Predictors of Symptom Trajectories After Cognitive-Behavioral Therapy in Adolescents With an Age-Adapted Diagnosis of Binge-Eating Disorder

Although evidence demonstrated efficacy of cognitive-behavioral therapy (CBT) in adolescents with binge-eating disorder (BED), treatment response is heterogeneous. This study uniquely examined baseline predictors of symptom trajectories in N = 73 adolescents (12–20 years) with an age-adapted diagnosis of BED (i.e., based on objective and subjective binge-eating episodes). Based on evidence from adult BED, dietary restraint, overvaluation of weight/shape, and depressive symptoms were used to predict changes in abstinence from binge eating and eating disorder psychopathology after 4 months of individual, face-to-face CBT using growth models. Longitudinal trajectories of abstinence from objective and subjective binge eating and global eating disorder psychopathology assessed via the Eating Disorder Examination were modeled for five time points (pre- and posttreatment, 6-, 12-, and 24-month follow-up). Beyond significant, positive effects for time, no significant predictors for abstinence from binge eating emerged. In addition to significant decreases in eating disorder psychopathology over time, higher pretreatment dietary restraint and overvaluation of weight/shape significantly predicted greater decreases in eating disorder psychopathology over time. Consistent with research in adult BED, adolescents with higher than lower eating disorder-specific psychopathology especially benefit from CBT indicating that restrained eating and overvaluation of weight/shape may be BED-specific prognostic characteristic across developmental stages. Future predictor studies with an additional focus on potential age-specific predictors, such as family factors, and within-treatment processes may be critical in further evaluating treatment-related symptom trajectories in adolescent BED.     

Overvaluation of shape and weight in binge eating disorder and overweight controls: refinement of a diagnostic construct

Debate continues regarding the nosological status of binge eating disorder (BED) as a diagnosis as opposed to simply reflecting a useful marker for psychopathology. Contention also exists regarding the specific criteria for the BED diagnosis, including whether, like anorexia nervosa and bulimia nervosa, it should be characterized by overvaluation of shape/weight. The authors compared features of eating disorders, psychological distress, and weight among overweight BED participants who overvalue their shape/weight (n=92), BED participants with subclinical levels of overvaluation (n=73), and participants in an overweight comparison group without BED (n=45). BED participants categorized with clinical overvaluation reported greater eating-related psychopathology and depression levels than those with subclinical overvaluation. Both BED groups reported greater overall eating pathology and depression levels than the overweight comparison group. Group differences existed despite similar levels of overweight across the 3 groups, as well as when controlling for group differences in depression levels. These findings provide further support for the research diagnostic construct and make a case for the importance of shape/weight overvaluation as a diagnostic specifier.     

Overvaluation of shape and weight in binge eating disorder, bulimia nervosa, and sub-threshold bulimia nervosa

Increasing empirical evidence supports the validity of binge eating disorder (BED), a research diagnosis in the appendix of DSM-IV, and its inclusion as a distinct and formal diagnosis in the DSM-V. A pressing question regarding the specific criteria for BED diagnosis is whether, like bulimia nervosa (BN), it should be characterized by overvaluation of shape and weight. This study compared features of eating disorders in 436 treatment-seeking women comprising four groups: 195 BED participants who overvalue their shape/weight, 129 BED participants with subclinical levels of overvaluation, 61 BN participants, and 51 participants with sub-threshold BN. The BED clinical overvaluation group had significantly higher levels of specific eating disorder psychopathology than the three other groups which did not differ significantly from each other. Findings suggest that overvaluation of shape and weight should not be considered as a required criterion for BED because this would exclude a substantial proportion of BED patients with clinically significant problems. Rather, overvaluation of shape and weight warrants consideration either as a diagnostic specifier or as a dimensional severity rating as it provides important information about severity within BED.     

The significance of overvaluation of shape and weight in binge eating disorder

As publication of DSM-V draws near, research is needed to validate the diagnostic scheme for binge eating disorder (BED). Shape and weight overvaluation has stimulated considerable debate in this regard, given associations with psychosocial impairment and poor treatment outcome in BED. This study sought to further explore the convergent validity and diagnostic specificity of shape and weight overvaluation in BED. A total of 160 women with BED, and 108 women with non-eating disordered psychiatric disorders were recruited from the community. Women with BED were classified as more or less severe based on a global measure of eating-related psychopathology; subsequent receiver operating characteristics analysis determined that a threshold of at least “moderate” overvaluation best predicted membership into a more severe group. BED participants with threshold overvaluation exhibited poorer psychosocial functioning than those with subthreshold overvaluation, as well as participants with other psychiatric disorders. Discriminant function analysis revealed that threshold overvaluation predicted a diagnosis of BED versus other psychiatric disorder with 67.7% accuracy. Results suggest that shape and weight overvaluation is a useful diagnostic specifier in BED. Continued research is warranted to examine its predictive validity in natural course and treatment outcome studies.     

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

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

Recurrent binge eating with and without the "undue influence of weight or shape on self-evaluation": implications for the diagnosis of binge eating disorder

Levels of eating disorder psychopathology, impairment in psycho-social functioning and use of health services were compared among probable cases of binge eating disorder (BED) with and without extreme weight or shape concerns ("undue influence of weight or shape on self-evaluation") recruited from a large community sample of women. Data for obese non-binge eaters (n=457), also recruited from the community sample, and for a clinical sample of eating disorder patients (n=128), recruited separately, were included for comparative purposes. BED cases who reported extreme weight or shape concerns (n=51, 46.4%) had significantly higher levels of eating disorder psychopathology and functional impairment than those who did not report such concerns (n=59), after controlling for between-group differences in age and body weight. In addition, BED cases who reported extreme weight or shape concerns were more likely to have sought treatment for an eating or weight problem than those who did not. Whereas levels of eating disorder psychopathology and functional impairment were markedly elevated among BED cases with extreme weight or shape concerns, BED cases who did not report extreme weight or shape concerns resembled obese non-binge eaters in most respects. The findings support the inclusion of an undue influence of weight or shape on self-evaluation as a diagnostic criterion for BED. In the absence of this influence, eating disorders that otherwise resemble BED do not appear to be "clinically significant".     

Body image interventions in cognitive-behavioural therapy of binge-eating disorder: a component analysis

The present study sought to investigate effects of body exposure in the treatment of binge-eating disorder (BED). Cognitive-behavioural therapy with a body exposure component (CBT-E) was compared with CBT with a cognitive restructuring component focused on body image (CBT-C). Twenty-eight patients diagnosed with BED were randomly assigned to CBT-E or CBT-C, both delivered in a group format. Negative automatic thoughts about one's body, dysfunctional assumptions about shape and weight, and body dissatisfaction were assessed using experimental thought-sampling techniques, a clinical interview (Eating Disorder Examination), and self-report questionnaires. At posttreatment and at 4-month follow-up, CBT-E and CBT-C were equally effective in improving body image disturbance on all indicators assessed. Both CBT-E and CBT-C produced substantial and stable improvements in the specific and general eating disorder psychopathology. Results suggest that both treatment components are equally effective in the treatment of BED.     

Assessment of eating disorder psychopathology in obese children and adolescents: interview versus self-report questionnaire

The present study compared two methods for assessing binge eating and related eating disorder psychopathology in obese children and adolescents. A comparison was made between the child version of the Eating Disorder Examination (ChEDE) and the self-report version of the interview (ChEDE-Q). A total of 139 children and adolescents (aged 10-16 years) seeking inpatient treatment for obesity completed the ChEDE questionnaire and were administered the ChEDE interview afterwards. The ChEDE and ChEDE-Q were significantly correlated for the four subscales: restraint, eating concern, weight concern and shape concern. The ChEDE-Q generated consistently higher levels of eating disorder psychopathology. There was a significant discrepancy for the assessment of a more complex feature such as binge eating. Overall, the current study found lower levels of agreement between the EDE and EDE-Q than previously reported in adult samples. It appears that children and adolescents have difficulties in identifying binge-eating episodes when they receive no detailed instruction. It is concluded that a clinical interview is necessary to identify eating disorders in obese children and that a self-report questionnaire can only be used as a screening tool. Even then, thorough clarification of the definition of the eating disorder features is needed when using a self-report questionnaire.     

Self-help for binge eating disorder in primary care: A randomized controlled trial with ethnically and racially diverse obese patients

Objective

The objective was to examine the effectiveness of a self-help treatment as a first line primary care intervention for binge eating disorder (BED) in obese patients. This study compared the effectiveness of a usual care plus self-help version of cognitive behavioral therapy (shCBT) to usual care (UC) only in ethnically/racially diverse obese patients with BED in primary care settings in an urban center.

Method

48 obese patients with BED were randomly assigned to either shCBT (N = 24) or UC (N = 24) for four months. Independent assessments were performed monthly throughout treatment and at post-treatment.

Results

Binge-eating remission rates did not differ significantly between shCBT (25%) and UC (8.3%) at post-treatment. Mixed models of binge eating frequency determined using the Eating Disorder Examination (EDE) revealed significant decreases for both conditions but that shCBT and UC did not differ. Mixed models of binge eating frequency from repeated monthly EDE-questionnaire assessments revealed a significant treatment-by-time interaction indicating that shCBT had significant reductions whereas UC did not during the four-month treatments. Mixed models revealed no differences between groups on associated eating disorder psychopathology or depression. No weight loss was observed in either condition.

Conclusions

Our findings suggest that pure self-help CBT did not show effectiveness relative to usual care for treating BED in obese patients in primary care. Thus, self-help CBT may not have utility as a front-line intervention for BED for obese patients in primary care and future studies should test guided-self-help methods for delivering CBT in primary care generalist settings.     

Overvaluation of shape and weight among overweight children and adolescents with loss of control eating

Little is known about the phenomenology of pediatric loss of control (LOC) eating. Overvaluation of shape and weight, however, appears to be diagnostically meaningful among binge eating adults. We explored the significance of shape and weight overvaluation among children and adolescents with LOC eating. Participants (n = 526) included 149 overweight youth with LOC eating and 377 overweight controls (CON). Participants were categorized as those reporting at least moderate overvaluation (LOC-Mod, n = 74; CON-Mod, n = 106) or less than moderate overvaluation (LOC-Low, n = 75; CON-Low, n = 271), and compared on measures of eating-related and general psychopathology. LOC-Mod evidenced lower self-esteem than CON-Low, and greater behavioral problems than CON-Mod and CON-Low, but did not differ from LOC-Low in these domains. With the exception of LOC-Low and CON-Mod, all groups differed on global eating-disorder severity, with LOC-Mod scoring the highest. Overvaluation of shape and weight appears to be of questionable importance in defining subtypes of youth with LOC eating. However, as overvaluation and LOC eating each independently predicts eating-disorder onset, their confluence may confer even further risk for eating-disorder development. Longitudinal studies should address this possibility. Developmentally appropriate discussion about body image disturbance may be indicated in interventions targeting pediatric LOC eating and/or obesity.     

Loss of control over eating in obese youngsters

OBJECTIVE: To investigate loss of control over eating in a sample of obese youngsters seeking treatment. METHOD: Obese youngsters (aged 10-16) were categorized into those having experienced loss of control (LC) and those who had not (NoLC) using the child version of the Eating Disorder Examination. Furthermore, the LC group was subdivided into an objective binge eating (OBE) and a subjective binge eating (SBE) group. The groups were compared on psychological measures. RESULTS: LC subjects (17.9%) showed more concern about eating, weight and shape. They also reported more emotional and external eating behaviors and more depression. Youngsters who report SBE show resemblances to both NoLC and OBE subjects. DISCUSSION: LC subjects are characterized by more eating-related psychopathology and higher levels of depression. Especially obese youngsters with OBE turned out to be a pathological group.     

Randomized Controlled Trial of an Internet-Based Cognitive-Behavioral Treatment Program for Binge-Eating Disorder

Binge-eating disorder (BED) is a prevalent health condition associated with obesity. Few people with BED receive appropriate treatment. Personal barriers include shame, fear of stigma, geographic distance to mental health services, and long wait-lists. The aims of this study were to examine the efficacy of an Internet-based cognitive-behavioral intervention for adults with threshold BED (DSM-IV) and to examine the stability of treatment effects over 12 months. Participants were randomly assigned to a 16-week Internet-based cognitive-behavioral intervention (n = 69) or a wait-list condition (n = 70). Binge-eating frequency and eating disorder psychopathology were measured with the Eating Disorder Examination–Questionnaire and the Eating Disorder Examination administered over the telephone. Additionally, body weight and body mass index, depression, and anxiety were assessed before and immediately after treatment. Three-, 6-, and 12-month follow-up data were recorded in the treatment group. Immediately after the treatment the number of binge-eating episodes showed significant improvement (d = 1.02, between group) in the treatment group relative to the wait-list condition. The treatment group had also significantly reduced symptoms of all eating psychopathology outcomes relative to the wait-list condition (0.82 ≤ d ≤ 1.11). In the treatment group significant improvement was still observed for all measures 1 year after the intervention relative to pretreatment levels. The Internet-based intervention proved to be efficacious, significantly reducing the number of binge-eating episodes and eating disorder pathology long term. Low-threshold e-health interventions should be further evaluated to improve treatment access for patients suffering from BED.     

Body checking and avoidance and the core features of eating disorders among obese men and women seeking bariatric surgery

This study examined two aspects of body checking and avoidance, and their relations to the core psychopathology of eating disorders (EDs), in severely obese men and women seeking bariatric surgery. A consecutive series of 260 (44 male and 216 female) gastric bypass candidates were administered measures to assess body checking and avoidance, binge eating, restraint, and overevaluation of weight and shape. The majority of patients reported regularly pinching areas of their body to check for fatness and avoided wearing clothing that made them particularly aware of their body. Significant associations were observed between checking and restraint, and between avoidance and binge eating. Both checking and avoidance behaviors were significantly associated with overevaluation of weight and shape. The positive associations between each of the two behaviors (body checking and avoidance) with overevaluation of weight/shape remained significant even after controlling for the effects of avoidance on body checking and vice versa. Stepwise multiple regression analyses revealed that binge eating, body checking, and avoidance behaviors made significant unique contributions and jointly accounted for 22-25% of the variance in overevaluation of weight and shape, respectively. This study documents the presence of eating disorder psychopathology among severely obese patients seeking bariatric surgery. The findings support the view that body checking and avoidance behaviors are manifestations of overevaluation of weight and shape and disordered eating.     

Eating patterns and breakfast consumption in obese patients with binge eating disorder

This study examined eating patterns and breakfast consumption, and their relationships to weight and binge eating, in obese individuals with binge eating disorder (BED). One-hundred seventy-three consecutively evaluated men (n=46) and women (n=127) with BED were administered semi-structured interviews and self-report measures to assess the frequency of meals and snacks eaten, as well as binge eating and eating disorder features. Overall, those who consumed more frequent meals, particularly breakfast, and snacks, weighed less. Breakfast, which was eaten on a daily basis by less than half of participants (n=74; 43%), was the least frequently eaten meal of the day. Participants (n=56; 32%) who ate three meals per day weighed significantly less, and had significantly fewer binges, than participants (n=117; 68%) who did not regularly eat three meals per day. Thus, eating more frequently, having breakfast and consuming three meals every day, have potentially important clinical applications for the treatment of BED given that the effectiveness of specific interventions within treatments for BED are unknown, and that weight loss outcome for BED has been poor.     

Clarifying boundaries of binge eating disorder and psychiatric comorbidity: a latent structure analysis

Binge eating disorder (BED) presents with substantial psychiatric comorbidity. This latent structure analysis sought to delineate boundaries of BED given its comorbidity with affective and anxiety disorders. A population-based sample of 151 women with BED, 102 women with affective or anxiety disorders, and 259 women without psychiatric disorders was assessed with clinical interviews and self-report-questionnaires. Taxometric analyses were conducted using DSM-IV criteria of BED and of affective and anxiety disorders. The results showed a taxonic structure of BED and of affective and anxiety disorders. Both taxa co-occurred at an above-chance level, but also presented independently with twice-as-large probabilities. Within the BED taxon, diagnostic co-occurrence indicated greater general psychopathology, lower social adaptation, and greater premorbid exposure to parental mood and substance disorder, but not greater eating disorder psychopathology. Eating disorder psychopathology discriminated individuals in the BED taxon from individuals in the affective and anxiety disorders taxon. Diagnostic criteria of BED were more indicative of the BED taxon than were criteria of affective and anxiety disorders. The results show that at the latent level, BED was co-occurring with, yet distinct from, affective and anxiety disorders and was not characterized by an underlying affective or anxiety disorder.     

Adapted motivational interviewing for women with binge eating disorder: a randomized controlled trial

In this randomized controlled trial, 108 women with binge-eating disorder (BED) recruited from the community were assigned to either an adapted motivational interviewing (AMI) group (1 individual AMI session + self-help handbook) or control group (handbook only). They were phoned 4, 8, and 16 weeks following the initial session to assess binge eating and associated symptoms (depression, self-esteem, quality of life). Postintervention, the AMI group participants were more confident than those in the control group in their ability to change binge eating. Although both groups reported improved binge eating, mood, self-esteem, and general quality of life 16 weeks following the intervention, the AMI group improved to a greater extent. A greater proportion of women in the AMI group abstained from binge eating (27.8% vs. 11.1%) and no longer met the binge frequency criterion of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) for BED (87.0% vs. 57.4%). AMI may constitute a brief, effective intervention for BED and associated symptoms.     

Early Change Trajectories in Cognitive-Behavioral Therapy for Binge-Eating Disorder

Rapid response is considered the most well-established outcome predictor across treatments of binge-eating disorder (BED), including cognitive-behavioral therapy (CBT). This study sought to identify latent trajectories of early change in CBT and compare them to common rapid response classifications. In a multicenter randomized trial, 86 adults with BED (DSM-IV) or subsyndromal BED provided weekly self-reports of binge eating over the first 4 weeks of CBT, which were analyzed to predict binge eating, depression, and body mass index at posttreatment, 6-, and 18-month follow-up. Using latent growth mixture modeling, three patterns of early change—including moderate and low decreasing—as well as low stable binge eating were identified, which significantly predicted binge-eating remission at 6-month follow-up. Other classifications of rapid response based on Receiver Operating Characteristics curve analyses or on the literature (≥ 10% reduction in binge eating at week 1, ≥ 70% reduction in binge eating at week 4) only predicted posttreatment remission or overall depression, respectively. Latent change trajectories, but not other rapid response classifications, predicted binge-eating frequency over time. A fine-grained analysis of change over the first 4 weeks of CBT for BED revealed different trajectories of early change in binge eating that led to an improved prediction of binge-eating outcome, compared to that of common rapid response classifications. Thorough monitoring of early change trajectories during treatment may have clinical utility.     

Perception of parental acceptance in women with binge eating disorder

The authors contribute to the validating literature for binge eating disorder (BED) by examining perceptions of parents and satisfaction with life among obese women with and without BED. Participants were female patients, recruited through a private medical clinic, who were assigned to groups on the basis of body mass index (BMI) and scores on the Questionnaire on Eating and Weight Patterns (QEWP; R. L. Spitzer et al., 1992). Groups consisted of (a) obese women with BED (n = 32), (b) obese women who had no eating disorders (n = 51), and (c) nonobese women with no eating disorders (n = 30). All participants completed the Parental Acceptance/Rejection Questionnaire (PARQ; R. P. Rohner, 1986), the Satisfaction with Life Scale (SWLS; J. Fischer & K. Corcoran, 1994), and the Beck Depression Inventory (BDI; A. T. Beck & R. A. Steer, 1987). Obese women with BED perceived their fathers as more rejecting than did women in the other groups. Moreover, obese women with BED perceived their fathers as significantly more rejecting than their mothers. The BED group indicated lower satisfaction with life and higher levels of depression than the groups without eating disorders. These findings further validate the diagnostic category of BED. Obese women with BED appear to be a distinct subgroup of the obese population. The results indicate a need for further assessment of the father-daughter relationship in connection to BED and other eating disorders.     

Body-related film clip triggers desire to binge in women with binge eating disorder

Previous research suggests that excessive influence of shape or weight concern on self-evaluation is strongly associated with psychological functioning in women with binge eating disorder (BED). However, little is known so far about its direct influence on binge episodes. In an experimental study, 27 women with BED (DSM-IV) and 25 overweight healthy controls watched a body-related film clip. Ratings of the desire to binge and mood were assessed prior to and at the end of the film clip. Additionally, measures of heart rate, finger pulse and electrodermal activity were obtained. Main results revealed a significant increase in the desire to binge, sadness and anxiety, as well as a significant increase in non-specific skin conductance fluctuation on the body-related clip in the group of BED only. The results underline the importance of shape and weight concerns in BED.     

Cognitive-behavioral treatment with and without response prevention for Bulimia

We compared cognitive-behavior therapy (CBT) with and without exposure and response prevention (ERP) in the treatment of eating disorder patients who both binged and purged, and reported abnormal attitudes concerning body weight and shape. Both treatments produced significant and comparable reductions in binge-eating and purging, eating patterns, and attitudes about weight and shape at posttreatment. Treatment effects were generalized to improvements in different measures of general psychopathology, and were maintained over follow-ups of 3 and 12 months. The findings are consistent with prior research showing that CBT is an effective treatment for patients with the core features of bulimia nervosa. Furthermore, the data suggest that the addition of in-session exposure and response prevention does not enhance the effectiveness of the basic CBT program.