A Pilot Multisensory Approach for Emotional Eating: Pivoting from Virtual Reality to a 2-D Telemedicine Intervention during the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Emotional eating (EE), or eating in response to negative emotions or stress, can be understood as a manifestation of difficulties regulating emotions among individuals with eating disorders. To date, many virtual reality treatments for eating disorders have focused on body image or exposure methods and have not exclusively targeted EE. There has been a call made by experts in the field for a "new generation" of virtual reality interventions, capable of utilizing virtual reality's potential more fully. We developed a novel emotion regulation (ER) intervention based upon virtual reality to improve EE among adults with an eating disorder diagnosis. The study hypothesized that a novel ER protocol utilizing evidence-based strategies, as well as innovative techniques, would be feasible and acceptable and show preliminary signals of effectiveness for EE. MATERIALS AND METHODS: Due to COVID-19, the study pivoted from the original completely immersive intervention to a 2-D intervention deliverable over telehealth. Twenty-one patients were recruited from the Adult Eating Disorders Program within Stanford University to receive seven weekly one-hour virtual experiences (VEs) focusing on ER. Participants were not randomized but, as part of a pragmatic study design, chose between the novel VE-Emotion Regulation (VE-ER) intervention or continuing their treatment as usual. Before and after the seven sessions, participants completed an assessment by filling out online questionnaires. RESULTS: Overall, VE-ER treatment was feasible, and the participant and therapist acceptability of VE-ER treatment was fairly high. In terms of preliminary effectiveness, the results showed a significant reduction in the frequencies of disordered eating behaviors in both groups, but a greater improvement in EE in the VE-ER group and a significant reduction in emotion dysregulation after the treatment. CONCLUSIONS: This novel pilot study makes a valuable contribution to the scant literature by demonstrating the feasibility, acceptability, and preliminary effectiveness of combining somatic, multisensory, and cognitive manipulations delivered via telemedicine to help patients with EE to manage their emotions. The findings can serve as the basis for larger, controlled studies evaluating the translation of the somatic marker theory from the research literature into real-world U.S. clinic settings.

An exploratory investigation of predictors of outcome in face-to-face and online cognitive-behavioural therapy for bulimia nervosa.

OBJECTIVE: Cognitive-behavioural therapy (CBT) delivered face-to-face and via the internet reduces bulimia nervosa (BN) symptoms. However, our empirical understanding of factors affecting patient outcomes is limited. METHOD: Using data from a randomised, controlled trial comparing internet-based (CBT4BN, n = 78) with face-to-face (CBTF2F, n = 71) group CBT (97% female, M = 28 years), we examined general treatment (across conditions) and modality-specific predictors of end-treatment and 1-year outcomes (abstinence, binge-eating frequency, purging frequency). RESULTS: Improved eating disorder-related quality of life (EDQOL) during treatment and follow-up predicted abstinence at end-treatment and 1-year assessments. Improved EDQOL, disordered eating cognitions, and anxiety symptoms predicted less frequent binge eating and purging. Previous CBT and being employed predicted more frequent binge eating and purging at both assessments. Higher self-transcendence and self-directedness predicted less frequent binge eating. More severe binge eating and purging at baseline and end-treatment predicted more frequent binge eating and purging at subsequent assessments. Improved EDQOL was more strongly associated with positive outcome in CBT4BN; improved depressive symptoms and health-related QOL predicted positive outcome in CBT4BN but not CBTF2F. DISCUSSION: Symptom improvement and certain character traits predicted positive outcome, whereas more severe presentation and prior CBT experience predicted poorer outcome. Consideration of intreatment symptom improvement may facilitate care recommendations, particularly for internet-based modalities.

Translating Virtual Reality Cue Exposure Therapy for Binge Eating into a Real-World Setting: An Uncontrolled Pilot Study.

Binge-eating disorder (BED) and bulimia nervosa (BN) have adverse psychological and medical consequences. Innovative interventions, like the integration of virtual reality (VR) with cue-exposure therapy (VR-CET), enhance outcomes for refractory patients compared to cognitive behavior therapy (CBT). Little is known about the feasibility and acceptability of translating VR-CET into real-world settings. To investigate this question, adults previously treated for BED or BN with at least one objective or subjective binge episode/week were recruited from an outpatient university eating disorder clinic to receive up to eight weekly one-hour VR-CET sessions. Eleven of 16 (68.8%) eligible patients were enrolled; nine (82%) completed treatment; and 82% (9/11) provided follow-up data 7.1 (SD = 2.12) months post-treatment. Overall, participant and therapist acceptability of VR-CET was high. Intent-to-treat objective binge episodes (OBEs) decreased significantly from 3.3 to 0.9/week (p < 0.001). Post-treatment OBE 7-day abstinence rate for completers was 56%, with 22% abstinent for 28 days at follow-up. Among participants purging at baseline, episodes decreased from a mean of one to zero/week, with 100% abstinence maintained at follow-up. The adoption of VR-CET into real-world clinic settings appears feasible and acceptable, with a preliminary signal of effectiveness. Findings, including some loss of treatment gains during follow-up may inform future treatment development.

Parent-based prevention after parental weight loss surgery: a pilot case-series trial.

BACKGROUND: Overeating and obesity are elevated in children of parents who have undergone weight loss surgery. Parents who have undergone weight loss surgery often report their personal history of obesity interferes with their knowledge, skills, and self-efficacy in developing their children's healthy habits, thus reducing the likelihood of addressing obesogenic environmental factors. OBJECTIVES: This study examines whether a 6-session parent-based prevention after bariatric surgery online intervention is feasible and acceptable for parents. The study also explores the program's signal of efficacy in improving short-term outcomes related to decreased long-term risks for obesity by examining short-term impact on targeted parental cognitions, feeding practices, and child eating behaviors and physical activity habits. SETTING: University Hospital, United States. METHODS: Parents were recruited using flyers, clinician referrals, and social media. Measures assessed parental feeding practices, children's eating behaviors, daily hours of screen time, and outdoor play. RESULTS: Ten families enrolled and 7 completed the study. Parents found the intervention relevant and suitable for addressing their parenting concerns. Parental feeding behaviors, such as restriction and pressure to eat, reduced while tracking of sweets and high-fat snacks increased. Children reduced both emotional overeating and undereating. Children's daily hours of screen time reduced as well as their outdoor play time. CONCLUSIONS: Parent-based prevention after bariatric surgery aimed at helping parents who have undergone weight loss surgery engineer healthier family lifestyles is feasible, acceptable, and associated with reduced obesogenic risk factors.

Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy.

Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally.

The offspring of parents undergoing a weight loss surgery: a systematic review.

The offspring of parents with obesity are at an increased risk of developing this condition themselves because of genetic and environmental factors. One subgroup that may be at particularly high risk of developing obesity is the offspring of parents who have undergone weight loss surgery (PWLS). To date, little research has focused on these offspring or their parents. This systematic review addresses this gap by integrating available literature and assessing the quality of the evidence. To be included, studies were required to have researched characteristics of the offspring of PWLS or parental feeding practices within this population. After review, 12 studies met inclusion criteria. Findings include evidence for heightened risk of obesity among children of PWLS. However, research suggests these children may experience positive, although time-limited, health outcomes after their parents' surgeries. Quality of the evidence was rated as low, primarily because of the lack of randomized controlled studies and information regarding available interventions specifically targeting this vulnerable population. This review underscores the need for research to improve understanding of PWLS families to better support them and capitalize on postbariatric surgery benefits.

Parenting after Weight Loss Surgery: A Conceptual Model and Two Case Reports.

The ways families approach eating, shape, and weight can result in stress for individual family members and challenge the overall functioning of the family. This is further complicated among families with a parent who has history of obesity or undergone weight loss surgery (WLS). Although WLS can positively impact other family members, it can also exacerbate conflicts regarding feeding and weight. Such conflicts can involve uncertainty regarding the extent to which the entire family should make the dietary changes recommended for the post-WLS parent. Conflict might also center on the appropriate level of concern regarding the children's risk of developing (or maintaining) obesity. This paper uses two case examples to describe the application of a specialized, time-limited intervention: Parent-Based Prevention following Bariatric Surgery (PBP-B). The program was developed to address the unique challenges and concerns that arise after, or are exacerbated by, WLS. Each detailed case example illustrates a common child-feeding challenge and the employment of key PBP-B strategies throughout the course of treatment. In the first case, the parent who had undergone WLS believed the family's current eating behaviors were the same as those that had led to her own overeating, obesity, and co-occurring psychiatric symptoms, while her husband disagreed. In the second case, both parents were concerned about their son's weight, yet due to their prior eating histories, they felt unable to construct boundaries around the feeding experience. Both cases follow families through the entire intervention and illustrate key points and challenges. These cases underscore the need for novel treatment modalities to support families following parental WLS.

Las maneras en las que las familias abordan la alimentación, la figura y el peso pueden causar estrés en los integrantes individuales de la familia y poner a prueba el funcionamiento general de la familia. Esto es aun más complicado entre las familias con un padre que tiene antecedentes de obesidad o que se sometió a una cirugía para adelgazar. Aunque la cirugía para adelgazar puede repercutir de manera positiva en otros miembros de la familia, también puede exacerbar conflictos con respecto a la alimentación y al peso. Dichos conflictos pueden consistir en la incertidumbre con respecto al grado en el cual toda la familia debería hacer los cambios alimentarios recomendados para el padre que se ha operado para adelgazar. El conflicto también podría centrarse en el nivel adecuado de preocupación en relación con el riesgo de los niños de desarrollar (o mantener) la obesidad. Este artículo utiliza dos ejemplos de casos para describir la aplicación de una intervención especializada y limitada temporalmente: "La prevención basada en los padres después de una cirugía bariátrica" (Parent-Based Prevention following Bariatric Surgery, PBP-B). El programa se desarrolló para abordar los desafíos y las preocupaciones particulares que surgen después de la cirugía para adelgazar o que son exacerbados por esta. Cada ejemplo de un caso detallado ilustra un desafío común con respecto a la alimentación de los niños y al empleo de estrategias fundamentales de la PBP-B a lo largo del transcurso del tratamiento. En el primer caso, la madre que se había sometido a la cirugía para adelgazar creía que los comportamientos alimentarios actuales de la familia eran los mismos que los que la habían conducido a su propia sobreingesta, obesidad, y síntomas psiquiátricos concomitantes, mientras que su esposo no estaba de acuerdo. En el segundo caso, ambos padres estaban preocupados acerca del peso de su hijo, sin embargo, debido a sus antecedentes alimentarios previos, se sentían incapaces de establecer límites en torno a la experiencia alimentaria. Ambos casos siguen a las familias durante toda la intervención e ilustran puntos clave y desafíos. Estos casos subrayan la necesidad de incorporar modalidades innovadoras de tratamiento orientadas a apoyar a las familias después de la cirugía para adelgazar de uno de los padres.

Interventions to Empower Adults with Eating Disorders and Their Partners around the Transition to Parenthood.

The transition to parenthood is perceived as a stressful life event, when parents experience an immense change of their psychological focus and a reorientation of roles and responsibilities in the family system. This process may be even more challenging in the presence of a parental eating disorder history. This paper reviews the impact of parental eating disorders on the parents, the couple relationship, and their child during the perinatal period. A parental eating disorder is associated with more negative expectations of parental efficacy as well as specific difficulties in couple communication over the child's feeding, shape, and weight. Providers who better understand the effects of an eating disorder on parental functioning can more effectively intervene early on. We also present couple- or parent-based, empirically supported interventions for adults with eating disorders and their partners in the prenatal and postnatal periods: Uniting Couples in the treatment of Anorexia Nervosa (UCAN) and Uniting couples In the Treatment of Eating disorders (UNITE) both enhance recovery from the eating disorder through a couple-based intervention; the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) incorporates the support of partners, when appropriate; Parent-Based Prevention (PBP) focuses on improving parental functioning and reducing risk of negative parental and child outcomes. Finally, we discuss the clinical implications of addressing parental eating disorders and encourage more research on these families.

La transición a la paternidad se percibe como una situación estresante de la vida, cuando los padres sufren un cambio inmenso en su foco de atención psicológico y una reorientación de los roles y las responsabilidades en el sistema familiar. Este proceso puede ser aun más difícil en presencia de antecedentes de trastornos alimentarios en los padres. Este artículo analiza el efecto de los trastornos alimentarios parentales en los padres, la relación de pareja y su hijo durante el periodo perinatal. Un trastorno alimentario parental está asociado con expectativas más negativas de la eficacia parental así como con dificultades específicas en la comunicación entre la pareja sobre la alimentación, la figura y el peso del niño. Los profesionales que mejor comprendan los efectos de un trastorno alimentario en el funcionamiento parental pueden intervenir más eficazmente en etapas tempranas. También presentamos intervenciones respaldadas empíricamente basadas en la pareja o en los padres para adultos con trastornos alimentarios y sus parejas en los periodos prenatales y posnatales: la "Unión de las parejas en el tratamiento de la anorexia nerviosa" (UCAN) y la "Unión de las parejas en el tratamiento de los trastornos alimentarios" (UNITE) mejoran la recuperación del trastorno alimentario mediante una intervención basada en la pareja; el modelo Maudsley de tratamiento para adultos con anorexia nerviosa (MANTRA) incorpora el apoyo de las parejas, cuando es adecuado; la prevención basada en los padres (PBP) se centra en mejorar el funcionamiento parental y en reducir el riesgo de consecuencias negativas para los padres y los niños. Finalmente, debatimos las implicancias clínicas de abordar los trastornos alimentarios parentales y de fomentar más investigaciones sobre estas familias.

Body dissatisfaction in adolescent boys.

Body dissatisfaction is a significant mental health symptom present in adolescent girls and boys. However, it is often either disregarded in adolescent boys or examined using assessments that may not resonate with males. The present study addresses these issues, examining the manifestation, etiology, and correlates of 3 facets of body dissatisfaction in adolescent boys. Adolescent male twins aged 16- to 17-years-old from the Swedish Twin Study of Child and Adolescent Development were included along with a female comparison group: 915 monozygotic and 671 dizygotic same-sex twins. Body dissatisfaction was defined using measures of height dissatisfaction, muscle dissatisfaction, and the body dissatisfaction subscale of the Eating Disorder Inventory (EDI-BD). We examined the prevalence of body dissatisfaction, whether the facets of body dissatisfaction were phenotypically and etiologically distinct, and associations with specific externalizing and internalizing symptoms. For boys, muscle dissatisfaction scores were greater than height dissatisfaction scores. Results also indicated that height and muscle dissatisfaction were phenotypically and etiologically distinct from the EDI-BD. Unique associations were observed with externalizing and internalizing symptoms: muscle dissatisfaction with symptoms of bulimia nervosa and the EDI-BD with internalizing symptoms, body mass index, and drive for thinness. The facets of body dissatisfaction were also largely distinct in girls and unique between-sex associations with externalizing and internalizing symptoms emerged. Overall, male-oriented aspects of body dissatisfaction are distinct from female-oriented aspects of body dissatisfaction. To capture the full picture of male body dissatisfaction, multiple facets must be addressed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Association between Symptom Accommodation and Emotional Coregulation in Couples with Binge Eating Disorder.

Intense negative emotions and maladaptive behavioral strategies to reduce emotional distress occur not only in patients with various forms of psychopathology but also in their committed partners. One common strategy to reduce distress is for partners to accommodate to the symptoms of the disorder, which reduces distress short term but maintains symptoms long term. Accommodation is believed to be motivated by the partner reacting behaviorally to the patient's emotions, but the emotions of the partner in this context have yet to be examined. This pilot study examined how partner accommodation related to specific patterns of emotional coregulation between patients with binge eating disorder (BED) and their partners, before and after a couple-based intervention for BED. Vocally encoded emotional arousal was measured during couples' (n = 11) conversations about BED. As predicted, partners' emotional reactivity to patients' emotional arousal was associated with high accommodation before treatment. Thus, partners may use accommodation as a strategy to reduce both the patients' and their own distress. After treatment, partners' arousal was no longer associated with the patients' emotional arousal; instead, partners showed greater emotional stability over time, specifically when accommodation was low. Additionally, patients were less emotionally aroused after treatment. Therefore, treatment may have decreased overall emotionality of patients and altered the association between accommodation and partners' emotional reactivity. If replicated, this understanding of the emotional context associated with accommodation in BED can inform couple-based treatment by targeting specific emotional precipitants of behaviors that maintain symptoms.

La emociones negativas intensas y las estrategias conductuales desadaptativas para reducir el distrés emocional se producen no solo en pacientes con varias formas de psicopatología, sino también en sus parejas estables. Una estrategia común para disminuir el distrés es que las parejas se adapten a los síntomas del trastorno, lo cual reduce el distrés a corto plazo pero mantiene los síntomas a largo plazo. Se cree que la adaptación está motivada por la reacción conductual de la pareja a las emociones del paciente, pero las emociones de la pareja en este contexto aún no se han analizado. Este estudio piloto examinó cómo la adaptación de la pareja está relacionada con patrones específicos de corregulación emocional entre los pacientes con trastorno por atracón de alimentos y sus parejas, antes y después de una intervención en la pareja por trastorno por atracón de alimentos. Se midió la excitación emocional codificada en la voz durante conversaciones de las parejas (n = 11) acerca del trastorno por atracón de alimentos. Como se anticipó, la reacción emocional de las parejas a la excitación emocional de los pacientes estuvo asociada con una alta adaptación antes del tratamiento. Por lo tanto, las parejas pueden usar la adaptación como estrategia para reducir tanto el distrés de los pacientes como el propio. Después del tratamiento, la excitación de las parejas dejó de estar asociada con la excitación emocional de los pacientes. En cambio, las parejas demostraron una mayor estabilidad emocional con el tiempo, específicamente cuando la adaptación fue baja. Además, los pacientes estuvieron menos excitados emocionalmente después del tratamiento. En consecuencia, el tratamiento pudo haber disminuido la emocionalidad general de los pacientes y modificado la asociación entre la adaptación y la reacción emocional de las parejas. Si se reproduce, esta comprensión del contexto emocional asociada con la adaptación en los trastornos por atracón de alimentos puede fundamentar el tratamiento basado en la pareja abordando precipitantes emocionales específicos de conductas que mantienen los síntomas.

A pilot open trial of UNITE-BED: A couple-based intervention for binge-eating disorder.

OBJECTIVE: To evaluate the feasibility, acceptability, and preliminary efficacy of a couple-based intervention for binge-eating disorder (BED), called UNiting couples In the Treatment of Eating disorders-BED edition (UNITE-BED). METHOD: In an open pilot trial, 11 couples in which one or both adult partners had a diagnosis of DSM-5 threshold or sub-threshold BED participated in 22 weekly sessions of UNITE-BED. Patients also received individual treatment, outside of the context of the trial. Couples completed measures on treatment satisfaction, eating disorder symptom severity, depression, anxiety, emotion regulation, and relational functioning at post-treatment and 3-month follow-up. Statistical analyses were conducted to identify change over the course of treatment. RESULTS: UNITE was feasible and acceptable to the majority of couples (9% dropout; high satisfaction ratings). Objective binge abstinence was 81.8% and subjective binge abstinence was 45.5% by post-treatment. Patient binge-eating symptomatology reduced over the course of treatment with results maintained at follow up. Patients' depression symptoms decreased and patients' emotion regulation improved at both time points. DISCUSSION: Including partners in treatment for BED may be beneficial. Results support further evaluation of the efficacy of couple-based interventions for BED in larger randomized-controlled trials.

Cost-Effectiveness of Internet-Based Cognitive-Behavioral Treatment for Bulimia Nervosa: Results of a Randomized Controlled Trial.

OBJECTIVE: To evaluate the cost-effectiveness of Internet-based cognitive-behavioral therapy for bulimia nervosa (CBT-BN) compared to face-to-face delivery of CBT-BN. METHODS: This study is a planned secondary analysis of data from a randomized clinical trial. Participants were 179 adults (98% female, mean age = 28 years) meeting DSM-IV criteria for bulimia nervosa who were randomized to group face-to-face or group Internet-based CBT-BN for 16 sessions during 20 weeks. The cost-effectiveness analysis was conducted from a third-party payor perspective, and a partial societal perspective analysis was conducted to investigate cost-utility (ie, cost per gain in quality-adjusted life-years) and patient out-of-pocket travel-related costs. Net health care costs were calculated from protocol and nonprotocol health care services using third-party payor cost estimates. The primary outcome measure in the clinical trial was abstinence from binge eating and purging, and the trial start and end dates were 2008 and 2016. RESULTS: The mean cost per abstinent patient at posttreatment was $7,757 (95% confidence limit [CL], $4,515, $13,361) for face-to-face and $11,870 (95% CL, $6,486, $22,188) for Internet-based CBT-BN, and at 1-year follow-up was $16,777 (95% CL, $10,298, $27,042) for face-to-face and $14,561 (95% CL, $10,165, $21,028) for Internet-based CBT-BN. There were no statistically significant differences between treatment arms in cost-effectiveness or cost-utility at posttreatment or 1-year follow-up. Out-of-pocket patient costs were significantly higher for face-to-face (mean [95% CL] = $178 [$127, $140]) than Internet-based ($50 [$50, $50]) therapy. CONCLUSIONS: Third-party payor cost-effectiveness of Internet-based CBT-BN is comparable with that of an accepted standard. Internet-based dissemination of CBT-BN may be a viable alternative for patients geographically distant from specialist eating disorder services who have an unmet need for treatment. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00877786​.

Potential Predictors of Injury Among Pre-Professional Ballet and Contemporary Dancers.

Injuries occur frequently among ballet and contemporary dancers. However, limited literature exists on injuries to pre-professional dancers in the USA. The goals of this study were to 1. provide a descriptive epidemiology of the incidence of musculoskeletal injuries in an adolescent and young adult dance population and 2. identify parsimonious regression models that could be potentially used to predict injury incidence. The study was based at the University of North Carolina School of the Arts (UNCSA) from Fall 2009 to Spring 2015. An injury was defined as any event that caused a dancer to be seen at the UNCSA Student Health Services and caused the dancer to modify or curtail dance activity for at least 1 day. Injury rate ratios (IRRs) were calculated using negative binomial generalized estimating equations. Models predicting injury rates were built using forward selection, stratified by sex. Among 480 dancers, 1,014 injuries were sustained. Most injuries were to the lower extremity and the result of overuse. There were differences in upper extremity, lower extremity, and traumatic injury rates by demographic subgroups. Among females, the most parsimonious predictive model for injury rates included a self-reported history of depression, age at time of injury, and number of injuries sustained at UNCSA prior to the semester of current injury. Among males, the most parsimonious model was a univariate model with family history of alcohol or drug problems. Strategies for traumatic injury prevention among dancers should be both sex- and style-specific. No differences were observed in overuse injury rates by sex or style, suggesting that generic overuse prevention strategies may not need to be guided by these factors. It is concluded that strategies can be implemented to reduce and mitigate the consequences of injuries if not the injuries themselves.

The core symptoms of bulimia nervosa, anxiety, and depression: A network analysis.

Bulimia nervosa (BN) is characterized by symptoms of binge eating and compensatory behavior, and overevaluation of weight and shape, which often co-occur with symptoms of anxiety and depression. However, there is little research identifying which specific BN symptoms maintain BN psychopathology and how they are associated with symptoms of depression and anxiety. Network analyses represent an emerging method in psychopathology research to examine how symptoms interact and may become self-reinforcing. In the current study of adults with a Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) diagnosis of BN (N = 196), we used network analysis to identify the central symptoms of BN, as well as symptoms that may bridge the association between BN symptoms and anxiety and depression symptoms. Results showed that fear of weight gain was central to BN psychopathology, whereas binge eating, purging, and restriction were less central in the symptom network. Symptoms related to sensitivity to physical sensations (e.g., changes in appetite, feeling dizzy, and wobbly) were identified as bridge symptoms between BN, and anxiety and depressive symptoms. We discuss our findings with respect to cognitive-behavioral treatment approaches for BN. These findings suggest that treatments for BN should focus on fear of weight gain, perhaps through exposure therapies. Further, interventions focusing on exposure to physical sensations may also address BN psychopathology, as well as co-occurring anxiety and depressive symptoms. (PsycINFO Database Record

Predictors of dropout in face-to-face and internet-based cognitive-behavioral therapy for bulimia nervosa in a randomized controlled trial.

OBJECTIVE: We sought to identify predictors and moderators of failure to engage (i.e., pretreatment attrition) and dropout in both Internet-based and traditional face-to-face cognitive-behavioral therapy (CBT) for bulimia nervosa. We also sought to determine if Internet-based treatment reduced failure to engage and dropout. METHOD: Participants (N = 191, 98% female) were randomized to Internet-based CBT (CBT4BN) or traditional face-to-face group CBT (CBTF2F). Sociodemographics, clinical history, eating disorder severity, comorbid psychopathology, health status and quality of life, personality and temperament, and treatment-related factors were investigated as predictors. RESULTS: Failure to engage was associated with lower perceived treatment credibility and expectancy (odds ratio [OR] = 0.91, 95% CI: 0.82, 0.97) and body mass index (BMI) (OR = 1.10; 95% CI: 1.03, 1.18). Dropout was predicted by not having a college degree (hazard ratio [HR] = 0.55; 95% CI: 0.37, 0.81), novelty seeking (HR = 1.02; 95% CI: 1.01, 1.03), previous CBT experience (HR = 1.77; 95% CI: 1.16, 2.71), and randomization to the individual's nonpreferred treatment format (HR = 1.95, 95% CI: 1.28, 2.96). DISCUSSION: Those most at risk of failure to engage had a higher BMI and perceived treatment as less credible and less likely to succeed. Dropout was associated with less education, higher novelty seeking, previous CBT experience, and a mismatch between preferred and assigned treatment. Contrary to expectations, Internet-based CBT did not reduce failure to engage or dropout. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:569-577).

CBT4BN: A Randomized Controlled Trial of Online Chat and Face-to-Face Group Therapy for Bulimia Nervosa.

OBJECTIVE: Although cognitive-behavioral therapy (CBT) represents the first-line evidence-based psychotherapy for bulimia nervosa (BN), most individuals seeking treatment do not have access to this specialized intervention. We compared an Internet-based manualized version of CBT group therapy for BN conducted via a therapeutic chat group (CBT4BN) to the same treatment conducted via a traditional face-to-face group therapy (CBTF2F). METHOD: In a two-site, randomized, controlled noninferiority trial, we tested the hypothesis that CBT4BN would not be inferior to CBTF2F. A total of 179 adult patients with BN (2.6% males) received up to 16 sessions of group CBT over 20 weeks in either CBT4BN or CBTF2F, and outcomes were compared at the end of treatment and at the 12-month follow-up. RESULTS: At the end of treatment, CBT4BN was inferior to CBTF2F in producing abstinence from binge eating and purging. However, by the 12-month follow-up, CBT4BN was mostly not inferior to CBTF2F. Participants in the CBT4BN condition, but not CBTF2F, continued to reduce their binge-eating and purging frequency from the end of treatment to the 12-month follow-up. CONCLUSIONS: CBT delivered online in a group chat format appears to be an efficacious treatment for BN, although the trajectory of recovery may be slower than face-to-face group therapy. Online chat groups may increase accessibility of treatment and represent a cost-effective approach to service delivery. However, barriers in service delivery such as state-specific license and ethical guidelines for online therapists need to be addressed.

Body image, aging, and identity in women over 50: The Gender and Body Image (GABI) study.

We conducted a qualitative study of 1,849 women over age 50 to capture the thoughts, feelings, and attitudes that women at middle age have about their bodies and the experience of aging. Via an open-ended question online survey, four primary themes emerged: (a) the physical and psychological experience of aging; (b) the injustices, inequities, and challenges of aging; (c) the importance of self-care; and (d) a plea for recognition of the need to maintain a contributory role in society. Results highlight the complexities of women's psychological and physical aspects of aging and point toward important topics worthy of further study in this growing population.

Eating disorders in midlife women: A perimenopausal eating disorder?

Eating disorders afflict women across the lifespan with peak onset during critical or sensitive developmental periods of reproductive hormone change, such as puberty. A growing body of research supports the role of reproductive hormones, specifically estrogen, in the risk for eating disorders and related symptomatology in adolescence and young adulthood. Like puberty, perimenopause is characterized by estrogen change and may also present a window of vulnerability to eating disorder development. Here, we discuss the evidence that suggests perimenopause indeed may be a vulnerable period for the development or redevelopment of an eating disorder for midlife women. Drawing from what is known about the influence of estrogen on eating disorders at younger ages and from other psychiatric disorders with similar risk trajectories (i.e., perimenopausal depression), we describe a potential mechanism of risk for a perimenopausal eating disorder and how this can be explored in future research. Investigating vulnerability to perimenopausal eating disorders will clarify eating disorder etiology, identify reproductive stage-specific risk profiles, and guide future treatment directions.

Familial Liability for Eating Disorders and Suicide Attempts: Evidence From a Population Registry in Sweden.

IMPORTANCE: Suicide attempts are common in individuals with eating disorders. More precise understanding of the mechanisms underlying their concomitant occurrence is needed. OBJECTIVE: To examine the association between eating disorders and suicide attempts and whether familial risk factors contribute to the association. DESIGN, SETTING, AND PARTICIPANTS: A Swedish birth cohort including individuals born in Sweden between January 1, 1979, and December 31, 2001, was followed up from age 6 years to December 31, 2009 (N = 2,268,786). Information was acquired from Swedish national registers. All individuals were linked to their biological full siblings, maternal half siblings, paternal half siblings, full cousins, and half cousins. Data analysis was conducted from October 5, 2014, to April 28, 2015. MAIN OUTCOMES AND MEASURES: Eating disorders were captured by 3 variables (any eating disorder, anorexia nervosa, and bulimia nervosa) identified by any lifetime diagnoses recorded in the registers. Suicide attempts were defined as any suicide attempts, including death by suicide, recorded in the registers. We examined the association between eating disorders and death by suicide separately, but the study was underpowered to explore familial liability for this association. RESULTS: Of 2,268,786 individuals, 15,457 females (1.40% of all females) and 991 males (0.09% of all males) had any eating disorder, 7680 females (0.70%) and 453 males (0.04%) had anorexia nervosa, and 3349 females (0.30%), and 61 males (0.01%) had bulimia nervosa. Individuals with any eating disorder had an increased risk (reported as odds ratio [95% CI]) of suicide attempts (5.28 [5.04-5.54]) and death by suicide (5.39 [4.00-7.25]). The risks were attenuated but remained significant after adjusting for comorbid major depressive disorder, anxiety disorder, and substance use disorder (suicide attempts: 1.82 [1.72-1.93]; death by suicide: 2.04 [1.49-2.80]). Similar results were found for anorexia nervosa (suicide attempts: crude, 4.42 [4.12-4.74] vs adjusted, 1.70 [1.56-1.85]; death by suicide: crude, 6.46 [4.38-9.54] vs adjusted, 2.67 [1.78-4.01]) and bulimia nervosa (suicide attempts: crude, 6.26 [5.73-6.85] vs adjusted, 1.88 [1.68-2.10]; death by suicide: crude, 4.45 [2.44-8.11] vs adjusted, 1.48 [0.81-2.72]). Individuals (index) who had a full sibling with any eating disorder had an increased risk of suicide attempts (1.41 [1.29-1.53]). The risk was attenuated for any eating disorder in more-distant relatives (maternal half siblings, 1.10 [0.90-1.34]; paternal half siblings, 1.21 [0.98-1.49]; full cousins, 1.11 [1.06-1.18]; half cousins, 0.90 [0.78-1.03]). This familial pattern remained stable after adjusting for the index individuals' eating disorders. Similar patterns were found for anorexia nervosa and bulimia nervosa. CONCLUSIONS AND RELEVANCE: These results suggest an increased risk of suicide attempts in individuals with lifetime eating disorders and their relatives. The pattern of familial coaggregation suggests familial liability for the association between eating disorders and suicide. Psychiatric comorbidities partially explain this association, suggesting particularly high-risk presentations.

Couple-Based Interventions for Adults With Eating Disorders.

A significant number of adults with eating disorders fail to achieve relief from the disorder, with many dropping out of treatment or relapsing. The standard treatment remains individual therapy despite partners being negatively affected and typically wanting to help in an effective and loving way. We propose that couple-based interventions, which leverage the support of a partner and the relationship in treatment, may improve outcome and recovery rates for adults with eating disorders. In this article, we survey the empirical literature supporting the treatment of adults in a couple context and describe our existing and emerging couple-based interventions for eating disorders.