Physical and mental health outcomes of an integrated cognitive behavioural and weight management therapy for people with an eating disorder characterized by binge eating and a high body mass index: a randomized controlled trial.

BACKGROUND: Bulimia nervosa (BN) and binge eating disorder (BED) are eating disorders (EDs) characterized by recurrent binge eating. They are associated with medical complications, impaired adaptive function and often a high BMI, for which a multidisciplinary treatment approach may be needed. This study explored the efficacy of a novel intervention integrating Cognitive Behavioural Therapy- Enhanced (CBT-E) and weight management for people with recurrent binge eating episodes and high BMI with respect to physical, psychopathological and quality of life outcomes. METHODS: Ninety-eight adults diagnosed with BN, BED, or Other Specified/Unspecified Feeding or Eating Disorder (OSFED/UFED) and BMI ≥ 27 to <40 kg/m2 were randomized to a multidisciplinary approach, the Healthy APproach to weIght management and Food in Eating Disorders (HAPIFED) or to CBT-E. Metabolic parameters, health-related quality of life, general psychological and ED symptoms and ED diagnostic status outcomes are reported. Data were analyzed with mixed effects models adopting multiple imputed datasets where data were missing. RESULTS: Both HAPIFED and CBT-E showed statistical significance for the time effect, with reduction in stress (p < 0.001), improvement in mental health-related quality of life (p = 0.032), reduction in binge eating severity (p < 0.001), and also in global ED symptoms scores (p < 0.001), with the significant changes found at end of treatment and sustained at 12-month follow-up. However, no statistical significance was found for differences between the interventions in any of the outcomes measured. Despite a high BMI, most participants (> 75%) had blood test results for glucose, insulin, triglycerides and cholesterol within the normal range, and 52% were within the normal range for the physical component of quality of life at baseline with no change during the trial period. CONCLUSION: Integrating weight and ED management resulted in comparable outcomes to ED therapy alone. Although adding weight management to an ED intervention had no adverse effects on psychological outcomes, it also had no beneficial effect on metabolic outcomes. Therefore, more intense weight management strategies may be required where indicated to improve metabolic outcomes. Safety will need to be concurrently investigated. TRIAL REGISTRATION: US National Institutes of Health clinical trial registration number NCT02464345 , date of registration 08/06/2015. Changes to the present paper from the published protocol paper (Trials 18:578, 2015) and as reported in the Trial registration (clinicaltrials.gov) are reported in Supplementary File 1.

Integrated weight loss and cognitive behavioural therapy (CBT) for the treatment of recurrent binge eating and high body mass index: a randomized controlled trial.

PURPOSE: The association between binge eating and obesity is increasing. Treatments for disorders of recurrent binge eating comorbid with obesity reduce eating disorder (ED) symptoms, but not weight. This study investigated the efficacy and safety of introducing a weight loss intervention to the treatment of people with disorders of recurrent binge eating and a high body mass index (BMI). METHODS: A single-blind randomized controlled trial selected adults with binge eating disorder or bulimia nervosa and BMI ≥ 27 to < 40 kg/m2. The primary outcome was sustained weight loss at 12-month follow-up. Secondary outcomes included ED symptoms. Mixed effects models analyses were conducted using multiple imputed datasets in the presence of missing data. RESULTS: Ninety-eight participants were randomized to the Health Approach to Weight Management and Food in Eating Disorders (HAPIFED) or to the Cognitive Behavioural Therapy-Enhanced (CBT-E). No between-group differences were found for percentage of participants achieving weight loss or secondary outcomes, except for reduction of purging behaviour, which was greater with HAPIFED (p = 0.016). Binge remission rates specifically at 12-month follow-up favoured HAPIFED (34.0% vs 16.7%; p = 0.049). Overall, significant improvements in the reduction of ED symptoms were seen in both groups and these were sustained at the 12-month follow-up. CONCLUSION: HAPIFED was not superior to CBT-E in promoting clinically significant weight loss and was not significantly different in reducing most ED symptoms. No harm was observed with HAPIFED, in that no worsening of ED symptoms was observed. Further studies should test approaches that target both the management of ED symptoms and the high BMI. LEVEL OF EVIDENCE: Level I, randomized controlled trial TRIAL REGISTRATION: US National Institutes of Health clinical trial registration number NCT02464345, date of registration 1 June 2015.

Brain white matter microstructure in obese women with binge eating disorder.

OBJECTIVE: Research on potential brain circuit abnormalities in binge eating disorder (BED) is limited. Here, we assess white matter (WM) microstructure in obese women with BED. METHOD: Diffusion tensor imaging data were acquired, and tract-based spatial statistics used to examine WM in women with BED who were obese (n = 17) compared to normal-weight (NWC) (n = 17) and to women who were obese (OBC) (n = 13). Body mass index (BMI) was a covariate in the analyses. RESULTS: The BED group (vs. NWC) had greater axial diffusion (AD) in the forceps minor, anterior thalamic radiation, superior and inferior longitudinal fasciculus, that is, in pathways connecting fronto-limbic regions. Microstructures differences in AD between the BED and OBC groups were seen in fronto-limbic pathways extending to temporoparietal pathways. The BED (vs. OBC) group had greater fractional anisotropy in the forceps minor and greater AD in the superior longitudinal fasciculus, cingulate gyrus, and corpus callosum, consistent with fronto-tempoparietal pathways. CONCLUSION: Women with BED show WM alterations in AD in fronto-limbic and parietal pathways that are important in decision-making processes. As BMI was a covariate in the analyses, alterations in BED may be part of the pathology, but whether they are a cause or effect of illness is unclear.

The classification of feeding and eating disorders in the ICD-11: results of a field study comparing proposed ICD-11 guidelines with existing ICD-10 guidelines.

BACKGROUND: The World Health Organization (WHO) International Classification of Diseases and Related Health Problems (ICD) is used globally by 194 WHO member nations. It is used for assigning clinical diagnoses, providing the framework for reporting public health data, and to inform the organization and reimbursement of health services. Guided by overarching principles of increasing clinical utility and global applicability, the 11th revision of the ICD proposes major changes that incorporate empirical advances since the previous revision in 1992. To test recommended changes in the Mental, Behavioral, and Neurodevelopmental Disorders chapter, multiple vignette-based case-controlled field studies have been conducted which examine clinicians' ability to accurately and consistently use the new guidelines and assess their overall clinical utility. This manuscript reports on the results from the study of the proposed ICD-11 guidelines for feeding and eating disorders (FEDs). METHOD: Participants were 2288 mental health professionals registered with WHO's Global Clinical Practice Network. The study was conducted in Chinese, English, French, Japanese, and Spanish. Clinicians were randomly assigned to apply either the ICD-11 or ICD-10 diagnostic guidelines for FEDs to a pair of case vignettes designed to test specific clinical questions. Clinicians selected the diagnosis they thought was correct for each vignette, evaluated the presence of each essential feature of the selected diagnosis, and the clinical utility of the diagnostic guidelines. RESULTS: The proposed ICD-11 diagnostic guidelines significantly improved accuracy for all FEDs tested relative to ICD-10 and attained higher clinical utility ratings; similar results were obtained across all five languages. The inclusion of binge eating disorder and avoidant-restrictive food intake disorder reduced the use of residual diagnoses. Areas needing further refinement were identified. CONCLUSIONS: The proposed ICD-11 diagnostic guidelines consistently outperformed ICD-10 in distinguishing cases of eating disorders and showed global applicability and appropriate clinical utility. These results suggest that the proposed ICD-11 guidelines for FEDs will help increase accuracy of public health data, improve clinical diagnosis, and enhance health service organization and provision. This is the first time in the revision of the ICD that data from large-scale, empirical research examining proposed guidelines is completed in time to inform the final diagnostic guidelines.

Inpatient versus outpatient care, partial hospitalisation and waiting list for people with eating disorders.

BACKGROUND: Clinical guidelines recommend outpatient care for the majority of people with an eating disorder. The optimal use of inpatient treatment or combination of inpatient and partial hospital care is disputed and practice varies widely. OBJECTIVES: To assess the effects of treatment setting (inpatient, partial hospitalisation, or outpatient) on the reduction of symptoms and increase in remission rates in people with:1. Anorexia nervosa and atypical anorexia nervosa;2. Bulimia nervosa and other eating disorders. SEARCH METHODS: We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 2 July 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 20 November 2015). We also searched the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (6 July 2018). We ran a forward citation search on the Web of Science to identify additional reports citing any of the included studies, and screened reference lists of included studies and relevant reviews identified during our searches. SELECTION CRITERIA: We included randomised controlled trials that tested the efficacy of inpatient, outpatient, or partial hospital settings for treatment of eating disorder in adults, adolescents, and children, whose diagnoses were determined according to the DSM-5, or other internationally accepted diagnostic criteria. We excluded trials of treatment setting for medical or psychiatric complications or comorbidities (e.g. hypokalaemia, depression) of an eating disorder. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane procedures to select studies, extract and analyse data, and interpret and present results. We extracted data according to the DSM-5 criteria. We used the Cochrane tool to assess risk of bias. We used the mean (MD) or standardised mean difference (SMD) for continuous data outcomes, and the risk ratio (RR) for binary outcomes. We included the 95% confidence interval (CI) with each result. We presented the quality of the evidence and estimate of effect for weight or body mass index (BMI) and acceptability (number who completed treatment), in a 'Summary of findings' table for the comparison for which we had sufficient data to conduct a meta-analysis. MAIN RESULTS: We included five trials in our review. Four trials included a total of 511 participants with anorexia nervosa, and one trial had 55 participants with bulimia nervosa. Three trials are awaiting classification, and may be included in future versions of this review. We assessed a risk of bias from lack of blinding of participants and therapists in all trials, and unclear risk for allocation concealment and randomisation in one study.We had planned four comparisons, and had data for meta-analyses for one. For anorexia nervosa, there may be little or no difference between specialist inpatient care and active outpatient or combined brief hospital and outpatient care in weight gain at 12 months after the start of treatment (standardised mean difference (SMD) -0.22, 95% CI -0.49 to 0.05; 2 trials, 232 participants; low-quality evidence). People may be more likely to complete treatment when randomised to outpatient care settings, but this finding is very uncertain (risk ratio (RR) 0.75, 95% CI 0.64 to 0.88; 3 trials, 319 participants; very low-quality evidence). We downgraded the quality of the evidence for these outcomes because of risks of bias, small numbers of participants and events, and variable level of specialist expertise and intensity of treatment.We had no data, or data from only one trial for the primary outcomes for each of the other three comparisons.No trials measured weight or acceptance of treatment for anorexia nervosa, when comparing inpatient care provided by a specialist eating disorder service and health professionals and a waiting list, no active treatment, or treatment as usual.There was no clear difference in weight gain between settings, and only slightly more acceptance for the partial hospital setting over specialist inpatient care for weight restoration in anorexia nervosa.There was no clear difference in weight gain or acceptability of treatment between specialist inpatient care and partial hospital care for bulimia nervosa, and other binge eating disorders. AUTHORS' CONCLUSIONS: There was insufficient evidence to conclude whether any treatment setting was superior for treating people with moderately severe (or less) anorexia nervosa, or other eating disorders.More research is needed for all comparisons of inpatient care versus alternate care.

Dietary patterns as a red flag for higher risk of eating disorders among female teenagers with and without type I diabetes mellitus : Adolescents with type I diabetes mellitus are a risk factor for eating disorders: a case-control study.

BACKGROUND: Female adolescents with type I diabetes mellitus (TIDM) have an increased risk of developing eating disorders (ED) due to the dietary recommendations. OBJECTIVE: Investigate the association between dietary intake and increased risk of ED. METHODS: Case-control study with 50 T1DM female adolescents (11-16 years) and 100 healthy peers (CG). Measures included food frequency questionnaire (FFQ-PP), Child-EDE.12, economic and anthropometric data. RESULTS: Comparing female adolescents with T1DM vs CG, the first had higher intake of: bread, cereal, rice, and pasta (29.7 vs 23.8%, p = 0.001), vegetables (6.5 vs 2.8%, p < 0.001), milk yogurt and cheese (9.9 vs 7.6%, p = 0.032), fat, and oils (8.2 vs 5.9%, p = 0.003), besides higher fiber intake (19.2 vs 14.7%, p = 0.006) and lower consumption of sweets (13.6 vs 30.7%, p < 0.001). No differences on ED psychopathology (Child-EDE subscales and global score) were found between groups. In unadjusted association between the ED psychopathology and dietary intake, a diet rich in fiber was significantly associated with both the global and eating concern scores. Among CG, increased intake of meat, poultry, fish, and eggs and decreased bread, cereal, rice, and pasta consumption were significantly associated with higher ED psychopathology. When BMI and age are adjusted, the association between fiber intake and ED psychopathology is no longer significant among diabetic participants; however, in the CG, this association remains. CONCLUSIONS: The study suggests that an association between dietary intake and ED psychopathology might exist in female adolescents with and without TIDM and that careful evaluation of the dietary profile and risk of developing an ED should be considered in clinical practice. LEVEL OF EVIDENCE: Level III, case-control study.

Validity and Reliability of the Brazilian Version of the Weight Control Behaviors Scale.

OBJECTIVE: To develop and validate the weight-control behaviors (WCBs) scale and to evaluate its psychometric properties. STUDY DESIGN: We made use of data from a cluster-randomized trial assessing the effectiveness of the Brazilian New Moves Program. The Brazilian New Moves Program was a multicomponent intervention aimed at preventing weight-related problems among adolescent girls in public schools in São Paulo, Brazil. RESULTS: Healthy and unhealthy WCBs were strongly associated. A 2-factor solution was the best model to explain the correlation across items, including following constructs: (1) healthy WCB: exercising, eating more fruits and vegetables, drinking less regular soda or sweetened drinks, eating fewer sweets, and paying attention to portion sizes; and (2) unhealthy WCB: skipping meals and the presence of any other, combined unhealthy weight-control behaviors, including fasting, eating little, going on a diet, vomiting, taking diet pills, using diuretics (water pills), using laxatives, using food substitutes (powder/special drinks), and smoking more cigarettes. The WCB scale was determined to be reliable (internally consistent) and valid, with high scores positively associated with body dissatisfaction and high body mass index values. Individual reliability values were high for factors representing healthy and unhealthy WCBs. CONCLUSIONS: Our findings support the use of the WCB scale as a screening tool for overall weight control behaviors among female adolescents. This assessment tool should be considered in future observational and experimental prospective studies. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials: RBR-6ddpb3.

Systematic review of the diagnostic category muscle dysmorphia.

OBJECTIVES: (1) To collect, analyze and synthetize the evidence on muscle dysmorphia diagnosis as defined by Pope et al. and (2) To discuss its appropriate nosology and inclusion as a specific category in psychiatric classificatory systems. METHOD: A systematic search in the MEDLINE, the PsycNET, the LILACS and SciELO databases and in the International Journal of Eating Disorders was conducted looking for articles published between January 1997 and October 2014 and in EMBASE database between January 1997 and August 2013. Only epidemiological and analytical studies were considered for selection. The methodological quality of included studies was assessed according to the Evidence-Based Mental Health and the National Health and Medical Research Council's guidelines. The support for inclusion of muscle dysmorphia in psychiatric classificatory systems was examined against Blashfield et al.'s criteria. RESULTS: Thirty-four articles were considered eligible out of 5136. Most of the studies were cross-sectional and enrolled small, non-clinical samples. The methodological quality of all selected papers was graded at the lowest hierarchical level due to studies' designs. Forty-one percent of the publications considered the available evidence insufficient to support the inclusion of muscle dysmorphia in any existing category of psychiatric disorders. The current literature does not fulfill Blashfield et al.'s criteria for the inclusion of muscle dysmorphia as a specific entity in psychiatric diagnostic manuals. CONCLUSION: The current evidence does not ensure the validity, clinical utility, nosological classification and inclusion of muscle dysmorphia as a new disorder in classificatory systems of mental disorders.

Comparing symptomatic and functional outcomes over 5 years in two nonclinical cohorts characterized by binge eating with and without objectively large episodes.

OBJECTIVE: The aim was to compare symptomatic and functional outcomes over 5 years in women with regular subjective (SBEs), objective (OBEs), and no regular binge eating episodes. METHOD: Data were derived from two cohorts of 330 women with high levels of eating disorders symptoms followed over 5 years. Three groups were formed: (a) regular SBEs but no regular OBEs (N = 68), (b) regular OBEs with or without regular SBEs (N = 154), and (c) with no regular binge eating episodes (N = 108). RESULTS: At baseline, the groups did not differ significantly in restraint scores and quality of life. People in the OBE group scored higher than those in the SBE group in body mass index (BMI). Those who had no regular binge eating had lower global Eating Disorder Examination Questionnaire (EDE-Q) and weight and shape concern scores than those with regular SBEs, and lower eating concern scores than either binge eating groups. Across the follow-up, there were no significant effects of being in either binge eating or the nonbinge eating group on the rates of change in BMI, general psychological distress, quality of life, or EDE-Q scores with the exception that OBE group had a significantly different rate of change in eating concern and psychological distress compared to the group without regular binge eating. DISCUSSION: Individuals that report regular SBEs without regular OBEs represent a group with similar mental hardship and outcomes to those with regular OBEs. The findings support inclusion of regular SBEs in criteria for eating disorder diagnostic categories characterized by recurrent binge eating.

The effects of repetitive transcranial magnetic stimulation in obese females with binge eating disorder: a protocol for a double-blinded, randomized, sham-controlled trial.

BACKGROUND: Binge eating disorder is a new category in DSM-5 and highly associated with higher body mass index. The neural mechanisms that underlie binge eating are of great interest in order to improve treatment interventions. Brain mechanisms underlying drug and food craving are suggested to be similar: for example, both are reported to be associated with increased neural activity in the orbitofrontal and anterior cingulate cortex, and a diminished regulatory influence from lateral prefrontal circuits. Several studies have begun to assess the potential benefits of brain stimulation in reducing craving and addictive behaviors. Data from a study of a one-off session of transcranial magnetic stimulation in healthy women identified as strong cravers and of individuals with bulimic-type eating disorders, reported a reduction in food craving and binge eating episodes. This provides support for a more extensive investigation of the potential therapeutic benefits of transcranial magnetic stimulation. Lastly, brain imaging studies and a dimensional approach, will improve understanding of the neural correlates of the disorders and of the mode of action of transcranial magnetic stimulation. METHODS/DESIGN: Sixty eligible obese females, with binge eating disorder, will be randomly allocated to receive 20 sessions of transcranial magnetic stimulation intervention (n = 30) or the sham transcranial magnetic stimulation intervention (n = 30) scattered 3 days/week. Thirty eligible controls will complete the baseline assessment. The primary outcome (number of binge eating episodes) will be assed at each treatment sessions, and 8 weeks after intervention completion (follow-up). It is hypothesized that mean weekly binge-eating episodes will be reduced in the intervention group, compared to the sham group, and that the effect will be maintained at follow-up. DISCUSSION: Despite the severity associated with Binge Eating Disorder, there are limited treatment options. This study is an important step in the development of more effective treatments. Importantly, the study is the first to investigating binge eating disorder using a dimensional approach, by looking at the different aspects of the disorder, such as behavioral factors, biological factors, brain circuits and chemistry. TRIAL REGISTRATION: Clinical Trials NCT02180984 . Registered in July 2014.

Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa.

BACKGROUND: Anorexia nervosa is a disorder with high morbidity and significant mortality. It is most common in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting, and a number of differing psychological therapies are presently used in treatment. This is an update of a Cochrane review which was last published in 2008. OBJECTIVES: To assess the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents treated in an outpatient setting. SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) (16 July 2014). This register includes relevant randomised controlled trials from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We screened reference lists of all included studies and sent letters to identified, notable researchers requesting information on unpublished or ongoing studies. SELECTION CRITERIA: All randomised controlled trials of one or more individual outpatient psychological therapies for adults with anorexia nervosa, as defined by DSM-5 or similar international criteria. DATA COLLECTION AND ANALYSIS: We selected a range of outcome variables, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons used the mean or standardised mean difference (MD or SMD), and binary outcome comparisons used the risk ratio (RR). Two review authors (PH and AC or ST) extracted data independently. MAIN RESULTS: We identified 10 trials from the search, with a total of 599 anorexia nervosa participants, and included them in the review. Seven had been identified in the previous versions of this review and we now include three new trials. We now deem one previously identified ongoing trial to be ineligible, and six ongoing trials are new for this update. Two of the 10 trials included children. Trials tested diverse psychological therapies and comparability was poor. Risks of bias were mostly evident through lack of blinded outcome assessments (in 60% of studies) and incomplete data reporting (attrition bias).The results suggest that treatment as usual (TAU) when delivered by a non-eating-disorder specialist or similar may be less efficacious than focal psychodynamic therapy. This was suggested for a primary outcome of recovery by achievement of a good or intermediate outcome on the Morgan and Russell Scale (RR 0.70, 95% confidence interval (CI) 0.51 to 0.97; 1 RCT, 40 participants; very low-quality evidence). However there were no differences between cognitive analytic therapy and TAU for this outcome (RR 0.78, 95% CI 0.61 to 1.00; 2 RCTs, 71 participants; very low-quality evidence), nor for body mass index (BMI). There were no differences in overall dropout rates between individual psychological therapies and TAU.Two trials found a non-specific specialist therapy (Specialist Supportive Clinical Management) or an Optimised TAU delivered by therapists with eating disorder expertise was similar in outcomes to cognitive behaviour therapy (BMI MD -0.00, 95% CI -0.91 to 0.91; 197 participants, low-quality evidence). When comparing individual psychological therapies with each other, no specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non-completion rate in one trial (35 participants). None of the trials identified any adverse effects. Insufficient power was problematic for the majority of trials. AUTHORS' CONCLUSIONS: There was a suggestion in one trial that focal psychodynamic therapy might be superior to TAU, but this is in the context of TAU performing poorly. An alternative control condition of dietary advice alone appeared to be unacceptable, but again this is based on just one trial. Owing to the risk of bias and limitations of studies, notably small sample sizes, we can draw no specific conclusions about the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents. Larger RCTs of longer treatment duration and follow-up are needed.

Clinical psychopharmacology of eating disorders: a research update.

The paper presents a critical review (with search date 2010) of the major psychotropic medications assessed in eating disorders, namely antipsychotics, antidepressants, mood-stabilizing medications, anxiolytic and other agents. The evidence of efficacy of drug treatments is mostly weak or moderate. In addition, attrition rates are usually higher than for psychotherapies. However, there is support for use of antidepressants, particularly high-dose fluoxetine in bulimia nervosa, and anticonvulsants (topiramate) for binge-eating disorder. Low-dose antipsychotic medication may be clinically useful as adjunct treatment in acute anorexia, particularly where there is high anxiety and obsessive eating-related ruminations and failure to engage, but more trials are needed. Drug therapies such as topiramate and anti-obesity medication may aid weight loss in obese or overweight patients with binge-eating disorder; however, common or potentially serious adverse effects limit their use.

Eating disorders.

This Seminar adds to the previous Lancet Seminar about eating disorders, published in 2003, with an emphasis on the biological contributions to illness onset and maintenance. The diagnostic criteria are in the process of review, and the probable four new categories are: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. These categories will also be broader than they were previously, which will affect the population prevalence; the present lifetime prevalence of all eating disorders is about 5%. Eating disorders can be associated with profound and protracted physical and psychosocial morbidity. The causal factors underpinning eating disorders have been clarified by understanding about the central control of appetite. Cultural, social, and interpersonal elements can trigger onset, and changes in neural networks can sustain the illness. Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery.

Baseline Predictors of Adherence in a Randomised Controlled Trial of a New Group Psychological Intervention for People with Recurrent Binge Eating Episodes Associated to Overweight or Obesity.

PURPOSE: Understanding the high rate of treatment adherence in trials of people with eating disorders is important as it can compromise the quality of the trials. In clinical practice, it may also contribute to illness chronicity, relapse, and costs. Thus, we investigated factors associated with adherence to a new treatment HAPIFED, which integrates cognitive behavioural therapy having extended sessions with body weight loss therapy compared to cognitive behavioural therapy with extended sessions alone, for individuals with Bulimia Nervosa or Binge Eating Disorder or other eating disorders comorbid with overweight or obesity. METHODS: In total, 98 participants having bulimia nervosa, binge eating disorder and other specified and unspecified eating disorders were recruited with 50 randomised to HAPIFED and 48 to the control intervention CBT-E, all administered in groups of up to 10 participants. An investigator external to the site conducted the random allocation, which was concealed from the statistician involved in the analysis, and known only to the therapists until the finalization of the 12-month follow-up after the end of active treatment. Three scenarios in the timeline treatment of a total of 30 sessions were assessed: 33% or 60% or 75% of presence. Mixed-effects logistic regression analysis was performed to find the correlates of adherence after adjusting for clustering by number of group participants. To account for heterogeneity by types of eating disorders in the sample, the latter variable was considered as a control factor in the models. A subgroup analysis was performed for those with binge eating disorder as this was the largest (N = 66) eating disorder group. RESULTS: None of the six variables-frequency of binge eating episodes, purging, eating disorder symptom severity, weight, illness duration and mental health-related quality of life-significantly predicted adherence at 33%, but longer illness duration predicted higher treatment adherence at both 60% and 75% presence of the interventions. Also for 75% presence, higher body weight predicted lower treatment adherence. For the subgroup analysis, those having higher illness duration had significantly higher odds of treatment adherence for 60% and 75% of the sessions. CONCLUSIONS: Higher adherence due to late treatment completion was associated with longer binge eating illness length and a lower body weight. More research is needed to recognize factors that may interfere with engagement in treatments aiming to avoid early dropout.

An organization- and category-level comparison of diagnostic requirements for mental disorders in ICD-11 and DSM-5.

In 2013, the American Psychiatric Association (APA) published the 5th edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In 2019, the World Health Assembly approved the 11th revision of the International Classification of Diseases (ICD-11). It has often been suggested that the field would benefit from a single, unified classification of mental disorders, although the priorities and constituencies of the two sponsoring organizations are quite different. During the development of the ICD-11 and DSM-5, the World Health Organization (WHO) and the APA made efforts toward harmonizing the two systems, including the appointment of an ICD-DSM Harmonization Group. This paper evaluates the success of these harmonization efforts and provides a guide for practitioners, researchers and policy makers describing the differences between the two systems at both the organizational and the disorder level. The organization of the two classifications of mental disorders is substantially similar. There are nineteen ICD-11 disorder categories that do not appear in DSM-5, and seven DSM-5 disorder categories that do not appear in the ICD-11. We compared the Essential Features section of the ICD-11 Clinical Descriptions and Diagnostic Guidelines (CDDG) with the DSM-5 criteria sets for 103 diagnostic entities that appear in both systems. We rated 20 disorders (19.4%) as having major differences, 42 disorders (40.8%) as having minor definitional differences, 10 disorders (9.7%) as having minor differences due to greater degree of specification in DSM-5, and 31 disorders (30.1%) as essentially identical. Detailed descriptions of the major differences and some of the most important minor differences, with their rationale and related evidence, are provided. The ICD and DSM are now closer than at any time since the ICD-8 and DSM-II. Differences are largely based on the differing priorities and uses of the two diagnostic systems and on differing interpretations of the evidence. Substantively divergent approaches allow for empirical comparisons of validity and utility and can contribute to advances in the field.

Scrutinizing Domains of Executive Function in Binge Eating Disorder: A Systematic Review and Meta-Analysis.

BACKGROUND: Cognitive deficits are implicated in theoretical explanatory models for binge eating disorder (BED). Furthermore, evidence suggest that alterations in executive function may underlie symptoms in BED. The current systematic review and meta-analysis provides an update on executive functioning in individuals with BED. METHODS: Literature searches (up to November 2019) were conducted in electronic databases combining binge eating or BED with executive functions. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines was used. Studies of any design comparing adults with BED with those without BED in executive function domains were selected. Methodological quality of studies was based on the Newcastle-Ottawa scale. RESULTS: Of 1,983 citations identified, 28 case-control studies met inclusion criteria for this review. Six meta-analyses that examined four domains (decision-making, cognitive flexibility, inhibitory control, and working memory) were conducted. The only meta-analysis to show a significant difference in executive functioning between BED and obese controls was working memory (SMD = 0.32, 95% IC: -0.60, -0.03; p = 0.028), with an effect size of small magnitude. Qualitative inspection of the literature indicated mixed findings for control inhibition, decision making and cognitive flexibility in individuals with BED compared to controls (obese or normal weight). In addition, people with BED showed poorer problem solving performance, but similar planning abilities to obese controls. CONCLUSIONS: Individuals with BED were found to show worse performance on working memory tasks compared to obese individuals without the disorder. The findings did not provide definitive evidence of alterations in other aspects of executive functioning. Interest in executive functioning in people with BED is increasing but is limited by insufficient data from small studies with varied methodology. Future studies should focus on using similar tests and outcome measures, in order to enable more pertinent comparisons across studies.

Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders.

Following approval of the ICD-11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD-10 to the ICD-11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders following ICD-11's approval. The development of the ICD-11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD-11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture-related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery-based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD-11 classification of mental disorders as compared to the ICD-10, and the development of two new ICD-11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD-11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD-11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD-11 and in preparing for implementation in their own professional contexts.

An Investigation of the Clinical Utility of the Proposed ICD-11 and DSM-5 Diagnostic Schemes for Eating Disorders Characterized by Recurrent Binge Eating in People with a High BMI.

The aims of this paper were to compare (1) the proportion of participants diagnosed with threshold or subthreshold Bulimia Nervosa (BN) and Binge Eating Disorder (BED) (clinical utility), and (2) the severity of participants' clinical features and mental Health-Related Quality of Life (HRQoL) (convergent validity), when diagnosed according to either the Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5) or the proposed International Classification of Diseases 11th edition (ICD-11) schemes. One hundred and seven adult men and women, with a high Body Mass Index (BMI) were evaluated by interview to confirm their eating disorder diagnoses. All participants completed self-report assessments of current symptoms and mental HRQoL. The majority of participants in either diagnostic scheme were included in the main categories of BN or BED (102/107, 95% in the ICD-11 and 85/107, 79% in the DSM-5). Fewer individuals received a subthreshold other or unspecified diagnosis with the ICD-11 compared to the DSM-5 scheme (5% vs. 21%). No significant differences in demographic, clinical features or mental HRQoL of participants with complete or partial BN or BED were found between diagnostic categories. Compared to the DSM-5, the proposed ICD-11 was not over inclusive, i.e., it did not appear to include people with less severe and potentially less clinically relevant symptoms. These results support the greater clinical utility of the ICD-11 whilst both schemes showed convergent validity.

Preventing weight-related problems among adolescent girls: A cluster randomized trial comparing the Brazilian 'New Moves' program versus observation.

PURPOSE: To conduct a cluster randomized controlled trial comparing the Brazilian version of the New Moves program (NMP) versus observation among Brazilian adolescent girls. METHODS: Ten schools were randomly allocated to the Brazilian NMP or the observation arm. Study participants included 12-14-year-old girls. Recruitment occurred between February 2014 and March 2015. The NMP included sports, nutritional support, motivational interviews, collective lunch, and parental information materials. Our main outcome was the Body Shape Questionnaire (BSQ). Secondary outcomes included the Rosenberg Self-Esteem Scale and the Unhealthy Weight-Control Behaviors Index, as well as body mass index. Study results were evaluated through generalized estimating equations. RESULTS: A total of 270 adolescents participated in the study. At baseline, mean age was 13.4 years, and average BMI was 21.4. The intervention did not result in any statistically significant differences between the NMP and the observation arm, including BSQ (predicted means of 64.33 - IC 95% 59.2-69.47 vs. 62.02 - IC 95% 56.63-67.4), respectively) and our secondary outcomes. Adherence was low during the intervention (32.9%) and maintenance (19.1%) phases of the program. CONCLUSION: The New Moves program did not lead to significant changes in our measured outcomes. Future studies should investigate whether changes might occur when comprehensive behavioral programs are sustained over longer periods while also being customized to local population characteristics.

Psychiatric disorders in adolescents with type 1 diabetes: a case-control study.

OBJECTIVES: To study the prevalence of psychiatric disorders in adolescents with and without type 1 diabetes, the factors associated with its presence, and to test the reliability of a screening tool for use in clinical settings. METHODS: Eighty-one adolescents were enrolled in this case-control study, including 36 diabetic participants and 45 controls. Clinical and sociodemographic data were collected and psychiatric symptoms and diagnoses were obtained from adolescents and their parents using a screening tool (Strengths & Difficulties Questionnaire) and a semi-structured interview (Development and Well-Being Assessment). RESULTS: Psychiatric disorders were identified in 22.2% of the sample (30.56% among diabetic adolescents vs. 15.56% of controls: OR = 2.39, 95%CI 0.82-6.99; p = 0.11). Overweight (body mass index percentile ≥ 85) was the only factor associated with psychiatric disorder (OR = 3.07; 95%CI 1.03-9.14; p = 0.04). Compared to the semi-structured interview, the screening instrument showed 80% sensitivity, 96% specificity, 88.9% positive predictive value and 92.3% negative predictive value for the presence of psychiatric diagnoses in adolescents. CONCLUSION: Psychiatric morbidity was high in this sample of adolescents, especially among those with diabetes. Routine use of the Strengths and Difficulties Questionnaire can help with early detection of psychiatric disorders in this at-risk group.