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1.  Restrictive Eating in Anorexia Nervosa: Examining Maintenance and Consequences in the Natural Environment 
This study examined negative and positive affect in relation to restrictive eating episodes (i.e., meals/snacks perceived as restrictive) and whether restrictive eating was associated with likelihood of subsequent eating disorder behaviors (i.e., additional restrictive eating, binge eating, vomiting, laxative use, weighing, exercising, meal skipping, drinking fluids to curb appetite, body checking).
Women with anorexia nervosa (N = 118) completed a two-week ecological momentary assessment protocol.
For both restrictive and non-restrictive eating, negative affect significantly increased from pre-behavior to the time of the behavior but remained stable thereafter, while positive affect remained stable from pre-behavior to the time of the behavior but decreased significantly thereafter. Across time, negative affect was significantly lower and positive affect was significantly greater in restrictive than non-restrictive episodes. Engagement in restrictive eating was associated with an increased likelihood of subsequent restrictive eating, laxative use, and body checking, but not other behaviors. Engagement in non-restrictive eating was associated with a decreased likelihood of subsequent restrictive eating, binge eating, vomiting, laxative use, weighing, meal skipping, drinking fluids to curb appetite, and body checking.
Despite similar patterns of affect across eating episodes over time, results suggest affect may be involved in the maintenance of restrictive eating in anorexia nervosa since restrictive episodes were associated with lower negative and greater positive affect across time compared to non-restrictive episodes. Further, while restrictive episodes increased the likelihood of only three subsequent eating disorder behaviors, non-restrictive episodes were protective since they decreased likelihood of all but one behavior.
PMCID: PMC4618028  PMID: 26310991
anorexia nervosa; ecological momentary assessment; negative affect; positive affect; restrictive eating
2.  Depression and personality traits associated with emotion dysregulation: correlates of suicide attempts in women with bulimia nervosa 
The objective of this study was to identify personality traits and psychiatric comorbidities associated with a lifetime history of a suicide attempt in women with bulimia nervosa (BN).
Data from two samples of women with BN (n = 204 and n = 133) were examined. Participants in both samples completed the Dimensional Assessment of Personality Pathology – Basic Questionnaire (DAPP-BQ) and reported whether they had ever had a lifetime suicide attempt. Comorbid psychopathology was based on self-reported questionnaire and interview data. Univariate and multivariate logistic regression analyses were run predicting a lifetime suicide attempt.
Based on the DAPP-BQ, identity problems were associated with lifetime suicide attempt in both samples; cognitive dysregulation, anxiousness and insecure attachment were associated with lifetime suicide attempt in one but not both samples. Lifetime anxiety disorder was associated with lifetime suicide attempt in one sample and depression was associated with a lifetime suicide attempt in both samples. Multivariate analyses revealed that only depression was uniquely associated with a lifetime suicide attempt in both samples.
Although personality traits associated with aspects of emotion dysregulation were associated with a lifetime suicide attempt, depression was found to have the strongest association with a lifetime suicide attempt in two samples of women with BN. These findings suggest that depression severity may be the most important target of treatment and suicide prevention efforts in women with BN.
PMCID: PMC4868334  PMID: 26315489
Suicide; eating disorders; bulimia nervosa
3.  Revisiting Differences in Individuals with Bulimia Nervosa with and without a History of Anorexia Nervosa: Eating Pathology, Personality, and Maltreatment 
Early research in subtyping bulimia nervosa (BN) by history of anorexia nervosa (AN) generally found more similarities than differences, but recent research and limitations of the early work suggest the need to revisit this approach. We examine differences between women with BN with and without a history of AN regarding eating pathology, personality, and childhood maltreatment.
Participants were women (aged 18–55) recruited from the community and eating disorder clinics who met DSM-IV criteria for BN; 37 had a history of AN and 101 did not. Participants completed questionnaires related to eating disorder pathology, multidimensional perfectionism, multidimensional impulsivity, and childhood maltreatment.
Women with BN and a history of AN had higher levels of dietary restraint and purging and lower body mass indices as well as higher levels of all forms of childhood neglect and abuse. In contrast, no group differences were found for perfectionism or impulsivity dimensions.
The group differences in terms of eating pathology and maltreatment have clinical implications. Further research is needed regarding if and how a history of AN among those with BN may reflect different etiological pathways and predict different outcomes.
PMCID: PMC5086030  PMID: 18570195
bulimia nervosa; anorexia nervosa; childhood maltreatment; eating pathology; perfectionism; impulsivity
4.  Change in Pain and Physical Function Following Bariatric Surgery for Severe Obesity 
JAMA  2016;315(13):1362-1371.
The variability and durability of improvements in pain and physical function following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) are not well described.
To report changes in pain and physical function in the first 3 years following bariatric surgery, and to identify factors associated with improvement.
The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study at 10 US hospitals. Adults with severe obesity undergoing bariatric surgery were recruited between February 2005 and February 2009. Research assessments were conducted prior to surgery and annually thereafter. Three-year follow-up through October 2012 is reported.
Bariatric surgery as clinical care.
Primary outcomes were clinically meaningful presurgery to postsurgery improvements in pain and function using scores from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) (ie, improvement of ≥5 points on the norm-based score [range, 0–100]) and 400-meter walk time (ie, improvement of ≥24 seconds) using established thresholds. The secondary outcome was clinically meaningful improvement using the Western Ontario McMaster Osteoarthritis Index (ie, improvement of ≥9.7 pain points and ≥9.3 function points on the transformed score [range, 0–100]).
Of 2458 participants, 2221 completed baseline and follow-up assessments (1743 [78.5%] were women; median age was 47 years; median body mass index [BMI] was 45.9; 70.4% underwent RYGB; 25.0% underwent LAGB). At year 1, clinically meaningful improvements were shown in 57.6% (95% CI, 55.3%-59.9%) of participants for bodily pain, 76.5% (95% CI, 74.6%-78.5%) for physical function, and 59.5% (95% CI, 56.4%-62.7%) for walk time. Additionally, among participants with severe knee or disability (633), or hip pain or disability (500) at baseline, approximately three-fourths experienced joint-specific improvements in knee pain (77.1% [95% CI, 73.5%-80.7%]) and in hip function (79.2% [95% CI, 75.3%-83.1%]). Between year 1 and year 3, rates of improvement significantly decreased to 48.6% (95% CI, 46.0%-51.1%) for bodily pain and to 70.2% (95% CI, 678%-72.5%) for physical function, but improvement rates for walk time, knee and hip pain, and knee and hip function did not (P for all ≥.05). Younger age, male sex, higher income, lower BMI, and fewer depressive symptoms presurgery; no diabetes and no venous edema with ulcerations postsurgery (either no history or remission); and presurgery-to-postsurgery reductions in weight and depressive symptoms were associated with presurgery-to-postsurgery improvements in multiple outcomes at years 1,2, and 3.
Among a cohort of participants with severe obesity undergoing bariatric surgery, a large percentage experienced improvement, compared with baseline, in pain, physical function, and walk time over 3 years, but the percentage with improvement in pain and physical function decreased between year 1 and year 3.
TRIAL REGISTRATION Identifier: NCT00465829
PMCID: PMC4856477  PMID: 27046364
5.  Associations between Weight Suppression and Dimensions of Eating Disorder Psychopathology in a Multisite Sample 
Evidence suggests that weight suppression, the difference between an individual’s highest historical body weight and current body weight, may play a role in the etiology and/or maintenance of eating disorders (EDs), and may also impact ED treatment. However, there are limited findings regarding the association between weight suppression and dimensions of ED psychopathology, particularly in multi-diagnostic ED samples. Participants were 1748 adults (94% female) from five sites with a variety of DSM-IV ED diagnoses who completed the Eating Disorder Questionnaire, a self-report measure of various attitudinal, behavioral, and medical features of EDs. Four factor analytically derived dimensions of ED psychopathology were examined: (a) weight/shape concerns, (b) binge eating/vomiting, (c) exercise/restrictive eating behaviors, and (d) weight control medication use. Hierarchical regression analyses were conducted to examine the unique association of weight suppression with each dimension (controlling for ED diagnosis and BMI), as well as the independent unique associations of three interactions: (a) weight suppression × BMI, (b) weight suppression × ED diagnosis, and (c) BMI × ED diagnosis. Results revealed that weight suppression was uniquely associated with all of the ED psychopathology dimensions except binge eating/vomiting. The weight suppression × BMI interaction was significant only for weight/shape concerns, whereas the weight suppression × ED diagnosis was not significant for any of the dimensions. Significant BMI × ED diagnosis interactions were found for all dimensions except weight/shape concerns. Overall, the current results support the salience of weight suppression across multiple dimensions of ED psychopathology, with the exception of binge eating/vomiting.
PMCID: PMC4561862  PMID: 26343599
weight suppression; eating disorders; binge eating; compensatory behaviors; body image
6.  Examination of Early Group Dynamics and Treatment Outcome in a Randomized Controlled Trial of Group Cognitive Behavior Therapy for Binge Eating Disorder 
This study examined whether perceptions of group dynamics early in treatment predicted eating disorder outcomes in a sample of adults (N = 190) with binge eating disorder (BED) who participated in a 15-session group cognitive behavior therapy (gCBT) treatment with differing levels of therapist involvement (therapist led, therapist assisted, and self-help). The group dynamic variables included the Engaged subscale of the Group Climate Questionnaire – Short Form and the Group Attitude Scale, measured at session 2 and session 6. Treatment outcome was assessed in terms of global eating disorder severity and frequency of binge eating at end of treatment, 6-month, and 12-month follow-up. Session 2 engagement and group attitudes were associated with improved outcome at 12-month follow-up. No other group dynamic variables were significantly associated with treatment outcome. Group dynamic variables did not differ by levels of therapist involvement. Results indicate that early engagement and attitudes may be predictive of improved eating disorder psychopathology at 12 month follow-up. However, the pattern of mostly insignificant findings indicates that in gCBT, group process variables may be less influential on outcomes relative to other treatment components. Additionally, participants were able to engage in group treatment regardless of level of therapist involvement.
PMCID: PMC4764079  PMID: 26264648
Binge eating disorder; eating disorder; group therapy; cognitive-behavioral therapy
7.  Addictive Disorders after Roux-en-Y Gastric Bypass 
Recent literature suggests that some patients may develop addictive disorders after bariatric surgery, in particular following Roux-en-Y gastric bypass (RYGB). These may include traditional addictions and so called “behavioral addictions”, although prevalence data on the latter have not been published.
To establish prevalence of addictive behaviors in adults following RYGB.
2 university hospitals and 1 not-for-profit research institute in the U.S.
Participants from a large observational study of bariatric surgery who had undergone RYGB were recruited to complete additional measures. Of 241 consented participants, 201 provided data (i.e., Structured Clinical Interview for DSM-IV Axis I [SCID], additional Impulsive Control Disorder Modules, and various self-report measures, including the Alcohol Use Disorder Identification Test [AUDIT]) to assess status prior to surgery and in the first three post-operative years.).
Based on the SCID, 16 (8.0%) developed alcohol use disorder [AUD] within three years post-RYGB, 7 (43.8%) of whom had no history of AUD. When both the SCID and AUDIT were used to identify AUD, the corresponding numbers/percentages were 32 (18.4%) and 13 (40.6%). Data on other behavioral addictive disorders indicated 19 (9.5%) had a post-surgery disorder, 6 (31.6%) of whom had no history.
These data add to a growing literature suggesting there is a substantial risk for the development of AUD after bariatric surgery. Understanding the risk for non-drug related addictive disorders requires more data from larger studies before clear conclusions can be drawn.
PMCID: PMC4430439  PMID: 25862182
8.  Pre-Operative History of Depression and Cognitive Changes in Bariatric Surgery Patients 
Psychology, health & medicine  2014;20(7):802-813.
Obesity associated cognitive impairments may be partially reversible through bariatric surgery. Depression, a prevalent comorbidity in bariatric surgery candidates, is linked with cognitive impairment and poorer surgical outcomes in other populations. No study has examined the effects of pre-operative depression on cognitive changes in bariatric surgery patients. 67 bariatric surgery patients completed a computerized cognitive test battery prior to surgery and 12-months post-operatively. The Structured Clinical Interview for the DSM-IV Axis I disorders assessed Major Depressive Disorder (MDD). Pre-surgery history of MDD was found in 47.8% of patients, but was not associated with greater baseline cognitive impairments. Repeated measures revealed improved cognitive abilities 12-months after surgery. Pre-surgery history of MDD did not influence post-operative cognitive function. Pre-operative history of MDD did not limit post-operative cognitive improvements. Larger studies with extended follow-ups are needed to clarify our findings and identify factors (e.g., older age) that may modify cognitive changes following surgery.
PMCID: PMC5010917  PMID: 25222138
Obesity; bariatric surgery; cognitive function; weight loss; depression
9.  Clinical Utility of Subtyping Binge Eating Disorder by History of Anorexia or Bulimia Nervosa in a Treatment Sample 
This study examined whether having a history of anorexia nervosa (AN) or bulimia nervosa (BN) is associated with response to treatment in adults with binge eating disorder (BED).
Data from 189 adults diagnosed with BED who were randomly assigned to one of three group cognitive-behavioral (CBT) treatments were analyzed to compare those with and without a history of AN/BN.
A total of 16% of the sample had a history of AN/BN. The BED subgroup with a history of AN/BN presented with higher rates of mood disorders and greater eating-related symptom severity at baseline. Participants with a history of AN/BN also had higher global eating disorder (ED) symptoms at end of treatment (EOT), and more frequent objective binge-eating episodes at EOT and 12-month follow-up.
These findings suggest that in adults with BED, a history of AN/BN is predictive of greater eating-related symptom severity following group-based CBT and poorer short- and long-term binge-eating outcomes. These findings suggest that considering ED history in the treatment of adults with BED may be clinically useful.
PMCID: PMC4860342  PMID: 25959549
10.  Preoperative Factors and Three Year Weight Change in the Longitudinal Assessment of Bariatric Surgery (LABS) Consortium 
Limited data guide the prediction of weight loss success or failure following bariatric surgery according to pre-surgery factors. There is significant variation in weight change following bariatric surgery and much interest in identifying pre-operative factors that may contribute to these differences.
This report evaluates the associations of a comprehensive set of baseline factors and three-year weight change.
Ten hospitals in six geographically diverse clinical centers in the United States.
Adults undergoing a first bariatric surgical procedure as part of clinical care by participating surgeons were recruited between 2006 and 2009. Participants completed research assessments utilizing standardized and detailed data collection on over 100 preoperative and operative parameters for individuals undergoing Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB). Weight was measured 3 years following surgery.
Percent weight change for RYGB or LAGB from baseline to 3 years was analyzed as both a continuous and dichotomous outcome with cut points at 25% for RYGB and 10% for LAGB. Multivariable linear and logistic regression models were used to identify independent baseline predictors of the continuous and categorical outcomes, respectively.
The median weight loss 3 years following surgery for RYGB (n=1513) participants was 31.5% (IQR: 24.6%–38.4%; range, 59.2% loss to 0.9% gain) of baseline weight and 16.0% (IQR: 8.1%–23.1%; range, 56.1% loss to 12.5% gain) for LAGB (n=509) participants. The median age was 46 years for RYGB and 48 years for LAGB; 80% of RYGB participants and 75% of LAGB participants were female; and the median baseline Body Mass Index (BMI) was 46 kg/m2 for RYGB and 44 kg/m2 for LAGB. For RYGB, Black participants lost 2.7% less weight compared to Whites and participants with diabetes at baseline had 3.7% less weight loss at year 3 than those without diabetes at baseline. There were small but statistically significant differences in weight change for RYGB in those with abnormal kidney function and current or recent smoking. For LAGB participants, those with a large band had 75% greater odds of experiencing less than 10% weight loss after adjusting for BMI and sex.
Few baseline variables were associated with three year weight change and the effects were small. These results indicate that baseline variables have limited predictive value for an individual’s chance of a successful weight loss outcome following bariatric surgery.
PMCID: PMC4512927  PMID: 25824474
Bariatric surgery; Weight change; Predictors; LABS; Cohort study; Diabetes
11.  Initial Test of an Emotional Avoidance Model of Restriction in Anorexia Nervosa Using Ecological Momentary Assessment 
It has been hypothesized that restrictive eating allows individuals with anorexia nervosa (AN) to avoid contact with negative emotions; however, this presumption has not been directly tested. In this study, we conducted an initial investigation examining whether restrictive eating serves an emotional avoidance function among individuals with AN. Females with AN (n = 118) reported on negative and positive affect, anxiety/tension, and eating behaviors at multiple time points daily over a 2-week period using ecological momentary assessment methodology. Affective patterns were compared using generalized estimating equation models between days in which participants reported either: (1) relatively high restriction (without binge eating); (2) relatively low restriction (without binge eating); (3) binge eating; or (4) no restriction or binge eating. We hypothesized that, if restriction were functioning to avoid negative affect, average negative affect and anxiety/tension, as well as average negative and positive affect lability, would be lower and average positive affect would be higher on days characterized by high levels of restriction compared to other eating patterns. Contrary to hypotheses: (1) average negative affect, anxiety/tension, and positive affect were not significantly different between days characterized by high restriction and those characterized by low or no restriction; (2) Negative affect and anxiety/tension lability were higher on days characterized by high restriction compared to no restriction or binge eating days; (3) Anxiety/tension lability was higher on days characterized by high versus low levels of restriction. This patterns of findings does not support an avoidance model of restrictive eating for individuals with AN.
PMCID: PMC4522040  PMID: 26228412
anorexia nervosa; restrictive eating; emotion regulation; avoidance
12.  Objective Assessment of Changes in Physical Activity and Sedentary Behavior: Pre-through 3-Years Post- Bariatric Surgery 
Obesity (Silver Spring, Md.)  2015;23(6):1143-1150.
To evaluate change in sedentary behavior (SB) and physical activity (PA) over three years following bariatric surgery.
A subset of participants in an observational study (n=473 of 2458; 79% female, median body mass index 45kg/m2) wore an activity monitor pre-surgery and at 1–3 annual post-surgery assessments.
Over the first year, on average, sedentary time decreased from 573 (95%CI 563–582) to 545 (95%CI 534–555) min/d and moderate-to-vigorous intensity PA (MVPA) increased from 77 (95%CI: 71–84) to 106 (95%CI: 98–116) min/wk, or 7 (95%CI: 5–10) to 24 (95%CI: 18–29) min/wk in MVPA bouts ≥10 minutes. There were no changes in these parameters from years 1 to 3 (P for all>.05). The percentage of participants achieving ≥150 min/wk of bout-related MVPA was not different at year 3 [6.5% (95%CI: 3.1–12.7)] vs. pre-surgery [3.4% (95%CI: 1.8–5.0); p=.45]. Most participants followed SB and PA trajectories that paralleled mean change and were consistent with their pre-surgery position in relation to the group.
On average, bariatric surgical patients make small reductions in SB and increases in PA during the first post-surgery year, which are maintained through 3 years. Still, post-surgery PA levels fall short of PA guidelines for general health or weight control.
PMCID: PMC4445467  PMID: 26010326
physical activity; sedentary behavior; longitudinal; bariatric surgery; Roux-en-Y gastric bypass
13.  Binge Eating Disorder and Medical Comorbidities in Bariatric Surgery Candidates 
To determine whether binge eating disorder (BED) status is associated with medical comorbidities in obese adults scheduled for bariatric surgery.
The study utilized Longitudinal Assessment of Bariatric Surgery-2 data obtained from 6 clinical centers around the United States. This is a well-phenotyped cohort of individuals who were evaluated within 30 days prior to their scheduled surgery using standardized protocols. In the cohort, 350 participants were classified as having BED and 1875 as not having BED (non-BED). Multivariable logistic regression was used to determine whether BED status was independently related to medical comorbidities. As an exploratory analysis, significance was based on nominal P-values (p<.05). Holm-adjusted P-values were also reported.
After adjusting for age, sex, education and body mass index, BED status was independently associated with 4 of 15 comorbidities (i.e., impaired glucose levels (odds ratio [OR]=1.45 (95%CI: 1.12–1.87), high triglycerides (OR=1.28 (95%CI: 1.002–1.63) and urinary incontinence (OR=1.30 (95%CI: 1.02,1.66) all being more common among the BED sample, and severe walking limitations being less common in the BED sample (OR=0.53 (95%CI: 0.29–0.96)). With further adjustment for psychiatric/emotional health indicators, BED status was independently associated with 3 comorbidities (impaired glucose levels (OR=1.36 (95%CI: 1.04–1.79), cardiovascular disease (OR=0.50 (95%CI: 0.30–0.86) and severe walking limitations (OR=0.38 (95%CI: 0.19–0.77)). However, Holm’s adjusted P-values for all variables were greater than .05.
The results suggest the possibility of a contribution of BED to risk of specific medical comorbidities in severely obese adults.
PMCID: PMC4980070  PMID: 25778499
binge eating disorder; metabolic syndrome; medical comorbidities
14.  Dimensions of Emotion Dysregulation in Anorexia Nervosa and Bulimia Nervosa: A Conceptual Review of the Empirical Literature 
Clinical psychology review  2015;40:111-122.
Several existing conceptual models and psychological interventions address or emphasize the role of emotion dysregulation in eating disorders. The current article uses Gratz and Roemer’s (2004) multidimensional model of emotion regulation and dysregulation as a clinically relevant framework to review the extant literature on emotion dysregulation in anorexia nervosa (AN) and bulimia nervosa (BN). Specifically, the dimensions reviewed include: (1) the flexible use of adaptive and situationally appropriate strategies to modulate the duration and/or intensity of emotional responses, (2) the ability to successfully inhibit impulsive behavior and maintain goal-directed behavior in the context of emotional distress, (3) awareness, clarity, and acceptance of emotional states, and (4) the willingness to experience emotional distress in the pursuit of meaningful activities. The current review suggests that both AN and BN are characterized by broad emotion regulation deficits, with difficulties in emotion regulation across the four dimensions found to characterize both AN and BN, although a small number of more specific difficulties may distinguish the two disorders. The review concludes with a discussion of the clinical implications of the findings, as well as a summary of limitations of the existing empirical literature and suggestions for future research.
PMCID: PMC4537813  PMID: 26112760
eating disorders; affect; emotion regulation; affect regulation; affect dysregulation
15.  The association between reduced inflammation and cognitive gains after bariatric surgery 
Psychosomatic medicine  2015;77(6):688-696.
Bariatric surgery is associated with improved cognitive function, though the mechanisms are unclear. Elevated inflammation is common in obesity and associated with impaired cognition. Inflammation decreases after bariatric surgery, implicating it as a possible mechanism for cognitive improvement. The objective of this study was to examine whether reduced inflammation is a possible mechanism for post-operative cognitive improvement in bariatric surgery patients.
Participants were 77 bariatric surgery patients who completed cognitive testing before surgery and one year post-surgery. Cognitive domains assessed were attention/executive function, language, and memory. High-sensitivity C-reactive protein (hs-CRP) was assessed at both time points.
Patients exhibited pre-operative cognitive impairment, though attention/executive (M±SDbaseline= 53.57 ± 8.68 vs.M±SDfollow-up= 60.32 ± 8.19) and memory (M±SDbaseline= 44.96 ± 7.98 vs.M±SDfollow-up= 51.55 ± 8.25) improved one year post-surgery. CRP was elevated at baseline and fell into the normative range post-surgery (M±SDbaseline= 0.9 ± 0.7vs.M±SDfollow-up= 0.2 ± 0.3 mg/dL). Pre-operative CRP was not associated with baseline cognitive function (β-values = -0.10 to 0.02) and changes in CRP also did not correspond to changes in cognition post-surgery (β-values = 0.02 to β = 0.11; ps>0.05 for all domains). A trend was detected for smaller improvements in memory among participants with elevated baseline CRP (>0.30 mg/dL) versus those with normal levels (Group x Time: p=0.083).
Improvements in hs-CRP were not associated with post-operative cognitive benefits. Future studies are needed to explore other inflammatory markers and potential mechanisms of cognitive improvement after bariatric surgery, including improved glycemic control and neurohormone changes.
PMCID: PMC4456339  PMID: 25478707
Obesity; bariatric surgery; cognitive function; inflammation; C-reactive protein; prospective study
16.  The Eating Disorder Assessment for DSM-5 (EDA-5): Development and Validation of a Structured Interview for Feeding and Eating Disorders 
Existing measures for DSM-IV eating disorder diagnoses have notable limitations, and there are important differences between DSM-IV and DSM-5 feeding and eating disorders. This study developed and validated a new semi-structured interview, the Eating Disorders Assessment for DSM-5 (EDA-5).
Two studies evaluated the utility of the EDA-5. Study 1 compared the diagnostic validity of the EDA-5 to the Eating Disorder Examination (EDE) and evaluated the test-retest reliability of the new measure. Study 2 compared the diagnostic validity of an EDA-5 electronic application (“app”) to clinician interview and self-report assessments.
In Study 1, the kappa for EDE and EDA-5 eating disorder diagnoses was 0.74 across all diagnoses (n= 64), with a range of κ=0.65 for Other Specified Feeding or Eating Disorder (OSFED)/Unspecified Feeding or Eating Disorder (USFED) to κ=0.90 for Binge Eating Disorder (BED). The EDA-5 test-retest kappa coefficient was 0.87 across diagnoses. For Study 2, clinical interview versus “app” conditions revealed a kappa of 0.83 for all eating disorder diagnoses (n=71). Across individual diagnostic categories, kappas ranged from 0.56 for OSFED/USFED to 0.94 for BN.
High rates of agreement were found between diagnoses by EDA-5 and the EDE, and EDA-5 and clinical interviews. As this study supports the validity of the EDA-5 to generate DSM-5 eating disorders and the reliability of these diagnoses, the EDA-5 may be an option for the assessment of Anorexia Nervosa, Bulimia Nervosa, and BED. Additional research is needed to evaluate the utility of the EDA-5 in assessing DSM-5 feeding disorders.
PMCID: PMC4721239  PMID: 25639562
17.  Eating Behavior and Eating Disorders in Adults Prior to Bariatric Surgery 
To describe eating patterns, prevalence of problematic eating behaviors, and determine factors associated with binge eating disorder (BED), prior to bariatric surgery.
Prior to surgery, 2,266 participants (median age 46 years; 78.6% female; 86.9% white; median body mass index 45.9 kg/m2) of the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study completed eating behavior survey items in the self-administered LABS-2 Behavior form. Other measures included the Alcohol Use Disorder Identification Test, the LABS-2 Psychiatric and Emotional Test Survey, the Beck Depression Inventory, the Interpersonal Support Evaluation List-12, the Short Form-36 Health Survey and Impact of Weight Quality of Life-Lite Survey.
The vast majority (92.1%) of participants reported eating dinner regularly, while just over half (54.0%) reported eating breakfast regularly. Half of the participants reported eating at least 4 meals/week at restaurants; two meals/week were fast food. Loss of control eating was reported by 43.4%, night eating syndrome by 17.7%; 15.7% satisfied criteria for binge eating disorder (BED), 2% for bulimia nervosa. Factors that independently increased the odds of BED were being a college graduate, eating more times per day, taking medication for psychiatric or emotional problems, and having symptoms of alcohol use disorder, lower self-esteem and greater depressive symptoms.
Prior to undergoing bariatric surgery a substantial proportion of patients report problematic eating behaviors. Several factors associated with BED were identified, most suggesting other mental health problems, including higher levels of depressive symptomotology. The strengths of this study include the large sample size, the multi-center design and use of standardized assessment practices.
PMCID: PMC4192110  PMID: 24719222
Roux-en-Y Gastric Bypass; laparoscopic gastric banding; binge eating; binge eating disorder; night eating syndrome; nocturnal eating; evening hyperphagia
18.  Therapeutic alliance in a randomized clinical trial for bulimia nervosa 
This study examined the temporal relation between therapeutic alliance and outcome in two treatments for bulimia nervosa (BN).
Eighty adults with BN symptoms were randomized to 21 sessions of integrative cognitive-affective therapy (ICAT) or enhanced cognitive-behavioral therapy (CBT-E). Bulimic symptoms (i.e., frequency of binge eating and purging) were assessed at each session and post-treatment. Therapeutic alliance (Working Alliance Inventory) was assessed at sessions 2, 8, 14, and post-treatment. Repeated-measures analyses using linear mixed models with random intercepts were conducted to determine differences in alliance growth by treatment and patient characteristics. Mixed-effects models examined the relation between alliance and symptom improvement.
Overall, patients in both treatments reported strong therapeutic alliances. Regardless of treatment, greater therapeutic alliance between (but not within) subjects predicted greater reductions in bulimic behavior; reductions in bulimic behavior also predicted improved alliance. Patients with higher depression, anxiety, or emotion dysregulation had a stronger therapeutic alliance in CBT-E than ICAT, while those with more intimacy problems had greater improvement in therapeutic alliance in ICAT compared to CBT-E.
Therapeutic alliance has a unique impact on outcome, independent of the impact of symptom improvement on alliance. Within- and between-subject effects revealed that changes in alliance over time did not predict symptom improvement, but rather that individuals who had a stronger alliance overall had better bulimic symptom outcomes. These findings indicate that therapeutic alliance is an important predictor of outcome in the treatment of BN.
PMCID: PMC4446165  PMID: 25894667
bulimia nervosa; psychotherapy; therapeutic alliance; between-subject effects
19.  Glucose Regulation and Cognitive Function after Bariatric Surgery 
Obesity is associated with cognitive impairment and bariatric surgery has been shown to improve cognitive functioning. Rapid improvements in glycemic control are common after bariatric surgery and likely contribute to these cognitive gains. We examined whether improvements in glucose regulation are associated with better cognitive function following bariatric surgery.
A total of 85 adult bariatric surgery patients underwent computerized cognitive testing and fasting blood draw for glucose, insulin, and glycated hemoglobin (HbA1c) at baseline and 12 month post-operatively.
Significant improvements in both cognitive function and glycemic control were observed among patients. After controlling for and baseline factors, 12-month homeostatic model assessment of insulin resistance HOMA-IR predicted 12-month digits backward (β = −.253, p < .05), switching of attention- A (β = .156, p < .05), and switching of attention-B (β = −.181, p < .05). Specifically, as HOMA-IR decreased over time, working memory, psychomotor speed, and cognitive flexibility improved. Decreases in HbA1c were not associated with post-operative cognitive improvements. After controlling for baseline cognitive test performance, changes in BMI were also not associated with 12-month cognitive function.
Small effects of improved glycemic control on improved aspects of attention and executive function were observed following bariatric surgery among severely obese individuals. Future research is needed to identify the underlying mechanisms for the neurocognitive benefits of these procedures.
PMCID: PMC4853761  PMID: 25875124
Cognitive function; bariatric surgery; glycemic control; obesity; memory
20.  Post-Operative Psychosocial Predictors of Outcome in Bariatric Surgery 
Obesity surgery  2015;25(2):330-345.
Although there are several recent reviews of the pre-operative factors that influence treatment outcome for bariatric surgery, commensurate efforts to identify and review the predictive validity of post-operative variables are lacking. This review describes the post-operative psychosocial predictors of weight loss in bariatric surgery. Results suggest empirical support for post-operative binge eating, uncontrolled eating/grazing, and presence of a depressive disorder as negative predictors of weight loss outcomes; whereas, adherence to dietary and physical activity guidelines emerged as positive predictors of weight loss. With the exception of depression, psychological comorbidities were not consistently associated with weight loss outcomes. Results highlight the need for post-operative assessment of disordered eating and depressive disorder, further research on the predictive value of post-operative psychosocial factors, and development of targeted interventions.
PMCID: PMC4538993  PMID: 25381119
bariatric surgery; post-operative; psychopathology; psychosocial; weight loss
21.  Habitual Starvation and Provocative Behaviors: Two Potential Routes to Extreme Suicidal Behavior in Anorexia Nervosa 
Behaviour research and therapy  2010;48(7):634-645.
Anorexia nervosa (AN) is perhaps the most lethal mental disorder, in part due to starvation-related health problems, but especially because of high suicide rates. One potential reason for high suicide rates in AN may be that those affected face pain and provocation on many fronts, which may in turn reduce their fear of pain and thereby increase risk for death by suicide. The purpose of the following studies was to explore whether repetitive exposure to painful and destructive behaviors such as vomiting, laxative use, and non-suicidal self-injury (NSSI) was a mechanism that linked AN-binge-purging (ANBP) subtype, as opposed to AN-restricting subtype (ANR), to extreme suicidal behavior. Study 1 utilized a sample of 787 individuals diagnosed with one or the other subtype of AN, and structural equation modeling results supported provocative behaviors as a mechanism linking ANBP to suicidal behavior. A second, unexpected mechanism emerged linking ANR to suicidal behavior via restricting. Study 2, which used a sample of 249 AN patients, replicated these findings, including the second mechanism linking ANR to suicide attempts. Two potential routes to suicidal behavior in AN appear to have been identified: one route through repetitive experience with provocative behaviors for ANBP, and a second for exposure to pain through the starvation of restricting in ANR.
PMCID: PMC4731222  PMID: 20398895
anorexia; suicide; restricting; purging; self-injury
22.  Therapeutic Factors Affecting the Cognitive Behavioral Treatment of Bulimia Nervosa via Telemedicine versus Face-to-Face Delivery 
Recently, Mitchell and colleagues (2008) conducted a randomized controlled trial of an empirically supported treatment for bulimia nervosa (BN) delivered face-to-face (FTF-CBT) or via telemedicine (TV-CBT). Results suggested that the TV-CBT and FTF-CBT were generally equivalent in effectiveness. The objective of the current study was to examine ratings of therapeutic alliance factors in TV-CBT and FTF-CBT.
Data obtained from 116 adults who met criteria for BN or eating disorder—not otherwise specified (EDNOS) with binge eating or purging weekly and 6 doctoral-level psychologists who delivered the therapy were used in the analyses.
Therapists generally endorsed greater differences between the treatment delivery methods than patients. Patients tended to make significantly higher ratings of therapeutic factors than therapists.
TV-CBT is an acceptable method for the delivery of BN treatment compared to FTF-CBT, and TV-CBT is more easily accepted as a treatment delivery method by patients than therapists.
PMCID: PMC4496947  PMID: 22072405
23.  The Role of Cognitive Function in Postoperative Weight Loss Outcomes: 36 Month Follow-Up 
Obesity surgery  2014;24(7):1078-1084.
Cognitive dysfunction is associated with reduced postoperative weight loss up to two years following surgery, though the role of cognition at more extended follow-up is not yet understood. Thirty-six months following bariatric surgery, we retrospectively compared obese and non-obese patients on12-week postoperative cognitive performance. We hypothesized that early postoperative cognitive dysfunction would predict higher body mass index (BMI) and lower percent weight loss (%WL) in the total sample at 36 month follow-up.
Materials and Methods
Fifty-five individuals undergoing bariatric surgery completed cognitive testing at preoperative baseline and serial postoperative timepoints, including 12 weeks and 36 months. Cognitive test scores were normed for demographic variables. Percent weight loss (%WL) and body mass index (BMI) were calculated at 36-month follow-up.
Adjusting for gender, baseline cognitive function, and 12-week %WL, 12-week global cognitive test performance predicted 36 month postoperative %WL and BMI. Partial correlations revealed recognition memory, working memory, and generativity were most strongly related to weight loss.
Cognitive function shortly after bariatric surgery is closely linked to extended postoperative weight loss at 36 months. Further work is necessary to clarify mechanisms underlying the relationship between weight loss durability and cognitive function, including contribution of adherence, as this may ultimately help identify individuals in need of tailored interventions to optimize postoperative weight loss.
PMCID: PMC4047156  PMID: 24570090
memory; cognition; executive function; adherence
24.  Refining Behavioral Dysregulation in Borderline Personality Disorder Using a Sample of Women with Anorexia Nervosa 
Personality disorders  2010;1(4):250-257.
One of the primary facets of borderline personality disorder (BPD) is behavioral dysregulation, a wide array of behaviors that are difficult to control and harmful to the individual. The purpose of this study was to explore the association between BPD and a variety of dysregulated behaviors, some of which have received little empirical attention. Using a large sample of individuals diagnosed with anorexia nervosa, 41 individuals diagnosed with BPD were compared to the rest of the sample on the presence of dysregulated behaviors using logistic regression analyses. Anorexia nervosa subtypes, age, and other Cluster B personality disorders were used as covariates. Results support an association between BPD and alcohol misuse, hitting someone/breaking things, provoking fights/ arguments, self-injury, overdosing, street drug use, binge-eating, impulsive spending, shoplifting/stealing and risky sexual behaviors. Differences between dichotomous and continuous measures of BPD yielded somewhat different results.
PMCID: PMC4688899  PMID: 22448667
borderline personality disorder; behavioral dysregulation; substance abuse; anorexia nervosa
25.  Binge Eating, Binge Eating Disorder and Loss of Control Eating: Effects on Weight Outcomes after Bariatric Surgery 
There is increasing evidence that patients who have problems with binge eating (BE) or BE disorder (BED) are quite common among the severely obese, including bariatric surgery candidates. The literature suggests that in many cases such eating behaviours improve after bariatric surgery, although this is not uniformly true. The current paper reviews the data on the development of BE, BED and loss of control (LOC) eating after bariatric surgery and the impact of these problems on long-term weight outcome. A search was made of various databases regarding evidence of BE, BED and LOC eating post-operatively in bariatric surgery patients. The data extracted from the literature suggests that 15 research studies have now examined this question. Fourteen of the available 15 studies suggest that the development of problems with BE, BED or LOC eating post-bariatric surgery is associated with less weight loss and/or more weight regain post-bariatric surgery. These data suggests that it is important to identify individuals at high risk for these problems, to follow them post-operatively, and, if appropriate interventions can be developed if such behaviours occur in order to maximize weight loss outcomes.
PMCID: PMC4420157  PMID: 24347539
binge eating disorder; obesity; outcome

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