Heterogeneity moderates treatment response among patients with binge eating disorder

Causal discovery analysis: A promising tool in advancing precision medicine for eating disorders

OBJECTIVE

Precision medicine (i.e., individually tailored treatments) represents an optimal goal for treating complex psychiatric disorders, including eating disorders. Within the eating disorders field, most treatment development efforts have been limited in their ability to identify individual-level models of eating disorder psychopathology and to develop and apply an individually tailored treatment for a given individual's personalized model of psychopathology. In addition, research is still needed to identify causal relationships within a given individual's model of eating disorder psychopathology. Addressing this limitation of the current state of precision medicine-related research in the field will allow us to progress toward advancing research and practice for eating disorders treatment.

METHOD

We present a novel set of analytic tools, causal discovery analysis (CDA) methods, which can facilitate increasingly fine-grained, person-specific models of causal relations among cognitive, behavioral, and affective symptoms.

RESULTS

CDA can advance the identification of an individual's causal model that maintains that individuals' eating disorder psychopathology.

DISCUSSION

In the current article, we (1) introduce CDA methods as a set of promising analytic tools for developing precision medicine methods for eating disorders including the potential strengths and weaknesses of CDA, (2) provide recommendations for future studies utilizing this approach, and (3) outline the potential clinical implications of using CDA to generate personalized models of eating disorder psychopathology.

PUBLIC SIGNIFICANCE STATEMENT

CDA provides a novel statistical approach for identifying causal relationships among variables of interest for a given individual. Person-specific causal models may offer a promising approach to individualized treatment planning and inform future personalized treatment development efforts for eating disorders.

Binge Eating, Purging, and Restriction Symptoms: Increasing Accuracy of Prediction Using Machine Learning

Eating disorders are severe mental illnesses characterized by the hallmark behaviors of binge eating, restriction, and purging. These disordered eating behaviors carry extreme impairment and medical complications, regardless of eating disorder diagnosis. Despite the importance of these disordered behaviors to every eating disorder diagnosis, our current models are not able to accurately predict behavior occurrence. The current study utilized machine learning to develop longitudinal predictive models of binge eating, purging, and restriction in an eating disorder sample (N = 60) using real-time intensive longitudinal data. Participants completed four daily assessments of eating disorder symptoms and emotions for 25 days on a smartphone (total data points per participant = 100). Using data, we were able to compute highly accurate prediction models for binge eating, restriction, and purging (.76-.96 accuracy). The ability to accurately predict the occurrence of binge eating, restriction, and purging has crucial implications for the development of preventative interventions for the eating disorders. Machine learning models may be able to accurately predict onset of problematic psychiatric behaviors leading to preventative interventions designed to disrupt engagement in such behaviors.

Bottom-up transdiagnostic personality subtypes are associated with state psychopathology: A latent profile analysis

Introduction

Personality-based profiling helps elucidate associations between psychopathology symptoms and address shortcomings of current nosologies. The objective of this study was to bracket the assumption of a priori diagnostic class borders and apply the profiling approach to a transdiagnostic sample. Profiles resembling high-functioning, undercontrolled, and overcontrolled phenotypes were expected to emerge.

Methods

We used latent profile analysis on data from a sample of women with mental disorders (n = 313) and healthy controls (n = 114). 3-5 profile solutions were compared based on impulsivity, perfectionism, anxiety, stress susceptibility, mistrust, detachment, irritability, and embitterment. The best-fitting solution was then related to measures of depression, state anxiety, disordered eating, and emotion regulation difficulties to establish clinical significance.

Results

A 5-profile solution proved best-fitting. Extracted profiles included a high-functioning, a well-adapted, an impulsive and interpersonally dysregulated, an anxious and perfectionistic, and an emotionally and behaviorally dysregulated class. Significant differences were found in all outcome state measures, with the emotionally and behaviorally dysregulated class exhibiting the most severe psychopathology.

Discussion

These results serve as preliminary evidence of the predictive nature and clinical utility of personality-based profiles. Selected personality traits should be considered in case formulation and treatment planning. Further research is warranted to replicate the profiles and assess classification stability and profiles' association with treatment outcome longitudinally.

Die Spiegelkonfrontationstherapie zur Behandlung von Körperbildstörungen bei Essstörungen – Evidenz, Wirkmechanismen und Vorgehensweise

Zusammenfassung. Körperbildprobleme sind ein Kernmerkmal von Essstörungen. Daher gilt eine Verbesserung des Körperbildes bei der Behandlung von Essstörungen als zentrales Therapieziel. Verschiedene empirische Befunde weisen auf die Spiegelkonfrontation als wirksame Methode zur Reduktion von Körperbildstörungen hin. Ziel dieses Übersichtsartikels ist es, den aktuellen Stand der wissenschaftlichen Literatur zum Thema Spiegelkonfrontationstherapie bei Essstörungen darzulegen. Insbesondere sollen die Wirksamkeitsstudien getrennt für nicht-klinische, körperunzufriedene Gruppen mit und ohne Übergewicht sowie die verschiedenen Essstörungsgruppen systematisiert und unterschiedliche Vorgehensweisen beschrieben werden. Der Übersichtsartikel liefert Hinweise dafür, dass die Spiegelkonfrontationstherapie bei Hochrisikogruppen mit erhöhter Körperunzufriedenheit sowie bei Essstörungen zu positiven Veränderungen hinsichtlich der kognitiv-affektiven und behavioralen Komponente des Körperbildes führt. Jedoch mangelt es insgesamt an randomisiert-kontrollierten Studien, die die Wirksamkeit der Spiegelkonfrontationstherapie mit ausreichend großen Stichproben gezielt untersuchen – vor allem bei der Anorexia nervosa. Der Übersichtsartikel schließt mit einer Diskussion über mögliche Wirkmechanismen, (Kontra–)‌Indikationen und einem Ausblick für zukünftige Forschung ab.

A network approach can improve eating disorder conceptualization and treatment

Eating disorders are severe mental illnesses with the second highest mortality rate of all psychiatric illnesses. Eating disorders are exceedingly deadly because of their complexity. Specifically, eating disorders are highly comorbid with other psychiatric illnesses (up to 95% of individuals with an eating disorder have at least one additional psychiatric illness), have extremely heterogeneous presentations, and individuals often migrate from one specific eating disorder diagnosis to another. In this Perspective, we propose that understanding eating disorder comorbidity and heterogeneity via a network theory approach offers substantial benefits for both conceptualization and treatment. Such a conceptualization, strongly based on theory, can identify specific pathways that maintain psychiatric comorbidity, how diagnoses vary across individuals, and how specific symptoms and comorbidities maintain illness for one individual, thereby paving the way for personalized treatment.

The Value of Patient Registries to Advance Basic and Translational Research in the Area of Traumatic Brain Injury

The number of individuals affected by traumatic brain injury (TBI) is growing globally. TBIs may cause a range of physical, cognitive, and psychiatric deficits that can negatively impact employment, academic attainment, community independence, and interpersonal relationships. Although there has been a significant decrease in the number of injury related deaths over the past several decades, there has been no corresponding reduction in injury related disability over the same time period. We propose that patient registries with large, representative samples and rich multidimensional and longitudinal data have tremendous value in advancing basic and translational research and in capturing, characterizing, and predicting individual differences in deficit profile and outcomes. Patient registries, together with recent theoretical and methodological advances in analytic approaches and neuroscience, provide powerful tools for brain injury research and for leveraging the heterogeneity that has traditionally been cited as a barrier inhibiting progress in treatment research and clinical practice. We report on our experiences, and challenges, in developing and maintaining our own patient registry. We conclude by pointing to some future opportunities for discovery that are afforded by a registry model.

Predictors of Symptom Trajectories After Cognitive-Behavioral Therapy in Adolescents With an Age-Adapted Diagnosis of Binge-Eating Disorder

Although evidence demonstrated efficacy of cognitive-behavioral therapy (CBT) in adolescents with binge-eating disorder (BED), treatment response is heterogeneous. This study uniquely examined baseline predictors of symptom trajectories in N = 73 adolescents (12-20 years) with an age-adapted diagnosis of BED (i.e., based on objective and subjective binge-eating episodes). Based on evidence from adult BED, dietary restraint, overvaluation of weight/shape, and depressive symptoms were used to predict changes in abstinence from binge eating and eating disorder psychopathology after 4 months of individual, face-to-face CBT using growth models. Longitudinal trajectories of abstinence from objective and subjective binge eating and global eating disorder psychopathology assessed via the Eating Disorder Examination were modeled for five time points (pre- and posttreatment, 6-, 12-, and 24-month follow-up). Beyond significant, positive effects for time, no significant predictors for abstinence from binge eating emerged. In addition to significant decreases in eating disorder psychopathology over time, higher pretreatment dietary restraint and overvaluation of weight/shape significantly predicted greater decreases in eating disorder psychopathology over time. Consistent with research in adult BED, adolescents with higher than lower eating disorder-specific psychopathology especially benefit from CBT indicating that restrained eating and overvaluation of weight/shape may be BED-specific prognostic characteristic across developmental stages. Future predictor studies with an additional focus on potential age-specific predictors, such as family factors, and within-treatment processes may be critical in further evaluating treatment-related symptom trajectories in adolescent BED.

Clinical moderators and predictors of cognitive-behavioral therapy by guided-self-help versus therapist-led for binge-eating disorder: Analysis of aggregated clinical trials

OBJECTIVE

Cognitive-behavioral therapy (CBT)-therapist-led (CBTth) and guided-self-help (CBTgsh)-has efficacy for binge-eating disorder (BED) but many patients do not benefit sufficiently. We examined predictors and moderators for these two CBT methods.

METHOD

Data were aggregated from randomized controlled trials (RCTs) testing psychosocial treatments for BED in the U.S. Predictors and moderators of outcomes (treatment completion and binge-eating remission) were examined in N = 457 participants who received either CBTgsh (N = 164) or CBTth (N = 293).

RESULTS

Analyses, adjusting for demographic/clinical variables, indicated CBTth was significantly superior to CBTgsh for treatment completion (odds ratio [OR] = 20.0) and remission (OR = 14.6). For remission, analyses revealed significant predictors (age, treatment length, Weight Concern), a moderator (weight concern [OR = 5.13]), and a significant interaction between CBT-type and treatment length (OR = 2.66). For CBTgsh, longer treatment was associated with less remission, whereas for CBTth, longer treatment was associated with greater remission. For CBTgsh, 44.1% with low weight concern versus 56.3% with high weight concern achieved remission whereas for CBTth, 43.5% with high weight concern and 61.0% with low weight concern achieved remission.

DISCUSSION

Analyses of aggregated RCT BED data, adjusting for demographic/clinical characteristics, indicated superiority (large effect-sizes) in treatment outcomes of CBTth over CBTgsh and that Weight Concern moderated outcomes.

Heterogeneity Is a Hallmark of Traumatic Brain Injury, Not a Limitation: A New Perspective on Study Design in Rehabilitation Research

Purpose In both basic science and intervention research in traumatic brain injury (TBI), heterogeneity in the patient population is frequently cited as a limitation and is often interpreted as a factor reducing certainty in the generalizability of research findings and as a source of conflicting findings across studies. Historically, much of TBI research in rehabilitation and cognition has relied upon case-control studies, with small to modest sample sizes. In this context, heterogeneity is indeed a significant limitation. Here, however, we argue that heterogeneity in patient profiles is a hallmark characteristic of TBI and therefore cannot be avoided or ignored. We argue that this inherent heterogeneity must be acknowledged and accounted for prior to study design. Fortunately, advances in statistical methods and computing power allow researchers to leverage heterogeneity, rather than be constrained by it. Method In this article, we review sources of heterogeneity that contribute to challenges in TBI research, highlight methodological advances in statistical analysis and in other fields with high degrees of heterogeneity (e.g., psychiatry) that may be fruitfully applied to decomposing heterogeneity in TBI, and offer an example from our research group incorporating this approach. Conclusion Only by adopting new methodological approaches can we advance the science of rehabilitation following TBI in ways that will impact clinical practice and inform decision making, allowing us to understand and respond to the range of individual differences that are a hallmark in this population.

Overweight and obesity are associated with increased eating disorder correlates and general psychopathology in university women with eating disorders

OBJECTIVE

Examine how eating disorder (ED) correlates, ED-related clinical impairment, general psychopathology, and ED diagnoses differ across weight statuses in a sample of university women with EDs.

METHOD

Participants were 690 women from 28 U.S. universities who screened positive for an ED (with the exception of anorexia nervosa [AN]) and participated in the Healthy Body Image Program study. ED correlates, ED-related clinical impairment, general psychopathology (i.e., depression and anxiety), and ED diagnoses were compared across weight statuses (i.e., healthy weight, overweight, obesity) using analyses of variance and chi-square tests.

RESULTS

Women with EDs and overweight or obesity had higher levels of, perceived benefit of thinness, depressive symptoms, anxiety, and weight/shape concerns (obesity only) than those with healthy weight (ps ≤ .017). Compared to those with healthy weight, those with obesity had higher rates of clinical and sub-clinical binge eating disorder and lower rates of bulimia nervosa (p < .001).

DISCUSSION

Overweight and obesity in individuals with EDs, excluding AN, are associated with greater severity of ED correlates, ED-related clinical impairment, and co-morbid general psychopathology. The current study highlights the need to consider weight status in ED treatment and for optimization of ED treatments to address shared risk factors between EDs and overweight and obesity.

Group and longitudinal intra-individual networks of eating disorder symptoms in adolescents and young adults at-risk for an eating disorder

Several studies have identified risk factors that predict future onset of eating disorders (ED) in adolescence, however, it is currently unknown how specific ED symptom dynamics operate both across time and within individuals. Advances in network methodologies allow for the study of how dynamic symptoms interrelate and predict each other within-persons and across time. In the current study, we used longitudinal group-level (N = 1272) (addressing symptom interrelations across people and across time; between-subjects, contemporaneous, and temporal networks) and intra-individual (symptom interrelations within each person and across time; contemporaneous and temporal networks) network analyses (subset n = 50) in prospective 48-month interview data in at-risk adolescents and young adults. We computed between-subject networks (how symptoms are associated on average, for group sample only), contemporaneous networks (how symptoms are associated at one time point, accounting for previous time points), and temporal networks (examining how symptoms predict each other across time). We replicated prior network results which suggest that overvaluation of weight and shape are central in at-risk adolescents and young adults. We found that individual networks (n = 1 networks) were highly variable across individuals. Overall, our results show how both group-level and longitudinal intra-individual network analysis can inform our understanding of how EDs develop in adolescence and point to the importance of conceptualizing development on an individual level of analysis.

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.

Latent trajectories of eating disorder treatment response among female patients in residential care

OBJECTIVE

Eating disorder (ED) treatment outcomes are highly variable from beginning to end of treatment; however, little is known about differential trajectories during the course of treatment. This study sought to characterize heterogeneous patterns of ED treatment response during residential care.

METHOD

Participants were adolescent girls and adult women (N = 360) receiving residential ED treatment for anorexia nervosa, bulimia nervosa, binge-eating disorder, other specified feeding or eating disorder, unspecified feeding or eating disorder, or avoidant/restrictive food intake disorder. Self-report symptom assessments were completed at admission, discharge, and approximately weekly throughout the residential stay to assess curvilinear patterns of change. Latent growth mixture modeling was applied to identify subgroups of patients with similar treatment response trajectories.

RESULTS

Three latent groups emerged, including gradual response (58.3%; steady improvements from admission to discharge), rapid response (23.9%; steep early improvements that were maintained through discharge), and low-symptom static response (17.8%; nearly nonclinical self-reported symptoms at admission that remained static through discharge). Groups differed on important clinical characteristics, such as body mass index, endorsement of compensatory behaviors, severity of global ED psychopathology at admission, and degree of symptom improvement by end of treatment.

DISCUSSION

Patients follow heterogeneous response patterns in residential ED treatment, and these patterns are associated with differential treatment outcome. Future work should explore whether these trajectories are associated with differential outcomes at follow-up and whether tailoring clinical intervention to a patient's trajectory type can improve treatment response.

Functional health status of adults with serious mental illness and diabetes mellitus: A latent profile analysis

OBJECTIVE

Adults with serious mental illness are at increased risk for diabetes mellitus and diabetes-related complications. This article classifies subgroups among people with serious mental illness and comorbid diabetes with respect to functional status and examines differences among those groups.

METHODS

This analysis used a baseline sample of 157 adults with serious mental illness and diabetes mellitus enrolled in a National Institute of Health-funded research study. Latent profile analysis was used to distinguish health status profiles and investigate how these subgroups differed across assessment domains.

RESULTS

Participants with depression, schizophrenia, and bipolar disorder (n = 157) were included in the study. Mean age was 52.9 years (standard deviation = 9.8), and 62 (40%) were African American. From the latent profile analysis, a three-class model appeared to provide the best fit. Class 1 (34.9%) had a very low functional health status approximately two standard deviations below the general population mean. Class 2 (43.7%) had a low functional status approximately one standard deviation below the general mean. Class 3 (21.4%) had moderate functional status with scores near population mean. Groups differed on measures of personal characteristics, clinical status and symptom severity, self-care behaviors, and environmental characteristics.

CONCLUSIONS

Although individuals with schizophrenia generally have poor prognosis once they develop diabetes, latent profile analysis identified distinct health status subgroups. Although all three groups demonstrated illness burden, the pattern of differences between these groups across measures may suggest the need for different interventions for highly diverse adults who received care within safety-net primary care.

Longitudinal and personalized networks of eating disorder cognitions and behaviors: Targets for precision intervention a proof of concept study

INTRODUCTION

Despite the high mortality and significant societal and personal costs associated with eating disorders (EDs) there are few evidence-based treatments. Part of the difficulty developing and implementing evidence-based treatments in EDs is due to the extremely high heterogeneity (e.g., variability in treatment outcome, symptom presentation etc) present.

METHODS

To begin to identify specific symptom heterogeneity within persons, the current study used novel within and between group and intra-individual network analyses to create longitudinal and within-person networks of ED cognitions and behaviors (N = 66 individuals diagnosed with an ED). This article provides a proof of concept study for how to use between and within-person network analyses both for the EDs and other forms of psychopathology.

RESULTS

We found that cognitions focused on desiring thinness played a likely maintaining role in ED pathology, across network type and across time. Furthermore, we showed that three individuals with the same diagnosis (anorexia nervosa) differed in which symptoms maintained the disorder. We use these participants to exemplify how to use intra-individual network analysis to personalize treatment focused on the primary maintaining symptoms. Finally, we found that amount of time (e.g., 4 hr vs. simultaneously) impacts how symptoms maintain each other.

CONCLUSIONS

These findings have implications for the development of novel personalized evidence-based treatments for EDs, as well as implications for how the field understands how psychopathology maintains itself. These data represent a first-step towards using intra-individual network analyses in the ED field, as well as for hypotheses generation in future research.

Interpersonal psychotherapy for eating disorders: current perspectives

Background

Interpersonal psychotherapy (IPT) is a time-limited and affect-, life-event-, and present-focused psychotherapy originally conceptualized for unipolar depression, and then adapted to the treatment of other disorders, including eating disorders (EDs). The purpose of this paper is to conduct a systematic review of studies on IPT for EDs.

Methods

The authors performed literature searches, study selection, method, and quality evaluation independently. Data were summarized using a narrative approach.

Results

Of the 534 papers retrieved, 37 studies met the inclusion criteria, and 15 were considered for the systematic review (randomized controlled trials and long-term follow-up studies derived from the randomized controlled trials). Their analysis revealed six main findings: 1) no significant differences between IPT and cognitive-behavioral therapy (CBT) were found when administered as monotherapy to patients with anorexia nervosa; 2) when administered as monotherapy to patients with bulimia nervosa (BN), IPT had lower outcomes than CBT and its enhanced version; 3) patients with BN who remitted with IPT showed a prolonged time spent in clinical remission, when followed up on the long term; 4) IPT and CBT, with different timings and methods, have both shown efficacy in the mid-term/long-term period in patients with BN; 5) CBT and its enhanced version produced rapid changes in the acute phase. IPT led to improvements occurring later, with slower changes that tended to maintain efficacy in the long term; 6) abstinence from binge eating with group IPT for binge eating disorder is stable and maintained (or further improved) in the long term.

Conclusion

IPT is a reasonable, cost-effective alternative to CBT for the overall ED spectrum.

Using person-specific neural networks to characterize heterogeneity in eating disorders: Illustrative links between emotional eating and ovarian hormones

OBJECTIVE

Emotional eating has been linked to ovarian hormone functioning, but no studies to-date have considered the role of brain function. This knowledge gap may stem from methodological challenges: Data are heterogeneous, violating assumptions of homogeneity made by between-subjects analyses. The primary aim of this paper is to describe an innovative within-subjects analysis that models heterogeneity and has potential for filling knowledge gaps in eating disorder research. We illustrate its utility in an application to pilot neuroimaging, hormone, and emotional eating data across the menstrual cycle.

METHOD

Group iterative multiple model estimation (GIMME) is a person-specific network approach for estimating sample-, subgroup-, and individual-level connections between brain regions. To illustrate its potential for eating disorder research, we apply it to pilot data from 10 female twins (N = 5 pairs) discordant for emotional eating and/or anxiety, who provided two resting state fMRI scans and hormone assays. We then demonstrate how the multimodal data can be linked in multilevel models.

RESULTS

GIMME generated person-specific neural networks that contained connections common across the sample, shared between co-twins, and unique to individuals. Illustrative analyses revealed positive relations between hormones and default mode connectivity strength for control twins, but no relations for their co-twins who engage in emotional eating or who had anxiety.

DISCUSSION

This paper showcases the value of person-specific neuroimaging network analysis and its multimodal associations in the study of heterogeneous biopsychosocial phenomena, such as eating behavior.

Form and formulation: Examining the distinctiveness of body image constructs in treatment-seeking patients with binge-eating disorder

OBJECTIVE

Body-image disturbance is a core aspect of eating disorders, yet the clinical manifestations of individuals' weight and shape concerns are complex, vary considerably, and are poorly understood by clinicians and researchers. This study aimed to distinguish different aspects of body-image disturbance-including weight/shape dissatisfaction, weight/shape overvaluation, weight/shape preoccupation, and fear of weight gain-in patients with binge-eating disorder (BED). Examining how each specific body image construct relates to biopsychosocial features of BED could contribute to the refinement of conceptualization and treatment planning.

METHOD

The current study assessed body-image disturbance and eating-disorder psychopathology in 748 treatment-seeking patients with BED using established investigator-based interviews reliably administered by doctoral clinicians.

RESULTS

The 4 body image constructs, although related to one another, showed some important similarities in associations with biopsychosocial clinical features, as well as some important distinctions. The relation between overvaluation and self-esteem was, as conceptualized, more strongly negative than for other body image variables, and preoccupation was more associated than other body image variables with eating concerns. Biopsychosocial features of BED were associated with different forms of body-image disturbance, but associations of body image variables with body mass index (BMI) were not significant and associations with binge-eating frequency did not differ across body image variables.

CONCLUSION

Manifestations of body-image disturbance in BED are complex and understanding the distinctions between different body image constructs can contribute to treatment formulation. (PsycINFO Database Record

Universal prevention efforts should address eating disorder pathology across the weight spectrum: Implications for screening and intervention on college campuses

PURPOSE

Given shared risk and maintaining factors between eating disorders and obesity, it may be important to include both eating disorder intervention and healthy weight management within a universal eating disorder care delivery program. This study evaluated differential eating disorder screening responses by initial weight status among university students, to assess eating disorder risk and pathology among individuals with overweight/obesity versus normal weight or underweight.

METHODS

1529 individuals were screened and analyzed. Screening was conducted via pilot implementation of the Internet-based Healthy Body Image program on two university campuses.

RESULTS

Fifteen percent of the sample had overweight/obesity. Over half (58%) of individuals with overweight/obesity screened as high risk for an eating disorder or warranting clinical referral, and 58% of individuals with overweight/obesity endorsed a ≥10-pound weight change over the past year. Compared to individuals with normal weight or underweight, individuals with overweight/obesity were more likely to identify as Black, endorse objective binge eating and fasting, endorse that eating disorder-related concerns impaired their relationships/social life and made them feel badly, and endorse higher weight/shape concerns.

CONCLUSIONS

Results suggest rates of eating disorder pathology and clinical impairment are highest among students with overweight/obesity, and targeted intervention across weight categories and diverse races/ethnicities is warranted within universal eating disorder intervention efforts. Integrating eating disorder intervention and healthy weight management into universal prevention programs could reduce the incidence and prevalence of eating disorders, unhealthy weight control practices, and obesity among university students.

Assessment of Dysfunctional Cognitions in Binge-Eating Disorder: Factor Structure and Validity of the Mizes Anorectic Cognitions Questionnaire-Revised (MAC-R)

Background: Dysfunctional cognitions regarding weight and shape and their implications for self-esteem are considered core features of anorexia nervosa and bulimia nervosa. However, they have also been associated with the severity of binge eating disorder (BED). Therefore, they should be screened with appropriate instruments to tailor treatment to individual patient needs. The Mizes Anorectic Cognitions-Revised (MAC-R) is a self-report questionnaire that lists dysfunctional cognitions related to three hypothesized core beliefs typical of the psychopathology of eating disorders: weight and eating as the basis of approval from others; the belief that rigid self-control is fundamental to self-worth; and the rigidity of weight- and eating-regulation efforts.

Objectives: The goal of the study was to confirm the factor structure and to assess the validity of the MAC-R among a sample that met full-threshold and subthreshold criteria for BED.

Methods: We used data of women meeting full-threshold (n = 94) and subthreshold (n = 22) criteria for BED to conduct confirmatory factor analyses and to compute Spearman's correlations, in order to assess factorial, convergent, and discriminant validity.

Results: Two models having a structure of three factors with or without a total score proved to be acceptable. The MAC-R total score was correlated with questionnaires assessing dimensions related to eating disorder psychopathology, adding to the validity of the questionnaire.

Conclusion: These results were similar to those found in studies on the psychometric properties of the MAC among samples with anorexia nervosa or bulimia nervosa, encouraging the use of the MAC-R as a research or clinical tool in order to further document the core beliefs underlying BED.

Does impulsivity predict outcome in treatment for binge eating disorder? A multimodal investigation

Multiple dimensions of impulsivity (e.g., affect-driven impulsivity, impulsive inhibition - both general and food-specific, and impulsive decision-making) are associated with binge eating pathology cross-sectionally, yet the literature on whether impulsivity predicts treatment outcome is limited. The present pilot study explored impulsivity-related predictors of 20-week outcome in a small open trial (n = 17) of a novel treatment for binge eating disorder. Overall, dimensions of impulsivity related to emotions (i.e., negative urgency) and food cues emerged as predictors of treatment outcomes (i.e., binge eating frequency and global eating pathology as measured by the Eating Disorders Examination), while more general measures of impulsivity were statistically unrelated to global eating pathology or binge frequency. Specifically, those with higher levels of negative urgency at baseline experienced slower and less pronounced benefit from treatment, and those with higher food-specific impulsivity had more severe global eating pathology at baseline that was consistent at post-treatment and follow-up. These preliminary findings suggest that patients high in negative urgency and with poor response inhibition to food cues may benefit from augmentation of existing treatments to achieve optimal outcomes. Future research will benefit from replication with a larger sample, parsing out the role of different dimensions of impulsivity in treatment outcome for eating disorders, and identifying how treatment can be improved to accommodate higher levels of baseline impulsivity.

Characteristics of binge eating disorder in relation to diagnostic criteria

The objective of this review was to examine the evidentiary basis for binge eating disorder (BED) with reference to the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) diagnostic criteria for BED. A PubMed search restricted to titles and abstracts of English-language reviews, meta-analyses, clinical trials, randomized controlled trials, journal articles, and letters using human participants was conducted on August 7, 2015, using keywords that included "binge eating disorder," DSM-5, DSM-IV, guilt, shame, embarrassment, quantity, psychological, behavior, and "shape and weight concerns." Of the 257 retrieved publications, 60 publications were considered relevant to discussions related to DSM-5 diagnostic criteria and were included in the current review, and 20 additional references were also included on the basis of the authors' knowledge and/or on a review of the reference lists from relevant articles obtained through the literature search. Evidence supports the duration/frequency criterion for BED and the primary importance of loss of control and marked distress in identifying individuals with BED. Although overvaluation of shape/weight is not a diagnostic criterion, its relationship to the severity of BED psychopathology may identify a unique subset of individuals with BED. Additionally, individuals with BED often exhibit a clinical profile consisting of psychiatric (eg, mood, obsessive-compulsive, and impulsive disorders) and medical (eg, gastrointestinal symptoms, metabolic syndrome, and type 2 diabetes) comorbidities and behavioral profiles (eg, overconsumption of calories outside of a binge eating episode and emotional eating). Future revisions of the BED diagnostic criteria should consider the inclusion of BED subtypes, perhaps based on the overvaluation of shape/weight, and an evidence-based reassessment of severity criteria.

Extracting body image symptom dimensions among eating disorder patients: the Profile Analysis via Multidimensional Scaling (PAMS) approach

The present study employs Profile Analysis via Multidimensional Scaling (PAMS), a procedure for extracting dimensions, in order to identify core eating disorder symptoms in a clinical sample. A large sample of patients with eating disorders (N=5193) presenting for treatment completed the Eating Disorders Inventory-2 (EDI-2; Garner, 1991), and PAMS was then employed to estimate individual profile weights that reflect the degree to which an individual's observed symptom profile approximates the pattern of the dimensions. The findings revealed three symptom dimensions: Body Thinness, Body Perfectionism, and Body Awareness. Subsequent analysis using individual level data illustrate that the PAMS profiles properly operate as prototypical profiles that encapsulate all individuals' response patterns. The implications of these dimensional findings for the assessment and diagnosis of eating disorders are discussed.

Recent Advances in Developmental and Risk Factor Research on Eating Disorders

The Diagnostic and Statistical Manual of Mental Disorders (i.e., DSM-5) currently recognizes three primary eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder. The origins of eating disorders are complex and remain poorly understood. However, emerging research highlights a dimensional approach to understanding the multifactorial etiology of eating disorders as a means to inform assessment, prevention, and treatment efforts. Guided by research published since 2011, this review summarizes recent findings elucidating risk factors for the development of eating disorders across the lifespan in three primary domains: (1) genetic/biological, (2) psychological, and (3) socio-environmental. Prospective empirical research in clinical samples with full-syndrome eating disorders is emphasized with added support from cross-sectional studies, where relevant. The developmental stages of puberty and the transition from adolescence to young adulthood are discussed as crucial periods for the identification and prevention of eating disorders. The importance of continuing to elucidate the mechanisms underlying gene by environmental interactions in eating disorder risk is also discussed. Finally, controversial topics in the field of eating disorder research and the clinical implications of this research are summarized.

Prospective association between overvaluation of weight and binge eating among overweight adolescent girls

PURPOSE

We investigated whether overvaluation of weight, defined as having a high degree of concern with weight such that it unduly influences self-evaluation, was prospectively associated with binge eating onset among overweight adolescent girls and whether overvaluation of weight signaled greater impairment among those with weekly binge eating.

METHODS

We used generalized estimating equations to assess the prospective association between weight overvaluation at Time 1 and the onset of weekly binge eating at Time 2 among 767 overweight adolescent girls (ages 12-18 years) participating in the Growing Up Today Study. In a cross-sectional analysis of overweight girls with weekly binge eating at Time 2, we examined whether overvaluation of weight was associated with greater impairment assessed by examining their rates of more severe depressive symptoms and low subjective social status.

RESULTS

At Time 1, 24.5% of overweight/obese girls overvalued weight. Overweight girls who overvalued weight were more likely to have started binge eating weekly 2 years later (odds ratio, 2.9; 95% confidence interval [CI], 1.2-7.3). Among overweight girls who reported weekly binge eating at Time 2, those who overvalued weight were at greater risk of having more severe depressive symptoms (odds ratio, 10.4; 95% CI, 1.3-85.6). Also among girls with weekly binge eating at Time 2, we saw a significant association between continuous measures of overvaluation and subjective social status (β, .71; 95% CI, .08-1.34) but not in analyses using binary measures.

CONCLUSIONS

We found that overvaluation was associated with the development of weekly binge eating in overweight girls and with greater impairment among those with weekly binge eating.

Interpersonal Change Following Intensive Inpatient Treatment

OBJECTIVE

Persons admitted for inpatient psychiatric care often present with interpersonal difficulties that disrupt adaptive social relations and complicate the provision of treatment. Whereas domains of psychosocial functioning in this population demonstrate clear growth in response to intervention, the impact of treatment on more complex patterns of interpersonal behavior has been largely overlooked within the existing literature. Interpersonal profiles characteristic of psychiatric inpatients were identified in the current study to determine rates of transition to adaptive functioning following hospitalization.

METHODS

Personality disturbance was assessed in 513 psychiatric inpatients using the Inventory of Interpersonal Problems. Scores were analyzed within a series of latent profile models to isolate unique interpersonal profiles at admission and at discharge. Longitudinal modeling was then employed to determine rates of transition from dysfunctional to adaptive profiles. Relationships with background characteristics, clinical presentation, and treatment response were explored.

RESULTS

Normative, Submissive, and Hostile/Withdrawn profiles emerged at both admission and discharge. Patients in the Normative profile demonstrated relatively moderate symptoms. Submissive and Hostile/Withdrawn profiles were related to known risk factors and elevated psychopathology. Approximately half of the patients who had been identified as Submissive or Hostile/Withdrawn transitioned to the Normative profile by discharge. Transition status evidenced modest associations with background characteristics and clinical presentation. Treatment engagement and reduction of clinical symptoms were strongly associated with adaptive transition.

CONCLUSION

Maladaptive interpersonal profiles characteristic of psychiatric inpatients demonstrated categorical change following inpatient hospitalization. Enhanced therapeutic engagement and overall reductions in psychiatric symptoms appear to increase potential for interpersonal change.

Predictive significance of the overvaluation of shape/weight in obese patients with binge eating disorder: findings from a randomized controlled trial with 12-month follow-up

BACKGROUND

Undue influence of body shape or weight on self-evaluation - referred to as overvaluation - is considered a core feature across eating disorders, but is not a diagnostic requirement for binge eating disorder (BED). This study examined the concurrent and predictive significance of overvaluation of shape/weight in obese patients with BED participating in a randomized clinical trial testing cognitive behavioral therapy (CBT) and behavioral weight loss (BWL). Method A total of 90 participants were randomly assigned to 6-month group treatments of CBT or BWL. Assessments were performed at baseline, throughout- and post-treatment, and at 6- and 12-month follow-ups after completing treatments with reliably administered semi-structured interviews and established measures.

RESULTS

Participants categorized with overvaluation (n = 52, 58%) versus without overvaluation (n = 38, 42%) did not differ significantly in demographic features (age, gender and ethnicity), psychiatric co-morbidity, body mass index or binge eating frequency. The overvaluation group had significantly greater levels of eating disorder psychopathology and poorer psychological functioning (higher depression and lower self-esteem) than the non-overvaluation group. Overvaluation of shape/weight significantly predicted non-remission from binge eating and higher frequency of binge eating at the 12-month follow-up, even after adjusting for group differences in depression and self-esteem levels.

CONCLUSIONS

Our findings suggest that overvaluation does not simply reflect concern commensurate with being obese or more frequent binge eating, but also is strongly associated with heightened eating-related psychopathology and psychological distress, and has negative prognostic significance for longer-term treatment outcomes. Overvaluation of shape/weight warrants consideration as a diagnostic specifier for BED as it provides important information about severity and treatment outcome.

Predicting group cognitive-behavioral therapy outcome of binge eating disorder using empirical classification

The purpose of this study was to use empirical classification based on Latent Profile Analysis to identify subgroups of binge eating disorder (BED) and to evaluate the extent to which these subgroups were predictive of treatment outcome in group cognitive-behavioral therapy (CBT). The Eating Disorder Examination (EDE), Structured Clinical Interview for DSM-IV, and Inventory of Depressive Symptomatology-Self-Report were administered to 259 participants at baseline in a 15-session CBT trial (190 of whom received active treatment). The best fitting model included three profiles: dietary restraint only (DRO; n = 96; 51%); low dietary restraint (LDR; n = 52; 27%); and dietary restraint plus psychopathology (DRP; n = 42; 22%). Regression analyses revealed that after controlling for baseline score and treatment condition, EDE Global scores were lower for the DRO compared to the LDR profile at one year follow-up (p = .047). Class assignment was not predictive of EDE binge eating frequency or abstinence at end of treatment or follow-up. These results suggest that meaningful empirical classes based on eating disorder symptoms, psychopathology, dietary restraint, and BMI can be identified in BED and that these classes may be useful in predicting long-term group CBT outcome.

Why no cognitive body image feature such as overvaluation of shape/weight in the binge eating disorder diagnosis?

OBJECTIVE

Undue influence of body shape or weight on self-evaluation--referred to as overvaluation--is considered a core feature across eating disorders, but is not a diagnostic requirement for binge eating disorder (BED). This article addresses the relevance of a feature reflecting disturbance in body image for the diagnosis of BED.

METHOD

The distinction between overvaluation of shape/weight and body dissatisfaction is discussed, and empirical research regarding the concurrent and predictive significance of overvaluation of shape/weight for BED is reviewed.

RESULTS

The literature suggests that overvaluation does not simply reflect concern or distress commensurate with excess weight, is reliably associated with greater severity of eating-related psychopathology and psychological distress, and has reliably shown negative prognostic significance.

DISCUSSION

Overvaluation of shape/weight warrants consideration as a diagnostic specifier for BED.

Therapeutic options for binge eating disorder

OBJECTIVE

This article addresses the state of the art concerning the treatment of binge eating disorder (BED). Pharmacological and psychotherapeutic strategies, together with issues concerning the involvement in bariatric surgery are considered.

METHOD

A Medline enquiry of published articles was performed using the following keywords: BED, pharmacological treatment, duloxetine, venlafaxine, SSRI, psychotherapy, bariatric surgery; reviews and single-case studies were also analyzed.

RESULTS

Psychological interventions that have shown efficacy in the treatment of Bulimia Nervosa have also been tested in BED with positive results, in particular modified cognitive behavioral therapy, interpersonal therapy and dialectical behavior therapy. In addition pharmacotherapy with SSRIs is successful in transiently reducing binge-eating and body weight; the SNRI duloxetine is effective for reducing binge eating, and global severity of illness with a controversial effect on body weight; both topiramate and sibutramine seem promising, but their use is restricted due to labeling and side effect limitations, respectively. Finally, adequate psychological/pharmacological support can help BED patients obtain positive outcomes from bariatric surgery.

CONCLUSION

Studies on BED treatment are burdened by several limitations as selection biases (e.g. mostly women and overweight), small samples, high drop-out rates and placebo response.

Submitted for your consideration: potential advantages of a novel clinical trial design and initial patient reaction

In many circumstances, individuals do not respond identically to the same treatment. This phenomenon, which is called treatment response heterogeneity (TRH), appears to be present in treatments for many conditions, including obesity. Estimating the total amount of TRH, predicting an individual's response, and identifying the mediators of TRH are of interest to biomedical researchers. Clinical investigators and physicians commonly postulate that some of these mediators could be genetic. Current designs can estimate TRH as a function of specific, measurable observed factors; however, they cannot estimate the total amount of TRH, nor provide reliable estimates of individual persons' responses. We propose a new repeated randomizations design (RRD), which can be conceived as a generalization of the Balaam design, that would allow estimates of that variability and facilitate estimation of the total amount of TRH, prediction of an individual's response, and identification of the mediators of TRH. In a pilot study, we asked 118 subjects entering a weight loss trial for their opinion of the RRD, and they stated a preference for the RRD over the conventional two-arm parallel groups design. Research is needed as to how the RRD will work in practice and its relative statistical properties, and we invite dialog about it.

Psychological treatments for binge eating disorder

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

Pharmacological management of binge eating disorder: current and emerging treatment options

Growing evidence suggests that pharmacotherapy may be beneficial for some patients with binge eating disorder (BED), an eating disorder characterized by repetitive episodes of uncontrollable consumption of abnormally large amounts of food without inappropriate weight loss behaviors. In this paper, we provide a brief overview of BED and review the rationales and data supporting the effectiveness of specific medications or medication classes in treating patients with BED. We conclude by summarizing these data, discussing the role of pharmacotherapy in the BED treatment armamentarium, and suggesting future areas for research.

Cognitive-behavioral guided self-help for eating disorders: effectiveness and scalability

Given the well-documented shortage of cognitive-behavioral therapy (CBT) for eating disorders, there is a compelling need for advances in dissemination. Guided self-help based on cognitive-behavioral principles (CBTgsh) provides a robust means of improving implementation and scalability of evidence-based treatment for eating disorders. It is a brief, cost-effective treatment that can be implemented by a wide range of mental health providers, including non-specialists, via face-to-face contact and internet-based technology. Controlled studies have shown that CBTgsh can be an effective treatment for binge eating disorder and bulimia nervosa, although it is contraindicated for anorexia nervosa. Several studies have shown that CBTgsh can be as effective as more complex specialty therapies and that it is not necessarily contraindicated for patients with comorbid conditions. Mental health providers with relatively minimal professional credentials have in some studies obtained results comparable to specialized clinicians. Establishing the nature of optimal "guidance" in CBTgsh and the level of expertise and training required for effective implementation is a research priority. Existing manuals used in CBTgsh are outdated and can be improved by incorporating the principles of enhanced transdiagnostic CBT. Obstacles to wider adoption of CBTgsh are identified.

Does the heterogeneity of chronic fatigue syndrome moderate the response to cognitive behaviour therapy? An exploratory study

BACKGROUND

Chronic fatigue syndrome (CFS) is a heterogeneous condition. A few studies have shown that some independent factors predict outcomes after cognitive behaviour therapy (CBT). Two recent systematic reviews suggest that heterogeneity may moderate treatment outcomes. However, no study has explored whether subgroups of CFS predict response to treatment.

METHODS

We used both latent class analysis (LCA) and latent class regression (LCR) to clarify the relationship between subgroups of CFS patients (n = 236), diagnosed using the Oxford diagnostic criteria, and the response to CBT. We measured symptoms, demographics, mood, and cognitive and behavioural responses to illness to define subgroups.

RESULTS

We found 5 latent classes by LCA, which did not differ in the direction of their response to CBT, with all classes showing improvement. In contrast, an exploratory LCR identified 4 latent classes, 1 of which predicted a poor response to CBT, whereas the other 3 predicted a good outcome, accounting for more than 70% of the patients. The negative outcome class was defined by weight fluctuations and physical shakiness, anxiety, pain and being focused on symptoms.

CONCLUSIONS

CBT should be offered to all classes of patients with CFS, when defined by these measures. It may be possible to predict a minority group with a negative outcome, but this exploratory work needs replication.

Predictors and moderators of response to cognitive behavioral therapy and medication for the treatment of binge eating disorder

OBJECTIVE

To examine predictors and moderators of response to cognitive behavioral therapy (CBT) and medication treatments for binge-eating disorder (BED).

METHOD

108 BED patients in a randomized double-blind placebo-controlled trial testing CBT and fluoxetine treatments were assessed prior, throughout, and posttreatment. Demographic factors, psychiatric and personality disorder comorbidity, eating disorder psychopathology, psychological features, and 2 subtyping methods (negative affect, overvaluation of shape/weight) were tested as predictors and moderators for the primary outcome of remission from binge eating and 4 secondary dimensional outcomes (binge-eating frequency, eating disorder psychopathology, depression, and body mass index). Mixed-effects models analyzed all available data for each outcome variable. In each model, effects for baseline value and treatment were included with tests of both prediction and moderator effects.

RESULTS

Several demographic and clinical variables significantly predicted and/or moderated outcomes. One demographic variable signaled a statistical advantage for medication only (younger participants had greater binge-eating reductions), whereas several demographic and clinical variables (lower self-esteem, negative affect, and overvaluation of shape/weight) signaled better improvements if receiving CBT. Overvaluation was the most salient predictor/moderator of outcomes. Overvaluation significantly predicted binge-eating remission (29% of participants with vs. 57% of participants without overvaluation remitted). Overvaluation was especially associated with lower remission rates if receiving medication only (10% vs. 42% for participants without overvaluation). Overvaluation moderated dimensional outcomes: Participants with overvaluation had significantly greater reductions in eating disorder psychopathology and depression levels if receiving CBT. Overvaluation predictor/moderator findings persisted after controlling for negative affect.

CONCLUSIONS

Our findings have clinical utility for prescription of CBT and medication and implications for refinement of the BED diagnosis.

Relations between pure dietary and dietary-negative affect subtypes and impulsivity and reinforcement sensitivity in binge eating individuals

To investigate potential predictors of the severity of binge eating disorder (BED), two subtypes of patients with the disorder, a pure dietary subtype and a dietary-negative affect subtype, were identified. This study investigated the relationships between the two subtypes and impulsivity and reinforcement sensitivity. Ninety-two women meeting threshold and subthreshold criteria for BED diagnosis filled out questionnaires to determine eating disorder severity, impulsivity and reinforcement sensitivity before and after participating in an online guided self-help program for BED. Cluster analyses revealed a pure dietary subtype (N=66, 71.7%) and a dietary-negative affect subtype (N=26, 28.3%). Compared to the pure dietary subtype, the dietary-negative affect subtype reported a higher frequency of objective binge episodes, more severe eating disorders, higher urgency scores (defined as a tendency to act rashly in the context of negative affect), a greater sensitivity to punishment, and a higher dropout rate during treatment. These findings suggest that BED patients in the dietary-negative affect subtype exhibit heightened anxiety and are highly impulsive, especially in contexts of negative affect. For these individuals, psychological interventions for BED should focus on inhibiting automatic responses to negative emotions.

Treatment of binge eating disorder

The two specialty psychological therapies of CBT and IPT remain the treatments of choice for the full range of BED patients, particularly those with high levels of specific eating disorder psychopathology such as overvaluation of body shape and weight. They produce the greatest degree of remission from binge eating as well as improvement in specific eating disorder psychopathology and associated general psychopathology such as depression. The CBT protocol evaluated in the research summarized above was the original manual from Fairburn and colleagues. Fairburn has subsequently developed a more elaborate and sophisticated form of treatment, namely, enhanced CBT (CBT-E) for eating disorders. Initial research suggests that CBT-E may be more effective than the earlier version with bulimia nervosa and Eating Disorder Not Otherwise Specified patients. CBT-E has yet to be evaluated for the treatment of BED, although it would currently be the recommended form of CBT. Of relevance in this regard is that the so-called broad form of the new protocol includes 3 optional treatment modules that could be used to address more complex psychopathology in BED patients. One of the modules targeted at interpersonal difficulties is IPT, as described earlier in this chapter. Thus, the broader protocol could represent a combination of the two currently most effective therapies for BED. Whether this combined treatment proves more effective than either of the components alone, particularly for a subset of BED patients with more complex psychopathology, remains to be tested. CBT-E also includes a module designed to address what Fairburn terms “mood intolerance” (problems in coping with negative affect) that can trigger binge eating and purging. The content and strategies of this mood intolerance module overlap with the emotional regulation and distress tolerance skills training of Linehan's dialectical behavior therapy (DBT). Two randomized controlled trials have tested the efficacy of an adaptation of DBT for the treatment of BED (DBT-BED) featuring mindfulness, emotion regulation, and distress tolerance training. A small study by Telch and colleagues found that modified DBT-BED was more effective than a wait list control in eliminating binge eating. A second study showed that DBT-BED resulted in a significantly greater remission rate from binge eating at posttreatment than a group comparison treatment designed to control for nonspecific therapeutic factors such as treatment alliance and expectations.50 This difference between the two treatments disappeared over a 12-month follow-up, indicating the absence of DBT-BED-specific influences on long-term outcomes. Both CBT and IPT have been shown to be more effective in eliminating binge eating than BWL in controlled, comparative clinical trials. Nonetheless, BWL has been effective in reducing binge eating and associated eating problems in BED patients in some studies and might be suitable for treatment of BED patients without high levels of specific eating disorder psychopathology. A finding worthy of future research is the apparent predictive value of early treatment response to BWL, indicating when BWL is likely to prove effective or not. No evidence supports the concern that BWL's emphasis on moderate caloric restriction either triggers or exacerbates binge eating in individuals with BED. Initially, CBTgsh was recommended as a feasible first-line treatment that might be sufficient treatment for a limited subset of patients in a stepped care approach. More recent research, however, has shown that CBTgsh seems to be as effective as a specialty therapy, such as IPT, with a majority of BED patients. The subset of patients that did not respond well to CBTgsh in this research were those with a high level of specific eating disorder psychopathology, as noted. A plausible explanation for this moderator effect is that the original Fairburn CBTgsh manual does not include an explicit emphasis on body shape and weight concerns. Subsequent implementation of this treatment has incorporated a module that directly addresses overvaluation of body shape and weight. Future research should determine whether an expanded form of CBTgsh is suitable for the full range of patients with BED. CBTgsh is recommended as a treatment for BED on two other counts. First, its brief and focused nature makes it cost effective. Second, its structured format makes it more readily disseminable than other longer, multicomponent psychological therapies. It can be implemented by a wider range of treatment providers than more technically complex, time-consuming, and clinical expertise-demanding specialty therapies such as CBT-E and IPT. The latter evidence-based therapies are rarely available to patients with BED in routine clinical care settings. Nevertheless, it must be noted that much of the research on CBTgsh to date has been conducted in an eating disorder specialty clinic setting. The degree to which the treatment can be adapted to a range of clinical service settings remains to be determined. In addition, little is known about the specific provider qualifications and level of expertise required to implement CBTgsh successfully. Despite its brief and focal nature, specific provider skills regarding what and what not to address in treatment are required. Currently available pharmacologic treatments cannot be recommended for treatment of BED. Aside from the inconsistent results of existing studies, the striking absence of controlled long-term evaluation of such treatment argues against its use.As summarized, the evidence-based treatments of CBT, IPT, and CBTgsh result in significant improvement and large treatment effects on multiple outcome measures aside from binge eating in overweight and obese patients. These include specific eating disorder psychopathology (eg, overvaluation of body shape and weight), general psychopathology (eg, depression), and psychosocial functioning. Moreover, these changes are typically well-maintained over 1 to 2 years of follow-up. The exception to this profile of improvement remains weight loss and its maintenance over time. These specialty psychological treatments do not produce weight loss, although successfully eliminating binge eating might protect against future weight gain. BWL consistently produces short-term weight loss, the extent of which has varied across different studies. Long-term weight loss has yet to be demonstrated, however. In this regard, the findings with obese patients with BED are not different than those on the treatment of obesity in general, in which there is little robust evidence of enduring weight loss effects of BWL.

Profiles of importance, readiness and confidence in quitting tobacco use

OBJECTIVE

This study examined whether rulers of importance, readiness and confidence (IRC) in quitting smoking could be used to identify subgroups of smokers, with the future goal of potentially tailoring interventions to specific readiness profiles.

METHODS

Consecutive emergency department patients ≥18 years old were considered for enrolment. Participants provided information on their tobacco use and motivation to quit smoking using 10-point IRC rulers. We used latent profile analysis on the IRC rulers to identify subgroups of smokers and examined associations between profile membership and participant's nicotine dependence and demographics.

RESULTS

A total of 1549 patients were screened, yielding a sample of 609 tobacco users. According to statistical fit indices, a four-profile solution fits best: 32% displayed maximum importance and readiness with strong confidence, 43% of the sample displayed relatively average levels of all three variables, 17% displayed below average importance with least favourable readiness and confidence and 7% displayed least favourable importance and readiness but relatively high confidence. Profiles were then shown to differ on nicotine dependence and educational level.

CONCLUSIONS

Four distinct profiles of IRC responses were observed. Identifying and describing these patterns has the potential to enhance future targeted intervention efforts and has implications for theory development.

A latent class analysis of psychiatric symptoms among 125 adolescents in a bariatric surgery program

OBJECTIVE

The purpose of this study was to examine whether subgroups could be identified among a sample of adolescents presenting for bariatric surgery.

METHODS

Participants were 125 severely obese adolescents enrolled in a bariatric surgery program referred for a psychiatric evaluation. A latent class analysis was conducted with self-report and clinician-rated measures of depressive symptoms, total problems by the Youth Self-Report Scale, anxiety severity, eating pathology, psychiatric diagnoses, quality of life, and family functioning.

RESULTS

A 3-class model yielded the best overall fit to the data. Adolescents in the ?eating pathology? class demonstrated high levels of both eating disordered and other psychopathology. The second class, or ?low psychopathology? class exhibited the fewest psychosocial problems, whereas adolescents in the third class were intermediate on measures of psychopathology, which is consistent with ?non-specific psychopathology.?

CONCLUSIONS

The latent class analysis identified homogeneous subgroups with different levels of psychopathology among a heterogeneous sample of severely obese adolescents. The identification of clinically relevant subgroups in this study offers an important initial means for examining psychopathology among adolescent bariatric surgery candidates and suggests a number of avenues for future research.

CLINICAL TRIALS REGISTRY

Laparoscopic Adjustable Gastric Banding (LAGB) as a Treatment for Morbid Obesity in Adolescents, NCT01045499.