A latent profile analysis of childhood trauma in women with bulimia nervosa: Associations with borderline personality disorder psychopathology.

OBJECTIVE: The aim of this study was to empirically examine naturally occurring groups of individuals with bulimia nervosa (BN) based on their childhood trauma (CT) histories and to compare these groups on a clinically relevant external validator, borderline personality disorder (BPD) psychopathology. METHOD: This study examined the relationship between CT and BPD psychopathology among 133 women with BN using latent profile analysis (LPA) to classify participants based on histories of CT. Participants completed the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P), the Diagnostic Interview for Borderlines-Revised (DIB-R), and the Childhood Trauma Questionnaire (CTQ). RESULTS: The LPA revealed four trauma profiles: low/no trauma, emotional trauma, sexual trauma, and polytrauma. Results indicated that the sexual and polytrauma profiles displayed significantly elevated scores on the DIB-R and that the low/no and emotional trauma profiles did not differ significantly on the DIB-R. Secondary analyses revealed elevated levels of a composite CT score among those with both BN and BPD psychopathology compared to those with BN only. DISCUSSION: These findings suggest that both childhood sexual abuse and the additive effects of childhood polytrauma may be linked to BPD psychopathology in BN. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:689-694).

Meal patterning in the treatment of bulimia nervosa.

OBJECTIVE: This study examined the relationship between changes in meal and snack consumption and eating disorder behaviors in a treatment sample of bulimic adults. METHOD: Eighty adults with bulimia nervosa (BN) were randomized to one of two treatments. Meal and snack consumption, binge eating frequency, and purging behavior frequency were assessed at baseline, end-of-treatment, and at four month follow-up using the Eating Disorder Examination (EDE). RESULTS: Generalized linear models indicated that increased consumption of evening meals over the course of treatment was related to a significant decrease in the rate of binge eating and purging at four month follow-up; these results remained significant when controlling for changes in depression over the course of treatment. CONCLUSIONS: The findings support the importance of focusing efforts on developing a pattern of regular evening meal consumption among individuals in the treatment of BN.

Emotion Dysregulation and Affective Intensity Mediate the Relationship Between Childhood Abuse and Suicide-Related Behaviors Among Women with Bulimia Nervosa.

Self-harm and suicide attempts occur at elevated rates among individuals with bulimia nervosa, particularly among those who have experienced childhood abuse. This study investigated the potential mediating roles of emotion dysregulation and affective intensity in the relationship between these variables in 125 women with bulimia nervosa. Analyses revealed that emotion dysregulation mediated the relationship between sexual and emotional abuse with both self-harm and suicide attempts. Negative affective intensity mediated the relationship between abuse and suicide attempts. The findings may advance the understanding of mechanisms underlying suicide-related behaviors in women with bulimia nervosa who experienced abuse and suggest potential clinical targets.

The role of affect in the maintenance of anorexia nervosa: evidence from a naturalistic assessment of momentary behaviors and emotion.

The current study examines the relationship of affect and eating disorder behavior in anorexia nervosa (AN) using ecological momentary assessment. Participants were 118 adult females recruited at three sites from eating disorder treatment centers and community advertisements. All participants met full Diagnostic and statistical manual of mental disorders (4th ed.) criteria or subthreshold criteria for AN. Participants were provided handheld computers and asked to report positive affect, negative affect, loss of control (LOC) eating, purging, exercise, drinking fluids to curb appetite, and weighing one's self multiple times per day as well as dietary restriction once daily over a 2-week interval. Mixed-effects models were used to examine the extent to which affective states predict dietary restriction. In addition, we used two analytic approaches to compare affect before and after other eating disorder behaviors. We found that higher daily ratings of negative affect were associated with a greater likelihood of dietary restriction on subsequent days. When examining the single rating immediately before and after behaviors, we found that negative affect increased significantly after LOC eating, purging, the combination of LOC and eating/purging, and weighing of one's self. Using this same analytic approach, we also found negative affect to decrease significantly after the consumption of fluids to curb appetite and exercise. When examining the covariation of AN behaviors and negative affect assessed multiple times in the hours and minutes before the behaviors, we found negative affect significantly increased before LOC eating, purging, the combination of LOC eating/and purging, and weighing behavior. Negative affect also significantly decreased after the occurrence of these behaviors. These findings are consistent with the idea that that negative affect is potentially a critical maintenance mechanism of some AN symptoms, but that the analytic approach used to examine affect and behavior may have significant implications on the interpretation of findings.

Picking or nibbling: frequency and associated clinical features in bulimia nervosa, anorexia nervosa, and binge eating disorder.

OBJECTIVE: Picking or ribbling (P&N) is a newly studied eating behavior characterized by eating in an unplanned and repetitious manner in between meals and snacks. This behavior seems to be related to poorer weight loss outcomes after bariatric surgery for weight loss in severely obese patients, but clarification is still required regarding its value in other clinical samples. The purpose of this study was to investigate the frequency of P&N across different eating disorder samples, as well as to examine its association with psychopathological eating disorder features. METHOD: Our sample included treatment-seeking adult participants, recruited for five different clinical trials: 259 binge eating disorder (BED); 264 bulimia nervosa (BN), and 137 anorexia nervosa (AN). Participants were assessed using the Eating Disorders Examination interview before entering the clinical trials. RESULTS: P&N was reported by 44% of the BED; 57.6% of the BN; and 34.3% of the AN participants. No association was found between P&N and BMI, the presence of compensatory behaviors, binge eating, or any of the eating disorder examination subscales. DISCUSSION: This study suggests that P&N behavior is highly prevalent across eating disorder diagnoses, but it is not associated with psychopathology symptoms or other eating disordered behaviors.

Examining duration of binge eating episodes in binge eating disorder.

OBJECTIVE: The primary goal of this article is to examine and clarify characteristics of binge eating in individuals with binge eating disorder (BED), particularly the duration of binge eating episodes, as well as potential differences between individuals with shorter compared to longer binge eating episodes. METHOD: Two studies exploring binge eating characteristics in BED were conducted. Study 1 examined differences in clinical variables among individuals (N = 139) with BED who reported a short (<2 h) versus long (≥ 2 h) average binge duration. Study 2 utilized an ecological momentary assessment design to examine the duration and temporal pattern of binge eating episodes in the natural environment in a separate sample of nine women with BED. RESULTS: Participants in Study 1 who were classified as having long duration binge eating episodes displayed greater symptoms of depression and lower self-esteem, but did not differ on other measures of eating disorder symptoms, compared to those with short duration binge eating episodes. In Study 2, the average binge episode duration was approximately 42 min, and binge eating episodes were most common during the early afternoon and evening hours, as well as more common on weekdays versus weekends. DISCUSSION: Past research on binge episode characteristics, particularly duration, has been limited to studies of binge eating episodes in bulimia nervosa. This study contributes to the existing literature on characteristics of binge eating in BED.

Posttraumatic stress disorder as a moderator of the association between negative affect and bulimic symptoms: an ecological momentary assessment study.

OBJECTIVE: The purpose of this study was to examine the potential moderating effect of posttraumatic stress disorder (PTSD) on the emotion-behavior relationship in individuals with bulimia nervosa (BN). METHOD: A total of 119 women with BN were involved in the study. Participants were divided into 2 groups: those with BN and PTSD (n = 20) and those with BN only (n = 99). Ecological momentary assessment procedures were used for the examination of affect, frequency of bulimic behaviors, and the relationship of affect and bulimic behavior over time. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders was conducted for the diagnosis of BN, PTSD, mood disorders, anxiety disorders, and substance use disorders. Mood disorders, anxiety disorders, and substance use disorders functioned as covariates in all analyses. RESULTS: Statistical models showed that those in the PTSD group reported a greater daily mean level of negative affect (NA) and a greater daily frequency of bulimic behaviors than those in the BN-only group. Moderation was found for the association between NA and time in that the PTSD group showed a faster acceleration in NA before purging and faster deceleration in NA after purging. The association between positive affect and time was also moderated by group, indicating that the PTSD group had a faster acceleration in positive affect after purging than the BN-only group. CONCLUSION: These findings highlight the importance of recognizing PTSD when interpreting the emotion-behavior relationship in individuals with BN.

The Yale-Brown-Cornell eating disorders scale self-report questionnaire: a new, efficient tool for clinicians and researchers.

OBJECTIVE: The YBC-EDS is a semistructured interview assessing core preoccupations and rituals related to eating disorders. METHOD: We developed and conducted an examination of the reliability and validity of a self-report questionnaire (SRQ) version of the YBC-EDS. Convergent validity of YBC-EDS-SRQ with the YBC-EDS was examined for 112 eating disordered patients. RESULTS: All subscales and total scores were significantly intercorrelated. Thirty-one additional patients completed YBC-EDS-SRQ at admission and again 1 week later. All correlations revealed significant test-retest reliability. Discriminant validity of the SRQ was evaluated for a smaller subset of participants who completed the Beck Depression Inventory (BDI) and State Trait Anxiety Inventory (STAI). There were no significant correlations between various symptom dimensions of the YBC-EDS-SRQ and the BDI and STAI. DISCUSSION: Taken together, these findings indicate that the self-report form of the YBC-EDS is both valid and reliable. The SRQ can serve as a useful and efficient assessment of eating disorder patients for clinicians and researchers.

A fine-grained analysis of eating behavior in women with bulimia nervosa.

OBJECTIVE: In the current study, we were interested in developing a typology of eating in patients with bulimia nervosa (BN) based on the size of the eating episode, whether the episode was followed by self-induced vomiting, and the degree of loss of control (LOC) self-reported by participants. METHOD: Twenty-one women with BN, purging type, were evaluated using the Nutritional Data System for Research, the Eating Disorders Examination, and the Matrix. RESULTS: The most common type of episode resembled what might be termed "normal" eating, which involved the consumption of <1,000 kcal with no sense of LOC and no vomiting. There was an increase in severity of self-assessed LOC in objectively large eating episodes with vomiting. Self-reported hunger prior to eating episodes did not seem to be predictive of subsequent behavior. Most people were engaged in other behaviors while eating. DISCUSSION: The results of this study suggest a typology that included primarily four types of eating episodes. The results also suggest that when LOC is assessed on a Likert-scale rather than as a dichotomous variable, there is considerable variability in self-assessed degree of LOC.

Evidence-based mental health interventions for traumatized youth: a statewide dissemination project.

Psychological trauma in childhood has been shown to increase a variety of psychological disturbances and psychiatric disorders. Although evidence-based treatments for children who have been traumatized exist, they are infrequently used by clinicians treating children. The present paper describes the creation of the Treatment Collaborative for Traumatized Youth (TCTY) which is a statewide partnership in North Dakota designed to disseminate efficacious treatments for traumatized children and monitor outcomes across a broad, rural, geographic expanse. The paper reviews the dissemination strategy developed by the TCTY, reports outcomes regarding both clinicians and child participants, and highlights problems identified in the project and solutions that were generated.

Comprehensive interview assessment of eating behavior 18-35 months after gastric bypass surgery for morbid obesity.

BACKGROUND: Weight loss surgery induces a marked change in eating behavior. However, not much work has been done characterizing the eating behavior after weight loss surgery. We conducted a detailed analysis of patients' eating behavior 18-35 months after Roux-en-Y gastric bypass surgery, determined whether preoperative eating disorders might be associated with non-normative postoperative eating, and examined the association of such eating behaviors with weight loss and psychopathology. METHODS: A sample of 59 patients who had undergone Roux-en-Y gastric bypass was interviewed in person after surgery about a range of eating behaviors, including binge eating, chewing and spitting out food, picking at and nibbling food, and nocturnal eating and compensatory behaviors such as vomiting and laxative and diuretic misuse. An established semistructured interview was used. The prevalence of preoperative eating disorders was assessed retrospectively. The eating-related and general psychopathology and quality of life were assessed using self-report questionnaires before and after surgery. RESULTS: Subjective bulimic episodes were reported by 25% and vomiting for weight and shape reasons by 12% of the participants, on average, 2 years after surgery. Subjective bulimic episodes were significantly associated with a preoperative binge eating disorder, with more eating-related and general psychopathology after surgery, and with less weight loss. CONCLUSION: A substantial subgroup of patients with a preoperative eating disorder will develop binge eating after surgery that might be associated with less weight loss. A subsample will start vomiting for weight and shape reasons after bariatric surgery. Clinicians must probe carefully for these behaviors postoperatively to identify patients in need of treatment of pathological eating behaviors.

Eating behavior in obese BED, obese non-BED, and non-obese control participants: a naturalistic study.

Laboratory studies have shown considerable differences between the eating behavior, particularly binge eating behavior, of participants with and without binge eating disorder (BED). However, these findings were not replicated in two field experiments employing ecological momentary assessment (EMA) in which obese BED and obese non-BED participants reported comparable binge eating behavior. In the current study, we examined differences in binge eating with an innovative assessment scheme employing both EMA and a standardized computer-based dietary recall program to avoid some of the limitations of past laboratory and field research. Obese BED, obese non-BED, and non-obese control participants reported significant differences in eating patterns, loss of control, overeating, and binge eating behavior. Of particular importance was the finding that BED participants engaged in more overeating and more binge eating episodes than non-BED participants. These findings suggest that the use of EMA in combination with dietary recall may be a relatively objective and useful approach to assessing binge eating behavior. The findings further suggest that individuals with BED are observably different from those without the disorder, which may have implications for eating disorder diagnoses in DSM-V.

Daily mood patterns and bulimic behaviors in the natural environment.

OBJECTIVE: Negative affect has been purported to play an important role in the etiology and maintenance of bulimic behaviors. The objective of this study was to identify daily mood patterns in the natural environment exhibited by individuals with bulimia nervosa and to examine the relationship between these patterns and bulimic behaviors. METHOD: One hundred thirty-three women aged 18-55 meeting DSM-IV criteria for bulimia nervosa were recruited through clinical referrals and community advertisements. Ecological momentary assessment was used to collect multiple ratings of negative affect, binge eating and purging each day for a two-week period using palmtop computers. Latent growth mixture modeling was used to identify daily mood patterns. RESULTS: Nine distinct daily mood patterns were identified. The highest rates of binge eating and purging episodes occurred on days characterized by stable high negative affect or increasing negative affect over the course of the day. CONCLUSIONS: These findings support the conclusion that negative mood states are intimately tied to bulimic behaviors and may in fact precipitate such behavior.

Emotional states preceding and following acts of non-suicidal self-injury in bulimia nervosa patients.

Bulimia nervosa and non-suicidal self-injury (NSSI) co-occur at high rates, and both have been conceptualized as maladaptive emotion regulation strategies. Treatments focusing on emotion regulation have been designed for both problem behaviors, yet, there exists very little research examining the temporal emotional states surrounding acts of NSSI. Using ecological momentary assessment (EMA) methodology, the current study examined the temporal association between positive and negative emotional states prior to and consequent to acts of NSSI within a subset of bulimia nervosa patients. Results indicate significant increases in negative affect, and decreases in positive affect, prior to an NSSI act. Post-NSSI, positive affect significantly increased while negative affect remained unchanged. The findings offer partial support for an emotion regulation paradigm to understanding NSSI within bulimic populations and implications for treatment are discussed.

Examining the conceptual model of integrative cognitive-affective therapy for BN: Two assessment studies.

OBJECTIVE: Two studies sought to examine predictions of the Integrative Cognitive-Affective Therapy (ICAT) model, which views bulimic symptoms in terms of inter-relations between self-concept discrepancies, negative affect, and self-directed coping styles. The present results examine assessment-related predictions of this model. METHOD: Individuals with bulimic symptoms were compared to noneating disorder control participants in two studies involving central constructs of the ICAT model. RESULTS: In both studies, bulimic individuals displayed higher levels of self-discrepancy and negative self-directed styles, supporting predictions of the model. Also predicted by the model, negative mood states mediated relations between bulimic status and negative self-directed coping styles in Study 2. CONCLUSION: Assessment-related predictions of the ICAT model of bulimic symptoms were supported in two studies. These initial results support further tests of the model in longitudinal designs, contrasts of different clinical populations, and treatment-evaluation studies.

The desire for body contouring surgery after bariatric surgery.

BACKGROUND: Obesity has become far more prevalent over the last few decades. In parallel, bariatric surgery has been increasingly utilized as a method of treatment. This appears to be having an impact on the rate of body contouring surgery for hanging redundant skin after the massive weight loss that usually results from bariatric surgery. Little literature is available addressing how frequently patients who have undergone bariatric surgery receive or desire body contouring surgery or regarding how satisfied these patients are with the hanging skin in certain body areas. METHODS: Seventy individuals (out of 250 who were mailed the questionnaire) who had undergone Roux-en-Y gastric bypass surgery 6-10 years previously completed a questionnaire, which obtained information regarding their experiences with as well as their desire for body contouring surgery and more general body area satisfaction. RESULTS: Thirty three of the seventy patients reported having undergone a total of 38 body contouring procedures. The most common were abdominoplasties (24.3%), breast lifts (8.6%), and thigh lifts (7.1%). However, subjects were not uniformly satisfied with body areas that had undergone body contouring surgery; some found the areas unattractive. The majority of patients, at least to some extent, desired body contouring surgery, often in several areas, most notably the waist/abdomen, rear/buttock, upper arms, and chest/breast. CONCLUSION: Paralleling the increasing use of bariatric surgery is an increasing desire for body contouring surgery. Most patients desire body contouring surgery after bariatric surgery. However, third party payors usually do not reimburse for such procedures.

Mediational significance of PTSD in the relationship of sexual trauma and eating disorders.

OBJECTIVE: To examine the mediational significance of posttraumatic stress disorder (PTSD) and the development of eating disorder symptomatology following sexually traumatic experiences. METHOD: Seventy-one victims of sexual trauma and 25 control subjects completed interviews and questionnaires assessing eating disorder psychopathology and posttraumatic stress disorder symptomatology. Mediational analyses were conducted examining the relationships among trauma, posttraumatic stress, and eating disorder symptoms. Mediational significance was assessed by the drop in the overall correlation between trauma and eating disorder symptoms when PTSD symptoms were included in the regression model. RESULTS: There is a significant association between a history of trauma and eating disorder symptoms. Also, there was a significant association between a history of trauma and posttraumatic stress disorder symptoms. Importantly, the relationship between trauma and eating disorder symptoms was significantly reduced when posttraumatic stress disorder symptoms were included in the regression analyses, indicating mediational significance of the posttraumatic stress construct. These findings were most pronounced for the physiological arousal and avoidance components of posttraumatic stress disorder. DISCUSSION: The present findings support the idea that individuals who develop eating disorders after sexual trauma are likely to have experienced posttraumatic stress disorder symptomatology. These findings have significant implications for causal models of eating disorder onset in trauma victims. Furthermore, clinical interventions for traumatized eating disordered individuals may benefit from a focus on posttraumatic stress symptomatology.

A randomized trial comparing the efficacy of cognitive-behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face.

OBJECTIVE: A major problem in the delivery of mental health services is the lack of availability of empirically supported treatment, particularly in rural areas. To date no studies have evaluated the administration of an empirically supported manual-based psychotherapy for a psychiatric condition via telemedicine. The aim of this study was to compare the relative efficacy and acceptability of a manual-based cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) delivered in person to a comparable therapy delivered via telemedicine. METHOD: One hundred twenty-eight adults meeting DSM-IV criteria for BN or eating disorder-not otherwise specified with binge eating or purging at least once per week were recruited through referrals from clinicians and media advertisements in the targeted geographical areas. Participants were randomly assigned to receive 20 sessions of manual-based, CBT for BN over 16 weeks delivered either face-to-face (FTF-CBT) or via telemedicine (TV-CBT) by trained therapists. The primary outcome measures were binge eating and purging frequency as assessed by interview at the end of treatment, and again at 3- and 12-month follow-ups. Secondary outcome measures included other bulimic symptoms and changes in mood. RESULTS: Retention in treatment was comparable for TV-CBT and FTF-CBT. Abstinence rates at end-of-treatment were generally slightly higher for FTF-CBT compared with TV-CBT, but differences were not statistically significant. FTF-CBT patients also experienced significantly greater reductions in eating disordered cognitions and interview-assessed depression. However, the differences overall were few in number and of marginal clinical significance. CONCLUSIONS: CBT for BN delivered via telemedicine was both acceptable to participants and roughly equivalent in outcome to therapy delivered in person.

Perfectionism and eating disorders: current status and future directions.

The literature examining the relation between perfectionism and eating disorders was reviewed and content and methodological comparisons were made with the perfectionism literature in anxiety disorders and depressive disorders. A PsychInfo search using the key words "perfectionism/perfect/perfectionistic," "anorexia," "bulimia," and "eating disorders" was performed and the generated list of papers was supplemented based on a review of reference lists in the papers. A total of 55 papers published between 1990 and 2005 were identified that assessed perfectionism among individuals with diagnosed eating disorders. The key research questions were distilled from these publications and empirical findings were summarized for each question, followed by a comparison with perfectionism papers in the anxiety and depressive disorder literatures. Also, key research design methodological parameters were identified and comparisons made across the three literatures: eating disorders, anxiety disorders, depressive disorders. The current review concludes with conceptual and methodological recommendations for researchers interested in perfectionism and eating disorders.

An empirical analysis of eating disorders and anxiety disorders publications (1980-2000)--part I: Research methods.

OBJECTIVE: The current study compared the eating disorder and anxiety disorder literature in terms of research design and methodologic features in 1980, 1990, and 2000. METHOD: Computer literature searches were conducted using PubMed and PsychInfo databases to identify relevant eating disorder and anxiety disorder articles published at each of the three time points. A total of 456 articles were randomly selected, including 228 articles from the eating disorder literature and the anxiety disorder literature. Within each specific literature, one third (76) of the articles were selected from each of the three time points (1980, 1990, 2000). Two raters, from a team of eight trained raters, were randomly assigned to independently rate each article in terms of 75 separate methodologic features. Disagreements in ratings were resolved via consensus. Ratings were tabulated separately for eating disorders and anxiety disorders across the three time points. RESULTS: Although there were some differences between anxiety disorders and eating disorders, most of the variables did not substantially differ between these two fields. There was a consistent trend for both fields to show increases in more rigorous methodologies over time. However, both the eating disorder literature and the anxiety disorder literature were characterized by a pervasive absence of many recommended methodologic procedures across the past two decades. CONCLUSION: Although the eating disorder literature and the anxiety disorder literature are increasingly characterized by improved reporting of rigorous methodologic procedures, there is still a pervasive absence of such procedures in both literatures, which limits the strength of inference in these studies.