State of the art and new perspectives in the diagnosis, prevention and treatment of eating disorders: a contribution to an etiological model of eating disorders - sociocultural risk factors and the role of body-related cognitive distortions

On the basis of the German S3-guidelines, this thesis provides a comprehensive overview of the state of the art for the diagnosis, prevention and treatment of eating disorders (EDs). Publication 1 constitutes a critical review of the guidelines regarding their applicability to the clinical practice in Switzerland. The importance of early detection and accurate diagnosis of subthreshold and threshold EDs is emphasized. Consequently, it is argued that valid screening instruments need to be developed and implemented, followed by appropriate preventive efforts. Furthermore, the guidelines provide an important source of orientation and information for evidence-based treatment. In this context the difficulty of overcoming the science-practice-gap as well as the challenge of the implementation of evidence-based interventions is discussed and the necessity for stepped-care approaches and tailored interventions is highlighted. Based on the observation that ED treatment faces multiple challenges and more effective treatments are needed, an attempt is made to develop new perspectives. A basic requirement in this regard is an elaborated understanding of factors that contribute to the development and maintenance of EDs. Due to the high prevalence of body dissatisfaction (BD) in the general population and the finding that BD poses one of the best established risk factors for EDs, a basic etiological model of EDs with a focus on sociocultural risk factors is described. In publication 2 the proposed model is complemented with a newly introduced factor termed Thought-Shape Fusion (TSF) that describes the susceptibility to body-related cognitive distortions, negative emotions and dysfunctional behaviors. TSF is conceptualized as a cognitive vulnerability factor within a cognitive-behavioral framework of EDs. The main result of publication 2 revealed that TSF partially mediates the relationship between BD and disordered eating. Publication 3 goes a step further in demonstrating the inducibility of body-related cognitive distortions through thin-ideal imagination following a media exposure (TSF-B). This underlines the relevance of such cognitive processes in everyday settings where individuals are repeatedly confronted with media contents that promote an unattainable body ideal. It is proposed to consider TSF/ TSF-B in etiological models and new approaches in prevention and treatment of EDs

BED‐online: Acceptance and efficacy of an internet‐based treatment for binge‐eating disorder: A randomized clinical trial including waitlist conditions

Objective: Internet-based guided self-help (GSH) programs increase accessibility and utilization of evidence-based treatments in binge-eating disorder (BED). We evaluated acceptance and short as well as long-term efficacy of our 8-session internet-based GSH program in a randomized clinical trial with an immediate treatment group, and two waitlist control groups, which differed with respect to whether patients received positive expectation induction during waiting or not. Method: Sixty-three patients (87% female, mean age 37.2 years) followed the eight-session guided cognitive-behavioural internet-based program and three booster sessions in a randomized clinical trial design including an immediate treatment and two waitlist control conditions. Outcomes were treatment acceptance, number of weekly binge-eating episodes, eating disorder pathology, depressiveness, and level of psychosocial functioning. Results: Treatment satisfaction was high, even though 27% of all patients dropped out during the active treatment and 9.5% during the follow-up period of 6 months. The treatment, in contrast to the waiting conditions, led to a significant reduction of weekly binge-eating episodes from 3.4 to 1.7 with no apparent rebound effect during follow-up. All other outcomes improved as well during active treatment. Email-based positive expectation induction during waiting period prior to the treatment did not have an additional beneficial effect on the temporal course and thus treatment success, of binge episodes in this study. Conclusion: This short internet-based program was clearly accepted and highly effective regarding core features of BED. Dropout rates were higher in the active and lower in the follow-up period. Positive expectations did not have an impact on treatment effects

Association between muscle dysmorphia psychopathology and binge eating in a large at-risk cohort of men and women.

BACKGROUND Current research on muscle dysmorphia (MD) has focused on restrained eating behaviors and has adopted a primarily male perspective. Despite initial evidence, the role of possible binge eating associated with MD has only been scarcely investigated. To extend the transdiagnostic and cross-gender approaches and address the dearth in research related to MD, this study investigated the association between MD psychopathology and binge eating in men and women. METHODS This study investigated the association between MD psychopathology and binge eating in both men and women. Participants were a sample of 5905 men (n = 422) and women (n = 5483) social media users aged 18-72 years. They completed an online survey that included self-report measures assessing demographics, binge eating, MD psychopathology, and drive for thinness and leanness. Binge eating was assessed using the diagnostic questions of the validated German version of the Eating Disorder Examination-Questionnaire. The Muscle Dysmorphic Disorder Inventory (MDDI) was used to assess MD psychopathology. A total score of > 39 was set as a cutoff to define an "MD at-risk" state for both men and women. Hierarchical logistic regression analysis was used to analyze the association between MD psychopathology and binge eating. RESULTS MD psychopathology was significantly positively associated with binge eating in both men and women. Among the three MDDI subscales, only appearance intolerance was significantly associated with MD, and drive for size and functional impairment were not associated. MD at-risk status yielded a predicted probability of binge eating of 25% for men and 66.9% for women. The increased probability of binge eating associated with MD at-risk status was mainly accounted for by appearance intolerance in men and drive for thinness in women. CONCLUSION MD psychopathology is positively associated with binge eating in both men and women. Binge eating episodes should therefore form part of the clinical assessment of MD

Association between muscle dysmorphia psychopathology and binge eating in a large at-risk cohort of men and women

Background Current research on muscle dysmorphia (MD) has focused on restrained eating behaviors and has adopted a primarily male perspective. Despite initial evidence, the role of possible binge eating associated with MD has only been scarcely investigated. To extend the transdiagnostic and cross-gender approaches and address the dearth in research related to MD, this study investigated the association between MD psychopathology and binge eating in men and women. Methods This study investigated the association between MD psychopathology and binge eating in both men and women. Participants were a sample of 5905 men (n = 422) and women (n = 5483) social media users aged 18–72 years. They completed an online survey that included self-report measures assessing demographics, binge eating, MD psychopathology, and drive for thinness and leanness. Binge eating was assessed using the diagnostic questions of the validated German version of the Eating Disorder Examination-Questionnaire. The Muscle Dysmorphic Disorder Inventory (MDDI) was used to assess MD psychopathology. A total score of > 39 was set as a cutoff to define an “MD at-risk” state for both men and women. Hierarchical logistic regression analysis was used to analyze the association between MD psychopathology and binge eating. Results MD psychopathology was significantly positively associated with binge eating in both men and women. Among the three MDDI subscales, only appearance intolerance was significantly associated with MD, and drive for size and functional impairment were not associated. MD at-risk status yielded a predicted probability of binge eating of 25% for men and 66.9% for women. The increased probability of binge eating associated with MD at-risk status was mainly accounted for by appearance intolerance in men and drive for thinness in women. Conclusion MD psychopathology is positively associated with binge eating in both men and women. Binge eating episodes should therefore form part of the clinical assessment of MD

Comparing the new concept of impairment in personality functioning with borderline personality disorder: differential psychosocial and psychopathological correlates in a clinical adolescent sample.

Borderline personality disorder (BPD) is an established diagnosis in adolescence with high comorbidity and psychosocial impairment. With the introduction of the alternative model for personality disorders in DSM-5 (AMPD), personality functioning is operationalized using the Level of Personality Functioning Scale (LPFS), which has been shown to be associated with severity of personality pathology. The present study aimed at examining differential psychopathological and psychosocial correlates of LPFS and BPD. A total of 526 adolescent in- and outpatients were interviewed with the STiP-5.1 (LPFS) and the SCID-II. Mixed linear regression was used to investigate the associations between the two interviews with measures of psychopathology and psychosocial impairment. 11.4% met the diagnostic threshold of both interviews, 16.1% only of the LPFS, and 64.1% were below the diagnostic threshold in both interviews (no PD). The BPD only group was larger than expected-8.4% of patients who met criteria for BPD did not fulfill criteria for significant impairment in the LPFS. The highest burden was found in individuals concurrently showing significant impairment in LPFS and fulfilling BPD diagnosis (LPFS + BPD). Differences between the LPFS only group and the BPD only group were found in risk behavior and traumatic experiences, with higher prevalence in the BPD group. Findings confirm the high psychopathological burden and psychosocial impairment associated with both BPD and LPFS. Those exceeding the diagnostic threshold of LPFS in combination with a BPD diagnosis are characterized by greatest disability. Not all adolescents fulfilling formal BPD diagnosis showed a clinically significant impairment in LPFS, which may refer to a distinct diagnostic group

The impact of outcome expectancy on therapy outcome in adolescents with borderline personality disorder.

BACKGROUND Outcome expectancy has been found to be a significant predictor of psychotherapy outcome. However, given that severity, chronicity and comorbidity are moderators of outcome expectancy, it is important to provide evidence of whether the same holds true in clinical conditions marked by these attributes, such as in borderline personality disorder (BPD). The aim of the present study was to investigate the role of patients' outcome expectancy in adolescents undergoing early intervention for BPD using pre-post difference of psychosocial functioning as outcome. METHODS Forty-four adolescent BPD patients were treated with Dialectical Behavior Therapy for Adolescents (DBT-A) or Adolescent Identity Treatment (AIT). We investigated the effect of outcome expectancy on outcome with type of treatment as moderator. Based on the relevant literature, we assess the correlation between outcome expectancy and pretreatment symptomatology, namely BPD severity, personality functioning, childhood trauma and depression. RESULTS The results showed a significant effect of expectancy on outcome (stand. β = 0.30, p = 0.020) above autoregression. ANOVA analysis revealed no difference between the two treatments. Further, results indicate that pretreatment symptomatology, i.e., depression, childhood trauma and personality functioning dimensions self-direction and intimacy, are associated with early treatment expectancy. CONCLUSION Outcome expectancy as a common factor plays a key role in successful psychotherapy with adolescent BPD patients. Elevated pretreatment depression, childhood trauma and impairment in personality functioning dimensions self-direction and intimacy are risk factors associated with lower expectancy. Low outcome expectancy should be addressed in early psychotherapy to improve the therapeutical process

Sports psychiatric examination in competitive sports

Pre-Participation Examination (PPE) is recommended in many countries prior to or during the practice of competitive sports. The dedicated exploration of psychological complaints and illnesses in the sense of a psychiatric basic assessment within the PPE is not yet the rule. The implementation of a Psychiatric Basic Assessment (PBA) in the PPE is proposed and presented in terms of content. Abnormal findings in the PBA, crises, emergencies as well as conspicuous changes in behaviour should lead to further sports psychiatric evaluation (SPE) by child, adolescent and adult psychiatrists and psychotherapists qualified for this purpose. The goal is to use diagnostic and procedural standards to identify risks to mental health, stress, and already manifest illnesses in a timely manner and to provide qualified, specialized medical or psychiatric treatment. The diagnostic standards are intended to promote research and the benefits are to be verified by studies. Key Words: Psychiatric Basic Assessment (PBA), Sports Psychiatric Evaluation (SPE), Mental Health, Mental Disorders, Pre-Participation Examination (PPE

Self-reported emotion regulation difficulties are associated with mood but not with the biological stress response to thin ideal exposure

BACKGROUND:Difficulties in emotion regulation have been related to psychological and physiological stress responses such as lower mood and lower parasympathetic activation (HF-HRV) under resting condition, but evidence on the potential link to the hypothalamic-pituitary-adrenal (HPA) axis functioning and to physiological stress responses during a stress task is still scarce. The aim of the study was to investigate stress responses in young women when confronted to a daily stressor such as exposure to thin ideals and to understand the role of correlates of self-reported trait-like emotion regulation difficulties (ERD). METHODS:Heart rate variability (HRV) and salivary cortisol data were collected in a sample of 273 young women aged 18-35 with and without mental disorders during a vivid imagination of thin ideals (experimental condition) or landscapes (control condition). Changes in mood states were measured on a visual analogue scale (0-100). Correlates of trait-like ERD were self-reported using the Difficulties in Emotion Regulation Scale (DERS). RESULTS:Participants with higher ERD showed a stronger decline in self-reported mood after vivid imagination of thin ideals compared to participants with lower ERD in the experimental condition but also a stronger increase of positive mood with increasing ERD in the control condition. ERD were not related to baseline HF-HRV or baseline salivary cortisol levels nor to any physiological response during and after the imagination of thin ideals. DISCUSSION AND CONCLUSION:The results corroborate the role of ERD regarding the immediate psychological impact of daily stressors. Exposition to daily stressors in the laboratory results in discrepant psychological and physiological reactivity. Future studies should investigate under what conditions the complex interrelations between immediate and long-term ERD and biological activation are amenable to assessment in a laboratory setting. The additive effects of multiple exposition to stressors, such as thin ideals in daily life, also need to be addressed