggest that the attitudes and beliefs of individuals with eating disorder symptoms differ systematically from those of individuals at high risk, but who do not yet have symptoms, and from those at low risk. They also indicate specific attitudes and beliefs that may need to be addressed in prevention and early intervention programs. The potential benefits of assessing individuals' attitudes and beliefs concerning the nature and treatment of eating-disordered behaviour and tailoring program content accordingly may be worthy of investigation.

Prior use of extreme weight-control behaviors in a community sample of women with binge eating disorder or subthreshold binge eating disorder: a descriptive study

OBJECTIVE AND METHOD

The prior occurrence of regular extreme weight-control behaviors was examined in a community sample of women (n = 27) with binge eating disorder (BED) or subthreshold BED.

RESULTS

Approximately two thirds of participants (65.4%) reported the prior use of either purging at least weekly or nonpurging behaviors three or more times per week, for a period of 3 months or more, whereas 38.5% of participants reported either purging at least twice weekly or nonpurging behaviors five or more times per week. Comparatively few participants (11.1%) had ever met formal diagnostic criteria for BN.

DISCUSSION

Considerable overlap between disorders characterized by binge eating in the absence of extreme weight-control behaviors and those characterized by extreme weight-control behaviors in the absence of binge eating may be apparent when a longitudinal perspective is taken. Caution needs to be exercised in drawing conclusions concerning the extent of this overlap based on any one operational definition of the term "regular extreme weight-control behaviors".

The factor structure of the eating disorder examination in clinical and community samples

OBJECTIVE

To assess the factor structure of the Eating Disorder Examination (EDE) in three different samples and to compare the goodness-of-fit of five models of EDE data.

METHOD

The EDE was administered to eating disordered (n = 158), treatment-seeking obese (n = 170) and non-eating disordered community-based (n = 329) participants. Confirmatory factor analysis was used to compare the validity of the original four-factor EDE model with that of three-, two-, and one-factor models.

RESULTS

None of the tested models provided a "good fit" to the data in any sample, with the exception of a brief one-factor model in the eating disorder group. Estimations of internal consistency, reliability, and validity were superior for the one-, two-, and three-factor models compared to the four-factor model in all samples.

DISCUSSION

Overall, there was more support for a one-factor model of EDE data than for a multi-factorial model. It may be more appropriate to use Global EDE scores than individual subscale scores for research purposes.

Objective and subjective bulimic episodes in the classification of bulimic-type eating disorders: another nail in the coffin of a problematic distinction

We sought to further explore the validity of the distinction between objective bulimic episodes (OBEs) and subjective bulimic episodes (SBEs) in the study of bulimic-type eating disorders. Drawing on data obtained at the second, interview phase of a large-scale epidemiological study, we identified mutually exclusive subgroups of women with bulimic-type eating disorders who engaged in regular OBEs but not SBEs (n = 37) or regular SBEs but not OBEs (n = 52). These subgroups were compared on a wide range of outcomes, including socio-demographic characteristics, current levels of eating disorder psychopathology, general psychological distress and impairment in role functioning, current and lifetime impairment in quality of life specifically associated with an eating problem, (self)-recognition of an eating problem, health service utilization and use of psychotropic medication. The only difference between groups was that participants who reported regular OBEs were heavier than those who reported regular SBEs. The findings converge with those of previous research in suggesting that bulimic-type eating disorders characterized by regular SBEs, but not OBEs, do not differ in any clinically meaningful way from those characterized by regular OBEs, but not SBEs. Inclusion of bulimic-type eating disorders characterized by regular SBEs as a provisional category requiring further research in DSM-V appears warranted.

Significance of overvaluation of shape/weight in binge-eating disorder: comparative study with overweight and bulimia nervosa

Increasing empirical evidence supports the validity of binge-eating disorder (BED) and its inclusion as a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Contention exists regarding the criteria for BED, including whether, like bulimia nervosa (BN), it should be characterized by overvaluation of shape/weight. This study examined the significance of overvaluation for BED using two complementary comparisons groups. Participants were 324 women who completed self-report instruments as part of an Internet study. Analyses compared BMI, eating disorder (ED) features, and depressive levels in four groups: 123 overweight participants without ED, 47 BED participants who do not overvalue shape/weight, 101 BED participants who overvalue shape/weight, and 53 BN participants. Both BED groups had significantly greater ED psychopathology than the overweight group. Within BED, the group with overvaluation had significantly greater ED psychopathology and depressive levels despite no differences in binge eating. BED with overvaluation and BN groups differed little from each other but had significantly higher ED psychopathology and depressive levels than the other groups. Group differences existed despite similar age and BMI across the groups, as well as when controlling for group differences in depressive levels. These findings provide further support for the validity of BED and suggest that overvaluation of shape/weight, which provides important information about BED severity, warrants consideration as either a diagnostic specifier or as a dimensional severity rating. Although inclusion of overvaluation of shape/weight could be considered as a required criterion for BED, this would exclude a substantial proportion of BED patients with clinically significant problems.

Gender difference in the prevalence of eating disorder symptoms

OBJECTIVE

This study examined gender differences in prevalence of eating disorder symptoms including body image concerns (body checking or avoidance), binge eating, and inappropriate compensatory behaviors.

METHOD

A random sample of members (ages 18-35 years) of a health maintenance organization was recruited to complete a survey by mail or on-line. Items were drawn from the Patient Health Questionnaire and the Body Shape Questionnaire.

RESULTS

Among the 3,714 women and 1,808 men who responded, men were more likely to report overeating, whereas women were more likely to endorse loss of control while eating. Although statistically significant gender differences were observed, with women significantly more likely than men to report body checking and avoidance, binge eating, fasting, and vomiting, effect sizes ("Number Needed to Treat") were small to moderate.

DISCUSSION

Few studies of eating disorders include men, yet our findings suggest that a substantial minority of men also report eating disorder symptoms.

Screening for eating disorders in primary care: EDE-Q versus SCOFF

OBJECTIVE AND METHODS

The comparative validity of the Eating Disorder Examination Questionnaire (EDE-Q) (22 items) and SCOFF (five items) in screening for cases of the more commonly occurring eating disorders was examined in a primary care sample of young adult women (n=257). Diagnoses were confirmed in a sub-group of interviewed participants (n=147).

RESULTS

Twenty-five cases, primarily variants of bulimia nervosa (BN) not meeting formal diagnostic criteria, were identified in the interviewed sample. An EDE-Q global score of >or= 2.80 yielded the optimal trade-off between sensitivity (Se) (0.80) and specificity (Sp) (0.80) (positive predictive value (PPV)=0.44), whereas a score of two or more positive responses on the SCOFF was optimal (Se=0.72, Sp=0.73, PPV=0.35). Validity coefficients for both measures varied as a function of participants' age and body weight, although these effects were more pronounced for the SCOFF.

CONCLUSIONS

Both measures performed well in terms of their ability to detect cases and to exclude non-cases of the more commonly occurring eating disorders in a primary care setting. The EDE-Q performed somewhat better than the SCOFF and was more robust to effects on validity of age and weight. These findings need to be weighed against the advantage of the SCOFF in terms of its brevity.