Overvaluation of shape/weight at posttreatment predicts relapse at 12-month follow-up after successful behaviorally-based treatment of binge-eating disorder

OBJECTIVE

To test whether overvaluation of shape/weight at the end of treatment prospectively predicts relapse at 12-month follow-up in patients with binge-eating disorder (BED).

METHOD

Participants were 129 patients with BED who achieved abstinence from binge eating after 6 months of behaviorally-based weight-loss treatments in a clinical trial. Independent assessments conducted at posttreatment and at 12-month follow-up included the Eating Disorder Examination interview, the Beck Depression Inventory, and weight measurements.

RESULTS

Of the 129 participants who attained abstinence from binge-eating at posttreatment, 46 (36%) were categorized with clinical overvaluation and 83 (64%) with subclinical overvaluation; 115 (89%) were re-assessed at 12-month follow-up. Participants with overvaluation at posttreatment were significantly more likely than those without to relapse at 12-months to non-abstinence from binge eating (54% vs. 28%) and to diagnosis-level binge-eating frequency of once weekly or greater (31% vs. 13%). Overvaluation at posttreatment predicted significantly higher eating-disorder psychopathology and depression scores at 12-month follow-up but were unrelated to weight and weight changes. Treatment groups did not have main or interaction effects; posttreatment overvaluation effects were observed regardless of treatment and of covarying for posttreatment value of dependent variables.

CONCLUSIONS

Our findings suggest that overvaluation of shape/weight at the end of treatment predicts relapse and heightened eating-disorder psychopathology and depression scores 1 year later in patients who achieved abstinence from binge eating with behaviorally-based treatments. Overvaluation of shape/weight has significant clinical implications and warrants consideration as a diagnostic specifier for BED as it provides important prospective prognostic information.

PUBLIC SIGNIFICANCE

Although effective treatments are available for binge-eating disorder, relapse following successful treatments is not uncommon. Almost nothing is known about what predicts relapse following treatments for binge-eating disorder. Our study found that overvaluation of shape/weight (i.e., body image concerns that overly impact self-worth) at posttreatment prospectively predicted relapse and higher eating-disorder psychopathology and depression 1 year later in patients who achieved binge-eating abstinence with behaviorally based treatments.

CLINICALTRIALS

gov registration: NCT00829283. (Treatment of obesity and binge eating: Behavioral weight loss vs. stepped care.).

Obesity in Latinx and White U.S. military veterans: Mental health, psychosocial burden, non-suicidal self-injury and suicidal behavior

Obesity disproportionately affects Latinx communities and is linked to an increased risk of mental health problems. Military veterans are more likely to develop mental health problems, but the role of Latinx ethnicity in moderating the association between obesity and these problems is unclear. To address this gap, this study examined psychiatric and psychosocial correlates of obesity in a nationally representative sample of Latinx and White U.S. military veterans. Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed 3524 Latinx and White veterans. Analyses revealed that Latinx ethnicity moderated associations between obesity and several measures. Specifically, among veterans with obesity, Latinx veterans had higher rates of major depression, generalized anxiety, post-traumatic stress disorders, drug use disorders, non-suicidal self-injury, and higher levels of childhood trauma, loneliness, and hostility relative to White veterans. These findings underscore the importance of culturally sensitive prevention and treatment efforts to help mitigate symptoms of internalizing disorders, drug use disorder, loneliness, and hostility, and to cultivate psychosocial resources such as resilience and coping self-efficacy among Latinx veterans with obesity.

Reliability of the original and brief versions of the Eating Disorder Examination in binge-eating disorder

OBJECTIVE

Psychometric studies evaluating the reliability of eating-disorder assessment among individuals with binge-eating disorder (BED) have been limited. The current study documents the interrater reliability and internal consistency of the Eating Disorder Examination (EDE) interview when administered to adults with Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5)-defined BED.

METHODS

Participants (N = 56) were adults seeking treatment for BED in the context of clinical trials testing pharmacological and psychological treatments. Doctoral-level, trained, and supervised clinical researchers evaluated eating-disorder psychopathology using the EDE interview and audio-recorded the interview. A second doctoral-level, trained, and supervised clinical researcher, who did not conduct the initial assessment, coded eating-disorder psychopathology using the audio recording.

RESULTS

Agreement among raters on the number of binge-eating episodes was near perfect. There was excellent interrater reliability for nearly all scales of the EDE interview. Agreement among raters for behavioral indicators of loss of control and marked distress regarding binge eating ranged from moderate to perfect. Internal consistency was variable for all scales, ranging from unacceptable to good.

CONCLUSIONS

Our study suggests that the EDE can be administered reliably by multiple interviewers to assess adults with BED. However, internal consistency was mostly subpar. Tests of reliability and other psychometric properties (e.g., validity) in other patient groups such as children with BED are warranted.

Racial differences after bariatric surgery: 24-month follow-up of a randomized, controlled trial for postoperative loss-of-control eating

BACKGROUND

While some bariatric surgery outcomes vary by race/ethnicity, less is known about racial/ethnic differences in loss-of-control (LOC) eating and psychosocial outcomes post-surgery.

OBJECTIVE

This prospective study examined and extended initial short-term findings regarding racial differences in post-bariatric surgery LOC eating and weight loss to longer-term outcomes through 24-month follow-ups.

SETTING

Academic medical center in the United States.

METHODS

Participants were 140 patients (46.4% non-White) in a 3-month randomized, controlled trial for LOC eating performed about 6 months after bariatric surgery. Participants were reassessed at 6, 12, 18, and 24 months after treatment ended (about 33 mo after surgery). Doctoral assessors administered the Eating Disorder Examination-Bariatric Surgery Version interview to assess LOC eating and eating-disorder psychopathology at 12- and 24-month follow-ups. The Beck Depression Inventory II was repeated, and measured weight was obtained at all follow-ups.

RESULTS

White patients had significantly greater percent excess weight loss at all follow-ups than non-White patients (p < .03). White patients reported significantly more LOC eating at 12- (p = .004) and 24-month (p = .024) follow-ups and significantly greater eating disorder psychopathology at 12-month follow-up (p < .028). Racial groups did not differ significantly in eating disorder psychopathology at 24-month follow-ups or in Beck Depression Inventory II depression scores at any follow-ups.

CONCLUSIONS

Our findings suggest that among patients with LOC eating after bariatric surgery, non-White patients attain a lower percent excess weight loss than White patients but have comparable or better outcomes in LOC eating, associated eating disorder psychopathology, and depression over time.

Shape discrepancy, weight bias internalization, and eating-disorder psychopathology in patients with loss-of-control eating after bariatric surgery

BACKGROUND

Postoperative loss-of-control (LOC) eating is associated with eating-disorder psychopathology, poorer weight loss, and mental health outcomes following bariatric surgery. The nature and significance of shape discrepancy has not been examined in patients with LOC eating following bariatric surgery.

OBJECTIVES

To examine shape discrepancy, WBI (weight bias internalization) and ED (eating-disorder) psychopathology in patients with LOC eating after bariatric surgery.

SETTING

Yale University School of Medicine, United States.

METHODS

Participants (N = 148, 84.5% female) seeking treatment for eating and weight concerns and with recurrent LOC eating approximately 6 months after bariatric surgery were assessed with the Eating Disorder Examination-Bariatric Surgery Version Interview and completed questionnaires measuring WBI and depression. Participants selected body shapes representing their current and ideal shapes, and a shape discrepancy score was calculated.

RESULTS

Most participants (N = 142/148) reported an ideal shape smaller than their current shape; shape discrepancy scores ranged from 0 to 5 (M = 1.89, SD = .82). Greater shape discrepancy was significantly correlated with greater current body mass index (BMI; r = .271, p=<.001) and percent weight loss (%WL) since surgery (r = -.19, p = .023). After adjusting for %WL, shape discrepancy was significantly correlated with greater WBI (r = .37, p < .001), depression (r = .27, p < .001), and ED psychopathology (r = .25, p = .002).

CONCLUSIONS

Nearly all participants preferred a significantly smaller shape than their current shape. Greater discrepancy between current and ideal shape was associated with higher levels of a range of behavioral (ED psychopathology), cognitive (WBI), and psychological/somatic (depression) concerns. These findings, which persisted after adjusting for %WL, highlight the importance of addressing body image in postoperative interventions.

The children of parents who receive treatment for binge-eating disorder experience improvements in disordered eating

OBJECTIVE

Parental eating disorders are associated with disordered eating behaviors and psychopathology in their children, but it is not known whether parent treatment for binge-eating disorder (BED) is associated with changes in child disordered eating behaviors and weight. Benefits or the "ripple" effect of treatment on untreated family members has been described in the obesity literature but not for BED.

METHOD

Participants evaluated for two randomized clinical trials for BED were screened for whether they had children. 76 parents completed baseline assessments about a school-aged child; 62 were randomized to treatment, of whom 41 completed end-of-treatment assessments about their child's eating behaviors and weight (which were not targeted in the parent treatments).

RESULTS

Analyses revealed a significant effect of time on children's binge-eating frequency and perceived weight category and a significant effect of parent medication on perceived weight category. Parental change in binge eating was associated significantly with changes in child secretive eating and food hoarding. Parental change in weight was not associated significantly with change in age/sex-normed child BMI percentile, but had some associations with parent-perceived child weight category.

CONCLUSIONS

Parent changes during their treatment were associated with changes in their children. Future longitudinal research is needed to examine when disordered eating emerges and clarify critical intervention timing related to children's age and parental BED. Further clinical research is also needed to assess the effectiveness of treating disordered eating at the family level.

PUBLIC SIGNIFICANCE

Prior cross-sectional work has found that parents with BED are more likely to have children who engage in binge eating compared to parents without eating-disorder psychopathology. This study was an initial exploration of change in children when parents received treatment in randomized controlled trials for BED. In this study, parent changes in binge eating were associated with reduced child secretive eating and food hoarding.

Treatment of Eating Disorders: Current Status, Challenges, and Future Directions

Specific psychological treatments have demonstrated efficacy and represent the first-line approaches recommended for anorexia nervosa, bulimia nervosa, and binge-eating disorder. Unfortunately, many patients, particularly those with anorexia nervosa, do not derive sufficient benefit from existing treatments, and better or alternative treatments for eating disorders are needed. Less progress has been made in developing pharmacologic options for eating disorders. No medications approved for anorexia nervosa exist, and only one each exists for bulimia nervosa and for binge-eating disorder; available data indicate that most patients fail to benefit from available medications. Longer and combined treatments have generally not enhanced outcomes. This review presents emerging findings from more complex and clinically relevant adaptive treatment designs, as they offer some clinical guidance and may serve as models for future enhanced treatment research. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 20 is May 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Naltrexone plus bupropion combination medication maintenance treatment for binge-eating disorder following successful acute treatments: randomized double-blind placebo-controlled trial

BACKGROUND

Certain treatments have demonstrated acute efficacy for binge-eating disorder (BED) but there is a dearth of controlled research examining pharmacotherapies as maintenance treatments for responders to initial interventions. This gap in the literature is particularly critical for pharmacotherapy for BED which is associated with relapse following discontinuation. The current study tested the efficacy of naltrexone/bupropion maintenance treatment amongst responders to acute treatments for BED.

METHODS

Prospective randomized double-blind placebo-controlled single-site trial, conducted August 2017-December 2021, tested naltrexone/bupropion as maintenance treatment for responders to acute treatments with naltrexone/bupropion and/or behavioral weight-loss therapy for BED with comorbid obesity. Sixty-six patients (84.8% women, mean age 46.9, mean BMI 34.9 kg/m2) who responded to acute treatments were re-randomized to placebo (N = 34) or naltrexone/bupropion (N = 32) for 16 weeks; 86.3% completed posttreatment assessments. Mixed models and generalized estimating equations comparing maintenance treatments (naltrexone/bupropion v. placebo) included main and interactive effects of acute treatments.

RESULTS

Intention-to-treat binge-eating remission rates following maintenance treatments were 50.0% (N = 17/34) for placebo and 68.8% (N = 22/32) for naltrexone/bupropion. Placebo following response to acute treatment with naltrexone/bupropion was associated with significantly decreased probability of binge-eating remission, increased binge-eating frequency, and no weight loss. Naltrexone/bupropion following response to acute treatment with naltrexone/bupropion was associated with good maintenance of binge-eating remission, low binge-eating frequency, and significant additional weight loss.

CONCLUSIONS

Adult patients with BED with co-occurring obesity who have good responses to acute treatment with naltrexone/bupropion should be offered maintenance treatment with naltrexone/bupropion.

Transcranial Magnetic Stimulation for Reducing the Relative Reinforcing Value of Food in Adult Patients With Obesity Pursuing Metabolic and Bariatric Surgery: Protocol for a Pilot, Within-Participants, Sham-Controlled Trial

BACKGROUND

Metabolic and bariatric surgery (MBS) is the most effective and durable obesity treatment. However, there is heterogeneity in weight outcomes, which is partially attributed to variability in appetite and eating regulation. Patients with a strong desire to eat in response to the reward of palatable foods are more likely to overeat and experience suboptimal outcomes. This subgroup, classified as at risk, may benefit from repetitive transcranial magnetic stimulation (rTMS), a noninvasive brain stimulation technique that shows promise for reducing cravings and consumption of addictive drugs and food; no study has evaluated how rTMS affects the reinforcing value of food and brain reward processing in the context of MBS.

OBJECTIVE

The goal of the Transcranial Magnetic Stimulation to Reduce the Relative Reinforcing Value of Food (RESTRAIN) study is to perform an initial rTMS test on the relative reinforcing value (RRV) of food (the reinforcing value of palatable food compared with money) among adult patients who are pursuing MBS and report high food reinforcement. Using a within-participants sham-controlled crossover design, we will compare the active and sham rTMS conditions on pre- to posttest changes in the RRV of food (primary objective) and the neural modulation of reward, measured via electroencephalography (EEG; secondary objective). We hypothesize that participants will show larger decreases in food reinforcement and increases in brain reward processing after active versus sham rTMS.

METHODS

Participants (n=10) will attend 2 study sessions separated by a washout period. They will be randomized to active rTMS on 1 day and sham rTMS on the other day using a counterbalanced schedule. For both sessions, participants will arrive fasted in the morning and consume a standardized breakfast before being assessed on the RRV of food and reward tasks via EEG before and after rTMS of the left dorsolateral prefrontal cortex.

RESULTS

Recruitment and data collection began in December 2022. As of October 2023, overall, 52 patients have been screened; 36 (69%) screened eligible, and 17 (47%) were enrolled. Of these 17 patients, 3 (18%) were excluded before rTMS, 5 (29%) withdrew, 4 (24%) are in the process of completing the protocol, and 5 (29%) completed the protocol.

CONCLUSIONS

The RESTRAIN study is the first to test whether rTMS can target neural reward circuits to reduce behavioral (RRV) and neural (EEG) measures of food reward in patients who are pursuing MBS. If successful, the results would provide a rationale for a fully powered trial to examine whether rTMS-related changes in food reinforcement translate into healthier eating patterns and improved MBS outcomes. If the results do not support our hypotheses, we will continue this line of research to evaluate whether additional rTMS sessions and pulses as well as different stimulation locations produce clinically meaningful changes in food reinforcement.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05522803; https://clinicaltrials.gov/study/NCT05522803.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50714.

Naltrexone/bupropion for binge-eating disorder: A randomized, double-blind, placebo-controlled trial

OBJECTIVE

Binge-eating disorder (BED) is a prevalent psychiatric disorder associated with obesity. Few evidence-based treatments exist for BED, particularly pharmacological options. This study tested the efficacy of naltrexone/bupropion for BED.

METHODS

A randomized, double-blind, placebo-controlled, 12-week trial tested naltrexone/bupropion for BED with and without obesity. Eighty-nine patients (70.8% women, 69.7% White, mean age 45.7 y, mean BMI 35.1 kg/m2 , 77.5% with BMI ≥ 30 kg/m2 ) were randomized to placebo (n = 46) or naltrexone/bupropion (n = 43), with randomization stratified by obesity status and gender; 92.1% completed post-treatment assessments.

RESULTS

Mixed models of binge-eating frequency revealed significant reductions that did not differ significantly between naltrexone/bupropion and placebo. Logistic regression of binge-eating remission rates revealed that naltrexone/bupropion and placebo did not differ significantly. Obesity status did not predict, or moderate, binge-eating outcomes considered either continuously or categorically. Mixed models revealed that naltrexone/bupropion was associated with significantly greater percentage weight loss than placebo. Logistic regression revealed that naltrexone/bupropion had significantly higher rates of attaining ≥5% weight loss than placebo (27.9% vs. 6.5%). Obesity status did not predict or moderate weight-loss outcomes.

CONCLUSIONS

Naltrexone/bupropion did not demonstrate effectiveness for reducing binge eating relative to placebo but showed effectiveness for weight reduction in patients with BED. Obesity status did not predict or moderate medication outcomes.

Improvements in cardiovascular disease risk factors associated with modest weight loss following treatment in patients with binge-eating disorder and obesity

BACKGROUND

Modest weight losses may be associated with improvements in cardiovascular disease risk factors (CVDRF) in patients with obesity. The effects of weight losses on CVDRF in persons with binge-eating disorder (BED) are unknown. This study prospectively examined changes in CVDRF among patients receiving behaviorally-based weight-loss treatment (BBWLT) who attained modest weight losses (≥5 to <10% and ≥10%).

METHOD

Of 191 participants, CVDRF variables were re-assessed in 168 participants at posttreatment and in 151 at 12-month follow-up. Participants who attained ≥5 to <10% weight loss were compared to those who did not on CVDRFs (total cholesterol, HDL, LDL, triglycerides, HbA1C, mean plasma glucose, heart rate, and systolic/diastolic blood pressure); similar comparisons were completed for those who attained ≥10% weight loss.

RESULTS

At posttreatment, ≥5 to <10% weight loss (N = 42; 25.0%) was associated with significant improvements in HbA1c and mean plasma glucose, whereas ≥10% weight loss (N = 40, 23.8%) was associated with significant improvements in total cholesterol, triglycerides, HbA1c, mean plasma glucose, and heart rate. At 12-month follow-up, ≥5 to <10% weight loss (N = 17; 11.1%) was related to significant improvements on HDL, triglycerides, HbA1c, and mean plasma glucose, whereas ≥10% weight loss (N = 40, 26.0%) was associated with significant improvements on all the CVDRF variables (except blood pressure).

CONCLUSIONS

Modest weight loss is associated with significant improvements in CVDRFs in patients with BED and obesity following treatment and at 12-month follow-up. Future work should examine whether improvements in CVDRF are attributable to weight loss per se and/or to other related lifestyle changes.

PUBLIC SIGNIFICANCE STATEMENT

Individuals with binge-eating disorder and obesity who attain modest weight loss following treatment exhibit improvements in various measures of cardiovascular disease risk compared to those who do not. While weight loss has been challenging for individuals with binge-eating disorder, clinicians should inform patients of the potential health benefits of modest weight loss. Future research should investigate whether weight loss itself and/or related behavioral lifestyle changes drive improved cardiovascular disease risk factors.

Binge-Eating Disorder Interventions: Review, Current Status, and Implications

PURPOSE OF REVIEW

Binge-eating disorder (BED) is a serious psychiatric problem associated with substantial morbidity that, unfortunately, frequently goes unrecognized and untreated. This review summarizes the current status of behavioral, psychological, pharmacological, and combined treatments for BED in adults with a particular focus on recent findings and advances.

RECENT FINDINGS

Certain specific psychological treatments, notably CBT and IPT, and to some extent DBT, have demonstrated efficacy and are associated with durable benefits after treatment. Certain specific lower-cost scalable interventions, notably CBTgsh, have demonstrated efficacy and have potential for broader uptake. An important advance is the emerging RCT data indicating that BWL, a generalist and available behavioral lifestyle intervention, has effectiveness that approximates that of CBT for reducing binge eating and eating-disorder psychopathology but with the advantage of also producing modest weight loss. There exists only one pharmacological agent (LDX) with approval by the FDA for "moderate-to-severe" BED. Research with other "off label" medications has yielded modest and mixed outcomes with a few medications statistically superior to placebo over the short-term and almost no longer-term data. Nearly all research combining medications and psychological treatments has failed to enhance outcomes (combined appears superior to pharmacotherapy-only but not to psychotherapy-only). Many people with BED suffer in silence and shame, go untreated, and rarely receive evidence-based treatments. Patients and practitioners need to recognize that research has identified several effective interventions for BED, and these can work quickly for many patients. Future research should identify treatments for those who do not derive benefit from initial interventions, identify additional pharmacological options, test agents with relevant mechanisms of action, and utilize innovative adaptative "SMART" designs to identify treatments to enhance outcomes among initial responders and to test alternative treatments to assist initial non-responders.

Cognitive-behavioral therapy for binge-eating disorder for non-responders to initial acute treatments: Randomized controlled trial

OBJECTIVE

Certain treatments have demonstrated acute efficacy for binge-eating disorder (BED) but many patients who receive "evidence-based" interventions do not derive sufficient benefit. Given the dearth of controlled research examining treatments for patients who fail to respond to initial interventions, this study tested the efficacy of cognitive-behavioral therapy (CBT) for patients with BED who do not respond to initial acute treatments.

METHODS

Prospective randomized double-blind placebo-controlled single-site trial, conducted August 2017-December 2021, tested 16-weeks of therapist-led CBT for non-responders to initial treatment (naltrexone/bupropion and/or behavioral therapy) for BED with obesity. Thirty-one patients (mean age 46.3 years, 77.4% women, 80.6% White, mean BMI 38.99 kg/m2 ) who were non-responders to initial acute treatments were randomized to CBT (N = 18) or no-CBT (N = 13), in addition to continuing double-blinded pharmacotherapy. Independent assessments were performed at baseline, throughout treatment, and posttreatment; 83.9% completed posttreatment assessments.

RESULTS

Intention-to-treat remission rates were significantly higher for CBT (61.1%; N = 11/18) than no-CBT (7.7%; N = 1/13). Mixed models of binge-eating frequency (assessed using complementary methods) converged revealing a significant interaction between CBT and time and a significant main effect of CBT. Binge-eating frequency decreased significantly with CBT but did not change significantly with no-CBT. Since only four patients received behavioral treatment during the acute treatments, we performed "sensitivity-type" analyses restricted to the 27 patients who received pharmacotherapy during the acute treatment and found the same pattern of findings for CBT versus no-CBT.

CONCLUSIONS

Adult patients with BED who fail to respond to initial pharmacological treatments should be offered CBT.

PUBLIC SIGNIFICANCE

Even with leading evidence-based treatments for binge-eating disorder, many patients do not derive sufficient benefit. Almost no controlled research has examined treatments for patients who fail to respond to initial interventions. This study found that that cognitive-behavioral therapy was effective for patients with binge-eating disorder who did not respond to initial interventions, with 61% achieving abstinence.

Predictors of early weight loss in post-bariatric surgery patients receiving adjunctive behavioural treatments for loss-of-control eating

This study examined baseline patient characteristics as predictors of early weight loss, defined as any weight loss within the first month of treatment, among patients receiving adjunctive behavioural treatments for loss-of-control (LOC) eating about 6 months after bariatric surgery. Participants were 126 patients in a treatment trial for LOC-eating (roughly 6 months postoperatively) categorized by early weight change following 1 month of treatment. Early weight-loss, defined as any weight loss following 1 month of treatment, and weight-gain, defined as any weight gain, groups were compared on sociodemographic and clinical variables assessed using a battery of reliably administered diagnostic and clinical interviews and established self-report measures, and on surgery-related variables (time since surgery, percent total [%TWL], and percent excess weight loss). Most patients (n = 99; 78.6%) lost weight after the first month of adjunctive treatments. Black patients (n = 24; 61.5%) were significantly less likely to achieve early weight loss compared to patients identifying as White (n = 60; 83%) or 'other' (n = 15; 100%) which was not predicted by any other sociodemographic variable. Severity of eating-disorder psychopathology, psychiatric comorbidity, and a broad range of psychosocial measures were not significantly predictive of early weight changes. Duration since surgery and percent weight loss from time of surgery to study enrolment 6-months post-surgery differed by early weight-loss and weight-gain groups. Findings suggest that among post-bariatric surgery patients receiving adjunctive behavioural treatments for LOC-eating, baseline patient characteristics, aside from race and surgery-related variables, do not predict early weight loss.

Borderline personality disorder symptom networks across adolescent and adult clinical samples: examining symptom centrality and replicability

BACKGROUND

Numerous theories posit different core features to borderline personality disorder (BPD). Recent advances in network analysis provide a method of examining the relative centrality of BPD symptoms, as well as examine the replicability of findings across samples. Additionally, despite the increase in research supporting the validity of BPD in adolescents, clinicians are reluctant to diagnose BPD in adolescents. Establishing the replicability of the syndrome across adolescents and adults informs clinical practice and research. This study examined the stability of BPD symptom networks and centrality of symptoms across samples varying in age and clinical characteristics.

METHODS

Cross-sectional analyses of BPD symptoms from semi-structured diagnostic interviews from the Collaborative Longitudinal Study of Personality Disorders (CLPS), the Methods to Improve Diagnostic Assessment and Service (MIDAS) study, and an adolescent clinical sample. Network attributes, including edge (partial association) strength and node (symptom) expected influence, were compared.

RESULTS

The three networks were largely similar and strongly correlated. Affective instability and identity disturbance emerged as relatively central symptoms across the three samples, and relationship difficulties across adult networks. Differences in network attributes were more evident between networks varying both in age and in BPD symptom severity level.

CONCLUSIONS

Findings highlight the relative importance of affective, identity, and relationship symptoms, consistent with several leading theories of BPD. The network structure of BPD symptoms appears generally replicable across multiple large samples including adolescents and adults, providing further support for the validity of the diagnosis across these developmental phases.

Change in impulsivity is prospectively associated with treatment outcomes for binge-eating disorder

BACKGROUND

Impulsivity may be a process underlying binge-eating disorder (BED) psychopathology and its treatment. This study examined change in impulsivity during cognitive-behavioral therapy (CBT) and/or pharmacological treatment for BED and associations with treatment outcomes.

METHODS

In total, 108 patients with BED (NFEMALE = 84) in a randomized placebo-controlled clinical trial evaluating the efficacy of CBT and/or fluoxetine were assessed before treatment, monthly throughout treatment, at post-treatment (16 weeks), and at 12-month follow-up after completing treatment. Patients completed established measures of impulsivity, eating-disorder psychopathology, and depression, and were measured for height and weight [to calculate body mass index (BMI)] during repeated assessments by trained/monitored doctoral research-clinicians. Mixed-effects models using all available data examined changes in impulsivity and the association of rapid and overall changes in impulsivity on treatment outcomes. Exploratory analyses examined whether baseline impulsivity predicted/moderated outcomes.

RESULTS

Impulsivity declined significantly throughout treatment and follow-up across treatment groups. Rapid change in impulsivity and overall change in impulsivity during treatment were significantly associated with reductions in eating-disorder psychopathology, depression scores, and BMI during treatment and at post-treatment. Overall change in impulsivity during treatment was associated with subsequent reductions in depression scores at 12-month follow-up. Baseline impulsivity did not moderate/predict eating-disorder outcomes or BMI but did predict change in depression scores.

CONCLUSIONS

Rapid and overall reductions in impulsivity during treatment were associated with improvements in specific eating-disorder psychopathology and associated general outcomes. These effects were found for both CBT and pharmacological treatment for BED. Change in impulsivity may be an important process prospectively related to treatment outcome.

Machine learning v. traditional regression models predicting treatment outcomes for binge-eating disorder from a randomized controlled trial

BACKGROUND

While effective treatments exist for binge-eating disorder (BED), prediction of treatment outcomes has proven difficult, and few reliable predictors have been identified. Machine learning is a promising method for improving the accuracy of difficult-to-predict outcomes. We compared the accuracy of traditional and machine-learning approaches for predicting BED treatment outcomes.

METHODS

Participants were 191 adults with BED in a randomized controlled trial testing 6-month behavioral and stepped-care treatments. Outcomes, determined by independent assessors, were binge-eating (% reduction, abstinence), eating-disorder psychopathology, and weight loss (% loss, ⩾5% loss). Predictors included treatment condition, demographic information, and baseline clinical characteristics. Traditional models were logistic/linear regressions. Machine-learning models were elastic net regressions and random forests. Predictive accuracy was indicated by the area under receiver operator characteristic curve (AUC), root mean square error (RMSE), and R2. Confidence intervals were used to compare accuracy across models.

RESULTS

Across outcomes, AUC ranged from very poor to fair (0.49-0.73) for logistic regressions, elastic nets, and random forests, with few significant differences across model types. RMSE was significantly lower for elastic nets and random forests v. linear regressions but R2 values were low (0.01-0.23).

CONCLUSIONS

Different analytic approaches revealed some predictors of key treatment outcomes, but accuracy was limited. Machine-learning models with unbiased resampling methods provided a minimal advantage over traditional models in predictive accuracy for treatment outcomes.

Examining changes in binge-eating disorder network centrality and structure in patients treated with cognitive-behavioral therapy versus interpersonal psychotherapy

OBJECTIVE

A sizeable minority of patients with binge-eating disorder (BED) do not fully respond to evidence-based treatments. Evidence to guide refinements of treatments is needed. Conceptualizing BED as arising from a network of symptom-to-symptom interactions allows for identification of the most strongly connected symptoms, which could inform intervention targets. This study estimated networks of BED features at pretreatment and posttreatment to assess whether cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) differentially impacted the interrelationships of BED symptoms/features.

METHODS

Participants were 392 adults (83% women, 88% white) with BED who received CBT (n = 236) or IPT (n = 156) and assessed at pretreatment and posttreatment. Networks were estimated across timepoints and treatments. Expected influence (EI) was calculated; symptoms with the highest EI have the most strong and frequent associations with other symptoms. We also assessed whether the symptoms with the highest and lowest EI predicted posttreatment remission indicators.

RESULTS

In the CBT and IPT networks, shape concern, weight concern, and eating concern had the highest EI at pretreatment and posttreatment. EI significantly increased from pretreatment to posttreatment for some symptoms in CBT but did not change for any symptoms in IPT. Shape concern significantly and positively predicted BED remission indicators in CBT and IPT.

CONCLUSIONS

CBT and IPT similarly impacted interrelations among BED features. Pretreatment EI predicted posttreatment remission indicators, indicating that pretreatment centrality could signal meaningful intervention targets. Clinical implications and avenues for future research are discussed including how personalized network analysis may advance the understanding of the clinical utility of centrality.

PUBLIC SIGNIFICANCE

Cognitive behavioral therapy and interpersonal therapy for binge-eating disorder, which are two leading evidence-based treatments for binge-eating disorder that are quite different in their models and approaches, similarly impacted interrelations among binge-eating disorder symptoms. In addition, the most strongly interconnected symptom predicted indicators of remission. Studying the interrelations among symptoms may provide new insight on how treatments impact symptom relationships and inform intervention targets.

Loss of control in binge-eating disorder: Fear and resignation

OBJECTIVE

Binge-eating disorder involves overeating while feeling a loss of control (LOC). Emotions around LOC appear to vary; some patients fear LOC whereas others feel powerless or "resigned" to LOC. This study examined differences in psychopathology among treatment-seeking patients with binge-eating disorder categorized with fear of LOC, resignation to LOC, and no fear/resignation of LOC.

METHOD

Doctoral research clinicians administered diagnostic and semistructured interviews to characterize psychopathology and establish a diagnosis of binge-eating disorder in participants (N = 382). The interview assessed fear of LOC in the past month. Further queries assessed whether, in the absence of fear of LOC, patients were resigned to LOC or had no fear/resignation.

RESULTS

Patients with fear of LOC and resigned to LOC endorsed significantly greater global eating-disorder psychopathology than patients with no fear/resignation. Patients with fear of LOC reported greater distress about binge eating and greater depression than those with no fear/resignation. Patients resigned to LOC reported significantly more frequent binge-eating episodes than those with fear of LOC and no fear/resignation. Black individuals and men were more likely to report no fear/resignation than other demographic groups.

DISCUSSION

This study describes a novel clinical aspect of binge-eating disorder: resignation to LOC. Findings highlight the importance of including anticipatory cognitive-affective experiences in treatment formulations and planning. Future research should examine co-occurrence of these experiences and their association with impairment. Future research should also examine how fear of LOC and resignation to LOC change during treatment and whether they predict or moderate treatment outcomes.

PUBLIC SIGNIFICANCE

Adults with binge-eating disorder have anticipatory cognitive-affective experiences about loss of control (LOC) over eating (i.e., fear of LOC, resigned to LOC, no fear nor resignation of LOC). Individuals who experience fear of LOC and those who are resigned to LOC had more severe psychopathology than those without fear/resignation. Binge-eating disorder has the highest prevalence of the eating disorders; thus, findings have high public significance in guiding clinicians' treatment planning.

Psychiatric comorbidity as a prospective predictor of long-term weight and psychosocial outcomes after bariatric surgery

OBJECTIVES

Psychiatric comorbidity is common among the bariatric population although the prognostic significance of psychiatric comorbidity on outcomes is uncertain. This prospective study examined differences in weight and psychosocial functioning outcomes based on lifetime and current (post-surgical) psychiatric comorbidity.

METHODS

Participants were 140 adults in a RCT for loss-of-control (LOC)-eating approximately six months post-bariatric surgery. Two structured interviews were administered: the Eating Disorder Examination-Bariatric Surgery Version (EDE-BSV) to assess LOC-eating and eating-disorder psychopathology, and the Mini International Neuropsychiatric Interview (MINI) to assess lifetime and current (post-surgical) psychiatric disorders. The EDE-BSV and Beck Depression Inventory (BDI-II) were repeated at post-treatment and 24-month follow-ups.

RESULTS

Lifetime (75.7%) and current/post-surgical (25%) psychiatric diagnoses were common. Groups with and without psychiatric comorbidity did not differ significantly in weight loss outcomes at any timepoint but psychiatric comorbidity was associated significantly with greater LOC-eating, eating-disorder psychopathology, and depression.

CONCLUSIONS

Among participants with LOC-eating post-bariatric surgery, lifetime and post-surgical psychiatric comorbidity was not associated with acute or longer-term weight outcomes but predicted poorer psychosocial functioning. Findings challenge prevailing views that psychiatric comorbidity is related to poorer longer-term weight outcomes following bariatric surgery but highlight its clinical significance as it is associated with broad psychosocial difficulties.

Predictors and significance of rapid response to behaviorally based treatment of binge eating disorder

OBJECTIVE

This study examined baseline predictors of rapid response and its prognostic significance in a clinical trial of behaviorally based weight loss treatment (BBWLT) for binge eating disorder in patients with obesity.

METHODS

One hundred ninety-one participants receiving BBWLT were assessed at baseline, throughout treatment, and at posttreatment (6 months) by independent assessors. Rapid response was defined as ≥ 65% reduction in binge eating by the fourth treatment week. Patients with versus without rapid response were compared on demographic features, a broad range of current/past clinical and psychiatric variables, and treatment attitudes. Rapid response was used to prospectively predict posttreatment outcomes.

RESULTS

Rapid response, which characterized 63% (N = 120) of participants, was not associated significantly with any demographic features or with any current/past clinical and psychiatric variables. Higher ratings (at week one) regarding the logic of BBWLT and greater confidence that treatment would help with binge eating and weight loss were associated significantly with rapid response (at week four). Rapid response was prospectively associated with significantly better binge eating and weight loss outcomes.

CONCLUSIONS

These findings indicate that rapid response to BBWLT for binge eating disorder prospectively predicts superior clinical outcomes in both binge eating and weight loss. Treatment attitudes, rather than patient demographic or clinical severity variables, are prospectively associated with rapid response.

Factor structure and measurement invariance of the English- versus Spanish-language Eating Disorder Examination Questionnaire: Brief Form (S-EDE-Q-BF) in Hispanic/Latino/a/x persons seeking bariatric surgery

BACKGROUND

Assessment of eating disorder psychopathology during preoperative psychological evaluations could be facilitated with psychometrically valid measures. One of the most commonly used measures, the Eating Disorder Examination Questionnaire (EDE-Q), is lengthy and has been found to have psychometric limitations. Research has identified a shorter version that has received reliable support across diverse samples but requires further validation for use with patients being evaluated for bariatric surgery.

OBJECTIVES

To cross-validate the factor structure of the EDE-Q: Brief Form (EDE-Q-BF, standalone, nonnested version) with patients being evaluated for bariatric surgery across English- and Spanish-language versions and establish measurement invariance for gender and language.

SETTING

Northeastern hospital in the United States.

METHODS

Participants (n = 618) undergoing evaluations prior to bariatric surgery who identified as Hispanic/Latino/a/x and consented to participate in this research study (which did not influence eligibility for bariatric surgery) completed self-reports. Of the 618 participants, 92 were male and 526 were female, 318 preferred English and were administered English versions of the measures, and 300 preferred Spanish and were administered Spanish versions of the measures.

RESULTS

The 3-factor structure ("Restraint," "Weight/Shape Concerns," and "Body Dissatisfaction") of the EDE-Q-BF fit the data well (χ² [11] = 18.47; P = .071; root mean square error of approximation [RMSEA] = .033; comparative fit index [CFI] > .99; standardized root mean squared residual [SRMR] = .02). Scaler invariance was met for both gender and language. Correlations with external criteria further supported its validity.

CONCLUSION

The EDE-Q-BF can easily be administered as part of a preoperative psychological assessment battery to screen for eating disorder psychopathology and is valid for Hispanic/Latino/a/x men and women who speak either English or Spanish.

Naltrexone-Bupropion and Behavior Therapy, Alone and Combined, for Binge-Eating Disorder: Randomized Double-Blind Placebo-Controlled Trial

OBJECTIVE

Binge-eating disorder, the most prevalent eating disorder, is a serious public health problem associated with obesity, psychiatric and medical comorbidities, and functional impairments. Binge-eating disorder remains underrecognized and infrequently treated, and few evidence-based treatments exist. The authors tested the effectiveness of naltrexone-bupropion and behavioral weight loss therapy (BWL), alone and combined, for binge-eating disorder comorbid with obesity.

METHODS

In a randomized double-blind placebo-controlled trial conducted from February 2017 to February 2021, using a 2×2 balanced factorial design, 136 patients with binge-eating disorder (81.6% women; mean age, 46.5 years; mean BMI, 37.1) were randomized to one of four 16-week treatments: placebo (N=34), naltrexone-bupropion (N=32), BWL+placebo (N=35), or BWL+naltrexone-bupropion (N=35). Overall, 81.7% of participants completed independent posttreatment assessments.

RESULTS

Intention-to-treat binge-eating remission rates were 17.7% in the placebo group, 31.3% in the naltrexone-bupropion group, 37.1% in the BWL+placebo group, and 57.1% in the BWL+naltrexone-bupropion group. Logistic regression of binge-eating remission revealed that BWL was significantly superior to no BWL, and that naltrexone-bupropion was significantly superior to placebo, but there was no significant interaction between BWL and medication. Mixed models of complementary measures of binge-eating frequency also indicated that BWL was significantly superior to no BWL. The rates of participants attaining 5% weight loss were 11.8% in the placebo group, 18.8% in the naltrexone-bupropion group, 31.4% in the BWL+placebo group, and 38.2% in the BWL+naltrexone-bupropion group. Logistic regression of 5% weight loss and mixed models of percent weight loss both revealed that BWL was significantly superior to no BWL. Mixed models revealed significantly greater improvements for BWL than no BWL on secondary measures (eating disorder psychopathology, depression, eating behaviors, and cholesterol and HbA1c levels).

CONCLUSIONS

BWL and naltrexone-bupropion were associated with significant improvements in binge-eating disorder, with a consistent pattern of BWL being superior to no BWL.

Epidemiology of eating disorders among US adults

PURPOSE OF REVIEW

Public policy efforts for prevention of and intervention upon eating disorders is severely limited in the United States due to the paucity of population-based data. This review article summarizes findings regarding eating disorders based on the National Epidemiological Studies on Alcohol and Related Conditions, Third Wave. The studies reviewed provide the most recent epidemiological indicators of anorexia nervosa, bulimia nervosa, and binge-eating disorder (BED) in the United States and demonstrate the utility of population-based data for validating the generalizability of findings from clinical samples.

RECENT FINDINGS

Anorexia nervosa, bulimia nervosa, and BED are widely distributed across sociodemographic characteristics, with substantially elevated risks for a variety of serious psychiatric, medical, and functional impairments, including heighted suicidality over the lifespan. Sexual minorities and individuals with adverse childhood experiences may be particularly vulnerable. Yet, many adults with eating disorders do not seek help, particularly professional help. National Epidemiological Studies on Alcohol and Related Conditions, Third Wave studies also validated some important clinical observations (e.g., overvaluation of shape/weight and physical inactivity in BED, more severe anorexia nervosa with onset prior to 14 years old).

SUMMARY

More rigorous population-based studies are needed to further advocate for appropriate resources and policies for eating disorders in the United States.

24-Month follow-up of randomized controlled trial of guided-self-help for loss-of-control eating after bariatric surgery

BACKGROUND

Loss-of-control (LOC)-eating postoperatively predicts suboptimal longer-term outcomes following bariatric surgery. This study examined longer-term effects through 24-month follow-ups after completing treatments in a randomized controlled trial testing guided-self-help treatments (cognitive-behavioral therapy [gshCBT] and behavioral weight-loss [gshBWL]) and control (CON) delivered postoperatively for LOC-eating.

METHODS

140 patients with LOC-eating 6 months after bariatric surgery were randomized (5:5:2 ratio) to 3-months of gshCBT (n = 56), gshBWL (n = 60), or CON (n = 24) delivered by trained allied-health clinicians. Independent assessments were performed throughout/after treatments and at 6-, 12-, 18-, and 24-month follow-ups; 83% of patients were assessed at 24-month follow-up.

RESULTS

Intention-to-treat analyses comparing the three groups (gshCBT vs. gshBWL vs. CON) in LOC-eating abstinence at posttreatment (30%, 27%, 38%), 12-month follow-up (34%, 32%, 42%), and 24-month follow-up (45%, 32%, 38%) revealed no significant differences. Mixed-models revealed significantly reduced LOC-eating frequency through posttreatment, no significant changes in LOC-eating frequency during follow-up, and no differences between the three groups. Weight reduced significantly, albeit modestly, through posttreatment but increased significantly and substantially during follow-ups, with no differences between groups.

CONCLUSIONS

Overall, the 12-week scalable guided-self-help treatments did not differ from each other or control, were associated with significantly reduced frequency of LOC-eating and modest weight loss at posttreatment but were followed by significant weight gain during the 24-month follow-up. Weight gain was substantial and nearly universal whereas the frequency of LOC-eating did not change over time (i.e., LOC-eating reductions and abstinence rates were well maintained through 24-moth follow-ups). Patients with postoperative LOC-eating require more intensive adjunctive treatments.

PUBLIC SIGNIFICANCE

Loss-of-control (LOC) eating postoperatively predicts poorer bariatric surgery outcomes and the longer-term effects of postoperative adjunctive postoperative interventions for LOC eating are unknown. In this 24-month follow-up of a controlled study of scalable guided-self-help treatments and a control condition, improvements in LOC-eating frequency, eating-disorder psychopathology, and depression during treatment were maintained well, with no differences between the three groups. Proportion of patients achieving abstinence from LOC-eating at the 24-month follow-up ranged from 38% to 45% across the three groups. In contrast, weight increased significantly during the 24-month follow-ups, with no differences between the three groups. Findings suggest LOC-eating following bariatric surgery might represent a "marker" for a subgroup of patients that are at risk for substantial weight gains over time. LOC eating following bariatric surgery is challenging to treat with low-intensity scalable treatments and may require more intensive specialist treatments.

A matter of time: A systematic scoping review on a potential role of the circadian system in binge eating behavior

Background

Emerging research suggests that food intake timing, eating behavior and food preference are associated with aspects of the circadian system function but the role that the circadian system may play in binge eating (BE) behavior in humans remains unclear.

Objective

To systematically evaluate the evidence for circadian system involvement in BE behavior.

Methods

Systematic searches of PubMed, EMBASE, and Scopus were performed for reports published from inception until May 2020 (PROSPERO Registration CRD42020186325). Searches were conducted by combining Medical Subject Headings related to the circadian system, BE behavior, and/or interventions. Observational and interventional studies in humans with BE behavior published in peer-review journals in the English language were included. Studies were assessed using quality and risk of bias tools (AXIS, ROB 2.0, or ROBINS).

Results

The search produced 660 articles, 51 of which were included in this review. Of these articles, 46 were observational studies and 5 were interventional trials. Evidence from these studies suggests that individuals with BE behavior tend to have more food intake, more binge cravings, and more BE episodes later in the day. Hormonal and day/night locomotor activity rhythm disturbances may be associated with BE behavior. Furthermore, late diurnal preference ("eveningness") was associated with BE behavior and chronobiological interventions that shift the circadian clock earlier (e.g., morning bright light therapy) were found to possibly decrease BE behavior. Substantive clinical overlap exists between BE and night eating behavior. However, there is a significant knowledge gap regarding their potential relationship with the circadian system. Limitations include the lack of studies that use best-established techniques to assess the chronobiology of BE behavior, heterogeneity of participants, diagnostic criteria, and study design, which preclude a meta-analytic approach.

Conclusion

Current evidence, although limited, suggests that the circadian system may play a role in the etiology of BE behavior. Further mechanistic studies are needed to fully characterize a potential role of the circadian system in BE behavior. A chronobiological approach to studying BE behavior may lead to identification of its neurobiological components and development of novel therapeutic interventions.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020186325], identifier [CRD42020186325].

Digital self-harm is associated with disordered eating behaviors in adults

PURPOSE

Eating-disorder psychopathology is associated with self-harm behaviors. With much time spent and many social interactions taking place online, self-cyberbullying has emerged as a new form of self-harm that is digital. The current study examined digital self-harm in adults and its associations with eating-disorder psychopathology and behaviors.

METHODS

Participants were adults (N = 1794) who completed an online cross-sectional survey. Participants reported whether they had ever posted mean things about themselves online, whether they had ever anonymously bullied themselves online and completed measures of eating-disorder psychopathology and disordered eating behaviors.

RESULTS

Digital self-harm was reported by adults across demographic characteristics and across the lifespan, although there were some significant differences in demographic characteristics associated with reported digital self-harm. Participants who engaged in digital self-harm were younger than those denying digital self-harm. Eating-disorder psychopathology and disordered eating behaviors were significantly higher among individuals reporting digital self-harm compared with age-matched controls.

CONCLUSIONS

This was the first study to examine digital self-harm among adults and the first study to examine associations of digital self-harm with eating-disorder psychopathology and disordered eating behaviors. Importantly, digital self-harm is reported by adults and therefore is not limited to youth. Our findings that digital self-harm is associated with disordered eating suggests that digital self-harm is a clinically significant topic that needs further research to inform clinical practice and clinical research.

LEVEL OF EVIDENCE

Level III, Evidence obtained from well-designed cohort or case-controlled analytic studies.

Change in eating-disorder psychopathology network structure in patients with binge-eating disorder: Findings from treatment trial with 12-month follow-up

OBJECTIVE

Effective treatments exist for binge-eating disorder (BED), although roughly 50% of patients fail to attain binge-eating abstinence. Evidence on how to refine treatments is lacking. Conceptualizing BED as arising from a network of symptom-to-symptom interactions allows for the identification of the most strongly connected symptoms, which could inform intervention targets. This study assessed how BED symptom centrality changed with behaviorally based weight-loss treatments (BBWLTs).

METHODS

Participants were 191 adult patients (71% female, 79% White) with BED with comorbid obesity participating in a randomized controlled trial testing 6-month BBWLTs for BED. Independent assessments of BED symptoms were performed at pretreatment, posttreatment, and 12 months after treatment. Strength centrality indicated how strongly and frequently symptoms were associated with each other in the network. Significant changes in centrality between timepoints were determined using permutation tests.

RESULTS

At pretreatment, overvaluation of shape/weight and preoccupation with shape/weight and food/eating had the highest strength centrality. At posttreatment and 12-month follow-up, dissatisfaction with shape/weight had the highest centrality, which significantly increased from pretreatment.

CONCLUSIONS

The relations among symptoms of BED are not static and change over time with treatment. BBWLTs do not appear to reduce connectivity of overvaluation of shape/weight (the most central BED symptom prior to treatment), but instead increase connectivity of dissatisfaction with shape/weight with other symptoms following treatment. The observed network structure of symptoms following BBWLTs resembles network analyses of people without eating disorders. Findings highlight the importance of understanding how treatments impact symptom relationships, not just symptom intensities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Does your past define you? How weight histories are associated with child eating-disorder psychopathology

PURPOSE

To examine how parents' and adolescents' weight histories were associated with parents' approach to eating/weight-related parenting and children's eating-disorder behaviors.

METHODS

Participants were 502 parents (69.3% mothers, 30.7% fathers) of children 12-16 years old who completed an online survey. Parents reported their own and their child's weight status during childhood and adolescence. Parents' and children's weight histories were categorized as "weight loss," "weight stability," or "weight gain" and were examined in relation to feeding practices and eating-disorder psychopathology.

RESULTS

Parents with a history of weight gain had greater personal eating-disorder psychopathology and more concerns about their child's weight than parents with weight stability or loss. They also reported greater parental overvaluation (judgment of themselves as parents according to their child's weight/shape). Children with a history of weight loss or gain were more likely to have eating-disorder behaviors than those with stable weight. Analyses revealed that results largely persisted after adjusting for child BMI-z.

CONCLUSIONS

Both parent and child weight gain between childhood and adolescence were associated with eating-disorder psychopathology, eating/weight-related parenting, and feeding practices. Pediatricians and clinicians should assess weight history when considering risk for eating disorders and obesity.

LEVEL OF EVIDENCE

Level III, Evidence obtained from well-designed cohort or case-controlled analytic studies.

Examination of night eating and loss-of-control eating following bariatric surgery

PURPOSE

Post-operative loss-of-control (LOC)-eating is a negative prognostic indicator for long-term outcomes following bariatric surgery. Emerging research suggests that night eating might also be associated with poorer post-operative outcomes. This study examined the co-occurrence and clinical features of night eating in patients with LOC-eating following bariatric surgery.

METHODS

Participants were 131 adults who sought treatment for eating/weight concerns 6 months following sleeve gastrectomy. The Eating Disorder Examination (EDE) interview (Bariatric-Surgery-Version) assessed LOC-eating, regular night eating (at least weekly), and eating-disorder psychopathology. Participants completed the Night Eating Questionnaire (NEQ), Beck Depression Inventory (BDI-II), and the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Approximately, 15% met screening criteria for night-eating syndrome based on the NEQ. Greater NEQ scores were associated significantly with race, lower percent total weight loss (%TWL), and greater EDE, BDI-II, and PSQI scores. Similar results were observed when comparing groups with regular night eating (21.4%) versus without (78.6%); adjusting for race and %TWL revealed similar findings.

DISCUSSION

In post-bariatric patients with LOC-eating, 15% likely had night-eating syndrome and 21.4% engaged in regular night-eating behavior. The co-occurrence of LOC-eating and regular night eating following sleeve gastrectomy may represent a more severe subgroup with elevated psychopathology, poorer sleep and %TWL.

LEVEL OF EVIDENCE

Level III, evidence obtained from well-designed cohort or case-control analytic studies.

Ethnic and racial comparisons of weight-loss treatment utilization history and outcomes in patients with obesity and binge-eating disorder

BACKGROUND

This study examined ethnic/racial differences in reported utilization of weight-loss methods/treatments and weight loss among adults with binge-eating disorder (BED) with co-existing obesity.

METHODS

Participants were 400 adults (non-Hispanic Black: n = 99, Hispanic: n = 38, non-Hispanic White: n = 263) seeking treatment for BED in Connecticut from 2007 to 2012. Participants were asked about prior weight-loss methods/treatments and resulting weight losses.

RESULTS

Overall, self-help diets were utilized most; mental-health services were utilized least. While non-significant differences for most methods/treatments were observed by ethnicity/race, significant differences emerged for self-help diets and supervised programs with non-Hispanic Whites, in general, utilizing these diets more frequently and losing more weight on these types of diets.

CONCLUSIONS

Among treatment-seeking patients with BED and obesity, non-Hispanic White patients reported histories of greater weight-loss treatment utilization and weight loss than non-White patients for supervised and self-help diets. Findings highlight the need for greater understanding of treatment utilization and outcomes among minority patients with obesity and BED.

Preoccupation in bulimia nervosa, binge-eating disorder, anorexia nervosa, and higher weight

OBJECTIVE

Preoccupation (excessive and constant thoughts) about shape/weight and food/eating is thought to be prominent in individuals with eating disorders but has received much less research than overt behavioral features. This study examined the significance and distinctiveness of different foci of preoccupation in individuals categorized with different forms of eating disorders and in individuals with higher weight.

METHOD

Participants (N = 1,363) completed a web-based survey with established measures of eating-disorder psychopathology and depression. The current study compared preoccupation among individuals with core features of bulimia nervosa (BN; n = 144), binge-eating disorder (BED; n = 576), anorexia nervosa (AN; n = 48), and higher body weight (body mass index [BMI] ≥ 25) without eating-disorder features (higher weight [HW]; n = 595). Associations of each type of preoccupation with other eating-disorder psychopathology and depression were examined both between and within study groups.

RESULTS

Preoccupation with shape/weight and with food/eating showed a graded pattern of statistically significant differences: AN and BN had higher preoccupation than BED, which was higher than HW. Within BN, BED, and AN study groups, correlation magnitudes of shape/weight and food/eating preoccupation with eating-disorder psychopathology and depression did not differ significantly. Within the HW group, shape/weight preoccupation was significantly more strongly correlated than food/eating preoccupation with overvaluation, body dissatisfaction, and depression.

DISCUSSION

The preoccupation cognitive style, as well as focus, appears associated with other facets of eating-disorder psychopathology and depression. If results are confirmed among individuals with formal diagnoses, clinicians addressing maladaptive cognitions in cognitive-behavioral therapy should consider the role of preoccupation. Future research should investigate whether preoccupation predicts or moderates eating disorder treatment outcomes.

Physical activity changes during behavioral weight loss treatment by Latinx patients with obesity with and without binge eating disorder

OBJECTIVE

This secondary analysis examined physical activity (PA) changes and their prognostic significance among Latinx patients with obesity, with and without binge eating disorder (BED), who participated in a randomized, placebo-controlled trial testing the addition of orlistat to behavioral weight-loss (BWL) treatment in a "real-world" clinical setting.

METHODS

In this randomized controlled trial at a community mental health center serving economically disadvantaged Spanish-speaking-only Latinx patients, 79 patients with obesity (40 with BED and 39 without BED) received BWL treatment and were randomized to orlistat or placebo. PA, weight, depression, and binge eating were assessed at baseline, posttreatment (end of treatment [4 months]), and the 6-month follow-up (10 months after baseline).

RESULTS

PA was low at baseline (9.3% categorized as "active"), increased during treatment (32.9% categorized as "active" at posttreatment), and declined from posttreatment to the 6-month follow-up (28.2% classified as "active"). At baseline, PA was lower among patients with BED than those without BED. Changes in PA during and after treatment did not differ by BED status or medication condition. PA change was associated with reduced depression but not weight loss.

CONCLUSIONS

Latinx patients with obesity receiving BWL treatment achieved significant, albeit modest, increases in PA. Although PA changes were not associated with weight loss, they were associated with reduced depression. Identifying methods to increase PA further is necessary.

Diabetes prevalence among diverse Hispanic populations: considering nativity, ethnic discrimination, acculturation, and BMI

PURPOSE

To compare prevalence of self-reported diabetes between U.S. state-born, Puerto Rico-born, Mexico-born, Cuba-born, and South/Central America-born Hispanic groups, and examine whether risk for diabetes differs by country of origin and experiences with discrimination when accounting for BMI.

METHODS

Data from 6223 Hispanic respondents from the nationally representative NESARC-III study was used. Sociodemographic characteristics were compared across nativity groups, and adjusted odds of self-reported diabetes diagnosis (past year) tested. Differences by perceived discrimination (using endorsement of individual items assessing specific experiences) and by nativity were examined when accounting for sociodemographic characteristics, acculturation, and BMI.

RESULTS

Prevalence of self-reported diabetes diagnosis was significantly higher among the Puerto Rico-born Hispanics, and remained significantly elevated when adjusting for perceived discrimination, acculturation, and health risk behaviors. When adjusting further for BMI, there were no significant differences in the odds of diabetes by nativity. Prevalence of lifetime perceived discrimination was significantly lower among Cuba-born Hispanics. Mean BMI was significantly lower in South/Central America-born Hispanic individuals relative to U.S. state-, Mexico-, and Puerto Rico-born Hispanic groups. Higher BMI was associated with significantly greater risk of diabetes diagnosis across groups.

CONCLUSION

Marked heterogeneity exists in prevalence and in factors associated with diabetes risk and weight status across Hispanic groups in the U.S. Experiences with discrimination may play an important role in accounting for these differences. This should be considered when planning future research to inform the most optimal patient-centered prevention efforts.

LEVEL OF EVIDENCE

Level III, Evidence obtained from well-designed cohort analytic study.

Factors linking perceived discrimination and weight bias internalization to body appreciation and eating pathology: A moderated mediation analysis of self-compassion and psychological distress

Stigma and recurrent discriminatory experiences can lead to distress and internalization of biases. Self-compassion is a widely-recognized resilience factor that may decrease the impact of discrimination on psychological well-being. Research highlights the potential utility of self-compassion in counteracting the harmful effects of discrimination, reducing psychological distress, and preventing the development of eating disorders. The current study examined the roles of self-compassion and psychological distress in perceived discrimination, internalized weight bias, body image, and eating pathology. Participants (N=694) living in the United States completed an online battery of measures assessing perceived discrimination, weight bias internalization, self-compassion, psychological distress, body appreciation, and eating pathology. Self-compassion was associated negatively with perceived discrimination, weight-bias internalization, psychological distress, and eating pathology and was associated positively with body appreciation. Moderated mediation analyses examined whether psychological distress statistically mediated the relationship between perceived discrimination (Model 1) or weight bias internalization (Model 2) on body appreciation, as well as between perceived discrimination (Model 3) or weight bias internalization (Model 4) on eating psychopathology. For all models, self-compassion was explored as a moderator of indirect and direct effects. Results revealed how psychological distress mediated the link between perceived discrimination and body appreciation/eating psychopathology, as well as between weight bias internalization and body appreciation, but not eating psychopathology. For weight bias internalization models only, the statistical links between psychological distress in relation to body appreciation/eating psychopathology were stronger for those with lower self-compassion. Self-compassion may promote more effective coping and outcomes for individuals who are subject to societal stigma.

Internalized weight bias and loss-of-control eating following bariatric surgery

OBJECTIVE

Internalized weight bias (IWB), or negative weight related self-evaluation, is associated with eating-disorder psychopathology and common among patients seeking bariatric surgery, but little is known about the clinical presentation of IWB post-operatively. This study examined IWB and clinical correlates among adult patients with loss-of-control (LOC) eating post-sleeve gastrectomy surgery.

METHODS

Participants (N = 145) were sleeve gastrectomy patients seeking treatment for eating/weight concerns and experiencing regular LOC eating approximately 6 months following surgery. Eating-disorder features were assessed with the Eating Disorder Examination-Bariatric Surgery Version interview (EDE-BSV) and participants completed established measures assessing IWB, depression, and mental and physical components of quality of life.

RESULTS

IWB was not associated significantly with percent excess weight loss, age, or gender, but White participants reported significantly greater IWB than Non-White participants. IWB was significantly associated with greater eating-disorder psychopathology, depression, and lower perceived mental quality of life. Hierarchical regression analysis revealed that IWB significantly predicted variance in eating-disorder psychopathology above and beyond other related variables.

CONCLUSIONS

Findings suggest that IWB is common and associated with a range of heightened eating-disorder and psychosocial difficulties among patients experiencing LOC eating following bariatric surgery. Future research exploring the longitudinal post-operative prognostic significance of IWB is recommended.

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.

Examining the significance of age of onset in persons with lifetime anorexia nervosa: Comparing child, adolescent, and emerging adult onsets in nationally representative U.S. study

OBJECTIVE

This study compared sociodemographic and clinical profiles of adult patients with lifetime DSM-5-defined anorexia nervosa (AN) categorized by age-of-onset using data from U.S. national sample of adults.

METHOD

Study included 216 participants from Third National Epidemiological Survey Alcohol and Related Conditions (NESARC-III) who met criteria for lifetime AN based on structured diagnostic interviews (AUDADIS-5) with age-of-onset prior to age 25. Of the 216 participants, 30 were categorized as child-onset (<15 years old), 104 adolescent-onset (15-18 years of age), and 82 "emerging-adult" (19-24 years of age); the three groups were compared on their clinical characteristics.

RESULTS

Among participants with lifetime diagnoses of AN with onsets earlier than 25 years, adjusted prevalence rates for the three groups were: 11.8% (SE = 2.04; child-onset), 39.6% (SE = 2.69; adolescent-onset), and 48.6% (SE = 2.67; emerging-adult). Child-onset group reported more frequent adverse childhood experiences (ACEs), lowest BMI, longest episode-duration, was least likely to attend college, and had highest rate of lifetime psychiatric comorbidity. Child-onset group had earliest age of help-seeking and were most likely to have been hospitalized. Group differences persisted in analyses adjusting for sociodemographic characteristics and duration of AN episode.

DISCUSSION

Our findings, based on a nationally representative sample of U.S. adults with lifetime diagnoses of AN, suggest that those with child-onset had more severe AN, greater life difficulties, and greater lifetime psychiatric comorbidity. Findings emphasize the importance of earlier recognition and rapid referral to effective treatments.

Body Image Concerns and Associated Impairment Among Adults Seeking Body Contouring Following Bariatric Surgery

BACKGROUND

The current study examined a range of body image concerns and associated distress and impairment in patients who have undergone bariatric surgery and are seeking subsequent body contouring surgery.

OBJECTIVES

The aim of this study was to investigate the hypotheses that individuals seeking body contouring endorse a broad pattern of body image concerns and that overall body image concern is associated with greater impairment and disability.

METHODS

The participants were 56 adults seeking body contouring surgery after bariatric surgery. All participants completed a self-report questionnaire designed for the present study to assess body image concerns specific to patients who have undergone bariatric surgery and a battery of established measures of disability, impairment, and eating-disorder psychopathology.

RESULTS

The most commonly endorsed concerns were related to loose skin (body dissatisfaction, feeling embarrassed in public, and skin rashes) whereas the least endorsed items included concerns related to scars from bariatric surgery (body dissatisfaction, avoidance of social situations, and difficulty concentrating). Participants endorsed a broad pattern of frequent distress and impairment related to physical body image changes post-bariatric surgery. Greater body image concerns were associated significantly with higher levels of disability, work-related impairment, and eating-disorder psychopathology.

CONCLUSIONS

Patients seeking body contouring surgery reported a range of body image concerns with significant associated distress, disability, and impairment related to physical changes post-bariatric surgery. The present findings underscore that although bariatric surgery is effective for reducing weight and metabolic disturbances, additional interventions for addressing body image concerns that are frequently distressing and impairing may be needed.

Getting a head start: identifying pretreatment correlates associated with early weight loss for individuals participating in weight loss treatment

Early weight loss is associated with greater weight loss following treatment cessation and years later. The present study aimed to identify pretreatment correlates associated with early weight loss in adults participating in weight-loss treatment in primary care. Participants (N = 89) were in the overweight/obesity range seeking weight-loss treatment in primary-care settings and randomized to one of three treatments: Motivational Interviewing and Internet Condition (MIC), Nutrition Psychoeducation and Internet Condition (NPC), or Usual Care (UC). At baseline, participants were assessed with the Eating Disorder Examination (EDE) interview and completed self-report measures of emotional overeating, exercise, exercise self-efficacy, and depression. Percent weight loss at week six was used as the Early Weight Loss variable. MIC/NPC groups had significantly greater Early Weight Loss than UC. Among MIC/NPC participants only, greater Early Weight Loss was associated with significantly lower pretreatment disordered eating and depressive symptoms. Participants in MIC/NPC who achieved clinically meaningful weight loss (>2.5%) by week six compared with those who did not (<2.5%) reported lower pretreatment disordered eating. Demographic factors and binge-eating disorder diagnosis were unrelated to Early Weight Loss. Our findings suggest that greater early weight loss may be associated with less pretreatment disordered eating and depressive symptoms.

CLINICAL TRIALS

NCT01558297.

Factor Structure and Measurement Invariance of the Attitudes Toward Persons with Obesity (ATOP) Scale in a Preoperative and Postoperative Bariatric Surgery Sample

BACKGROUND

The Attitudes Toward Persons with Obesity (ATOP) scale is widely used to assess stigmatization toward persons with obesity. The measure has previously been suggested to assess three facets-self-esteem, personality, and social difficulties-however, psychometric support for this has been inconsistent and warrants further study if the measure intends to be scored this way.

OBJECTIVES

Explore and confirm the factor structure of the ATOP in people assessed prior to bariatric surgery and reassessed 1 year postoperatively SETTING: Midwestern hospital in the USA.

MATERIALS AND METHODS

Three-hundred sixteen people who were seeking bariatric surgery were assessed preoperatively, and 161 of those people were reassessed 1 year after surgery with a battery of measures including the ATOP. Exploratory factor analysis (EFA) was performed on ATOP data from a random split-half of people before surgery, and confirmatory factor analysis (CFA) was performed on the second randomly selected half. With the postoperative sample, a CFA was performed, testing the best-fitting model from the preoperative CFA findings.

RESULTS

The EFA suggested a two-factor structure interpreted as self-esteem and personality/social difficulties. This structure was supported by CFA performed on the second randomly selected half of people at preoperative assessment and by CFA performed on people 1 year following surgery. Tests of measurement invariance suggested that the two-factor structure was similar at both time points.

CONCLUSIONS

Only two factors for the ATOP were empirically supported in the current sample (self-esteem and personality/social difficulties), which is slightly different from the three factors that were originally proposed when the measure was developed. This factor structure is supported both prior to bariatric surgery and 1 year after bariatric surgery.

12 Months later: Motivational interviewing plus nutrition psychoeducation for weight loss in primary care

PURPOSE

Motivational interviewing (MI) weight-loss interventions have garnered much attention, particularly in primary care. Few studies, however, have examined long-term outcomes of MI for weight loss in primary care. This study sought to examine the longer-term outcomes of a combination approach comprising MI and nutrition psychoeducation (MINP) with a publically available web-support component (i.e., livestrong.com).

METHODS

Thirty-one adults with overweight/obesity were enrolled in a 3-month MINP treatment delivered in primary care by medical assistants. Weight, blood pressure, and depression (beck depression inventory) were assessed at baseline and 1-year following treatment cessation (i.e., 15 months total).

RESULTS

Participants' average BMI was significantly lower 12-months following treatment. Approximately one-third of participants (34.8%) maintained 5% or more weight loss. Participants also experienced significant decreases in diastolic blood pressure, resting heart rate, and depression symptoms, but not systolic blood pressure or waist circumference.

CONCLUSION

The scalable (2.5 h total) MINP intervention delivered in primary care by medical assistants resulted in significant weight (medium effect size) and psychological improvements 12 months later. These findings complement previous RCT findings that MI or nutrition psychoeducation interventions, delivered separately, resulted in small weight loss effects after 12 months, with 5% and 17% of participants, respectively, maintaining 5% weight loss. It remains unclear, however, if implementing MI in primary care for weight loss is cost effective beyond providing nutrition psychoeducation alone.

CLINICAL TRIAL REGISTRATION

The clinical trial registration number is NCT02578199.

LEVEL OF EVIDENCE

IV, uncontrolled trial.

Examining depression scores as predictors and moderators of treatment outcomes in patients with binge-eating disorder

OBJECTIVE

A substantial proportion of patients with binge-eating disorder (BED) do not derive sufficient benefits from available evidence-based psychological interventions. We examined depression scores as predictors and moderators of response to cognitive-behavioral therapy (CBT) and behavioral weight-loss (BWL) for BED. We explored associations between changes in depression scores and changes in treatment outcomes.

METHOD

Ninety adults with BED with obesity were randomized to CBT or BWL (6 months) and were evaluated independently throughout treatment, at posttreatment, and 12-month follow-up after treatments (18 months post-randomization). Pre-treatment depression scores, early changes in depression, and changes in depression from pre- to post-treatment were tested as predictors/moderators of outcomes (binge-eating frequency and eating-disorder psychopathology).

RESULTS

Baseline depression scores did not predict nor moderate outcomes at post-treatment or 12-month follow-up. Changes in depression scores (both early and throughout treatment) were not associated significantly with changes in binge-eating frequency or eating-disorder psychopathology at post-treatment or 12-month follow-up.

DISCUSSION

Findings suggest depression scores do not predict nor moderate acute- or longer-term outcomes in patients with BED receiving CBT or BWL. Findings reinforce need to improve treatments for BED overall, although they provide confidence that patients with elevated depression scores derive benefits from existing CBT and BWL interventions.

Self-weighing behavior in individuals with binge-eating disorder

This study examined self-weighing behaviors and correlates in patients with BED. Hypotheses: (1) women would weigh more frequently than men, (2) > weekly weighers would have higher restraint scores than < weekly weighers, (3) the self-weighing-restraint relationship would be stronger in women, (4) self-weighing frequency would be inversely related to BMI, and (5) self-weighing frequency and depression would be independently but not interactively related to BMI. The EDE, administered by trained doctoral-level interviewers, assessed self-weighing and eating-disorder psychopathology in 423 treatment-seeking individuals meeting DSM-5 BED criteria. Self-weighing frequency (1) did not differ by gender (Wald = 1.3; p = .3). (2) > weekly weighers reported significantly higher restraint (2.0±1.2 versus 1.6±1.3; t(421) = 3.1, p = .02). (3) No significant gender*self-weighing interaction on restraint (p = .99). (4) Self-weighing is inversely correlated with BMI (rho = -0.20; p < .001). 5) Self-weighing nor depression, nor self-weighing*depression interaction predicted BMI (p = .51). These analyses lay the groundwork for further investigation of the role of self-weighing in BED treatment.

Association of Borderline Personality Disorder Criteria With Suicide Attempts Among US Adults

IMPORTANCE

Rates of suicide are increasing. Although borderline personality disorder (BPD) and other psychiatric disorders are associated with suicide, there is a dearth of epidemiological research on associations between BPD and suicide attempts (SAs). Delineating the SA risk associated with BPD and its specific criteria in a nationally representative sample of individuals could inform recognition and intervention efforts for SAs.

OBJECTIVE

To examine the association of a BPD diagnosis and specific BPD criteria with SAs in US adults.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data from the National Epidemiological Survey on Alcohol and Related Conditions-III (NESARC-III), a psychiatric epidemiological survey of noninstitutionalized US adults aged 18 or older conducted from April 2012 to June 2013. Eligible adults were randomly selected from households within census-defined counties or groups of counties. Data were analyzed from December 2020 to January 2021.

MAIN OUTCOMES AND MEASURES

Prevalence of Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) psychiatric and personality disorders, BPD and its specific criteria, SAs, and adverse childhood experiences (ACEs), as assessed by structured diagnostic or clinical interviews; prevalence is expressed as weighted means. Multivariable-adjusted logistic regression was used to compare the risk of lifetime and past-year SAs by BPD diagnosis and by each specific BPD criterion. Analyses were adjusted for demographic and clinical factors, including psychiatric comorbidity, age at BPD onset, and ACEs.

RESULTS

Of 36 309 respondents, 20 442 (56.3%) were women and 52.9% were non-Hispanic White; the mean (SD) age was 45.6 (17.5) years. The prevalence (SE) of lifetime and past-year SAs among participants with a lifetime diagnosis of BPD based on original NESARC-III diagnostic codes was 22.7% (0.8%) (adjusted odds ratio [AOR], 8.40; 95% CI, 7.53-9.37) and 2.1% (0.2%) (AOR, 11.77; 95% CI, 7.86-17.62), respectively. With use of diagnostic codes requiring 5 BPD criteria to meet social-occupational dysfunction, prevalence (SE) of lifetime and past-year SAs was 30.4% (1.1%) (AOR, 9.15; 95% CI, 7.99-10.47) and 3.2% (0.4%) (AOR, 11.42; 95% CI, 7.71-16.91), respectively. After excluding the BPD criterion of self-injurious behavior (to eliminate criterion overlap), the prevalence (SE) of lifetime and past-year SAs was 28.1% (1.1%) (AOR, 7.61; 95% CI, 6.67-8.69) and 3.0% (0.4%) (AOR, 9.83; 95% CI, 6.63-14.55), respectively. In analyses adjusting for sociodemographic variables, psychiatric disorders, age at BPD onset, and ACEs, BPD diagnosis and specific BPD criteria of self-injurious behaviors and chronic feelings of emptiness were significantly associated with increased odds of lifetime SAs (BPD diagnosis: AOR, 2.10; 95% CI, 1.79-2.45; self-injurious behaviors: AOR, 24.28; 95 CI, 16.83-32.03; feelings of emptiness: AOR, 1.58; 95% CI, 1.16-2.14) and past-year SAs (BPD diagnosis: AOR, 11.42; 95% CI, 7.71-16.91; self-injurious behaviors: AOR, 19.32; 95% CI, 5.22-71.58; feelings of emptiness: AOR, 1.99; 95% CI, 1.08-3.66). In analysis with BPD criteria simultaneously entered (excluding self-injurious behavior), chronic feelings of emptiness were significantly associated with increased odds of lifetime SAs (AOR, 1.66; 95% CI, 1.23-2.24) and past-year SAs (AOR, 2.45; 95% CI, 1.18-5.08).

CONCLUSIONS AND RELEVANCE

In a national sample of adults, after adjusting for demographic and clinical variables, a BPD diagnosis and the specific BPD criteria of self-injurious behaviors and chronic emptiness were significantly associated with increased SA risk. Although BPD is a complex heterogeneous diagnosis, the results of this study suggest that the criteria of self-injurious behaviors and chronic feelings of emptiness should be routinely considered in suicide risk assessment.

Examining Weight Bias and Loss-of-Control Eating among Individuals Seeking Bariatric Surgery

OBJECTIVE

Externalized weight bias (EWB), directed towards others, and internalized weight bias (IWB), directed towards the self, are thought to exacerbate obesity and disordered eating and may be important factors to assess and understand among individuals seeking bariatric surgery. This study examined clinical correlates (pre-surgical BMI, depressive symptoms, weight self-efficacy, and shape/weight overvaluation) of both EWB and IWB among individuals presenting for bariatric surgery with and without regular loss-of-control eating (LOC eating).

METHODS

A total of 316 adults presenting for bariatric surgery completed established self-report measures to assess EWB, IWB, depressive symptoms, weight self-efficacy, and core symptoms of disordered eating including LOC eating and overvaluation of shape/weight.

RESULTS

IWB and EWB were not associated with pre-surgical BMI, age, or sex, but were both significantly higher among White than non-White participants. Adjusting for race, IWB and EWB were significantly associated with greater eating disorder psychopathology and depressive symptoms and with less weight-related self-efficacy. Participants who endorsed regular LOC eating (53.5% of the sample) endorsed significantly lower weight self-efficacy and higher IWB, EWB, depressive symptoms, and overvaluation of shape/weight.

CONCLUSIONS

Findings suggest that regular LOC eating is common among individuals seeking bariatric surgery and associated with a range of heightened eating disorder and psychosocial concerns including both IWB and EWB. Future research exploring the longitudinal significance of the relationship between these two forms of weight bias and LOC eating is indicated.

Psychiatric comorbidity as predictor and moderator of binge-eating disorder treatment outcomes: an analysis of aggregated randomized controlled trials

BACKGROUND

Psychiatric comorbidity is common in binge-eating disorder (BED) but effects on treatment outcomes are unknown. The current study aimed to determine whether psychiatric comorbidity predicted or moderated BED treatment outcomes.

METHODS

In total, 636 adults with BED in randomized-controlled trials (RCTs) were assessed prior, throughout, and posttreatment by doctoral research-clinicians using reliably-administered semi-structured interviews, self-report measures, and measured weight. Data were aggregated from RCTs testing cognitive-behavioral therapy, behavioral weight loss, multi-modal (combined pharmacological plus cognitive-behavioral/behavioral), and/or control conditions. Intent-to-treat analyses (all available data) tested comorbidity (mood, anxiety, 'any disorder' separately) as predictors and moderators of outcomes. Mixed-effects models tested comorbidity effects on binge-eating frequency, global eating-disorder psychopathology, and weight. Generalized estimating equation models tested binge-eating remission (zero binge-eating episodes during the past month; missing data imputed as failure).

RESULTS

Overall, 41% of patients had current psychiatric comorbidity; 22% had mood and 23% had anxiety disorders. Psychiatric comorbidity did not significantly moderate the outcomes of specific treatments. Psychiatric comorbidity predicted worse eating-disorder psychopathology and higher binge-eating frequency across all treatments and timepoints. Patients with mood comorbidity were significantly less likely to remit than those without mood disorders (30% v. 41%). Psychiatric comorbidity neither predicted nor moderated weight loss.

CONCLUSIONS

Psychiatric comorbidity was associated with more severe BED psychopathology throughout treatment but did not moderate outcomes. Findings highlight the need to improve treatments for BED with psychiatric comorbidities but challenge perspectives that combining existing psychological and pharmacological interventions is warranted. Treatment research must identify more effective interventions for BED overall and for patients with comorbidities.

Randomized Controlled Trial of Treatments for Loss-of-Control Eating Following Bariatric Surgery

OBJECTIVE

Loss-of-control (LOC) eating postoperatively is a consistent predictor of suboptimal longer-term bariatric surgery outcomes. This randomized controlled trial examined the effectiveness of two guided self-help treatments (cognitive behavioral therapy [gshCBT] and behavioral weight loss [gshBWL]) compared with a control (CON) for reducing LOC eating and weight.

METHODS

A total of 140 patients with recurrent LOC eating approximately 6 months after bariatric surgery were randomly assigned (5:5:2 ratio) to one of three conditions: gshCBT (n  =  56), gshBWL (n  =  60), or CON (n  =  24). Three-month treatments were delivered by trained allied health clinicians to increase generalizability to bariatric surgery settings. Independent assessments were performed by doctoral research-clinicians using established interviews/measures; posttreatment outcomes were obtained for 89% of patients.

RESULTS

Mixed models revealed significant improvements for LOC eating frequency and weight loss but no significant differences between treatments; race neither predicted (main effect) nor moderated (interaction effect) treatment outcomes. Intent-to-treat categorical analyses of abstinence from LOC eating (30% for gshCBT, 27% for gshBWL, 38% for CON) and proportion attaining 5% weight loss (20%, 22%, 17%) revealed no significant differences between treatments; non-White participants had a higher proportion achieving LOC eating abstinence but a lower proportion attaining 5% weight loss compared with White participants.

CONCLUSIONS

In this 12-week randomized controlled trial following bariatric surgery, significant LOC eating reductions and weight loss did not differ significantly between treatments. Race was associated with posttreatment categorical outcomes.

Suicide attempts among people with eating disorders and adverse childhood experiences: Results from a nationally representative sample of adults

OBJECTIVE

People with eating disorders (EDs) have elevated rates of suicide attempts. A need exists to identify factors that help predict which people with EDs might be at greater risk for suicidal behavior. Adverse childhood experiences (ACEs) are associated with both EDs and with suicide attempts. Thus, the current study examined whether having histories of ACEs and EDs augments lifetime risk for suicide attempts.

METHOD

This study included 36,146 adult participants in the National Epidemiologic Survey on Alcohol and Related Conditions-III who completed structured diagnostic interviews and answered questions regarding ACEs and suicide attempts. Weighted means, frequencies, and cross-tabulations were computed for prevalence of ACEs and suicide attempts by ED diagnosis. Multiple logistic regression was used to compare risk of lifetime suicide attempts by ED diagnosis and ACE history.

RESULTS

Prevalence of ACEs among people with EDs was 54.1-67.8%. ACE history and ED diagnosis were associated with elevated odds of experiencing a lifetime suicide attempt (AORs = 4.64-6.45 and 3.20-4.06, respectively). There was no ACE history-by-ED interaction on risk of suicide attempt, regardless of forms of EDs.

DISCUSSION

ACEs are common among people with EDs and associated significantly with suicide attempts, but ACEs and EDs do not appear to interact to augment risk for suicide attempts. Considering ACE exposure in theoretical models of suicidal behavior in people with and without EDs and in suicide risk assessment and management with people with EDs may prove useful.