Depressive symptoms and weight change in inpatients with anorexia nervosa: A cross-lagged panel model.

OBJECTIVE: Anorexia nervosa (AN) is marked by a high rate of comorbid depression, which raises the question whether depressive symptoms may adversely affect treatment outcome. Thus, we examined whether depressive symptoms at admission would predict weight change from admission to discharge in a large sample of inpatients with AN. In addition, we also explored the reverse direction, that is, whether body mass index (BMI) at admission would predict changes in depressive symptoms. METHODS: A sample of 3011 adolescents and adults with AN (4% male) who received inpatient treatment at four Schoen Clinics was analyzed. Depressive symptoms were measured with the Patient Health Questionnaire-9. RESULTS: BMI significantly increased and depressive symptoms significantly decreased from admission to discharge. BMI and depressive symptoms were unrelated at admission and discharge. Higher BMI at admission predicted smaller decreases in depressive symptoms and higher depressive symptoms at admission predicted larger weight gain. The latter effect, however, was mediated by longer length of stay. CONCLUSION: Results indicate that depressive symptoms do not adversely affect weight gain during inpatient treatment in persons with AN. Instead, higher BMI at admission is predictive of smaller improvements in depressive symptoms but this effect seems to be negligible in terms of clinical relevance.

Comparing illness duration and age as predictors of treatment outcome in female inpatients with anorexia nervosa.

It has been widely assumed that longer illness duration predicts poorer treatment outcome in persons with anorexia nervosa (AN). However, studies on the prognostic effects of illness duration have produced mixed results. Thus, the aim of the current study was to examine the relationship between illness duration and short-term treatment outcome in a large sample of female inpatients with AN (n = 902, aged 12-73 years). Treatment outcome variables included body mass index, therapist-rated global functioning (Global Assessment of Functioning scale and Clinical Global Impression-Improvement scale) and subscales of the Eating Disorder Inventory-2. Longer illness duration predicted smaller weight gain, smaller improvements in global functioning, and smaller decreases in self-reported eating disorder symptoms. However, illness duration was almost perfectly correlated with patients' age (r = .81, 95% CI [.76, .85]), and comparing regression models revealed that models using either illness duration or age were indistinguishable. Results suggest that longer illness duration does indeed relate to worse short-term treatment outcome in inpatients with AN. This effect, however, does not add significant information above and beyond patients' age and, thus, the importance of illness duration for anticipating treatment outcome both in research and in clinical practice must be critically examined.

Inpatient psychotherapy for depression in a large routine clinical care sample: A Bayesian approach to examining clinical outcomes and predictors of change.

BACKGROUND: A routinely collected dataset was analyzed (1) to determine the naturalistic effectiveness of inpatient psychotherapy for depression in routine psychotherapeutic care, and (2) to identify potential predictors of change. METHODS: In a sample of 22,681 inpatients with depression, pre-post and pre-follow-up effect sizes were computed for various outcome variables. To build a probabilistic model of predictors of change, an independent component analysis generated components from demographic and clinical data, and Bayesian EFA extracted factors from the available pre-test, post-test and follow-up questionnaires in a subsample (N = 6377). To select the best-fitted model, the BIC of different path models were compared. A Bayesian path analysis was performed to identify the most important factors to predict changes. RESULTS: Effect sizes were large for the primary outcome and moderate for various secondary outcomes. Almost all pretreatment factors exerted significant influences on different baseline factors. Several factors were found to be resistant to change during treatment: suicidality, agoraphobia, life dissatisfaction, physical disability and pain. The strongest cross-loadings were observed from suicidality on negative cognitions, from agoraphobia on anxiety, and from physical disability on perceived disability. LIMITATIONS: No causal conclusions can be drawn directly from our results as we only used cross-lagged panel data without control group. CONCLUSIONS: The results indicate large effects of inpatient psychotherapy for depression in routine clinical care. The direct influence of pretreatment factors decreased over the course of treatment. However, some factors appeared stable and difficult to treat, which might hinder treatment outcome. Findings of different predictors of change are discussed.

Implicit approach-avoidance tendencies toward food and body stimuli absent in individuals with anorexia nervosa, bulimia nervosa, and healthy controls.

OBJECTIVE: Body and food-related information are thought to activate cognitive biases and contribute to the maintenance of eating disorders (ED). Approach-avoidance biases may play an important role in the maintenance of dietary restriction and excessive food intake. Therefore, the present study aimed to examine approach-avoidance biases toward food and body stimuli in individuals with anorexia nervosa (AN), bulimia nervosa (BN), and healthy controls (HC). METHODS: The study included 42 individuals with AN, 24 individuals with BN, and 38 HCs. We used two implicit Approach-Avoidance Tasks (AAT) to assess approach-avoidance biases: participants completed a Food-AAT (high-calorie vs. low-calorie food) and a Body-AAT (thin vs. normal weight bodies). Additionally, explicit ratings of food and body stimuli were assessed. RESULTS: There were no significant Group × Stimulus × Direction interactions in the implicit Food-AAT or implicit Body-AAT. In explicit ratings, individuals with AN and BN reported less urge to eat and more regret if they ate high-calorie and low-calorie food; individuals with AN and BN rated normal weight bodies as less normal weight, less attractive and less desirable than HCs. There were no group differences in explicit ratings of the thin body. DISCUSSION: We did not find evidence for biased approach-avoidance tendencies toward food or body stimuli in individuals with AN or BN. Future studies are necessary to understand conflicting findings regarding approach-avoidance biases toward food and body stimuli in individuals with ED.

Effects of interval-based inpatient treatment for anorexia nervosa: An observational study.

OBJECTIVE: After inpatient treatment for anorexia nervosa (AN), many patients relapse and need to be readmitted. To obtain a sustained improvement, a pre-planned multistep inpatient procedure might help to improve the patient's skills in dealing with symptoms and transdiagnostic problems, thus decreasing symptoms of AN. However, no data have been reported for such interval treatment yet. Therefore, this study examined effects of interval treatment in inpatients with AN. METHOD: Data of adult women with AN (N = 304) who received inpatient treatment and either received interval treatment (n = 179) or not (n = 125) were analyzed. Of these, 225 patients completed a follow up measurement after an average of 25 months. Treatment outcome variables were body mass index and subscales of the Eating Disorder Inventory-2 at admission, discharge, and follow up. RESULTS: Across measurements, the interval treatment group had larger increases in body mass index and larger decreases in drive for thinness and binge/purge symptoms than the no interval treatment group. These differences did not seem to be driven by longer treatment duration. DISCUSSION: Our data suggest that interval treatment for AN is effective and may even be superior to conventional single inpatient treatment. Given the observational nature of this study, however, controlled studies are necessary to corroborate these findings.

Drawing the borderline: Predicting treatment outcomes in patients with borderline personality disorder.

BACKGROUND: A routinely collected big data set was analyzed to determine the effectiveness of naturalistic inpatient treatment and to identify predictors of treatment outcome and discontinuation. METHODS: The sample included 878 patients with borderline personality disorder who received non-manualized dialectic behavioral therapy in a psychosomatic clinic. Effect sizes (Hedge's g) were calculated to determine effectiveness. A bootstrap-enhanced regularized regression with 91 potential predictors was used to identify stable predictors of residualized symptom- and functional change and treatment discontinuation. Results were validated in a holdout sample and repeated cross validation. RESULTS: Effect sizes were small to medium (g = 0.28-0.51). Positive symptom-related outcome was predicted by low affect regulation skills and no previous outpatient psychotherapy. Lower age, absence of work disability, high emotional and physical role limitations and low bodily pain were associated with greater improvement in functional outcome. Higher education and comorbid recurrent depressive disorder were the main predictors of treatment completion. The predictive quality of the models varied, with the best being found for symptom-related outcome (R2 = 18%). CONCLUSION: While the exploratory process of variable selection replicates previous findings, the validation results suggest that tailoring treatment to the individual patient might not be based solely on sociodemographic, clinical and psychological baseline data.

Pavlovian-to-instrumental transfer in Anorexia Nervosa: A pilot study on conditioned learning and instrumental responding to low- and high-calorie food stimuli.

Anorexia Nervosa is characterized by persistent restraint eating despite severe negative consequences and often a chronic course of the disease. Recent theoretical models suggest that abnormalities in reward processing and incentive salience of disorder-compatible stimuli as observed in addictive behaviours contribute to the development and maintenance of Anorexia Nervosa. The aim of the present study was to investigate the process of the acquisition of food-related conditioned responses and the influence of conditioned low-calorie and high-calorie food stimuli on instrumental responding for different foods. A Pavlovian-to-instrumental transfer paradigm and questionnaires on eating disorder psychopathology (EDE-Q, EDI-2) were administered to patients with Anorexia Nervosa (n = 39) and healthy controls (n = 41). Results indicated that patients with Anorexia Nervosa showed deficits of the acquisition of knowledge of the experimental contingencies. Nevertheless, in patients with Anorexia Nervosa and healthy controls instrumental responding for low- and high-calorie food rewards was affected by stimuli conditioned to these rewards; no group differences were observed. Importantly, in Anorexia Nervosa, instrumental responding for low-calorie food increased with increasing severity of eating disorder psychopathology suggesting weight-loss directed behaviour. Future studies are warranted to enhance our understanding of deficits of reward-associated learning and to replicate and extend findings with regard to the impact of conditioned stimuli on instrumental responding. At present, our findings suggest that cognitive treatment interventions might be warranted that challenge dysfunctional beliefs about weight loss.

[Pathways to Care and Duration of Untreated Illness of Inpatients with Anorexia and Bulimia nervosa]. / Wege in die Versorgung und Behandlungslatenzen bei stationären Patienten mit Anorexia und Bulimia nervosa.

OBJECTIVE: The study aimed to investigate pathways to care and duration of untreated illness of inpatients with eating disorders. METHODS: 206 patients were assessed using a self-developed questionnaire. RESULTS: On average, the delay between the onset of the eating disorder and treatment initiation was up to five years. The diagnosis of bulimia nervosa, a higher age and lack of problem perception predicted a higher duration of untreated illness. CONCLUSION: Duration of untreated illness should be reduced by adequate interventions in order to prevent chronification.

Virtual reality jogging as a novel exposure paradigm for the acute urge to be physically active in patients with eating disorders: Implications for treatment.

The acute urge to be physically active is a relevant clinical phenomenon in patients suffering from eating disorders. In this study with n = 20 female patients with anorexia nervosa and n = 10 female patients with bulimia nervosa, a virtual reality (VR) jogging paradigm was applied as a novel highly immersive 3D exposure paradigm. Patients were asked to rate their acute urge to be physically active during the exposure procedure. A 10-item self-report questionnaire (smQ) was developed to capture the cognitive, emotional, and behavioral aspects of the acute urge to move. We hypothesized that exposure would lead to habituation of the urge to be physically active. We also hypothesized that leptin levels would be associated with the degree of the subjective urge to be physically active, while habituation would be associated with a decrease in stress hormones (α-amylase, cortisol, and cortisone in saliva). A statistically significant change in subjective scores in the smQ from baseline to postexposure was seen. Our novel VR paradigm may serve as a therapeutic tool for exposure and habituation of the urge of acutely engaging in physical activity in patients with eating disorders.

Explicit and implicit approach vs. avoidance tendencies towards high vs. low calorie food cues in patients with anorexia nervosa and healthy controls.

Patients with anorexia nervosa (AN) have a strong ability to limit food intake. Thus, dysfunctional approach vs. avoidance behaviors towards food are evident in AN. We applied an approach-avoidance task (AAT), in which n = 41 AN patients and n = 42 controls either approached ("pull") or avoided ("push") high (HC) vs. low calorie (LC) food pictures based solely on the presented picture format (landscape vs. portrait). We tested the hypothesis that -in opposition to controls displaying an approach bias towards HC food cues- AN patients would show an avoidance bias (measured as different response times) towards HC food. Explicit ratings of food cues were also performed. We found a significant interaction "group" x "direction" (p = 0.03). rm-ANOVAs performed for each of the two groups separately showed a main effect for "direction" of motion in controls (p = 0.02), but not in AN patients (p = 0.40). The two groups did not differ in their reaction times (RTs) with regard to "push" (p = 0.27). However, RTs with regard to "pull" were significantly different between the groups (p = 0.04). Controls show a clear approach bias, expressed by significantly faster RTs for "pull" compared to "push", independent of "calorie" content of the food stimuli. This approach bias is absent in the group of AN patients. This is indicative of a global loss of incentive value of food in AN. Implicit trainings as add-on to psychotherapy in AN patients are asked for.

The Heterogeneity of Illness Behaviors in Patients with Medically Unexplained Physical Symptoms.

PURPOSE: To investigate the heterogeneity of illness behavior in patients with medically unexplained physical symptoms (MUPS), we clustered patients in regard to their degree of engaging in different aspects of illness behavior and identified related variables with these behaviors. METHOD: A sample of N = 224 patients attending treatment in primary care with a history of MUPS (at least two symptoms) was investigated by analyzing different aspects of illness behavior with the self-reported number of doctor visits during the last 6 months and the Scale for the Assessment of Illness Behavior (SAIB; e.g., expression of symptoms). RESULTS: Two distinct clusters were identified by cluster analysis: a low (n = 106) and a high (n = 118) illness behavior clusters. The high illness behavior cluster exhibited a significantly higher rate of health anxiety than the low illness behavior cluster. Regression analysis revealed a particular effect of sex in the high illness behavior cluster: whereas being male was associated with increased illness behavior as measured by the SAIB, being female was linked to a higher number of doctor visits. Increased health anxiety was associated with the SAIB illness behavior in both clusters. Depression and anxiety did not show incremental associations with all aspects of illness behavior. CONCLUSION: Knowledge of the pattern of illness behavior in patients with MUPS enables us to improve psychological treatments that directly address specific aspects of illness behavior or health anxiety. Differences between sexes in illness behaviors require more differentiated consideration in future research.

Body image, emotions and thought control strategies in body dysmorphic disorder compared to eating disorders and healthy controls.

OBJECTIVE: A disordered body image, emotions such as shame and disgust, and intrusive thoughts are described as important and interdependent features of body dysmorphic disorder (BDD). However, research in this field is scarce and knowledge is often based on clinical observation. METHODS: The present study examined body image dimensions, emotions, and thought control strategies in individuals with: BDD (n=31), anorexia nervosa (n=32), bulimia nervosa (n=34), and healthy controls (n=33). Assessment was based on structured diagnostic interviews and self-report questionnaires. RESULTS: Individuals with BDD scored higher on psychosocial and appearance manipulation dimensions of body image compared to healthy controls. Furthermore, they reported higher psychosocial impairment due to appearance than both eating disorder groups. In terms of emotions, BDD subjects reported a higher degree of negative emotions compared to healthy controls, whereas no differences were found in comparison to eating-disordered patients. Individuals with BDD reported using maladaptive strategies such as worrying and confrontation more often than healthy controls, when encountering intrusive and unwanted thoughts. CONCLUSION: The results indicate that individuals with BDD experience substantial psychosocial impairment due to appearance, high levels of various negative emotions and frequently use maladaptive thought control strategies.

Patients with medically unexplained symptoms and their significant others: illness attributions and behaviors as predictors of patient functioning over time.

OBJECTIVE: Previous research suggests that medically unexplained symptoms (MUS) are maintained in an interpersonal context. The current study examined MUS concurrently and prospectively by measuring specific interpersonal predictors of symptom severity and health care use. METHODS: A total of 127 patients with MUS and their significant others were recruited through primary care offices and assessed with self-report questionnaires and structured interviews about illness attributions, illness behavior and responses, relationship quality, symptom severity, and health care use at baseline and 6-month follow-up. RESULTS: Illness attributions and interpersonal illness behaviors of patients with MUS were cross-sectionally associated with illness attributions and responses of the patients' significant others. Relationship quality was related to specific illness behaviors and responses. Symptom severity at baseline was predicted by patients' somatic illness attributions. Symptom severity at 6-month follow-up was predicted by somatic illness attributions of patients and withdrawal of patients' significant others at baseline, but these predictors became insignificant when correcting for baseline symptomatology. Health care use at baseline was predicted by a greater amount of coping behavior and higher anxiety scores of patients, and health care use at 6-month follow-up was predicted by more attention-seeking behaviors and health care use of patients at baseline. CONCLUSION: The results document the interpersonal influences on the maintenance of MUS. The perspective of significant others should be considered for enhancement of psychological approaches to the treatment of patients with MUS.

A consultation with genetic information about obesity decreases self-blame about eating and leads to realistic weight loss goals in obese individuals.

OBJECTIVE: This study tested the effects of a consultation using genetic information about obesity on attitudes relating to weight loss goals, self-blame about eating, and weight-related coping in obese individuals. Furthermore, the study sought to explore possible predictors for weight gain/loss. METHOD: A total of 411 obese individuals were randomly assigned to two standardized consultations, with and without genetic information about obesity, and a control group without any intervention. After a 6-month follow-up, 253 obese individuals of the intervention groups and 98 individuals of the control group had a complete dataset. Data were analyzed regarding the independent variables assessment time, treatment group, and the familial predisposition (at least one obese parent or sibling). As dependent measures, attitudes about weight loss goals, weight-related self-blame, coping, and body shame were assessed via questionnaire or interview. RESULTS: Individuals with and without a familial predisposition profited in different ways from a consultation using genetic information about obesity: at follow-up, individuals with a familial predisposition reported mainly a relieving effect (less self-blame about eating). Both groups reported an adjustment to more realistic weight loss goals and a greater satisfaction with a 5% weight loss. Furthermore, the more negative obese individuals felt about their current weight at baseline, the higher the risk that these individuals had gained weight at follow-up. CONCLUSION: A consultation focusing on genetic factors might be helpful for obese individuals regardless of their familial predisposition, but only predisposed individuals showed a decrease in self-blame about eating. Negative thoughts and feelings about current weight might predict future weight gain.

Who copes well? Obesity-related coping and its associations with shame, guilt, and weight loss.

The relationship among weight-related coping, guilt, and shame was investigated in a sample of 98 obese German individuals over a 6-month period. In terms of the objectives, the study explored the kind and frequency of typical coping situations in which obese individuals become aware of being obese. Furthermore, the study sought to determine the predictive utility of weight-related shame and guilt concerning coping responses, and to establish whether there is an association between coping responses and weight change. A longitudinal examination over a 6-month period was chosen with two measurement points. As typical distressing coping situations, individuals reported mostly negative evaluations through others/self, physical exercise situations, or environmental hazards (mainly shopping for clothes). Weight-related shame at baseline was a significant negative predictor for problem-focused engagement coping, whereas weight-related guilt was a significant positive predictor for problem-focused engagement strategies and dietary restraint at follow-up. Although Body Mass Index showed no substantial association with the coping measures, weight loss was accompanied by a substantial drop in problem-focused disengagement coping (wishful thinking, problem avoidance). Discussion of these findings focuses on the issue of possible effects of weight-related feelings of guilt and shame on coping behavior, the link between weight loss and disengaging coping strategies, and the possible use of the findings for cognitive-behavioral therapy for obesity.

Is information on genetic determinants of obesity helpful or harmful for obese people?--A randomized clinical trial.

BACKGROUND AND OBJECTIVES: Although more and more genetic information is available, it is unclear whether this information is helpful for patients. Therefore, we assessed the positive and negative effects of informing obese people about the genetic etiology of being overweight. DESIGN, PARTICIPANTS: Two hundred ninety-four obese people were randomized to 2 interventions (a 1-session consultation for obese people on how to manage obesity either including genetic information or not); their results were compared to a control group (116). Subjects were assessed before and after consultation and 6 months later. MEASUREMENTS: Weight, scales on feeling guilty for being overweight, self-control, negative mood (primary endpoint), body acceptance, restraint eating. RESULTS: Both types of consultations were considered helpful by the participants, and had comparable effects on body weight. The consultation with genetic information was rated superior in terms of leading to new insights (advantage for consultation with genetic information, even 6 months later; p = 0.046). No negative effects (e.g., loss of self-efficacy/self-control, increase of body weight; all p > 0.20 for interaction consultation x time) were observed for informing obese people about the genetic etiology of being overweight. The consultation resulted in long-term improvement of negative mood if it included genetic information in the case of participants with a family history of obesity and if it included no genetic information in the case of obese people without a family history of obesity (p = 0.03 for interaction of group, intervention, and time). CONCLUSIONS: Consultations in obesity can be helpful in general. These consultations should include genetic information if people have a family history of obesity.

A one-session treatment for patients suffering from medically unexplained symptoms in primary care: a randomized clinical trial.

The aim of the study was to evaluate a one-session cognitive-behavior treatment (CBT) versus standard medical care for 140 primary-care patients with multiple somatoform symptoms. DSM-IV diagnoses were assessed with structured interviews. Primary outcome variables were healthcare utilization, number, and severity of somatoform symptoms, and secondary outcome measures were psychopathology dimensions. Assessments were done at study enrollment, at 4-weeks, and at 6-month follow-up. General acceptance of CBT was high (positive session evaluations, low dropout rate: 15%). Using an intent-to-treat analytic strategy, both groups improved. Yet results showed a stronger reduction in doctor visits and somatization severity in CBT versus standard care.

Development of the Weight- and Body-Related Shame and Guilt scale (WEB-SG) in a nonclinical sample of obese individuals.

In this article, we present the evaluation of the psychometric properties of a new self-report measure of Weight- and Body-Related Shame and Guilt (WEB-SG). The main purpose of the study was to measure shame and guilt feelings separately in obese individuals and investigate differing behavioral and emotional correlates of these emotions. Altogether, 331 obese participants completed the WEB-SG and other established self-report measures. A subset of the participants completed a 6-month follow-up. The WEB-SG proved to be internally consistent and temporally stable over a 6-month period. Regarding the factorial structure, a two-factor conceptualization was supported. The construct validity of the WEB-SG subscales was evidenced by a substantial overlap of common variance with related measures. The subscales Shame and Guilt showed differential correlation patterns to other scales. The WEB-SG is a brief, psychometrically sound measure for assessing body shame and guilt concerning weight control in obese individuals.

Evaluation of general practitioners' training: how to manage patients with unexplained physical symptoms.

Patients with unexplained physical symptoms ("somatoform disorders") tend to overuse the healthcare system. Therefore, the authors aimed to assess whether a training session for general practitioners (GPs) on managing patients with unexplained physical symptoms would be acceptable to GPs and lead to improvements in patient care. In a randomized clinical trial (GPs randomized), GPs got a 1-day training session and additional materials. Included were 26 GP offices in primary care and 295 patients with unexplained physical symptoms (minimum of two symptoms required). Outcome measures were healthcare utilization (number of doctor visits) 6 months before and 6 months after the index visit to the GP, somatization severity, depression, and hypochondriacal fears at the index visit to the GP's office and 6 months later. Training GPs to manage these patients led to significant reductions in healthcare utilization; patients of untrained GPs showed comparable attendance rates in the 6 months before and after the index visit. Differences in depression, somatization, and hypochondriacal fears, however, could not be attributed to the GP training. GPs rated the training as being highly relevant for their everyday practices, underlining the need for and acceptance of the training. Training GPs in managing patients with unexplained physical symptoms seems to be helpful for the reduction of excessive healthcare utilization. These 1-day workshops have high acceptability, so this approach could be a good model for empirically-validated continuing-education programs.

What determines well-being in obesity? Associations with BMI, social skills, and social support.

OBJECTIVE: Theory and research suggest that the stigma associated with obesity has an impact on the development of social skills and social relationships which may be related to subjective well-being. The main objective was to clarify the associations between BMI (kg/m2), social skills, social support and subjective well-being in a sample of obese subjects. METHODS: Cross-sectional study of 226 obese adults (75 females and 151 males) from the general population between the ages of 19 and 74 [mean (SD), 46.9 (13.7) years]. Mean (SD) BMI of the subjects was 36 (5.3). OUTCOME MEASURES: subjective well-being was measured by the Satisfaction With Life Scale (SWLS) and by the Positive And Negative Affect Scales (PANAS). Social support was assessed with scales of the Social Support Questionnaire F-SozU and social skills with a short form of the German Insecurity Questionnaire U-24. RESULTS: Hierarchical regression analysis showed that social support and social skill measures are relevant predictors of subjective well-being (with both independent and shared influences), while BMI is not. The obese people in our study neither differed from other comparison groups in their subjective well-being, nor did they report greater impairments in social skills or social support. CONCLUSION: BMI does not seem to be the major determinant of low subjective well-being in obesity. As in healthy controls, subjective well-being is principally associated with social skills and social support.