Impact of comorbid borderline personality disorder on the outcome of inpatient treatment for anorexia nervosa: a retrospective chart review.

BACKGROUND: Data on patients with anorexia nervosa (AN) and comorbid Borderline personality disorder (AN+BPD) are scarce. Therefore, we investigated (1) whether patients with AN and AN+BPD differ in characteristics related to admission to, discharge from, and course of specialized inpatient eating disorder treatment and (2) how comorbid BPD affects treatment outcome. METHOD: One-thousand one-hundred and sixty inpatients with AN (97.2% female, 5.9% with comorbid BPD; mean age = 26.15, SD = 9.41) were administered the Brief Symptom Inventory (BSI), the Eating Disorder Inventory 2 (EDI-2), and the Global Assessment of Functioning (GAF) at admission and discharge. Data were extracted by a retrospective chart review of naturalistic treatment data. Age, sex, weekly weight gain, length of stay, and discharge characteristics were compared with independent t-tests and χ2-tests. Changes in outcome variables, including body mass index (BMI), were analyzed with longitudinal multilevel mixed-effects models. RESULTS: No differences in age or sex were found between patients with AN and AN+BPD, but groups differed in previous inpatient treatments, BMI at admission, and frequency of at least one additional comorbidity with higher values for AN+BPD. Higher levels of disorder-specific and general psychopathology at admission were found for AN+BPD. Patients with AN showed statistically significant improvement in all examined variables, patients with AN+BPD improved in all variables except EDI-2 body dissatisfaction. Strongest improvements in patients with AN+BPD occurred in BMI (Cohen's d = 1.08), EDI-2 total score (Cohen's d = 0.99), EDI-2 interpersonal distrust (d = 0.84). Significant Group x Time Interactions were observed for BSI GSI, GAF, and EDI-2 body dissatisfaction, indicating a reduced benefit from inpatient treatment in AN+BPD. At discharge, no differences were found in weekly weight gain, BMI, length of stay, or discharge characteristics (e.g., ability to work, reason for discharge), however, patients with AN+BPD were more frequently treated with medication. CONCLUSIONS: Patients with AN+BPD differ from patients with AN in that they show higher general and specific eating disorder psychopathology and only partially improve under specialized inpatient treatment. In particular, aspects of emotion regulation and core AN symptoms like body dissatisfaction and perfectionism need to be even more targeted in comorbid patients.

Orthorexic tendencies in the general population: association with demographic data, psychiatric symptoms, and utilization of mental health services.

PURPOSE: Orthorexia nervosa (ON) is characterized by a preoccupation to eat healthily and restrictive eating habits despite negative psychosocial and physical consequences. As a relatively new construct, its prevalence and correlates in the general population and the associated utilization of mental health services are unclear. METHODS: Adults from the general population completed the Düsseldorf Orthorexia Scale (DOS), the Patient Health Questionnaire (PHQ), the Short Eating Disorder Examination (SEED). RESULTS: Five-hundred eleven (63.4% female) participants with a mean age of 43.39 (SD = 18.06) completed the questionnaires. The prevalence of ON according to the DOS was 2.3%. Considering only effects of at least intermediate size, independent samples t-tests suggested higher DOS scores for persons with bulimia nervosa (p < .001, Cohen's d = 1.14), somatoform syndrome (p = .012, d = .60), and major depressive syndrome (compared p < .001, d = 1.78) according to PHQ as well as those who reported to always experience fear of gaining weight (p < .001, d = 1.78). The DOS score correlated moderately strong and positively with the PHQ depression (r = .37, p < .001) and stress (r = .33, p < .001) scores as well as the SEED bulimia score (r = .32, p < .001). In multivariate logistic regression analyses, only PHQ depression scores were associated with past psychotherapeutic or psychiatric treatment (OR = 1.20, p = .002) and intake of psychotropic medication in the last year (OR = 1.22, p = .013). CONCLUSIONS: The prevalence of ON was low compared to international studies but is in line with other non-representative German studies. Orthorexic tendencies related to general mental distress and eating disorder symptoms but were no independent reason for seeking treatment. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Orthorexic tendencies moderate the relationship between semi-vegetarianism and depressive symptoms.

PURPOSE: Vegetarianism and semi-vegetarianism (i.e., overly vegetarian diet with rare consumption of meat) have been repeatedly linked with depression. As the nature of this association is unclear, we explored whether orthorexic (i.e., pathologically healthful eating) tendencies and ecological/ethical motives to follow a vegetarian diet may moderate the relationship between (semi-)vegetarian diets and depressive symptoms. METHODS: Five-hundred eleven adults (63.4% females; 71.2% omnivores, 19.2% semi-vegetarians, 9.6% vegetarians) completed the Patient Health Questionnaire (PHQ-9) questionnaire-measuring depressive symptoms-and the Düsseldorf Orthorexia Scale (DOS)-measuring orthorexic tendencies. Based on respective questions, participants were categorized as omnivores, semi-vegetarians, and vegetarians (including vegans) and were asked to indicate whether they chose their diet based on ecological/ethical motives. Moderation analyses were carried out with PROCESS. RESULTS: Adjusted for age, sex, and body mass index, there was a statistically significant interaction effect between diet (omnivore vs. semi-vegetarianism vs. vegetarianism) and DOS scores when predicting PHQ depression scores. At low or medium DOS scores, diets did not differ in PHQ depression scores (all ps > 0.05). At high DOS scores, however, semi-vegetarians had higher PHQ depression scores than both omnivores (p = 0.002) and vegetarians (p < 0.001). The interaction between diet and ecological/ethical eating motives when predicting PHQ depression scores was not statistically significant (p = 0.41). CONCLUSION: Semi-vegetarians with strong orthorexic tendencies show more depressive symptoms than omnivores and vegetarians. The complex nature of the relationship between vegetarianism and depression requires further investigation. LEVEL OF EVIDENCE: III, case-control analytic studies.

Orthorexic tendencies in inpatients with mental disorders.

OBJECTIVE: Most research on orthorexia nervosa (ON)-the tendency to only eat foods that are perceived as healthy-has been based on non-clinical samples. Thus, we examined prevalence of and changes in orthorexic tendencies in a large sample of inpatients with mental disorders. Cross-sectional and longitudinal associations with body weight and eating disorder (ED) symptoms were tested in subgroups of inpatients with anorexia nervosa (AN) and bulimia nervosa (BN). METHODS: Inpatients (N = 1167) receiving disorder-specific treatment for disorders classified in the ICD-10 in F3, F4, or F5 completed the Düsseldorf Orthorexia Scale (DOS) at admission and a subset (N = 647) at discharge. ED patients completed the Eating Disorder Inventory-2 and their body weight and height was measured. RESULTS: Prevalence of ON was higher in ED patients than in all other groups, in which prevalence rates were similar to findings from the general population. Across ED groups, DOS scores decreased from admission to discharge, while there was no change in the other groups. In patients with BN, higher DOS scores related to lower BMI and predicted larger decreases in body dissatisfaction. Across ED groups, higher DOS scores related to higher body dissatisfaction and drive for thinness and predicted larger decreases in drive for thinness. CONCLUSION: Our results highlight that ON is part of the ED spectrum. Associations with core ED symptoms question the suggested exclusive health focus on eating in ON and its potential as a distinct diagnosis. Rather, ON may represent a phenomenological subtype of restrictive EDs.

Frequency and level of self-efficacy predict the effectiveness of therapist- and self-guided exposure in obsessive compulsive disorder.

BACKGROUND: While exposure and response prevention (ERP) is the most effective treatment for obsessive compulsive disorder (OCD), less is known about the specific mechanisms underlying symptom change after ERP. AIMS: We tested the hypothesis that the frequency of self- and therapist-guided ERP related to the extent of symptom reduction and that this link is mediated by increased self-efficacy. METHOD: In a sample of 377 in-patients with a primary diagnosis of OCD receiving in-patient CBT, we assessed symptoms (YBOCS-SR) and self-efficacy (General Self-Efficacy Scale), before and after treatment, as well as the frequency of therapist- and self-guided ERP sessions. RESULTS: Patients with more therapist-guided ERP sessions during treatment showed more symptom reduction and the association of self-guided ERP on outcome was mediated by enhanced self-efficacy. CONCLUSIONS: These findings highlight the importance of both therapist- and self-guided ERP sessions and suggest that therapists should conduct a sufficient number of ERP sessions to optimise treatment.

Emotion regulation strategies in bulimia nervosa: an experimental investigation of mindfulness, self-compassion, and cognitive restructuring.

BACKGROUND: While improving emotion regulation (ER) is a central goal in the therapy of bulimia nervosa (BN), there is no experimental evidence on the efficacy of different ER strategies. (1) We hypothesized that mindfulness as well as self-compassion as contextual strategies and cognitive restructuring as classical cognitive behavioral strategy would outperform waiting in improving emotional and eating disorder related outcomes after an unpleasant mood induction. Further, we explored (2) whether contextual strategies outperformed cognitive restructuring and (3) whether comorbid mental disorders and previous treatment for BN influenced the efficacy of contextual ER strategies compared to cognitive restructuring. METHODS: Within their first 2 weeks of treatment, inpatients with BN were instructed to utilize mindfulness, self-compassion, and cognitive restructuring or to wait after a pre-induced sadness in a permuted repeated measures design. Patients further rated different emotional and cognitive outcomes on a visual analogue scale at baseline, and before and after each ER strategy. Multiple linear regression analyses were employed to compare (1) the active conditions to waiting, (2) the contextual strategies with cognitive restructuring, and (3) the latter analysis again, but separated according to comorbidity and previous treatment. RESULTS: Forty-eight female inpatients with BN (mean age = 26.44 years, SD = 6.64) completed the study. (1) Contextual ER strategies were more efficacious than waiting for eating disorder symptoms. Cognitive restructuring did not differ from waiting for any outcome. (2) Contextual strategies were more efficacious than cognitive restructuring for emotional outcomes. (3) Self-compassion was more efficacious than cognitive restructuring in patients with comorbid mental disorders and previous treatment in increasing control over the present feeling. CONCLUSIONS: Contextual strategies, especially self-compassion, seem more efficacious than waiting and cognitive restructuring in improving short-term ER in patients with BN in an experimental setting.

Measuring orthorexia nervosa: A comparison of four self-report questionnaires.

Orthorexia nervosa is characterized by a preoccupation to eat healthily. However, reliability and validity of some of the existing measures of orthorexic symptomatology are questionable. Therefore, the aim of the current study was to examine internal reliability of and intercorrelations between four of the most popular self-report scales for measuring orthorexia nervosa: Bratman's Orthorexia Test (BOT), the ORTO-15, the Eating Habits Questionnaire (EHQ), and the Düsseldorf Orthorexia Scale (DOS). Five-hundred and eleven adults (63% female) completed all four instruments. Model fit of the originally proposed factor structures of the BOT, DOS, and EHQ was good but was unacceptable for the ORTO-15. Similarly, internal reliability was good for the BOT, EHQ, and DOS, but was unacceptable for the ORTO-15. The BOT, EHQ, and DOS were highly correlated with each other while correlations with the ORTO-15 were of medium size. A subsequent exploratory item analysis suggested that the poor psychometric properties of the ORTO-15 are largely due to the originally proposed scoring procedure. In conclusion, the BOT, EHQ, and DOS are internally reliable instruments that seem to measure the same construct-orthorexic eating behavior. In line with previous suggestions, we conclude that the ORTO-15 cannot be recommended for the measurement of orthorexia nervosa, at least not when the originally proposed scoring procedure is used.

Care challenges in older general hospital patients : Impact of cognitive impairment and other patient-related factors.

BACKGROUND: Older general hospital patients, particularly those with cognitive impairment, frequently experience adverse events and other care complications during their stay. As these findings have so far been based on small and selected patient samples, the aim of the present study was to provide reliable data on a) the prevalence of adverse care issues (summarized under the term care challenges) in older general hospital patients and on b) associated patient-related risk factors (e.g. cognitive impairment). METHODS: A cross-sectional representative study comprising 1469 patients aged ≥65 years from 33 randomly selected general hospitals in southern Germany (GHoSt). Data collection included the use of different data sources, e.g. structured interviews with responsible nursing staff concerning care challenges and procedures for determining the patients' cognitive status. RESULTS: Care challenges were statistically significantly (p < 0.001) more often reported for patients with dementia and/or delirium (87.5%) and mild cognitive impairment (47.9%) compared to cognitively unimpaired patients (24.6%). Adjusted odds ratios suggested cognitive impairment, impaired activities of daily living, receiving long-term care and unplanned admission as significant patient-related risk factors for care challenges. Furthermore, the occurrence of such issues was associated with the application of physical restraints, support from relatives, prescription of psycholeptics and specialist consultations. CONCLUSION: The findings suggest a strong impact of different degrees of cognitive impairment on challenges in care. The results might help to design appropriate training programs for hospital staff and other interventions to prevent or reduce critical situations.

Comparing severity and qualitative facets of depression between eating disorders and depressive disorders: Analysis of routine data.

BACKGROUND: While it is know that depressive symptoms are common in eating disorders (EDs), it is unclear whether these symptoms differ from those in depressive disorders (DDs) with regard to severity and quality. METHODS: Beck Depression Inventory II (BDI-II) scores at admission to treatment of 4.895 inpatients with a unipolar DD and 3.302 inpatients with an ED were compared by means of independent t-tests and Cohen's d effect sizes with regard to: (1) overall severity (BDI-II total score), (2) six facets of depression identified by non-metric multidimensional scaling of the German BDI-II validation sample, and (3) individual items. RESULTS: (1) The two groups did not differ with regard to the BDI-II total score. (2) There was no difference in the facet Depressive Core Symptoms. Patients with DDs had higher scores for Diminished Activation (d = 0.40) and patients with EDs had higher scores for Negative View of Self (d = 0.40). (3) Patients with DDs showed higher score on the item Loss of Energy (d = 0.48), while patients with EDs sored higher on Self-Dislike (d = 0.48) and Changes of Appetite (d = 0.48). CONCLUSIONS: Depression in EDs seems to be as severe as in DDs and may show similar core aspects (e.g., Sadness, Loss of Pleasure). Qualitative differences suggested that individual additional symptoms of depression need to be differently addressed in therapy. The pronounced Negative View of Self in EDs is in line with the "core low self-esteem", a central component of the prevalent transdiagnostic model of EDs.