Words will never hurt me? Preferred terms for describing obesity and binge eating.

OBJECTIVE: This study evaluated individuals' language preferences for discussing obesity and binge eating. METHOD: Participants (N = 817; 68.3% female) were an online community sample. They rated the desirability of terms related to obesity and binge eating, and also completed psychometrically established eating-disorder measures. In addition to examining participants' preferences, analyses explored whether preferences differed by socio-demographic variables, weight status and binge-eating status. RESULTS: Preferred obesity-related terms were weight and BMI, although women rated undesirable obesity-related terms even lower than did men. Participants with obesity and binge eating rated weight, BMI, unhealthy BMI and large size as less desirable than participants with obesity but not binge eating. Binge-related terms were generally ranked neutrally; preferred descriptions were kept eating even though not physically hungry and loss of control. CONCLUSIONS: Preferred terms were generally consistent across sex, weight status and binge-eating status. Using terms ranked more preferably and avoiding terms ranked more undesirably may enhance clinical interactions, particularly when discussing obesity with women and individuals reporting binge eating, as these groups had stronger aversion to some non-preferred terms. Findings that the selected binge-related descriptions were rated neutrally on average provide support for their use by clinicians.

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

BACKGROUND: Undue influence of body shape or weight on self-evaluation - referred to as overvaluation - is considered a core feature across eating disorders, but is not a diagnostic requirement for binge eating disorder (BED). This study examined the concurrent and predictive significance of overvaluation of shape/weight in obese patients with BED participating in a randomized clinical trial testing cognitive behavioral therapy (CBT) and behavioral weight loss (BWL). Method A total of 90 participants were randomly assigned to 6-month group treatments of CBT or BWL. Assessments were performed at baseline, throughout- and post-treatment, and at 6- and 12-month follow-ups after completing treatments with reliably administered semi-structured interviews and established measures. RESULTS: Participants categorized with overvaluation (n = 52, 58%) versus without overvaluation (n = 38, 42%) did not differ significantly in demographic features (age, gender and ethnicity), psychiatric co-morbidity, body mass index or binge eating frequency. The overvaluation group had significantly greater levels of eating disorder psychopathology and poorer psychological functioning (higher depression and lower self-esteem) than the non-overvaluation group. Overvaluation of shape/weight significantly predicted non-remission from binge eating and higher frequency of binge eating at the 12-month follow-up, even after adjusting for group differences in depression and self-esteem levels. CONCLUSIONS: Our findings suggest that overvaluation does not simply reflect concern commensurate with being obese or more frequent binge eating, but also is strongly associated with heightened eating-related psychopathology and psychological distress, and has negative prognostic significance for longer-term treatment outcomes. Overvaluation of shape/weight warrants consideration as a diagnostic specifier for BED as it provides important information about severity and treatment outcome.

Rapid response predicts 12-month post-treatment outcomes in binge-eating disorder: theoretical and clinical implications.

BACKGROUND: We examined rapid response in obese patients with binge-eating disorder (BED) in a clinical trial testing cognitive behavioral therapy (CBT) and behavioral weight loss (BWL). METHOD: Altogether, 90 participants were randomly assigned to CBT or BWL. Assessments were performed at baseline, throughout and post-treatment and at 6- and 12-month follow-ups. Rapid response, defined as 70% reduction in binge eating by week four, was determined by receiver operating characteristic curves and used to predict outcomes. RESULTS: Rapid response characterized 57% of participants (67% of CBT, 47% of BWL) and was unrelated to most baseline variables. Rapid response predicted greater improvements across outcomes but had different prognostic significance and distinct time courses for CBT versus BWL. Patients receiving CBT did comparably well regardless of rapid response in terms of reduced binge eating and eating disorder psychopathology but did not achieve weight loss. Among patients receiving BWL, those without rapid response failed to improve further. However, those with rapid response were significantly more likely to achieve binge-eating remission (62% v. 13%) and greater reductions in binge-eating frequency, eating disorder psychopathology and weight loss. CONCLUSIONS: Rapid response to treatment in BED has prognostic significance through 12-month follow-up, provides evidence for treatment specificity and has clinical implications for stepped-care treatment models for BED. Rapid responders who receive BWL benefit in terms of both binge eating and short-term weight loss. Collectively, these findings suggest that BWL might be a candidate for initial intervention in stepped-care models with an evaluation of progress after 1 month to identify non-rapid responders who could be advised to consider a switch to a specialized treatment.

Comparison of alternative models for personality disorders, II: 6-, 8- and 10-year follow-up.

BACKGROUND: Several conceptual models have been considered for the assessment of personality pathology in DSM-5. This study sought to extend our previous findings to compare the long-term predictive validity of three such models: the five-factor model (FFM), the schedule for nonadaptive and adaptive personality (SNAP), and DSM-IV personality disorders (PDs). METHOD: An inception cohort from the Collaborative Longitudinal Personality Disorder Study (CLPS) was followed for 10 years. Baseline data were used to predict long-term outcomes, including functioning, Axis I psychopathology, and medication use. RESULTS: Each model was significantly valid, predicting a host of important clinical outcomes. Lower-order elements of the FFM system were not more valid than higher-order factors, and DSM-IV diagnostic categories were less valid than dimensional symptom counts. Approaches that integrate normative traits and personality pathology proved to be most predictive, as the SNAP, a system that integrates normal and pathological traits, generally showed the largest validity coefficients overall, and the DSM-IV PD syndromes and FFM traits tended to provide substantial incremental information relative to one another. CONCLUSIONS: DSM-5 PD assessment should involve an integration of personality traits with characteristic features of PDs.

The association of personality disorders with the prospective 7-year course of anxiety disorders.

BACKGROUND: This study prospectively examined the natural clinical course of six anxiety disorders over 7 years of follow-up in individuals with personality disorders (PDs) and/or major depressive disorder. Rates of remission, relapse, new episode onset and chronicity of anxiety disorders were examined for specific associations with PDs. METHOD: Participants were 499 patients with anxiety disorders in the Collaborative Longitudinal Personality Disorders Study, who were assessed with structured interviews for psychiatric disorders at yearly intervals throughout 7 years of follow-up. These data were used to determine probabilities of changes in disorder status for social phobia (SP), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder and panic disorder with agoraphobia. RESULTS: Estimated remission rates for anxiety disorders in this study group ranged from 73% to 94%. For those patients who remitted from an anxiety disorder, relapse rates ranged from 34% to 67%. Rates for new episode onsets of anxiety disorders ranged from 3% to 17%. Specific PDs demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders. Associations were identified between schizotypal PD with course of SP, PTSD and GAD; avoidant PD with course of SP and OCD; obsessive-compulsive PD with course of GAD, OCD, and agoraphobia; and borderline PD with course of OCD, GAD and panic with agoraphobia. CONCLUSIONS: Findings suggest that specific PD diagnoses have negative prognostic significance for the course of anxiety disorders underscoring the importance of assessing and considering PD diagnoses in patients with anxiety disorders.

Childhood maltreatment in women with binge-eating disorder: associations with psychiatric comorbidity, psychological functioning, and eating pathology.

OBJECTIVE: To examine correlates of childhood maltreatment in women with binge-eating disorder (BED). METHOD: Semistructured interviews evaluated 137 women with BED for psychiatric disorders and eating psychopathology, and self-reported childhood maltreatment was assessed. RESULTS: Emotional abuse was reported by 52% of participants, physical abuse by 28%, sexual abuse by 31%, emotional neglect by 66%, and physical neglect by 48%. Maltreatment categories were not associated with most lifetime psychiatric diagnoses, although specific associations were observed for dysthymic disorder, posttraumatic stress disorder, and alcohol use disorders. Few associations were noted with eating pathology, but most forms of childhood maltreatment were negatively associated with self-esteem. DISCUSSION: Women with BED report rates of childhood maltreatment comparable to those for clinical groups, and much higher than community samples. Although prevalent in women with BED, childhood maltreatment is not generally associated with variability in eating pathology or with psychiatric comorbidity, but is associated with lower self-esteem.

The mediational significance of negative/depressive affect in the relationship of childhood maltreatment and eating disorder features in adolescent psychiatric inpatients.

OBJECTIVE: Childhood maltreatment is a risk factor for eating disorder and negative/depressive affect appears to mediate this relation. However, the specific elements of eating- and body-related psychopathology that are influenced by various forms of childhood maltreatment remain unclear, and investigations among adolescents and men/boys have been limited. This study investigated the mediating role of negative affect/depression across multiple types of childhood maltreatment and eating disorder features in hospitalized adolescent boys and girls. METHOD: Participants were 148 adolescent psychiatric inpatients who completed an assessment battery including measures of specific forms of childhood maltreatment (sexual, emotional, and physical abuse), negative/depressive affect, and eating disorder features (dietary restriction, binge eating, and body dissatisfaction). RESULTS: Findings suggest that for girls, negative/depressive affect significantly mediates the relationships between childhood maltreatment and eating disorder psychopathology, although effects varied somewhat across types of maltreatment and eating disorder features. Generalization of mediation effects to boys was limited.

Attitudes toward obesity in obese persons: a matched comparison of obese women with and without binge eating.

No research has compared expressions of weight bias across different subgroups of obese individuals. This study compared attitudes toward and beliefs about obesity in women with and without binge eating disorder (BED) and examined whether these attitudes are related to psychological factors. Fifty obese women with BED were compared with an age- and body mass index (BMI)-matched group of 50 obese women without BED on a battery of established measures of anti-fat attitudes and beliefs about weight controllability and psychological factors (self-esteem, depression, and eating disorder features). The ageand BMI-matched groups did not differ with respect to beliefs about obesity or attitudes toward obese persons, or in self-esteem or depression. Correlational analyses conducted separately within each group revealed that women with BED who reported more favorable attitudes towards obese persons had higher self-esteem and lower levels of depression, whereas there were no significant associations between these variables among women without BED. In addition, weight controllability beliefs and eating disorder features were unrelated to self-esteem and depression in both groups. These findings suggest that stigmatizing attitudes endorsed by obese persons are neither tempered nor worsened by psychological distress or eating pathology. Given that stigmatizing attitudes did not differ between obese women with and without BED, it may be that obesity itself, rather than psychological features or disordered eating, increases vulnerability to negative weight-based attitudes. Potential implications for stigma reduction efforts and clinical practice are discussed.

Childhood food neglect and adverse experiences associated with DSM-5 eating disorders in U.S. National Sample.

OBJECTIVE: Adverse childhood experiences (ACEs) and restricted food access have been associated with risk for eating disorders (EDs). This study examined the relationship between childhood food neglect, an ACE specifically involving restricted food access, and DSM-5-defined EDs in a nationally representative sample of U.S. adults, with a particular focus on whether the relationship persists after adjusting for other ACEs and family financial difficulties. METHODS: Participants were 36,145 respondents from the National Epidemiological Survey on Alcohol and Related Conditions III (NESARC-III) who provided data regarding childhood food neglect. Prevalence rates of lifetime anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) were determined for those who reported versus denied childhood food neglect. Analyses compared the odds of each ED diagnosis after adjusting for sociodemographic characteristics (Model 1) and further adjusting for other ACEs and governmental-financial support during childhood (Model 2). RESULTS: Prevalence estimates for AN, BN, and BED with a history of childhood food neglect were 2.80% (SE = 0.81), 0.60% (SE = 0.21), and 3.50% (SE = 0.82), respectively and 0.80% (SE = 0.07), 0.30% (SE = 0.03), and 0.80% (SE = 0.05) for those without a history (all significantly different, p < .05). In the fully-adjusted model, odds of having an ED diagnosis were significantly higher for AN (AOR = 2.98 [95% CI = 1.56-5.71]) and BED (AOR = 2.95 [95% CI = 1.73-5.03]) in respondents with a history of childhood food neglect compared with those without. CONCLUSION: Individuals who experience childhood food neglect may be at increased risk for AN and BED and the elevated risk exists after adjusting for other adverse experiences and financial difficulties during childhood.

Improvement in borderline personality disorder in relationship to age.

OBJECTIVE: It is commonly believed that some features of borderline personality disorder (BPD) improve as individuals reach their late 30s and 40s. This study examined age-related change in borderline criteria and functional impairment, testing the hypothesis that older age would be associated with relatively more improvement than younger age. METHOD: A total of 216 male and female participants with BPD were followed prospectively with yearly assessments over 6 years. RESULTS: Participants showed similar rates of improvement in borderline features regardless of age. A significant age by study year interaction showed functioning in older subjects to reverse direction and begin to decline in the latter part of the follow-up, in contrast to younger subjects who maintained or continued improvement over the 6 years. Despite the decline, functioning for the older subjects was comparable with or slightly better at year 6 than at year 1. CONCLUSION: Improvement in borderline features is not specific to the late 30s and 40s. There may be a reversal of improvement in functioning in some borderline patients in this older-age range.

Personality traits as prospective predictors of suicide attempts.

OBJECTIVE: To examine higher order personality factors of negative affectivity (NA) and disinhibition (DIS), as well as lower order facets of impulsivity, as prospective predictors of suicide attempts in a predominantly personality disordered sample. METHOD: Data were analyzed from 701 participants of the Collaborative Longitudinal Personality Disorders Study with available follow-up data for up to 7 years. Cox proportional hazards regression analyses was used to examine NA and DIS, and facets of impulsivity (e.g. urgency, lack of perseverance, lack of premeditation and sensation seeking), as prospective predictors of suicide attempts. RESULTS: NA, DIS and all facets of impulsivity except for sensation seeking were significant in univariate analyses. In multivariate models which included sex, childhood sexual abuse, course of major depressive disorder and substance use disorders, only NA and lack of premeditation remained significant in predicting suicide attempts. DIS and the remaining impulsivity facets were not significant. CONCLUSION: NA emerged as a stronger and more robust predictor of suicide attempts than DIS and impulsivity, and warrants greater attention in suicide risk assessment. Distinguishing between facets of impulsivity is important for clinical risk assessment.

Prognostic significance of two sub-categorization methods for the treatment of binge eating disorder: negative affect and overvaluation predict, but do not moderate, specific outcomes.

Given the absence of known predictors and moderators for binge eating disorder (BED) treatment outcome and recent findings regarding meaningful sub-categorizations of BED patients, we tested the predictive validity of two subtyping methods. Seventy-five overweight patients with BED who participated in a randomized clinical trial of guided self-help treatments (cognitive-behavioral therapy (CBTgsh) and behavioral weight loss (BWLgsh)) were categorized in two ways. First, a cluster analytic approach yielded dietary-negative affect (29%) and pure dietary (71%) subtypes. Second, research conventions for categorizing patients based upon shape or weight self-evaluation yielded clinical overvaluation (51%) and subclinical overvaluation (49%) subtypes. At the end of treatment, participants subtyped as dietary-negative affect reported more frequent binge episodes compared to the pure dietary subtype, and those with clinical overvaluation reported greater eating disorder psychopathology compared to the subclinical overvaluation group. Neither method predicted binge remission, depressive symptoms, or weight loss. Neither sub-categorization moderated the effects of guided self-help CBT and BWL treatments on any BED outcomes, suggesting that these two specific treatments perform comparably across BED subtypes. In conclusion, dietary-negative affect subtyping and overvaluation subtyping each predicted, but did not moderate, specific and important dimensions of BED treatment outcome.

The complexity of body image following bariatric surgery: a systematic review of the literature.

Poor body image is common among individuals seeking bariatric surgery and is associated with adverse psychosocial sequelae. Following massive weight loss secondary to bariatric surgery, many individuals experience excess skin and associated concerns, leading to subsequent body contouring procedures. Little is known, however, about body image changes and associated features from pre-to post-bariatric surgery and subsequent body contouring. The objective of the present study was to conduct a comprehensive literature review of body image following bariatric surgery to help inform future clinical research and care. The articles for the current review were identified by searching PubMed and SCOPUS and references from relevant articles. A total of 60 articles examining body image post-bariatric surgery were identified, and 45 did not include body contouring surgery. Overall, there was great variation in standards of reporting sample characteristics and body image terms. When examining broad levels of body image dissatisfaction, the literature suggests general improvements in certain aspects of body image following bariatric surgery; however, few studies have systematically examined various body image domains from pre-to post-bariatric surgery and subsequent body contouring surgery. In conclusion, there is a paucity of research that examines the multidimensional elements of body image following bariatric surgery.

Food addiction and bariatric surgery: a systematic review of the literature.

Emerging research suggests that rates of food addiction are high among individuals seeking bariatric surgery, but little is known about associated features and the prognostic significance of pre-operative food addiction. Thus, this article provides a systematic review and synthesis of the literature on food addiction and bariatric surgery. Articles were identified through PubMed and SCOPUS databases, resulting in a total of 19 studies which assessed food addiction among pre-bariatric and/or post-bariatric surgery patients using the Yale Food Addiction Scale. Most studies were cross-sectional, and only two studies prospectively measured food addiction both pre-operatively and post-operatively. The presence of pre-surgical food addiction was not associated with pre-surgical weight or post-surgical weight outcomes, yet pre-surgical food addiction was related to broad levels of psychopathology. The relationship between food addiction and substance misuse among individuals undergoing bariatric surgery is mixed. In addition, very few studies have attempted to validate the construct of food addiction among bariatric surgery patients. Results should be interpreted with caution due to the methodological limitations and small sample sizes reported in most studies. Future rigorous research with larger and more diverse samples should prospectively examine the clinical utility and validity of the food addiction construct following bariatric surgery.

Factor analysis of the DSM-III-R borderline personality disorder criteria in psychiatric inpatients.

OBJECTIVE: The goal of this study was to examine the factor structure of the DSM-III-R criteria for borderline personality disorder in young adult psychiatric inpatients. METHOD: The authors assessed 141 acutely ill inpatients with the Personality Disorder Examination, a semistructured diagnostic interview for DSM-III-R personality disorders. They used correlational analyses to examine the associations among the different criteria for borderline personality disorder and performed an exploratory factor analysis. RESULTS: Cronbach's coefficient alpha for the borderline personality disorder criteria was 0.69. A principal components factor analysis with a varimax rotation accounted for 57.2% of the variance and revealed three homogeneous factors. These factors were disturbed relatedness (unstable relationships, identity disturbance, and chronic emptiness); behavioral dysregulation (impulsivity and suicidal/self-mutilative behavior); and affective dysregulation (affective instability, inappropriate anger, and efforts to avoid abandonment). CONCLUSIONS: Exploratory factor analysis revealed three homogeneous components of borderline personality disorder that may represent personality, behavioral, and affective features central to the disorder. Recognition of these components may inform treatment plans.

Comorbidity of borderline personality disorder with other personality disorders in hospitalized adolescents and adults.

OBJECTIVE: The authors examined the comorbidity of borderline personality disorder with other personality disorders in a series of consecutively admitted adolescents. For comparison, the comorbidity of borderline personality disorder with other personality disorders was also examined in a series of adults consecutively admitted to the same hospital during the same period. METHOD: A total of 138 adolescents and 117 adults were reliably assessed with the Personality Disorder Examination, a semistructured diagnostic interview for DSM-III-R personality disorders. Sixty-eight adolescents and 50 adults met the diagnostic criteria for borderline personality disorder. The co-occurrence of other personality disorders in the group of subjects with borderline personality disorder was statistically compared to that in the group without borderline personality disorder, for adolescents and adults separately. RESULTS: For the adults, Bonferroni-corrected chi-square analysis revealed significant diagnostic co-occurrence with borderline personality disorder for antisocial personality disorder only. For the adolescents, borderline personality disorder showed significant co-occurrence with schizotypal and passive-aggressive personality disorders. CONCLUSIONS: In the adults, borderline personality disorder was significantly comorbid only with another cluster B disorder. The adolescents, by comparison, displayed a broader pattern of comorbidity of borderline personality disorder, encompassing aspects of clusters A and C. These results suggest that the borderline personality disorder diagnosis may represent a more diffuse range of psychopathology in adolescents than in adults.

Psychological and behavioral functioning in adolescent psychiatric inpatients who report histories of childhood abuse.

OBJECTIVE: The purpose of this study was to examine psychological and behavioral functioning in psychiatrically hospitalized adolescents who report histories of childhood abuse. METHOD: Three hundred twenty-two subjects completed an assessment battery of psychometrically well-established instruments. Childhood abuse was assessed by using the childhood abuse scale of the Millon Adolescent Clinical Inventory. Childhood abuse scores of 30 or less and 70 or greater were used to create two study groups--no abuse (N = 93) and high abuse (N = 70), respectively. The two study groups were compared demographically and on the battery of instruments. RESULTS: The two groups differed substantially on most measures of psychological disturbance examined by the assessment battery. When age and depression level were controlled, the high-abuse group was characterized by significantly higher levels of dependency, suicidality, violence, impulsivity, substance use problems, and borderline tendency. Correlational analyses with the entire study group (N = 322) revealed that higher levels of these psychological problems were positively associated with higher levels of childhood abuse. CONCLUSIONS: Psychiatrically hospitalized adolescents who report childhood abuse present with a constellation of symptoms that, after removing the effects of depression, are consistent with borderline personality in statu nascendi.

Conduct disorder, substance use disorders, and coexisting conduct and substance use disorders in adolescent inpatients.

OBJECTIVE: The authors examined the association between conduct disorder and substance use disorders in adolescent inpatients. METHOD: Structured diagnostic interviews were given to 165 adolescent inpatients to assess the presence of DSM-III-R axis I disorders and personality disorders from axis II. Patients with conduct disorder (N = 25), substance use disorders (N = 24), and coexisting conduct and substance use disorders (N = 54) were compared to determine whether additional axis I and axis II disorders presented at significantly different rates. RESULTS: The groups with conduct disorder and coexisting conduct and substance use disorders had a higher proportion of male subjects than the group with substance use disorders alone. Patients with conduct disorder had an earlier age at first psychiatric contact and were diagnosed significantly more often with attention deficit hyperactivity disorder than the other two groups. Borderline personality disorder was diagnosed more frequently in the patients with substance use and coexisting conduct and substance use disorders than in the patients with conduct disorder. These differential co-occurrence patterns were observed for both male and female subjects. CONCLUSIONS: Conduct disorder and substance use disorders have high comorbidity rates with other psychiatric disorders in adolescent inpatients. The additional psychiatric comparison group (patients with coexisting conduct and substance use disorders) allowed for finer distinctions regarding psychiatric comorbidity. The validity of subtyping conduct disorder on the basis of the presence of a coexisting substance use disorder is suggested; conduct disorder patients without a coexisting substance use disorder are more likely to have attention deficit hyperactivity disorder.

Controlled study of psychiatric comorbidity in psychiatrically hospitalized young adults with substance use disorders.

OBJECTIVE: The purpose of this study was to examine DSM-III-R axis I and axis II comorbidity in psychiatrically hospitalized young adults with substance use disorders. METHOD: Structured diagnostic interviews were given to 117 consecutive inpatients. Seventy patients with substance use disorders and 47 patients without substance use disorders were compared. RESULTS: High rates of co-occurrence of axis I disorders were observed, but no disorder coexisted in the group with substance use disorders at a significantly higher rate than in the group without substance use disorders. Among axis II disorders, borderline personality disorder was diagnosed significantly more frequently in the group with substance use disorders. CONCLUSIONS: Significant additional diagnostic co-occurrence, defined as comorbidity, was observed only between borderline personality disorder and substance use disorders. The use of a relevant psychiatric comparison group allows for finer distinctions between covariation based on shared severity and comorbidity possibly based on shared pathophysiology.

Concurrent and predictive validity of the personality disorder diagnosis in adolescent inpatients.

OBJECTIVE: The authors investigated the concurrent and predictive validity of the DSM-III-R diagnosis of personality disorder in adolescents by means of baseline and follow-up assessments of inpatients treated at the Yale Psychiatric Institute. METHOD: One hundred sixty-five hospitalized adolescents were reliably assessed by using a structured interview for personality disorder diagnoses as well as two measures of impairment and distress--the Global Assessment of Functioning Scale and the SCL-90-R. Two years after initial assessment, 101 subjects were independently reassessed with the same measures; their functioning was also assessed at this time. RESULTS: At baseline, adolescents with personality disorders were significantly more impaired than those without personality disorders. At follow-up, adolescents with a personality disorder diagnosis at baseline had used significantly more drugs and had required more inpatient treatment during the follow-up interval. Over time, the scores on the Global Assessment of Functioning Scale and SCL-90-R of adolescents diagnosed with a personality disorder at baseline became more similar to the scores of adolescents without a personality disorder. CONCLUSIONS: The diagnosis of personality disorder in adolescent inpatients has good concurrent validity; however, the predictive validity of the diagnosis is mixed.