Changes in evening-shifted loss of control eating severity following treatment for binge-eating disorder.

BACKGROUND: Loss of control eating is more likely to occur in the evening and is uniquely associated with distress. No studies have examined the effect of treatment on within-day timing of loss of control eating severity. We examined whether time of day differentially predicted loss of control eating severity at baseline (i.e. pretreatment), end-of-treatment, and 6-month follow-up for individuals with binge-eating disorder (BED), hypothesizing that loss of control eating severity would increase throughout the day pretreatment and that this pattern would be less pronounced following treatment. We explored differential treatment effects of cognitive-behavioral guided self-help (CBTgsh) and Integrative Cognitive-Affective Therapy (ICAT). METHODS: Individuals with BED (N = 112) were randomized to receive CBTgsh or ICAT and completed a 1-week ecological momentary assessment protocol at baseline, end-of-treatment, and 6-month follow-up to assess loss of control eating severity. We used multilevel models to assess within-day slope trajectories of loss of control eating severity across assessment periods and treatment type. RESULTS: Within-day increases in loss of control eating severity were reduced at end-of-treatment and 6-month follow-up relative to baseline. Evening acceleration of loss of control eating severity was greater at 6-month follow-up relative to end-of-treatment. Within-day increases in loss of control severity did not differ between treatments at end-of-treatment; however, evening loss of control severity intensified for individuals who received CBTgsh relative to those who received ICAT at 6-month follow-up. CONCLUSIONS: Findings suggest that treatment reduces evening-shifted loss of control eating severity, and that this effect may be more durable following ICAT relative to CBTgsh.

Momentary skills use predicts decreased binge eating and purging early in day treatment: An ecological momentary assessment study.

OBJECTIVE: Emerging research indicates that skills acquisition may be important to behavior change in cognitive behavior therapy (CBT) for eating disorders. This study investigated whether skills use assessed in real time during the initial 4 weeks of CBT-based day treatment was associated with momentary eating disorder behavior change and rapid response to treatment. METHODS: Participants with DSM-5 bulimia nervosa or purging disorder (N = 58) completed ecological momentary assessments (EMA) several times daily for the first 28 days of treatment. EMA assessed skills use, the occurrence of binge eating and/or purging, and state negative affect. Rapid response was defined as abstinence from binge eating and/or purging in the first 4 weeks of treatment. RESULTS: Greater real-time skills use overall, and use of "planning ahead," "distraction," "social support," and "mechanical eating" skills in particular, were associated with a lower likelihood of engaging in binge eating or purging during the same period. After controlling for baseline group differences in overall difficulties with emotion regulation, rapid and non-rapid responders did not differ in overall skills use, or skills use at times of higher negative affect, during the EMA period. DISCUSSION: Momentary use of skills appears to play an important role in preventing binge eating and purging, and certain skills appear to be particularly helpful. These findings contribute to the literature elucidating the processes by which CBT treatments for eating disorders work by providing empirical evidence that skills use helps to prevent binge eating and purging behaviors. PUBLIC SIGNIFICANCE: Individuals with eating disorders learn new skills during treatment to help them improve their symptoms. This study shows that for people with eating disorders, using skills helps prevent eating disorder behaviors in the moment. Certain skills may be particularly helpful, including planning ahead, distracting activities, support from others, and focusing on eating meals and snacks regardless of how one is feeling. These findings help us better understand how treatments work.

Neurocognitive reward processes measured via event-related potentials are associated with binge-eating disorder diagnosis and ecologically-assessed behavior.

Altered reward processing has been implicated in the onset and maintenance of binge-eating disorder (BED). However, it is unclear which precise neurocognitive reward processes may contribute to BED. In the present study, 40 individuals with BED and 40 age-, sex-, and BMI-matched controls completed a reward (incentive delay) task while their neural activity was recorded using electroencephalography (EEG). Individuals with BED also completed a 10-day ecological momentary assessment (EMA) protocol assessing binge-eating behavior in the natural environment. Event-related potential (ERP) analysis of the EEG indicated that individuals with BED had stronger anticipatory (CNV) and outcome-related (RewP) neural reward activity to food and monetary rewards, compared to controls. However, within the BED group, greater frequency of binge eating during the EMA protocol was associated with stronger anticipatory (CNV) but weaker outcome-related (RewP) neural reward activity. These associations within the BED group were unique to food, and not monetary, rewards. Although preliminary, these results suggest that both anticipatory ("wanting") and outcome ("liking") reward processes may be generally amplified in BED. However, they also suggest that among individuals with BED, disorder severity may be associated with increased anticipatory reward processes ("wanting"), but relatively decreased reward-outcome processing ("liking"), of food rewards specifically.

An examination of state and trait urgency in individuals with binge-eating disorder.

OBJECTIVE: Negative urgency (i.e., acting rashly when experiencing negative affect; NU), is a theorised maintenance factor in binge-eating type eating disorders. This study examined the association between trait NU and eating disorder severity, momentary changes in state NU surrounding episodes of binge eating, and the momentary mechanistic link between affect, rash action, and binge-eating risk. METHODS: Participants were 112 individuals with binge-eating disorder (BED). Baseline measures included the UPPS-P Impulsive Behaviour Scale to assess trait NU and the Eating Disorders Examination to assess binge-eating frequency and global eating disorder severity. Ecological momentary assessment captured real-time data on binge eating, negative affect, and state NU. RESULTS: Multiple regression analysis revealed a strong association between trait NU and eating disorder severity. Generalised estimating equations showed that state NU increased before and decreased after binge-eating episodes, and that this pattern was not moderated by trait-level NU. Finally, a multilevel structural equation model indicated that increases in rash action mediated the momentary relationship between states of high negative affect and episodes of binge eating. CONCLUSION: These findings underscore the importance of both trait and state NU in binge-eating type eating disorders, and suggest NU as a potential key target for intervention.

Managing the common problem of co-occurring mental health conditions in eating disorders: A commentary on Wade et al. (2023).

It is well known that individuals with an eating disorder frequently experience a wide range of co-occurring mental health conditions which significantly impact eating disorders and quality of life. Clinicians attempt a variety of strategies to deal with the behavioral complexity of such co-occurrence, but little is known about empirically based interventions to treat this common comorbidity. The approach articulated by Wade and Colleagues highlights a potentially valuable strategy for empirically examining a range of treatment strategies to target the full spectrum of eating disorder psychopathology experienced by most patients with eating disorders.

Integrating aspects of affect, reward, and cognition to develop more comprehensive models of binge-eating pathology.

Reward-related processes are an increasing focus of eating disorders research. Although evidence suggests that numerous distinct reward processes may contribute to eating pathology (e.g., reward learning and delay discounting), existing etiological models of reward dysfunction tend to focus on only a limited number of reward processes, and frequently lack specificity when identifying the individual reward processes hypothesized to contribute to dysregulated eating behavior. Moreover, existing theories have been limited in their integration of reward-related processes with other demonstrated risk and maintenance factors for eating disorders (e.g., affect and cognition), potentially contributing to underdeveloped models of eating pathology. In this article, we highlight five distinct reward processes with theorized or demonstrated relevance to eating disorders involving binge-eating, followed by a review of two well-established risk/maintenance factors for binge-eating pathology. We then introduce two novel models of binge eating onset and maintenance that integrate these factors (i.e., the Affect, Reward, Cognition models), and discuss methods for testing each of the models in future research. Ultimately, we hope that the proposed models provide a springboard for the continued evolution of more precise and comprehensive theories of reward dysfunction in the eating disorders, as well as the development of novel intervention approaches. PUBLIC SIGNIFICANCE STATEMENT: Eating disorders are associated with abnormalities in multiple domains of reward functioning. However, models of reward dysfunction within the eating disorders have not been well-integrated with prominent models of affect and cognition. This article presents two novel models of onset and maintenance for binge-eating pathology, which attempt to integrate observed reward abnormalities with other affective and cognitive processes implicated in binge-type eating disorders.

Evaluating dietary restriction as a maintaining factor in binge-eating disorder.

OBJECTIVE: Prominent theories of binge-eating (BE) maintenance highlight dietary restriction as a key precipitant of BE episodes. Consequently, treatment approaches for eating disorders (including binge-eating disorder; BED) seek to reduce dietary restriction in order to improve BE symptoms. The present study tested the hypothesis that dietary restriction promotes BE among 112 individuals with BED. METHODS: Participants completed a 7-day ecological momentary assessment (EMA) protocol before and after completing 17 weeks of either Integrative Cognitive-Affective Therapy or guided self-help cognitive behavioral therapy. Analyses examined whether dietary restriction on 1 day of the baseline EMA protocol predicted risk for BE later that same day, and on the following day. Changes in dietary restriction over the course of treatment were also evaluated as a predictor of change in BE from pre-treatment to post-treatment. Baseline dietary restraint was examined as a moderator of the above associations. RESULTS: Dietary restriction did not predict BE later the same day, and changes in restriction were not related to changes in BE across treatment, regardless of baseline dietary restraint levels. Restriction on 1 day did predict increased BE risk on the following day for individuals with higher levels of dietary restraint, but not those with lower levels. DISCUSSION: These findings challenge the assumption that dietary restriction maintains BE among all individuals with BED. Rather, results suggest that dietary restriction may be largely unrelated to BE maintenance in this population, and that reducing dietary restriction generally does not have the intended effect on BE frequency.

Causal discovery analysis: A promising tool in advancing precision medicine for eating disorders.

OBJECTIVE: Precision medicine (i.e., individually tailored treatments) represents an optimal goal for treating complex psychiatric disorders, including eating disorders. Within the eating disorders field, most treatment development efforts have been limited in their ability to identify individual-level models of eating disorder psychopathology and to develop and apply an individually tailored treatment for a given individual's personalized model of psychopathology. In addition, research is still needed to identify causal relationships within a given individual's model of eating disorder psychopathology. Addressing this limitation of the current state of precision medicine-related research in the field will allow us to progress toward advancing research and practice for eating disorders treatment. METHOD: We present a novel set of analytic tools, causal discovery analysis (CDA) methods, which can facilitate increasingly fine-grained, person-specific models of causal relations among cognitive, behavioral, and affective symptoms. RESULTS: CDA can advance the identification of an individual's causal model that maintains that individuals' eating disorder psychopathology. DISCUSSION: In the current article, we (1) introduce CDA methods as a set of promising analytic tools for developing precision medicine methods for eating disorders including the potential strengths and weaknesses of CDA, (2) provide recommendations for future studies utilizing this approach, and (3) outline the potential clinical implications of using CDA to generate personalized models of eating disorder psychopathology. PUBLIC SIGNIFICANCE STATEMENT: CDA provides a novel statistical approach for identifying causal relationships among variables of interest for a given individual. Person-specific causal models may offer a promising approach to individualized treatment planning and inform future personalized treatment development efforts for eating disorders.

Time-of-day and day-of-week patterns of binge eating and relevant psychological vulnerabilities in binge-eating disorder.

OBJECTIVE: The present study sought to characterize the temporal patterns of binge eating and theorized maintenance factors among individuals with binge-eating disorder (BED). METHOD: Ecological momentary assessment of 112 individuals and mixed-effects models were used to characterize the within- and between-day temporal patterns of eating behaviors (binge eating, loss of control only eating, and overeating only), positive and negative affect, emotion regulation difficulty, and food craving. RESULTS: Risk for binge eating and overeating only was highest around 5:30 p.m., with additional binge-eating peaks around 12:30 and 11:00 p.m. In contrast, loss of control eating without overeating was more likely to occur before 2:00 p.m. Risk for binge eating, loss of control only eating, and overeating only did not vary across days in the week. There was no consistent pattern of change in negative affect throughout the day, but it decreased slightly on the weekend. Positive affect showed a decrease in the evenings and a smaller decrease on the weekend. The within-day patterns of food craving, and to some extent emotion regulation difficulty, resembled the pattern of binge eating, with peaks around meal times and at the end of the night. DISCUSSION: Individuals with BED appear most susceptible to binge-eating around dinner time, with heightened risk also observed around lunch time and late evening, though the effects were generally small. These patterns appear to most strongly mimic fluctuations in craving and emotion dysregulation, although future research is needed to test the temporal relationships between these experiences directly. PUBLIC SIGNIFICANCE: It is unknown which times of the day and days of the week individuals with binge-eating disorder are most at risk for binge eating. By assessing binge-eating behaviors in the natural environment across the week, we found that individuals are most likely to binge in the evening, which corresponds to the times when they experience the strongest food craving and difficulty with regulating emotions.

The role of eating expectancies and eating motives in the association between mood and loss-of-control eating: A national sample daily diary study.

Loss-of-control eating (LOCE, the subjective inability to refrain from eating or cease eating), is highly mood-driven. Mood-related eating motives and eating expectancies have been identified as contributors to binge eating. However, little is known about how these factors relate to LOCE, much less their relationship with daily-level LOCE. This study assessed the impact of trait eating expectancies and daily eating motives on the relationship between daily affective states and LOCE. United States adults (n = 109) reporting recent LOCE participated in a ten-day diary study, completing two surveys per day regarding eating behaviors, mood, and motives. Data were analyzed at the within- and between-subject levels utilizing a Bayesian approach to examine pathways from mood to LOCE, mediated by eating motives and accounting for a moderating impact of baseline eating expectancies on the path leg between mood and motives. Negative mood was associated with LOCE at both the within- and between-subjects level by way of coping motives, and directly at the within-subjects level. Negative affect (NA) reduction expectancies did not moderate the indirect pathway. Positive mood was only associated with LOCE at the within-subjects level, via pleasure motives. This relationship was potentiated via reward expectancies. Therefore, although negative mood appears be a robust predictor of LOCE regardless of trait NA reduction expectancies, positive mood appears to have a specific set of conditions under which individuals are at increased likelihood of LOCE at the within-subjects level. These findings suggest that eating expectancies and motives for eating may be meaningful targets in LOCE interventions.

Relative food abundance predicts greater binge-eating symptoms in subsequent hours among young adults experiencing food insecurity: Support for the "feast-or-famine" cycle hypothesis from an ecological momentary assessment study.

Food insecurity (FI) may increase risk for binge eating through a "feast-or-famine" cycle, where fluctuations in food availability correspond to alternating periods of food restriction and opportunities for binge eating, but research on this topic is limited. To clarify the relationship between food availability and binge eating in the context of FI, this study examined the association between momentary food security level and subsequent binge-eating symptoms among individuals in food-insecure households and investigated how this association differs by factors that may modify the extent to which food availability fluctuates. Ecological momentary assessment data were collected in 2020-2021 from 75 young adults (Mage = 25.3 ± 1.8 years; 72% female; 72% Black, Indigenous, or a Person of Color) in the United States who had experienced past-month household FI. For 14 days, participants reported four times per day on food security and eating episodes, and binge-eating symptoms were assessed for each reported eating episode. About 35% of the variance in momentary food security ratings was accounted for by within-person variability over time. A significant within-person association was observed in multilevel analyses, indicating that instances of greater food security relative to one's average level predicted greater subsequent binge-eating symptoms. Moderation analyses revealed that this association was significant only among individuals reporting use of food assistance programs, high engagement in resource trade-off coping strategies (e.g., skipping bill payments to buy food), or low food security-related self-efficacy. Overall, findings offer support for the "feast-or-famine" cycle hypothesis as an explanation for the link between FI and binge eating, emphasize the importance of identifying approaches to promote more stable access to adequate food, and suggest potential intervention targets to reduce risk for binge eating in populations experiencing FI.

Evaluation of an online modular eating disorders training (PreparED) to prepare healthcare trainees: a survey study.

BACKGROUND: Eating disorders (EDs) are serious, complex disorders for which broad-based clinical training is lacking. This study aimed to evaluate the efficacy of a free, brief, web-based curriculum, PreparED, in increasing comfort and confidence with, and knowledge about EDs in healthcare trainees, and to obtain program feedback from key stakeholders (i.e., learners). METHODS: This programmatic evaluation study was designed as a quantitative, repeated measures (i.e., pre- and post-test intervention) investigation. A convenience sample of two groups of healthcare trainees across geographically diverse training sites completed an anonymous survey pre- and post- engagement with PreparED. The survey included items to assess prior exposure to EDs, as well as program feasibility. The main educational outcomes included (1) Confidence and Comfort with EDs and (2) Knowledge of EDs. User experience variables of interest were likeability, usability, and engagement with the training modules. Mixed effects linear regression was used to assess the association between PreparED and educational outcome variables. RESULTS: Participants (N = 67) included 41 nutrition graduate students and 26 nurse practitioner students recruited from Teacher's College/Columbia University in New York, NY, USA, Columbia University School of Nursing in New York, NY, USA and North Dakota State University School of Nursing in Fargo, ND, USA. Confidence/Comfort scores and Knowledge scores significantly improved following engagement with PreparED (ß = for effect of intervention = 1.23, p < 0.001, and 1.69, p < 0.001, respectively). Neither training group nor prior exposure to EDs moderated the effect on outcomes. All learners agreed the program was easy to follow; the overwhelming majority (89.4%) felt the length of the modules was "just right." All participants perceived that PreparED had increased their knowledge of EDs, and the majority (94.0%) reported greater confidence in and comfort with caring for people with these disorders, including assessment of symptoms, awareness of associated medical complications, and likelihood of future screening. CONCLUSIONS: Findings suggest that brief, user-friendly, online courses can improve knowledge and attitudes about EDs, filling a critical gap in healthcare training.

Ecological momentary assessment of mood regulation eating expectancies in eating disorders: Convergent and predictive validity.

OBJECTIVE: Eating expectancies (EE) are the anticipation of various benefits or detriments from eating, with mood regulation being a salient type of EE associated with eating disorders. This study examined the convergent and predictive validity of ecological momentary assessment (EMA) mood regulation EE items, including mood improvement and mood worsening EE. METHODS: Thirty women with binge-eating pathology completed a 14-day EMA protocol, which included measures of mood regulation EE, affect, appetite, appearance- and body-related factors and disordered-eating behaviours. RESULTS: Greater within-subjects hunger and lower within-subjects positive affect and fullness were related to elevated mood improvement EE. Higher within-subjects appearance concerns, fullness, body social comparisons and thinness pressure were associated with higher mood worsening EE. Greater within-subjects mood worsening EE predicted greater likelihood of vomiting at the subsequent time point, but there were no within-subjects associations between mood improvement EE and behaviours. Yet, greater between-subjects mood worsening EE were associated with more restraint/restriction and binge eating, and greater between-subjects mood improvement EE were associated with more binge eating. CONCLUSIONS: Findings support the convergent validity of EMA mood regulation EE items. There was limited predictive validity evidence, suggesting complexities in how mood regulation EE predict behaviour in daily life.

Results of the first randomized controlled trial of integrated cognitive-behavioral therapy for eating disorders and posttraumatic stress disorder.

BACKGROUND: Eating disorders (EDs) and posttraumatic stress disorder (PTSD) frequently co-occur and can share a functional relationship. The primary aim of this initial randomized controlled trial was to determine whether integrated cognitive-behavioral therapy (CBT) for co-occurring ED-PTSD was superior to standard CBT for ED in improving PTSD symptoms. Intervention safety and desirability, as well as the relative efficacy of the treatments in improving anxiety, depression, and ED symptomatology, were also examined. METHODS: Following a course of intensive ED treatment, individuals with ED-PTSD were recruited to participate and randomized to integrated CBT for ED-PTSD or standard CBT for ED. The sample consisted of 42 individuals with a range of ED diagnoses. Outcomes were assessed at end-of-treatment, 3-, and 6-month follow-up using interview and self-report measures. RESULTS: Mixed models revealed significant interactions of time and therapy condition on clinician-rated and self-reported PTSD symptom severity favoring Integrated CBT for ED-PTSD. Both treatments were associated with statistically significant improvements in PTSD, anxiety, and depression. Improvements were maintained at 3- and 6-month follow-up. There was good safety with both interventions, and satisfaction with both treatments was high. However, there was a stronger preference for integrated treatment. CONCLUSIONS: Integrating CBTs for PTSD and ED following intensive ED treatment is safe, desirable, and efficacious for improving PTSD symptoms. Future studies with larger sample sizes are needed to determine whether Integrated CBT for ED-PTSD provides benefits over standard CBT for ED with respect to ED outcomes.

Micro-level de-coupling of negative affect and binge eating in relationship to macro-level outcomes in binge eating disorder treatment.

BACKGROUND: While negative affect reliably predicts binge eating, it is unknown how this association may decrease or 'de-couple' during treatment for binge eating disorder (BED), whether such change is greater in treatments targeting emotion regulation, or how such change predicts outcome. This study utilized multi-wave ecological momentary assessment (EMA) to assess changes in the momentary association between negative affect and subsequent binge-eating symptoms during Integrative Cognitive Affective Therapy (ICAT-BED) and Cognitive Behavior Therapy Guided Self-Help (CBTgsh). It was predicted that there would be stronger de-coupling effects in ICAT-BED compared to CBTgsh given the focus on emotion regulation skills in ICAT-BED and that greater de-coupling would predict outcomes. METHODS: Adults with BED were randomized to ICAT-BED or CBTgsh and completed 1-week EMA protocols and the Eating Disorder Examination (EDE) at pre-treatment, end-of-treatment, and 6-month follow-up (final N = 78). De-coupling was operationalized as a change in momentary associations between negative affect and binge-eating symptoms from pre-treatment to end-of-treatment. RESULTS: There was a significant de-coupling effect at follow-up but not end-of-treatment, and de-coupling did not differ between ICAT-BED and CBTgsh. Less de-coupling was associated with higher end-of-treatment EDE global scores at end-of-treatment and higher binge frequency at follow-up. CONCLUSIONS: Both ICAT-BED and CBTgsh were associated with de-coupling of momentary negative affect and binge-eating symptoms, which in turn relate to cognitive and behavioral treatment outcomes. Future research is warranted to identify differential mechanisms of change across ICAT-BED and CBTgsh. Results also highlight the importance of developing momentary interventions to more effectively de-couple negative affect and binge eating.

Borderline personality disorder symptoms as mediational mechanisms linking childhood trauma and nonsuicidal self-injury among women with bulimia nervosa.

OBJECTIVE: Nonsuicidal self-injury (NSSI) frequently co-occurs with eating disorders, especially bulimia nervosa (BN). Theoretical models and empirical evidence show many overlapping risk factors for the onset and maintenance of NSSI and BN. However, among those with BN, it remains unclear what distinguishes those who do versus do not engage in NSSI. The primary objective of the present study was to identify factors predicting NSSI among women with BN. Specifically, we tested four domains of borderline personality disorder as mediators between childhood trauma and NSSI. METHOD: Using structural equation modeling we tested a parallel mediation model to predict NSSI among women with BN (N = 130). Childhood trauma (measured by the Childhood Trauma Questionnaire at baseline) was the independent variable. The four parallel mediators (measured at baseline via the Diagnostic Interview for Borderlines, Revised) were lifetime negative affect, impulsive actions, atypical cognitions (e.g., odd thinking, unusual perceptual experiences, quasi-psychotic thinking), and interpersonal problems. The dependent variable was instances of NSSI during a subsequent two-week ecological momentary assessment protocol. RESULTS: Childhood trauma was significantly associated with all four mediators (all p values < .01), but only atypical cognitions predicted NSSI (p = .03). The indirect path from childhood trauma to NSSI, through atypical cognitions was significant (path coefficient = .001, SE < .001, p = .01). DISCUSSION: Among women with BN, childhood trauma was associated with atypical cognitions, which in turn predicted NSSI. Atypical cognitions may be a mechanism for NSSI in this population.

Attachment insecurity predicts worse outcome in patients with eating disorders treated with enhanced cognitive behavior therapy: A one-year follow-up study.

OBJECTIVE: This study aimed to explore the role of attachment insecurity in predicting a worse longitudinal trend of eating disorder (ED) psychopathology and body uneasiness in patients with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) treated with Enhanced Cognitive Behavior Therapy, considering the longitudinal interplay between these dimensions. METHOD: In total, 185 patients with AN or BN performed the baseline assessment, and 123 were re-evaluated after 1 year of treatment. Participants completed questionnaires evaluating ED psychopathology (Eating Disorders Examination Questionnaire) and body uneasiness (body uneasiness test). For the assessment of adult attachment, the Experiences in Close Relationships-Revised was administered at baseline. Bivariate latent change score analysis within the structural equation modeling framework was performed to investigate the evolution of ED psychopathology and body uneasiness, their longitudinal interplay, and the role of attachment style as an outcome predictor. RESULTS: After treatment, all psychopathological features showed an overall improvement. Higher baseline levels of body uneasiness predicted a worse course of ED psychopathology. The change in body uneasiness over time depended on changes over time in ED psychopathology, but not vice versa. Insecure attachment predicted a worse longitudinal trend of ED psychopathology, and, through this impairment, it indirectly maintained higher levels of body uneasiness, as confirmed by mediation analyses. DISCUSSION: The role of attachment insecurity as a predictor of treatment outcome suggests the need for an integration of the cognitive-behavioral conceptualization of EDs with a developmental perspective that considers attachment-related issues. PUBLIC SIGNIFICANCE STATEMENT: Considering the burden of EDs in terms of public health and the unsatisfactory response to standard treatments, the identification of outcome predictors is of considerable clinical interest. This study demonstrated that attachment insecurity was associated with worse longitudinal trends of ED psychopathology and body uneasiness in patients with AN and BN treated with CBT-E, highlighting the importance of personalizing treatment programs taking into account a developmental perspective on these disorders.

A 1-year follow-up study of the longitudinal interplay between emotion dysregulation and childhood trauma in the treatment of anorexia nervosa.

OBJECTIVE: The study aimed to investigate the complex relationship between eating disorder (ED) specific psychopathology, emotion dysregulation, and their longitudinal variations in patients with anorexia nervosa (AN) treated with a multidisciplinary approach including enhanced cognitive-behavior therapy (CBT-E), and to provide an integrated model which includes childhood trauma as a predictor of worse treatment outcomes. METHOD: In total, 120 female patients with AN were evaluated at admission (T0), and 105 were re-evaluated after 1 year (T1) of treatment. At T0, patients underwent a clinical assessment and filled the Symptom Checklist 90-Revised (SCL90-R), the Eating Disorders Examination Questionnaire (EDE-Q), the Difficulties in Emotion Regulation Scale (DERS), and the Childhood Trauma Questionnaire (CTQ). SCL-90-R, EDE-Q, and DERS were readministered at T1. Variations between T0 and T1 were evaluated, and the proposed model was investigated using bivariate latent change score analysis in a structural equation modeling (SEM) framework. RESULTS: An overall significant clinical amelioration was observed after treatment. A unidirectional effect of DERS scores on EDE-Q variations was outlined by SEM: patients with higher baseline DERS scores achieved less EDE-Q improvements, and EDE-Q latent change score was significantly predicted by longitudinal variations of DERS-but not vice versa. Higher CTQ scores predicted reduced treatment efficacy for ED-specific psychopathology through the mediating effect of higher baseline DERS scores. DISCUSSION: The present study sheds light on the mechanism by which early trauma compromises treatment outcome in patients with AN, underlining the crucial role of emotional dysregulation.

Negative affect and binge eating: Assessing the unique trajectories of negative affect before and after binge-eating episodes across eating disorder diagnostic classifications.

OBJECTIVE: Ecological momentary assessment (EMA) studies suggest that among individuals who binge eat, emotional states and binge eating are functionally related. However, it is unclear whether the trajectory of negative affect (NA) is the same across diagnostic groups or if specific changes in affect are unique to each diagnostic category. This study examined the moderating effect of diagnosis on the trajectory of negative affect before and after binge eating. METHOD: Adults with eating disorder diagnoses (anorexia nervosa [AN] = 118, bulimia nervosa [BN] = 133, binge-eating disorder [BED] = 112) completed an EMA where they reported binge eating and negative affect throughout the day. Generalized estimating equation analyses were used to model the trajectories of NA before and after binge eating. RESULTS: For all individuals, the linear trajectory of NA significantly increased before (B = 0.044, p < .001) and decreased following the binge-eating episode (B = -0.054, p < .001). However, diagnosis moderated this trajectory. Specifically, individuals with BN had a greater change in linear trajectories of NA before (B = 2.305, p < .001) and after (B = -4.149, p < .001) binge eating compared to those with BED, but not those with AN. There were no differences in the trajectory of NA between individuals with BED or AN. DISCUSSION: These findings suggest that binge-eating episodes in BN may be more strongly associated with NA than in BED, but similar to binge-eating episodes in AN.

It Is Not What Happens to You But How You React to It That Matters: PTSD as a Moderator of the Association Between Trauma and Impulsive Behaviors.

ABSTRACT: We examined the moderating role of posttraumatic stress disorder (PTSD) in the association between trauma and impulsive behaviors. Adult women ( N = 97) with a history of childhood sexual abuse (CSA; n = 26), rape in adulthood ( n = 21), both CSA and adult rape ( n = 25), or no history of sexual trauma ( n = 25) completed self-report questionnaires. PTSD symptoms were positively associated with self-harm and with stealing and accident proneness, but not with sexual impulsivity. Trauma group had no independent associations with impulsive behaviors. PTSD reexperiencing symptoms interacted with trauma group such that reexperiencing symptoms were positively associated with self-harm for the two trauma groups that included CSA but not for the control and adult rape-only groups. Overall, results indicate that PTSD symptoms-more so than the occurrence of trauma itself-associate with impulsive behavior. Results highlight the importance of assessing posttraumatic symptomatology, and not just trauma occurrence, when aiming to prevent or treat impulsive behaviors.