A closer look at homework compliance in behavior therapy for bulimia nervosa: does homework compliance in between-session period prospectively predict session-by-session change in bulimia symptoms?

INTRODUCTION

Homework assignments are considered key components of behavioral treatments for bulimia nervosa (BN), but little is known about whether homework compliance predicts BN symptom improvement. The present study is the first to examine whether session-by-session change in homework compliance predicts session-by-session changes in BN symptoms during behavioral treatment.

METHOD

Patients with BN-spectrum eating disorders (n = 42) received 20 sessions of behavioral treatment. Each session, their clinicians completed surveys assessing compliance with self-monitoring, behavioral, and written homework assignments and BN symptom frequency during the previous week.

RESULTS

Significant between-persons effects of self-monitoring and behavioral homework compliance were identified, such that patients with greater compliance in the past week experienced greater reductions in binge eating and purging the following week. There were significant within-persons effects of self-monitoring compliance on binge eating and behavioral homework compliance on restrictive eating, binge eating, and purging, such that greater than one's usual compliance predicted greater improvements in BN symptoms the following week. No significant effects of written homework compliance were identified.

CONCLUSION

Compliance with self-monitoring and behavioral homework predict improvements in BN symptoms during behavioral treatment. These findings reinforce the importance of self-monitoring and behavioral homework compliance as drivers of change during treatment for BN.

Understanding momentary associations between body dissatisfaction and exercise in binge-spectrum eating disorders

PURPOSE

Maladaptive exercise is common among individuals with binge-spectrum eating disorders. One mechanism that may drive engagement in exercise in this population is state body dissatisfaction. However, no studies to date have examined prospective, momentary relationships between state body dissatisfaction and exercise.

METHODS

Adults with binge-spectrum eating disorders (N = 58) completed a 7-14-day ecological momentary assessment protocol assessing exercise and state body dissatisfaction several times per day. Multilevel models were used to evaluate prospective reciprocal associations between state body dissatisfaction and exercise. Mixed models examined trajectories of change in state body dissatisfaction pre- and post-exercise. Additional models examined exercise type (maladaptive vs. adaptive) as a moderator.

RESULTS

Momentary increases (i.e., greater than one's average levels) in state body dissatisfaction at any given timepoint did not prospectively predict engagement in exercise at the next nearest timepoint. Exercise at any given timepoint did not prospectively predict momentary increases in state body dissatisfaction. State body dissatisfaction was found to increase in the initial hours preceding an exercise episode (linear estimate, β = - 0.012, p = 0.004). State body dissatisfaction did not significantly change in the hours following engagement in exercise. Exercise type did not moderate these associations.

CONCLUSION

If replicated, our results may suggest that momentary increases in state body dissatisfaction may not be associated with exercise behaviors in individuals with binge-spectrum eating disorders.

LEVEL OF EVIDENCE

Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, orreports of expert committees.

Real-time predictors of body dissatisfaction in females with binge eating: an ecological momentary assessment study

PURPOSE

Body dissatisfaction (BD) is supported as a maintenance factor for eating disorders (EDs) characterized by binge eating (BE). Although it is traditionally conceptualized as a trait construct, ecological momentary assessment (EMA) studies have shown that it fluctuates within-day and that momentary elevations in BD prospectively predict near-time ED behaviors. However, less is known about the contextual factors that precipitate these fluctuations in BD.

METHODS

The current study thus sought to examine whether certain internal (i.e., negative affect, shape/weight-related cognitions) and environmental (i.e., attending social events, being exposed to thin-ideal media, spending time on social media) factors prospectively predict momentary elevations in BD in females with BE. Participants (n = 25) completed an EMA protocol over 14 days.

RESULTS

Data on BD and internal and environmental factors were analyzed using generalized estimating equations. Results showed that (1) greater than one's usual negative affect and shape/weight-related cognitions, and (2) spending time on social media prospectively predicted momentary elevations in BD. Interestingly, attending social events prospectively predicted momentary reductions in BD.

CONCLUSION

These findings may have important implications for conceptualizing and managing BD to prevent ED behaviors.

LEVEL OF EVIDENCE

Level II, controlled trial without randomization.

Characterizing rates of physical activity in individuals with binge eating disorder using wearable sensor technologies and clinical interviews

OBJECTIVE

Research suggests physical activity (PA) improves behavioural, psychological and behavioural symptoms in individuals with binge eating disorder (BED), yet self-reported PA is notably low. Little remains known about objective rates of PA and subclinical levels of maladaptive PA (i.e., compensatory or driven PA), and few studies have attempted to understand the role that dissatisfaction and overvaluation with shape and weight plays in promoting PA in individuals with BED. We sought to characterize PA and investigate whether elevated rates of shape and weight concerns contribute to rates of PA in individuals with BED.

METHOD

Individuals meeting DSM-5 diagnosis of BED (N = 56) completed the Eating Disorder Examination and wore a Fitbit Flex 2 for 1 week.

RESULTS

On average, participants recorded 7621.12 (SD = 3034.20) daily steps and 194.30 (SD = 161.45) weekly moderate-to-vigorous PA minutes. About 21% of participants reported subclinical levels of maladaptive PA. Greater shape and weight overvaluation predicted lower duration of compensatory PA.

CONCLUSION

A small percentage of individuals with BED are engaging in subclinical levels of maladaptive PA, and there is a need to identify factors that influence rates of PA in individuals with BED.

Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: Feasibility, acceptability, and proof-of-concept for children and adolescents

OBJECTIVE

Little is known about the optimal treatment of avoidant/restrictive food intake disorder (ARFID). The purpose of this study was to evaluate feasibility, acceptability, and proof-of-concept for cognitive-behavioral therapy for ARFID (CBT-AR) in children and adolescents.

METHOD

Males and females (ages 10-17 years) were offered 20-30 sessions of CBT-AR delivered in a family-based or individual format.

RESULTS

Of 25 eligible individuals, 20 initiated treatment, including 17 completers and 3 dropouts. Using intent-to-treat analyses, clinicians rated 17 patients (85%) as "much improved" or "very much improved." ARFID severity scores (on the Pica, ARFID, and Rumination Disorder Interview) significantly decreased per both patient and parent report. Patients incorporated a mean of 16.7 (SD = 12.1) new foods from pre- to post-treatment. The underweight subgroup showed a significant weight gain of 11.5 (SD = 6.0) pounds, moving from the 10th to the 20th percentile for body mass index. At post-treatment, 70% of patients no longer met criteria for ARFID.

DISCUSSION

This is the first study of an outpatient manualized psychosocial treatment for ARFID in older adolescents. Findings provide evidence of feasibility, acceptability, and proof-of-concept for CBT-AR. Randomized controlled trials are needed.

Prevalence and correlates of psychiatric comorbidities in children and adolescents with full and subthreshold avoidant/restrictive food intake disorder

OBJECTIVE

We aimed to characterize the current and lifetime prevalence of comorbid psychiatric diagnoses and suicidality in treatment- and nontreatment-seeking individuals with full and subthreshold avoidant/restrictive food intake disorder (ARFID). We also sought to examine unique associations between the three DSM-5 ARFID profiles (i.e., sensory sensitivity, fear of aversive consequences, and lack of interest in food or eating) and specific categories of psychiatric diagnoses and suicidality.

METHOD

We conducted structured clinical interviews with 74 children and adolescents with full or sub threshold ARFID to assess the presence of comorbid psychiatric diagnoses, suicidality, and the severity of each of the three ARFID profiles.

RESULTS

Nearly half of the sample (45%) met criteria for a current comorbid psychiatric diagnosis, and over half (53%) met criteria for a lifetime comorbid diagnosis. A total of 8% endorsed current suicidality and 14% endorsed lifetime suicidality. Severity in the sensory sensitivity profile was uniquely associated with greater odds of comorbid disorders in the neurodevelopmental, disruptive, and conduct disorders category; the anxiety, obsessive-compulsive, and trauma-related disorders category; and the depressive and bipolar-related disorders category. Severity in the fear of aversive consequences profile was associated with greater odds of disorders in the anxiety, obsessive-compulsive, and trauma-related disorders category.

DISCUSSION

Our findings underscore the severity of psychopathology among individuals with ARFID and related presentations, and also highlight the potential that shared psychopathology between specific ARFID profiles and other psychiatric disorders represent transdiagnostic constructs (e.g., avoidant behavior) that may be relevant treatment targets.