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Objective: Asylum seekers who have experienced persecution, war and torture show high prevalence rates of stress-related mental disorders. After arrival in the host country, the early stages of resettlement seem to be a particularly vulnerable phase characterized by social instability. This longitudinal study aimed to explore predictors of the asylum seekers' course of mental health during the transition phase from a state registration and reception center to municipal shelters., Methods: We used hierarchical regression analysis to assess the symptom course of posttraumatic stress disorder (PTSD), depression, anxiety and panic disorders as well as well-being in n = 84 asylum seekers. The follow-up assessment took place three to five months after baseline assessment. The following blocks of possible predictors were included in the statistical models: (1) sociodemographic variables, (2) cultural background related variables, (3) psychometric measures of emotion regulation and sense of coherence and (4) time range to follow-up., Results: Language proficiency, origin, religion and gender were stronger predictors of the asylum seekers' mental health course in the early stages of resettlement than emotion regulation and sense of coherence., Conclusions: Sociodemographic and cultural background related variables, like language proficiency have a high psychosocial relevance for asylum seekers in the early phase of the asylum process. Therefore, language courses should be implemented progressively. Psychotherapy for asylum seekers should always be performed with awareness for cultural specific perspectives and acculturative adjustment processes., Competing Interests: Declaration of Competing Interest The authors have no competing interest to report., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Due to limited access to specialist services, most patients with common mental disorders (depression or anxiety, or both) usually receive treatment in primary care. More recently, innovative technology-based care models (eg, video consultations) have been proposed to facilitate access to specialist services. Against this background, the PROVIDE (Improving Cross-Sectoral Collaboration Between Primary and Psychosocial Care: An Implementation Study on Video Consultations) project aims to improve the provision of psychosocial care through implementing video consultations integrated into routine primary care., Objective: From the patients' perspective, this qualitative preimplementation study explored (1) anticipated benefits from and (2) barriers to implementing mental health specialist video consultations embedded in primary care services and (3) prerequisites for interacting with therapists via video consultations., Methods: Using a purposive (ie, stratified) sampling strategy, we recruited 13 patients from primary care practices and a tertiary care hospital (psychosomatic outpatient clinic) for one-off semistructured interviews. In a computer-assisted thematic analysis, we inductively (bottom-up) derived key themes concerning the practicability of mental health specialist video consultations. To validate our results, we discussed our findings with the interviewees as part of a systematic member checking., Results: Overall, we derived 3 key themes and 10 subthemes. Participants identified specific benefits in 2 areas: the accessibility of mental health specialist care (shorter waiting times: 11/13, 85%; lower threshold for seeking specialist mental health care: 6/13, 46%; shorter travel distances: 3/13, 23%); and the environment in primary care (familiar travel modalities, premises, and employees: 5/13, 38%). The main barriers to the implementation of mental health video consultations from the patients' perspective were the lack of face-to-face contact (13/13, 100%) and technical challenges (12/13, 92%). Notably, participants' prerequisites for interacting with therapists (12/13, 92%) did not seem to differ much from those concerning face-to-face contacts., Conclusions: Mental health service users mostly welcomed mental health specialist video consultations in primary care. Taking a pragmatic stance, service users, who are often frustrated about uncoordinated care, particularly valued the embedment of the consultations in the familiar environment of the primary care practice. With respect to interventional studies and implementation, our findings underscore the need to minimize technical disruptions during video consultations and to ensure optimal resemblance to face-to-face settings (eg, by training therapists in consistently reacting to nonverbal cues)., Trial Registration: German Clinical Trials Register DRKS00012487; https://tinyurl.com/uhg2one., (©Caroline Bleyel, Mariell Hoffmann, Michel Wensing, Mechthild Hartmann, Hans-Christoph Friederich, Markus W Haun. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 20.04.2020.)

Objective: Internet-based guided self-help (GSH-I) is an efficacious treatment for adults with binge-eating disorder (BED) and overweight or obesity. Although broadly accessible, high dropout from GSH-I has been reported. However, little is known about the factors explaining dropout from GSH-I, including patients' adherence to treatment., Method: Within a randomized trial on the treatment of BED, adherence to 4-month GSH-I was objectively assessed in N = 89 patients with BED and overweight or obesity. Objective adherence and subjective treatment evaluation were evaluated as predictors of dropout from GSH-I, defined as having accessed 5 or less of 11 modules. Cutoffs with optimal sensitivity and specificity were derived using Receiver Operating Characteristics curves analysis, and baseline sociodemographic and clinical correlates were determined., Results: According to our definition, n = 22 (24.7%) patients were defined as dropouts. Results of the full logistic regression model accounted for 72% of the variance in dropout and all objective adherence parameters (i.e., number of messages exchanged, days with a completed food diary, and days spent per module), but not patients' subjective GSH-I evaluation significantly predicted dropout. Specifically, not completing the food diary in week 7 had maximized sensitivity and specificity in predicting dropout. Patients' body mass index was positively associated with the number of messages exchanged between patients and coaches. No other associations between baseline variables and objective adherence were found., Discussion: Patients at risk for dropout from GSH-I can be reliably identified via monitoring of objective adherence and may be provided with additional interventions to prevent dropout., (© 2019 The Authors. International Journal of Eating Disorders published by Wiley Periodicals, Inc.)

Impulsivity is a major component of various mental disorders. A short form of the Barratt Impulsiveness Scale-the BIS-15-assesses three facets of impulsivity: non-planning, motor, and attentional. A confirmatory factor analysis tested its factor structure composed of three first-order latent factors and a second-order impulsivity factor in 453 patients with mental disorders (64% female). Model fit was acceptable as were internal reliabilities of the subscales and the total scale. The BIS-15 has sound psychometric properties in patients with mental disorders and, thus, can be used for assessing impulsivity and its subcomponents in this population., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflict of interest., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: Network approaches to psychopathology posit that mental disorders emerge from interrelated symptoms, and thus connectivity among symptoms are assumed to negatively predict the treatment response and decrease with efficacious treatment., Objective: This study uniquely sought to elucidate the network structure, its change, and its predictive value in cognitive-behavioral therapy (CBT) for binge-eating disorder (BED)., Methods: In a multicenter randomized trial of face-to-face and Internet-based guided self-help CBT, 178 individuals with full syndrome and subsyndromal BED, eating disorder and general psychopathology, and body mass index (BMI) were subjected to Gaussian Graphical Network and Exploratory Graph Analyses before and after treatment and at 6-month follow-up., Results: At pretreatment, 3 network communities of: eating disorder psychopathology; general psychopathology; and restraint and BMI were identified, with the latter community included in the first thereafter. Eating disorder-related impairment and self-esteem were the most central symptoms, while BMI and binge eating had the lowest centrality. Network connectivity significantly increased from pre- to posttreatment, with the greatest increases in strength centrality found in binge eating and shape concern, but it did not predict remission from binge eating., Conclusions: With decreasing symptom severity, CBT resulted in a greater integration and connectivity of the psychopathology network in BED, suggesting an increased patient understanding of relations between binge eating and other symptoms. Network connectivity was not a negative prognostic indicator of treatment outcome. These results indicate a need for further research on the predictive value of network variables in the explanation of therapeutic change for patients with BED., (© 2020 The Author(s) Published by S. Karger AG, Basel.)

Due to the pandemic caused by the coronavirus disease 2019 (COVID-19) and the resulting constraints on personal (i.e. face to face) treatment, video consultations have recently gained a major role in the delivery of healthcare services; however, until now, most psychotherapists have little experience with conducting video consultations, not least because of poor possibilities for reimbursement from the statutory health insurance. This article provides (1) an overview of the effectiveness of psychotherapy interventions delivered via video consultations for depression and anxiety disorders, (2) recommendations for setting up and conducting these consultations and (3) first experiences of psychotherapists from a German feasibility study and from the provision in routine care in hospital during the COVID-19 pandemic., (© The Author(s) 2020.)

Objective: Body dissatisfaction and eating disorders (ED) among young females may increase in limited-resource settings as exposure to media and higher-resource cultures increases. We examined ED prevalence and its predictors among adolescent girls in rural north-western Burkina Faso., Methods: Fieldworkers interviewed 696 female adolescents aged 12-20 years in the Nouna Health and Demographic Surveillance System (HDSS). ED were evaluated using the Structured Clinical Interview for DSM-5 (SCID-5), self-perceived appearance and body ideal were measured using Thompson and Gray's Contour Drawing Rating Scale (CDRS) and eating disorder predictors by the Eating Disorder Examination Questionnaire (EDE-Q). We assessed media exposure to magazines, radio, television, and the internet., Results: 16% of respondents had a BMI below WHO age-standardised 5th percentile, while 4% were above the 85th percentile; most respondents wanted to be larger. DSM-5 criteria for anorexia nervosa (AN) were fulfilled by four of 696 respondents (0.6%), those for bulimia nervosa by none, and those for binge eating disorder by two (0.3%). In multivariable regression, more AN symptoms were associated with greater EDE-Q body dissatisfaction, desiring a thinner body and a history of sexual harassment or assault, but not with media exposure. A thinner desired body was associated with greater media exposure, higher BMI z-score and greater EDE-Q disordered eating., Conclusion: ED were very rare in rural Burkinabé female adolescents, but factors predictive of ED in higher-resource settings were also predictive of ED precursor symptoms here. Our findings suggest that increasing media exposure in resource-limited settings may lead to increased body dissatisfaction, and potentially to increased future ED prevalence., (© 2019 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Background: Over a course of 10 weeks the psychosomatic-psychotherapeutic evening clinic at the University of Heidelberg offers an intensive and multimodal 3-h treatment program on three evenings a week. The clinic aims at accommodating patients who on the one hand do not fit the criteria of partial or full-time inpatient therapy, but on the other hand requires a more intensified therapy dose than the usual German outpatient settings can cater for. In the presented monocentric, qualitative study, we wanted to examine this treatment concept with regard to the patients' specific concerns, expectations, and individual experiences. By contrasting differences in intensity of outpatient and inpatient treatment, we aimed to identify those characteristics of the evening clinic setting that were perceived as especially helpful., Method: Each of the 25 patients was interviewed twice, using semi-structured interviews. The interviews took place before (T0) and after (T1) the 10-week treatment interval. A qualitative content analysis of the transcribed interviews was performed using the software "MaxQDA"., Results: We identified a total of 1609 separate codes and grouped them into 33 topics and 5 overarching categories. Here, we found some aspects independent of the therapeutic setting, and others concerning the patients' specific expectations and experiences resulting from the particularities of the evening clinic as an outpatient setting including certain inpatient characteristics. This included the possibility of patients continuing to work and being able to fulfil social obligations, i.e. childcare or caring for relatives, while at the same time undergoing intensive psychotherapeutic treatment., Conclusions: Our results show that the evening clinic concept is particularly suitable for patients with mental and psychosomatic disorders who require intensified multimodal therapy while continuing to meet their obligations in their private and working lives. However, in comparison to other therapeutic methods, this concept generated greater stress and time challenges. Patients should therefore have a reasonably good standard of functioning in everyday life and sufficient coping resources. This is especially important for patients who continue working in their jobs while undergoing treatment. So far, there is a lack of quantitative data which would be needed to evaluate the effectiveness of this novel setting., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2019.)

Background: Decisional regret during or after medical treatments is linked to significant distress. Regret affects not only patients but also caregivers having an active or passive role during decision making. The Decision Regret Scale (DRS) is a self-report measure for regret in patients after treatment decisions. However, practical and psychometrically robust instruments assessing regret in caregivers are lacking., Objective: To develop and validate a caregiver version of the DRS (Decision Regret Scale for Caregivers [DRS-C])., Design: Psychometric validation based on a web survey., Setting and Participants: 361 caregivers of deceased German people/patients with cancer., Main Variables Studied: Besides structural validity and test-retest reliability, we evaluated measurement invariance accounting for gender, age and closeness of relationship, and tested hypotheses on convergent/discriminant validity., Results: Forty-five per cent of all caregivers demonstrated decision regret. Confirmatory factor analyses strongly supported the unidimensional structure of the DRS-C and pointed to strict invariance. The DRS-C demonstrated very good internal consistency (α = 0.83, 95% CI [0.81, 0.86]) and test-retest reliability (ICC [A,1] = 0.73, 95% CI [0.59, 0.83]) along with sound convergent/discriminant validity. Concerning responsiveness, DRS-C scores remained stable over a 12-week period in 83.3% of all caregivers. Receiver operating characteristic analysis yielded a cut point of 43 for the identification of significant decision regret (AUC = 0.62, 95% CI [0.56, 0.68])., Discussion and Conclusions: The lack of a gold standard instrument prevented us from examining the criterion validity and determining a minimally important difference. Nevertheless, the DRS-C provides valid and reliable information regarding caregiver regret following medical decisions. Above all, it captures a crucial aspect of the treatment experience in caregivers., (© 2019 The Authors Health Expectations published by John Wiley & Sons Ltd.)

Mental health conditions represent a significant burden to the individual as well as the society. Within the health care system, the general practitioner is the first and, in most cases, the only provider. Timely referral of patients to specialized care is often difficult due to several barriers, particularly in rural areas. These barriers comprise long waiting times, the rising prevalence of psychosomatic and somatopsychic comorbidity, immobility in the elderly and stigmatisation related to mental health conditions. Following the Integrated Health Care approach, diagnosis and therapy of mental health conditions by psychotherapists directly within the general practice constitute an effective care model. We present a care model that is based on a telemental treatment approach for depression and anxiety disorders. Central is the piloting of psychotherapeutic video consultations in the general practice. The following article provides an overview of the care model and provides results concerning the intent to adopt the model in office-based psychotherapists., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Most people suffering from depression and anxiety disorders are entirely treated in primary care. Due to growing challenges in ageing societies, for example, patients' immobility and multimorbidity, the transition to specialised care becomes increasingly difficult. Although the co-location of general practitioners and mental health specialists improves the access to psychosocial care, integrated in-person approaches are not practical for rural and single-doctor practices with limited personnel and financial resources. Treating primary care patients via internet-based video consultations by remotely located mental health specialists bears the potential to overcome structural barriers and provide low-threshold care. The aim of this randomised controlled feasibility trial is to investigate the feasibility of implementing of mental health specialist video consultations in primary care practices., Methods and Analysis: Fifty primary care patients with significant depression and/or anxiety symptomatology will be randomised in two groups receiving either the treatment as usual as provided by their general practitioner or up to five video consultations conducted by a mental health specialist. The video consultations focus on (1) systematic diagnosis plus proactive monitoring using validated clinical rating scales, (2) the establishment of an effective working alliance and (3) a stepped-care algorithm within integrated care adjusting treatments based on clinical outcomes. We will investigate the following outcomes: effectiveness of the recruitment strategies, patient acceptance of randomisation, practicability of the technical and logistical processes related to implementing video consultations in the practices' workflows, feasibility of the data collection and clinical parameters., Ethics and Dissemination: This trial has undergone ethical scrutiny and has been approved by the Medical Faculty of the University of Heidelberg Ethics Committee (S-634/2018). The findings will be disseminated to the research community through presentations at conferences and publications in scientific journals. This feasibility trial will prepare the ground for a large-scale, fully powered randomised controlled trial., Trial Registration Number: DRKS00015812., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Even though asylum seekers show a high prevalence of trauma-related disorders and comorbid psychological stress symptoms, little is known about how their mental health develops during the asylum process and what options of care are provided. We aimed to investigate the mental health and treatment utilization of asylum seekers after they were transferred from a state registration- and reception-center to municipal shelters in Germany. N = 228 asylum seekers with on-going asylum procedure were recruited in the psychosocial walk-in clinic located in a state registration- and reception-center. We firstly captured symptoms of posttraumatic stress, depression, anxiety disorders, quality of life, as well as alcohol or drug abuse. Subsequently we performed a follow-up after three months to evaluate a potential shift in symptoms and determining rates of access to treatment. In the pre-post psychometric assessment, there were statistically significant changes in depression (PHQ-2), panic (PHQ-PD) and psychosocial well-being scores (WHO-5). However, all these scores still remained within a clinical relevant range, respectively. Traumatic stress (PC-PTSD-5) and general anxiety scores (GAD-2) did not change significantly. Although N = 44 (66%) of the interviewed patients had been referred to psychotherapy initially, none (0%) of them had received outpatient psychotherapeutic treatment after three months. Our results emphasize a strong need for low-threshold, cultural adapted psychotherapeutic treatment for asylum seekers., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Although real-time mental health specialist video consultations have been proposed as an effective care model for treating patients with mental health conditions in primary care, little is known about their integration into routine practice from the perspective of family physicians., Objective: This study aimed to determine the degree to which family physicians advocate that mental health specialist video consultations can be integrated into routine primary care, where most patients with mental health conditions receive treatment., Methods: In a cross-sectional qualitative study, we conducted 4 semistructured focus groups and 3 telephonic interviews in a sample of 19 family physicians from urban and rural districts. We conducted a qualitative content analysis applying the Tailored Implementation in Chronic Diseases framework in a combined bottom-up (data-driven) and top-down strategy for deriving key domains., Results: Family physicians indicated that mental health specialist video consultations are a promising and practical way to address the most pressing challenges in current practice, that is, to increase the accessibility and co-ordination of specialized care. Individual health professional factors were the most frequently discussed topics. Specifically, family physicians valued the anticipated clinical outcomes for patients and the anticipated resources set for the primary care practice as major facilitators (16/19, 84%). However, family physicians raised a concern regarding a lack of facial expressions and physical interaction (19/19, 100%), especially in emergency situations. Therefore, most family physicians considered a viable emergency plan for mental health specialist video consultations that clearly delineates the responsibilities and tasks of both family physicians and mental health specialists to be essential (11/19, 58%). Social, political, and legal factors, as well as guideline factors, were hardly discussed as prerequisites for individual family physicians to integrate mental health specialist video consultations into routine care. To facilitate the implementation of future mental health specialist video consultation models, we compiled a checklist of recommendations that covers (1) buy-in from practices (eg, emphasizing logistical and psychological relief for the practice), (2) the engagement of patients (eg, establishing a trusted patient-provider relationship), (3) the setup and conduct of consultations (eg, reliable emergency plans), and (4) the fostering of collaboration between family physicians and mental health specialists (eg, kick-off meetings to build trust)., Conclusions: By leveraging the primary care practice as a familiar environment for patients, mental health specialist video consultations provide timely specialist support and potentially lead to benefits for patients and more efficient processes of care. Integration should account for the determinants of practice as described by the family physicians., Trial Registration: German Clinical Trials Register DRKS00012487; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00012487., (©Mariell Hoffmann, Mechthild Hartmann, Michel Wensing, Hans-Christoph Friederich, Markus W Haun. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 19.08.2019.)

Abnormalities and alterations in brain function are commonly associated with the etiology and maintenance of anorexia nervosa (AN). Different symptom categories of AN have been correlated with distinct neurobiological patterns in previous studies. The aim of this literature review is to provide a narrative overview of the investigations into neural correlates of disorder-specific stimuli in patients with AN. Although findings vary across studies, a summary of neuroimaging results according to stimulus category allows us to account for methodological differences in experimental paradigms. Based on the available evidence, the following conclusions can be made: (a) the neural processing of visual food cues is characterized by increased top-down control, which enables restrictive eating, (b) increased emotional and reward processing during gustatory stimulation triggers disorder-specific thought patterns, (c) hunger ceases to motivate food foraging but instead reinforces disorder-related behaviors, (d) body image processing is related to increased emotional and hedonic reactions, (e) emotional stimuli provoke increased saliency associated with decreased top-down control and (f) neural hypersensitivity during interoceptive processing reinforces avoidance behavior. Taken together, studies that investigated symptom-specific neural processing have contributed to a better understanding of the underlying mechanisms of AN.

Background: The PHQ-9 is a standard screening tool for depressive disorders in cancer patients. As for the frequently reported symptom overlap with somatic disease, it has been debated whether somatic items are suitable for identifying depressive disorders in cancer patients. Thus, this study examines the diagnostic accuracy of somatic versus cognitive-emotional PHQ-9 items., Methods: The routine data of 4,705 patients, screened at the National Center for Tumor Diseases in Heidelberg between 2011 and 2016, was analyzed. For the single PHQ-9 items, receiver operating characteristics (ROC), sensitivity, specificity, positive, and negative predictive values (PPV and NPV), the Youden Index (YI), and the Clinical Utility Index (UI+/UI-) were applied for the diagnoses of major depressive disorder (MDD) and any depressive disorder (ADD)., Results: The non-somatic items played a pivotal role in the diagnosis of MDD, whereas the diagnostic accuracy of the somatic items increased in the diagnosis of ADD. For both MDD and ADD, the best performance was achieved by the non-somatic items "little interest" and "feeling down.", Limitations: In this study, only one self-reported instrument was used (i.e., the PHQ-9). In other words, the diagnoses were not validated by clinical interviews or other self-reported instruments., Conclusion: The somatic PHQ-9 items showed less discriminatory value than the non-somatic items. However, they may be useful as screening mechanisms for identifying at-risk cancer patients with mild/moderate depression. Disregarding the somatic items would lead to an underestimation of depressive syndromes and inadequate treatment of somatic symptoms., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Refugees have an increased risk of developing mental health problems. Due to the unstable setting in refugee state registration and reception centers, recommended trauma-focused treatment approaches are often not applicable. For this purpose, we devised a suitable therapeutic approach to treat traumatized refugees in a German state registration and reception center: Group therapy, focusing on stabilizing techniques and guided imagery according to Reddemann (2017). From May 2017 to April 2018, we conducted semi-structured interviews with n = 30 traumatized refugees to assess their experiences with the stabilizing techniques and guided imagery in group sessions and self-practice. Participants mainly reported that they had more pleasant feelings, felt increasingly relaxed, and could better handle recurrent thoughts. Additionally, the participants noticed that their psychosocial functioning had improved. The main difficulties that participants encountered were feeling stressed, having difficulties staying focused, or concentrating on the techniques. During self-practice, the participants found it most challenging that they did not have any verbal guidance, were often distracted by the surroundings in the accommodation, and had recurrent thoughts about post-migratory stressors, such as insecurity concerning the future or the application for asylum. Our results show that stabilizing techniques and guided imagery according to Reddemann (2017) are a suitable approach to treat traumatized refugees living in volatile conditions.

Aspects of global health are becoming increasingly relevant for doctors of future generations. However, medical curricula rarely include courses which focus on global health or forced migration. Furthermore, it remains unclear whether students are at risk to develop psychological strain, after being confronted with highly burdened or even traumatized asylum seekers. This is a prospective study using a mixed-methods approach. We included n = 22 medical students performing a medical clerkship in a state registration and reception center for refugees. By applying (1) qualitative interviews, (2) reflective diaries, and (3) psychometric questionnaires, we examined the students' experiences, teachable moments, and potential psychological burdens. In the interviews, the students emphasized the importance of cultural sensitivity during their clerkship. However, they also reported cognitive changes concerning their views of themselves and the world in general; this could indicate vicarious traumatization. The reflective diaries displayed high learning achievements. According to the psychometric questionnaires, the assignment in the reception center had not caused any significant psychological strain for the students. By completing their medical clerkship in a reception center, students were able to improve their medical, organizational, and interactional knowledge and skills. Furthermore, they reported that they had broadened their personal and cultural horizons.

Objective: Bulimia nervosa (BN) and binge-eating disorder (BED) are associated with poorly controlled approach behavior toward food resulting in binge eating. Approach bias modification (ABM) may reduce these automatic action tendencies (i.e., approach bias) toward food and may thus decrease binge eating and related symptoms., Method: A total of 56 patients with BN/BED participated in this double-blind, randomized controlled trial (RCT) comparing real and sham ABM. The real ABM condition adopted an implicit learning paradigm in which participants were trained to show avoidance behavior in response to food cues. Participants in the sham condition used a similar task but were not trained to avoid food cues. Both conditions comprised 10 training sessions within 4 weeks., Results: Participants in both groups experienced significant reductions in binge eating, eating disorder symptoms, trait food craving, and food cue reactivity. Real ABM tended to result in greater reductions in eating disorder symptoms than sham ABM. Food intake, approach bias, and attention bias toward food did not change., Discussion: This is the first RCT on ABM in eating disorders. The findings provide limited support for the efficacy of ABM in BN/BED and pose questions regarding its active ingredients and its usefulness as a stand-alone treatment for eating disorders., (© 2019 Wiley Periodicals, Inc.)

Objective: Patients with anorexia nervosa (AN) often show difficulties in the perception, expression, and regulation of emotions and a strong avoidance of aversive feelings. According to psychobiological models, dietary restraint and accompanying weight loss may serve as a maladaptive mechanism of emotion regulation by attenuating aversive emotional states in AN, thereby contributing to the maintenance of the disorder., Method: Twenty-seven women with AN and 26 age-matched healthy women were shown short film-clips to elicit fear, sadness, amusement, and neutral emotional states. Eyeblink startle response was measured by electromyography in reaction to startle-eliciting acoustic stimuli presented 12 times binaurally during each film-clip., Results: As compared to healthy controls, patients with AN showed a blunted startle response to the fear- but not to the sadness-eliciting stimulus., Discussion: The findings support the assumption that underweight is associated with attenuated emotional reactivity to fear-eliciting material in AN. This is in line with the hypothesis that starvation and low body weight constitute a maladaptive mechanism of emotion regulation in AN, contributing to the maintenance of the disorder., (© 2019 Wiley Periodicals, Inc.)

Purpose: Cognitive impairment and reduced quality of life is a common condition in patients with heart failure (HF). Percutaneous mitral valve repair using (PMVR) MitraClip (MC) has emerged as a promising interventional tool, reducing all-cause mortality and hospitalization as well as increasing cognitive functioning and quality of life. However, the benefit of HF patients with severely depressed cognitive functioning remains unknown., Methods: We assessed cognitive functioning (figural memory-FGT, executive function-TOL, TMT B), psychosocial functioning (depression-PHQ-9, quality of life-SF36), and clinical parameters (echocardiography, 6-min walk test distance, and cardiac biomarkers) 1 day before (t0) and 6 weeks after (t1) MC intervention in HF patients (n = 40). First, paired sample t tests were conducted to uncover improvements in cognitive functioning post-MC intervention. Second, the COGBAT Norm-sample, a representative age-matched healthy sample, was used to compare participants' individual scores. Third, bivariate linear regressions were calculated for all key predictors of the detected improvements in cognitive functioning post-MC intervention (t1-t0)., Results: Following the MC intervention, we found significant improvements in figural memory, executive functioning, and psychosocial functioning. Most of the patients with depressed executive functioning before the MC intervention showed post-intervention test scores within the normal range (> 50th percentile; t0 22.5% vs. t1 60%) as compared to the normative COGBAT sample. Regression analyses revealed that lower baseline scores in planning ability before the MC intervention (t0) were associated with greater planning ability (TOL; B = - 0.78, 95% CI - 1.04 to - 0.53), figural memory (FGT; B = - 0.26, 95% CI - 0.44 to - 0.07), and cognitive flexibility (TMT B; B = - 0.36, 95% CI - 0.50 to - 0.23) improvement post-MC intervention (t1-t0). Psychosocial functioning and age were not associated with these improvements., Conclusions: Patients with depressed executive functioning showed the greatest benefit from the MC intervention regarding cognitive functioning. Age and psychological functioning seem less important for cognitive performance improvements post-MC intervention. Hence, severely depressed cognitive functioning in patients is not a contraindication for PMVR using MitraClip.

Introduction: The etiology of bulimic-type eating (BTE) disorders such as binge eating disorder (BED) and bulimia nervosa (BN) is still largely unknown. Brain networks subserving the processing of rewards, emotions, and cognitive control seem to play a crucial role in the development and maintenance of eating disorders. Therefore, further investigations into the neurobiological underpinnings are needed to discern abnormal connectivity patterns in BTE disorders., Methods: The present study aimed to investigate functional as well as seed-based connectivity within well-defined brain networks. Twenty-seven individuals with BED, 29 individuals with BN, 28 overweight, and 30 normal-weight control participants matched by age, gender, and education underwent resting-state functional magnetic resonance imaging. Functional connectivity was assessed by spatial group independent component analysis and a seed-based correlation approach by examining the default mode network (DMN), salience network (SN), and executive network (EN)., Results: Group comparisons revealed that BTE disorder patients exhibit aberrant functional connectivity in the dorsal anterior cingulate cortex (dACC) within the SN, as well as in the medial prefrontal cortex within the DMN. Furthermore, BED and BN groups differed from each other in functional connectivity within each network. Seed-based correlational analysis revealed stronger synchronous dACC-retrosplenial cortex activity in the BN group., Conclusion: Our findings demonstrate abnormalities in brain networks involved in salience attribution, self-referential processing, and cognitive control in bulimic-type eating disorders. Together with our observation of functional connectivity differences between BED and BN, this study offers a differentiated account of both similarities and differences regarding brain connectivity in BED and BN., (© 2019 The Authors. Brain and Behavior published by Wiley Periodicals, Inc.)

This study investigates the role of body image self-appraisal in predicting the outcomes of outpatient psychotherapy in patients with anorexia nervosa (AN). Multiple linear regression analyses and a path-analysis model were applied to test the study hypotheses that body image at baseline predicts treatment outcomes of outpatient psychotherapy in patients with AN at follow-up measurement. The analyses were conducted as secondary analyses in a subgroup (n = 148) of the anorexia nervosa treatment of outpatient-cohort (ANTOP-study) (N = 242) of patients with AN. The results show that Negative Evaluation of the Body at baseline predicts perceived stress during psychotherapy, which in turn predicts depressive symptoms at the end of therapy which in turn predicts the outcomes body mass index and EDI-2 sum score at 12 months follow-up. The results underline the importance of body image disturbance in the course of AN and call for body image as a central target of psychotherapeutic interventions in patients with AN., (© 2018 John Wiley & Sons, Ltd and Eating Disorders Association.)

Rapid response is considered the most well-established outcome predictor across treatments of binge-eating disorder (BED), including cognitive-behavioral therapy (CBT). This study sought to identify latent trajectories of early change in CBT and compare them to common rapid response classifications. In a multicenter randomized trial, 86 adults with BED (DSM-IV) or subsyndromal BED provided weekly self-reports of binge eating over the first 4 weeks of CBT, which were analyzed to predict binge eating, depression, and body mass index at posttreatment, 6-, and 18-month follow-up. Using latent growth mixture modeling, three patterns of early change-including moderate and low decreasing-as well as low stable binge eating were identified, which significantly predicted binge-eating remission at 6-month follow-up. Other classifications of rapid response based on Receiver Operating Characteristics curve analyses or on the literature (≥ 10% reduction in binge eating at week 1, ≥ 70% reduction in binge eating at week 4) only predicted posttreatment remission or overall depression, respectively. Latent change trajectories, but not other rapid response classifications, predicted binge-eating frequency over time. A fine-grained analysis of change over the first 4 weeks of CBT for BED revealed different trajectories of early change in binge eating that led to an improved prediction of binge-eating outcome, compared to that of common rapid response classifications. Thorough monitoring of early change trajectories during treatment may have clinical utility., (Copyright © 2018. Published by Elsevier Ltd.)

Staffing level: Survey among psychosomatic-psychotherapeutic institutions in Germany Objectives: To establish the first nationwide hospital survey to assess the level of staffing for inpatient and daycare treatment in psychosomatic hospitals and specialist departments in Germany., Methods: Using a standardized written hospital survey from the Deutsches Krankenhausinstitut (DKI), we invited a total of 218 psychosomatic-psychotherapeutic hospitals and specialist departments to participate. The participation rate of the institutions was 35%., Results: In the overall sample, one psychotherapist (physician/clinical psychologist) was responsible for treating a median of 3.9 beds/patients (interquartile range 3.1-5.1) and one nurse a median of 2.9 beds/patients (interquartile range 2.3-3.9). There were significant differences for the nurse-patient ratio depending on the organizational size of the institution. To ensure quality treatment, professional experts saw increased staffing needs of about 12-17% across both professions. For the professional groups of specialist therapists and social workers, broad variances were observed for the therapist-patient ratio in the overall sample., Conclusions: The study provides an important and relevant data basis for the further discussion to determine mandatory minimal staffing levels in German psychosomatic-psychotherapeutic institutions.

Objective: Patients' processing of psychotherapy between sessions ("inter-session process" (ISP)) has been repeatedly shown to be related to outcome. The aim of this study was to compare ISP characteristics of cognitive-behavioral vs. psychodynamic psychotherapy in the treatment of anorexia nervosa (AN) and their relation to outcome., Methods: Data of 106 patients participating in a randomized-controlled trial who received either 40 sessions of enhanced cognitive-behavioral therapy (CBT-E) or focal psychodynamic therapy (FPT) were analyzed. The ISP was measured with the Inter-session Experience Questionnaire (IEQ). Three outcome classes were distinguished: full recovery, partial recovery, and still fulfilling all AN criteria., Results: Patients receiving CBT-E reported more on "applying therapy" in the initial and the final treatment phase compared to FPT patients. In terms of process-outcome relations, higher levels of "recreating the therapeutic dialogue between sessions," "recreating the therapeutic dialogue with negative emotions" as well as "applying therapy with negative emotions" in the final phase of treatment predicted negative outcome in FPT, whereas overall higher levels of negative emotions predicted negative outcome in CBT-E., Conclusions: In outpatient treatment in AN, the processing of therapy as measured by the IEQ showed surprisingly few differences between CBT-E and FPT. However, different ISP patterns were predictive of outcome, pointing to different mechanisms of change.

Individuals with bulimia nervosa (BN) or binge-eating disorder (BED) experience more frequent and intense food cravings than individuals without binge eating. However, it is currently unclear whether they also show larger food cue-induced increases in craving (i.e., food cue reactivity) than those without binge eating, as suggested by conditioning theories of binge eating. A group of individuals with BN or BED (binge-eating group, n = 27) and a group of individuals with low trait food craving scores and without binge eating (control group, n = 19) reported their current food craving before and after a food cue exposure. Although food craving intensity significantly increased in both groups, this increase was significantly stronger in the binge-eating group than in the control group. This result is in line with conditioning models of binge eating that propose that food cues are conditioned stimuli that elicit a conditioned response (e.g., food craving) and that this association is stronger in individuals with binge eating. As food craving increased in individuals with low trait food craving scores as well-although to a lesser extent-previous null results might be explained by methodological considerations such as not screening control participants for trait food craving., Competing Interests: The authors have declared that no competing interests exist.

The treatment of patients with anorexia nervosa (AN) is often challenging, due to a high degree of ambivalence towards recovery and weight gain these patients often express. One part of the multimodal treatment is the utilization of treatment contracts (i.e., contingency contracts) that aim to motivate patients to gain weight by applying positive and negative consequences for the (non-)achievement of weight goals. The main aim of this study is to assess and analyze current standards of contingency contracts' utilization in German eating disorder centers. n = 76 mental health professionals of twelve specialized university centers in Germany that are currently or were formerly treating patients with AN in an inpatient setting participated. Most experts use contingency contracts in their clinic with weekly weight goals ranging between 500 and 700 g. Overall effectiveness and significance of contingency contracts for the inpatient treatment of patients with AN was rated high. Typical characteristics of a contingency contract in specialized German university hospital centers, such as the most frequent consequences, are described. The survey results assist the planning of further studies aiming to improve the multimodal treatment of patients with AN. For clinical practice, using external motivators such as contingency contracts as well as targeting internal motivation (e.g., by using motivational interviewing) is proposed.

Background: Anorexia nervosa (AN) is a disabling, deadly and costly mental disorder. Until recently, treatment recommendations were based on expert opinion and limited evidence. The aim of this systematic review is to synthesise recent evidence on established and emerging AN treatments and to forecast trends for future developments., Methods: We systematically review trials of established treatments and associated process outcome studies from the last 5 years, published since a previous review in this journal. 'Established' treatments were those that are widely used in AN, recommended by guidelines and/or have been tested in at least one large randomised controlled trial. Secondly, we summarise emerging treatments for AN, i.e. those that have only been (or are currently being) tested in proof-of concept, feasibility or pilot trials., Results: We identified 19 published trials of established treatments (15 of high or moderate quality), mostly assessing psychological therapies (n = 17). We also found 11 published trials of emerging treatments, and a total of 34 registered, as yet unpublished trials. Promising emerging treatments include cognitive remediation therapy, exposure therapy and non-invasive neuromodulation., Conclusions: Evidence generation on the treatment of AN has dramatically accelerated, with our understanding of the role of family-based approaches for adolescents more nuanced and a range of psychological approaches available for the treatment of adults. Evidence on emerging treatments and from forthcoming trials suggests that there is a shift towards more targeted brain-based interventions. Future studies need to focus on elucidating mechanisms of action of treatments and what works best for whom.

A distorted body image and pronounced body dissatisfaction are hallmarks of anorexia nervosa (AN) that typically result in dietary restraint and compensatory behaviours. Cognitive biases such as negative interpretation bias are considered key maintaining factors of these maladaptive cognitions and behaviours. However, little attention has been paid to empirical tests whether negative interpretation bias exists in AN and to what degree it is associated with symptom severity. Participants in the present study were 40 women with AN and 40 healthy women with no history of an eating disorder. Body-related negative interpretation bias (i.e., a tendency to interpret ambiguous information about the own body in a negative way) was measured by a Scrambled Sentences Task. Patients with AN showed a stronger body-related negative interpretation bias than healthy controls. Within both groups, negative interpretation bias correlated strongly and positively with AN symptom severity and these effects were not moderated by levels of depressive symptoms. The findings support the idea that biased interpretation of body-related information is associated with the specific psychopathology of AN. Targeted, computerised interventions (e.g. interpretation bias modification) may help to alter these dysfunctional cognitive schemas that lie at the heart of AN., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The aim of the study was a systematic review of studies evaluating psychotherapeutic treatment approaches in anorexia nervosa and to compare their efficacy. Weight gain was chosen as the primary outcome criterion. We also aimed to compare treatment effects according to service level (inpatient vs. outpatient) and age group (adolescents vs. adults). Methods: The data bases PubMed, Cochrane Library, Web of Science, Cinahl, and PsychInfo were used for a systematic literature search (until Feb 2017). Search terms were adapted for data base, combining versions of the search terms anorexia, treat * /therap * and controlled trial . Studies were selected using pre-defined in- and exclusion criteria. Data were extracted by two independent coders using piloted forms. Network-meta-analyses were conducted on all RCTs. For a comparison of service levels and age groups, standard mean change (SMC) statistics were used and naturalistic, non-randomized studies included. Results: Eighteen RCTs (trials on adults: 622 participants; trials on adolescents: 625 participants) were included in the network meta-analysis. SMC analyses were conducted with 38 studies (1,164 participants). While family-based approaches dominate interventions for adolescents, individual psychotherapy dominates in adults. There was no superiority of a specific approach. Weight gains were more rapid in adolescents and inpatient treatment. Conclusions: Several specialized psychotherapeutic interventions have been developed and can be recommended for AN. However, adult and adolescent patients should be distinguished, as groups differ in terms of treatment approaches considered suitable as well as treatment response. Future trials should replicate previous findings and be multi-center trials with large sample sizes to allow for subgroup analyses. Patient assessment should include variables that can be considered relevant moderators of treatment outcome. It is desirable to explore adaptive treatment strategies for subgroups of patients with AN. Identifying and addressing maintaining factors in AN remains a major challenge.

Objective: Weight loss maintenance is one of the biggest challenges in behavioral weight loss programs. The present study aimed to examine metabolic influences on the mesolimbic reward system in people with successful and unsuccessful long-term weight loss maintenance., Methods: Thirty-three women with obesity at least 6 months after the completion of a diet were recruited: seventeen women were able to maintain their weight loss, whereas sixteen showed weight regain. Using functional magnetic resonance imaging in combination with the assessment of appetite-regulating hormones, neural reward processing during hunger and satiety was investigated. An incentive delay task was employed to investigate the expectation and receipt of both food-related and monetary reward., Results: Only participants with successful weight loss maintenance showed a satiety-induced attenuation of brain activation during the receipt of a food-related reward. Furthermore, in successful weight loss maintenance, the attenuation of active ghrelin levels was related to brain activation in response to food-related reward anticipation during satiety., Conclusions: The findings suggest that an attenuated influence of satiety signaling on the neural processing of food-related reward contributes to unsuccessful weight loss maintenance. Thus, intact satiety signaling to the mesolimbic reward system may serve as a promising target for tackling weight cycling., (© 2018 The Obesity Society.)

Objective: To determine the cost-effectiveness of individual face-to-face cognitive behavioral therapy (CBT) compared to therapist guided Internet-based self-help (GSH-I) in overweight or obese adults with binge-eating disorder (BED)., Method: Analysis was conducted alongside the multicenter randomized controlled INTERBED trial. CBT (n = 76) consisted of up to 20 individual therapy sessions over 4 months. GSH-I (n = 71) consisted of 11 modules combining behavioral interventions, exercises including a self-monitoring food diary, psychoeducation, and 2 face-to-face coaching sessions over 4 months. Assessments at baseline, after 4 months (post-treatment), as well as 6 and 18 months after the end of treatment included health care utilization and sick leave days to calculate direct and indirect costs. Binge-free days (BFD) were calculated as effect measure based on the German version of the Eating Disorder Examination. The incremental cost-effectiveness ratio (ICER) was determined, and net benefit regressions, adjusted for comorbidities and baseline differences, were used to derive cost-effectiveness acceptability curves., Results: After controlling for baseline differences, CBT was associated with non-significantly more costs (+€2,539) and BFDs (+40.1) compared with GSH-I during the 22-month observation period, resulting in an adjusted ICER of €63 per additional BFD. CBTs probability of being cost-effective increased above 80% only if societal willingness to pay (WTP) was ≥€250 per BFD., Discussion: We did not find clear evidence for one of the treatments being more cost-effective. CBT tends to be more effective but also more costly. If the societal WTP for an additional BFD is low, then our results suggest that GSH-I should rather be adopted., (© 2018 Wiley Periodicals, Inc.)

Anhedonia, or the inability to experience pleasure, is commonly observed in schizophrenia. It has been suggested that patients with schizophrenia are unable to predict future pleasurable events, but show intact experience of in-the-moment pleasure. Therefore, the Temporal Experience of Pleasure Scale (TEPS), a self-report measure allowing the assessment of anticipatory and consummatory pleasure, has been developed. To validate the German version of the TEPS, we recruited 59 healthy control participants and 51 patients with schizophrenia or schizoaffective disorder who completed the TEPS as well as a battery of psychometric tests to assess psychopathology, in particular self-rated anhedonia and clinician-rated apathy as well as overall measures of negative symptoms. We found acceptable to good internal consistency and a factor structure comparable to the original version. Scores of the TEPS were related to measures of anhedonia and apathy, but not with other measures of psychopathology. The present results suggest that the German version of the TEPS shows adequate reliability and validity to assess the construct of anhedonia. However, differential aspects of anticipatory and consummatory pleasure should be further investigated in clinical samples., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: To investigate whether depressed oncology patients show a specific depressive symptom profile, we compared depression symptoms in depressed cancer patients (CANCER-DEP) and depressed patients without a chronic somatic disease (NONCANCER-DEP)., Methods: Of a total of 2493 outpatients from a comprehensive cancer center and a center for psychosocial medicine, 1054 (42.3%) met the DSM-5 criteria for depression, measured with the Patient Health Questionnaire 9. Based on the Patient Health Questionnaire 9 scores, differences in severity of each of the 9 individual DSM-5 depression symptoms between CANCER-DEP (n = 542) and NONCANCER-DEP (n = 512) were examined. Non-depressed cancer patients (CANCER-NONDEP; n = 1216) served as a comparison group for somatic symptoms independent of depression in cancer. To control for depression severity, group comparisons were performed separately for patients with major depression and any depressive disorders., Results: Depressed cancer patients reported significantly lower levels of the cognitive-emotional depression symptoms "worthlessness" and "suicidal thoughts" than NONCANCER-DEP. Only 1 out of 5 somatic depression symptoms ("changes in appetite") was more pronounced in CANCER-DEP than in NONCANCER-DEP. Confirming previous research, somatic depression symptoms occurred more frequently in CANCER-DEP than in CANCER-NONDEP., Conclusions: The lower level of cognitive-emotional symptoms in CANCER-DEP than in NONCANCER-DEP is discussed in relation to different psychosocial phenomena. Our results indicate that somatic depression symptoms are similarly pronounced in CANCER-DEP and NONCANCER-DEP, and that CANCER-DEP show greater somatic depression symptoms than CANCER-NONDEP. The presence of high levels of somatic symptoms should alert clinicians to investigate for a potential comorbid depression in cancer patients., (Copyright © 2017 John Wiley & Sons, Ltd.)

Objective: The protein hormone adiponectin promotes metabolic and psychological health. The aim of the study was to track changes in adiponectin levels in response to weight gain and to assess associations between adiponectin and psychological aspects in patients with anorexia nervosa (AN)., Methods: To investigate if adiponectin levels depend on AN severity, data were assessed from 11 inpatients with a very low body mass index (BMI) and a high chronicity (high severity group; HSS), and nine with less severe symptoms (LSS). During the course of treatment, serum adiponectin concentrations were assessed on a weekly basis along with BMI. Psychological variables (i.e., depression, anxiety, stress, and AN-specific symptoms) were obtained by means of electronic diaries. Longitudinal regressions and correlations were calculated to evaluate the temporal course of adiponectin and its relationship with psychological self-ratings., Results: At the beginning adiponectin was not increased in HSS patients (p = .56), and only marginally elevated in LSS patients (p = 0.07) compared with controls. In HSS patients, adiponectin increased along with BMI during the first treatment phase (i.e., when the BMI of patients was below 16 kg/m2) and thereafter decreased with further weight gain. In LSS patients, adiponectin was not associated with BMI increase. Furthermore, adiponectin was strongly negatively correlated with psychological self-ratings when the BMI of patients was above 16 kg/m2, i.e., higher levels of adiponectin were related to lower ratings of depression, anxiety, and AN-specific symptoms., Discussion: The study connects previous varying results by indicating that the course of adiponectin is dependent on BMI and symptom severity. Similarly, associations of adiponectin and psychological health depended on BMI.

Background: Heightened sensitivity towards reward and insensitivity towards disadvantageous consequences may constitute a driving factor underlying unrestricted food intake and consequent weight gain in people with overweight and obesity. Therefore, the present study applied a behavioral economics approach to investigate the potential contribution of poor reward-related decision making to unsuccessful long-term weight loss maintenance (i.e. weight cycling). Based on previous research, it was expected that successful long-term weight loss maintainers would show a better performance in a gambling task than their less successful counterparts., Methods: Reward-related decision making was assessed post hoc using the Game of Dice Task in a total of 33 overweight and obese women who had either (a) successfully maintained initial weight loss of at least 10% of their body weight over one year or (b) had regained weight until at least their initial body weight prior to weight reduction (i.e. showed weight cycling)., Results: The groups did not differ in terms of age, current body weight, magnitude of initial weight reduction, educational level, and global intelligence level. As hypothesized, however, the group of successful long-term weight loss maintainers performed significantly better (i.e. showed less impulsive, more advantageous choices) in the Game of Dice Task than their less successful counterparts., Conclusions: The findings suggest that poor reward-related decision making is associated with weight cycling which is considered a key concern in weight loss treatments for overweight and obesity. Furthermore, the findings speak in favor of specific psychological interventions that are designed to bolster reward-related decision making., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Importance: Although cognitive behavioral therapy (CBT) represents the criterion standard for treatment of binge eating disorder (BED), most individuals do not have access to this specialized treatment., Objective: To evaluate the efficacy of internet-based guided self-help (GSH-I) compared with traditional, individual face-to-face CBT., Design, Setting, and Participants: The Internet and Binge Eating Disorder (INTERBED) study is a prospective, multicenter, randomized, noninferiority clinical trial (treatment duration, 4 months; follow-ups, 6 months and 1.5 years). A volunteer sample of 178 adult outpatients with full or subsyndromal BED were recruited from 7 university-based outpatient clinics from August 1, 2010, through December 31, 2011; final follow-up assessment was in April 2014. Data analysis was performed from November 30, 2014, to May 27, 2015., Interventions: Participants received 20 individual face-to-face CBT sessions of 50 minutes each or sequentially completed 11 internet modules and had weekly email contacts., Main Outcomes and Measures: The primary outcome was the difference in the number of days with objective binge eating episodes (OBEs) during the previous 28 days between baseline and end of treatment. Secondary outcomes included OBEs at follow-ups, eating disorder and general psychopathologic findings, body mass index, and quality of life., Results: A total of 586 patients were screened, 178 were randomized, and 169 had at least one postbaseline assessment and constituted the modified intention-to-treat analysis group (mean [SD] age, 43.2 [12.3] years; 148 [87.6%] female); the 1.5-year follow-up was available in 116 patients. The confirmatory analysis using the per-protocol sample (n = 153) failed to show noninferiority of GSH-I (adjusted effect, 1.47; 95% CI, -0.01 to 2.91; P = .05). Using the modified intention-to-treat sample, GSH-I was inferior to CBT in reducing OBE days at the end of treatment (adjusted effect, 1.63; 95% CI, 0.17-3.05; P = .03). Exploratory longitudinal analyses also showed the superiority of CBT over GSH-I by the 6-month (adjusted effect, 0.36; 95% CI, 0.23-0.55; P < .001) but not the 1.5-year follow-up (adjusted effect, 0.91; 95% CI, 0.54-1.50; P = .70). Reductions in eating disorder psychopathologic findings were significantly higher in the CBT group than in the GSH-I group at 6-month follow-up (adjusted effect, -0.4; 95% CI, -0.68 to -0.13; P = .005). No group differences were found for body mass index, general psychopathologic findings, and quality of life., Conclusions and Relevance: Face-to-face CBT leads to quicker and greater reductions in the number of OBE days, abstinence rates, and eating disorder psychopathologic findings and may be a better initial treatment option than GSH-I. Internet-based guided self-help remains a viable, slower-acting, low-threshold treatment alternative compared with CBT for adults with BED., Trial Registration: isrctn.org Identifier: ISRCTN40484777 and germanctr.de Identifier: DRKS00000409.

Background: Food intake is guided by homeostatic needs and by the reward value of food, yet the exact relation between the two remains unclear. The aim of this study was to investigate the influence of different metabolic states and hormonal satiety signaling on responses in neural reward networks., Methods: Twenty-three healthy participants underwent functional magnetic resonance imaging while performing a task distinguishing between the anticipation and the receipt of either food- or monetary-related reward. Every participant was scanned twice in a counterbalanced fashion, both during a fasted state (after 24 hours fasting) and satiety. A functional connectivity analysis was performed to investigate the influence of satiety signaling on activation in neural reward networks. Blood samples were collected to assess hormonal satiety signaling., Results: Fasting was associated with sensitization of the striatal reward system to the anticipation of food reward irrespective of reward magnitude. Furthermore, during satiety, individual ghrelin levels were associated with increased neural processing during the expectation of food-related reward., Conclusions: Our findings show that physiological hunger stimulates food consumption by specifically increasing neural processing during the expectation (i.e., incentive salience) but not the receipt of food-related reward. In addition, these findings suggest that ghrelin signaling influences hedonic-driven food intake by increasing neural reactivity during the expectation of food-related reward. These results provide insights into the neurobiological underpinnings of motivational processing and hedonic evaluation of food reward., Trial Registration: ClinicalTrials.gov NCT03081585., Funding: This work was supported by the German Competence Network on Obesity, which is funded by the German Federal Ministry of Education and Research (FKZ 01GI1122E).

Background: Incurable cancer, which often constitutes an enormous challenge for patients, their families, and medical professionals, profoundly affects the patient's physical and psychosocial well-being. In standard cancer care, palliative measures generally are initiated when it is evident that disease-modifying treatments have been unsuccessful, no treatments can be offered, or death is anticipated. In contrast, early palliative care is initiated much earlier in the disease trajectory and closer to the diagnosis of incurable cancer., Objectives: To compare effects of early palliative care interventions versus treatment as usual/standard cancer care on health-related quality of life, depression, symptom intensity, and survival among adults with a diagnosis of advanced cancer., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, OpenGrey (a database for grey literature), and three clinical trial registers to October 2016. We checked reference lists, searched citations, and contacted study authors to identify additional studies., Selection Criteria: Randomised controlled trials (RCTs) and cluster-randomised controlled trials (cRCTs) on professional palliative care services that provided or co-ordinated comprehensive care for adults at early advanced stages of cancer., Data Collection and Analysis: We used standard methodological procedures as expected by Cochrane. We assessed risk of bias, extracted data, and collected information on adverse events. For quantitative synthesis, we combined respective results on our primary outcomes of health-related quality of life, survival (death hazard ratio), depression, and symptom intensity across studies in meta-analyses using an inverse variance random-effects model. We expressed pooled effects as standardised mean differences (SMDs, or Hedges' adjusted g). We assessed certainty of evidence at the outcome level using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) and created a 'Summary of findings' table., Main Results: We included seven randomised and cluster-randomised controlled trials that together recruited 1614 participants. Four studies evaluated interventions delivered by specialised palliative care teams, and the remaining studies assessed models of co-ordinated care. Overall, risk of bias at the study level was mostly low, apart from possible selection bias in three studies and attrition bias in one study, along with insufficient information on blinding of participants and outcome assessment in six studies.Compared with usual/standard cancer care alone, early palliative care significantly improved health-related quality of life at a small effect size (SMD 0.27, 95% confidence interval (CI) 0.15 to 0.38; participants analysed at post treatment = 1028; evidence of low certainty). As re-expressed in natural units (absolute change in Functional Assessment of Cancer Therapy-General (FACT-G) score), health-related quality of life scores increased on average by 4.59 (95% CI 2.55 to 6.46) points more among participants given early palliative care than among control participants. Data on survival, available from four studies enrolling a total of 800 participants, did not indicate differences in efficacy (death hazard ratio 0.85, 95% CI 0.56 to 1.28; evidence of very low certainty). Levels of depressive symptoms among those receiving early palliative care did not differ significantly from levels among those receiving usual/standard cancer care (five studies; SMD -0.11, 95% CI -0.26 to 0.03; participants analysed at post treatment = 762; evidence of very low certainty). Results from seven studies that analysed 1054 participants post treatment suggest a small effect for significantly lower symptom intensity in early palliative care compared with the control condition (SMD -0.23, 95% CI -0.35 to -0.10; evidence of low certainty). The type of model used to provide early palliative care did not affect study results. One RCT reported potential adverse events of early palliative care, such as a higher percentage of participants with severe scores for pain and poor appetite; the remaining six studies did not report adverse events in study publications. For these six studies, principal investigators stated upon request that they had not observed any adverse events., Authors' Conclusions: This systematic review of a small number of trials indicates that early palliative care interventions may have more beneficial effects on quality of life and symptom intensity among patients with advanced cancer than among those given usual/standard cancer care alone. Although we found only small effect sizes, these may be clinically relevant at an advanced disease stage with limited prognosis, at which time further decline in quality of life is very common. At this point, effects on mortality and depression are uncertain. We have to interpret current results with caution owing to very low to low certainty of current evidence and between-study differences regarding participant populations, interventions, and methods. Additional research now under way will present a clearer picture of the effect and specific indication of early palliative care. Upcoming results from several ongoing studies (N = 20) and studies awaiting assessment (N = 10) may increase the certainty of study results and may lead to improved decision making. In perspective, early palliative care is a newly emerging field, and well-conducted studies are needed to explicitly describe the components of early palliative care and control treatments, after blinding of participants and outcome assessors, and to report on possible adverse events.

Objective: It is unclear whether observed memory impairment in anorexia nervosa (AN) depends on the semantic structure (categorized words) of material to be encoded. We aimed to investigate the processing of semantically related information in AN., Method: Memory performance was assessed in a recall, learning, and recognition test in 27 adult women with AN (19 restricting, 8 binge-eating/purging subtype; average disease duration: 9.32 years) and 30 healthy controls using an extended version of the Rey Auditory Verbal Learning Test, applying semantically related and unrelated word stimuli., Results: Short-term memory (immediate recall, learning), regardless of semantics of the words, was significantly worse in AN patients, whereas long-term memory (delayed recall, recognition) did not differ between AN patients and controls., Discussion: Semantics of stimuli do not have a better effect on memory recall in AN compared to CO. Impaired short-term versus long-term memory is discussed in relation to dysfunctional working memory in AN. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association., (Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.)

Rationale: Alcohol dependence is associated with impaired response inhibition and heightened cue reactivity towards alcohol-related stimuli. Several brain areas, but mainly prefrontal structures, have been linked to response inhibition in addiction. This study aimed at combining both aspects: salience of drug-associated cues and response inhibition using a go/no-go task with alcohol-associated stimuli during functional magnetic resonance imaging (fMRI)., Objectives: Nineteen abstinent alcohol-dependent patients (ADP) and 21 healthy control subjects (HC) were compared on blood oxygen level-dependent (BOLD) responses during successful inhibition of no-go stimuli and successful reactions to go stimuli., Results: ADP and HC did not significantly differ in their behavioural performance in the task. However, both groups performed worse during the inhibition of alcoholic-associated stimuli compared to neutral stimuli. On the neural level, ADP displayed enhanced BOLD activity relative to HC during successful response inhibition in several areas involved in visual processing, cognitive and impulse control, including occipital structures, anterior cingulate gyrus, medial frontal gyrus and medial orbitofrontal cortex., Conclusions: We interpret these findings as a possible compensation strategy for impaired cognitive processing. Furthermore, the results underline the impact of salience of alcohol-related stimuli on response inhibition, which seems to affect both ADP and HC.

Objective: To analyze the effect of an online support group (OSG) on the final treatment decision for localized prostate cancer., Methods: We performed a cross-sectional descriptive study of the largest German prostate cancer OSG between July and October 2013. The online survey comprised 127 questions covering sociodemographic and disease-related information, decision-making habits, health-related quality of life, distress, depression, and anxiety. The primary outcome was to measure the effect of an OSG on the final treatment decision., Results: We analyzed the completed questionnaires from 686 patients with prostate cancer, 200 (29.2%) of whom revised their initial treatment decision. After revising their decisions, these patients more frequently underwent external beam radiation therapy (44.5% vs. 36.4%, P = 0.048) and active surveillance (10.5% vs. 3.7%, P<0.001) and less frequently underwent radical prostatectomy (52.5% vs. 74.9%, P<0.001). Engaging longer in the OSG, demanding a more active role in the decision-making process, and participating in a conventional support group were independently associated with revision of the initial treatment decision., Conclusions: Of all patients participating in the OSG, 29.2% revised their initial treatment decision. We estimate that this phenomenon may affect 17,000 patients with prostate cancer in the United States of America every year. This finding highlights the importance of OSGs for the health care system. The patient׳s desired degree of involvement in decision-making should be routinely clarified to adjust counseling accordingly., Trial Registration: www.germanctr.de, number DRKS00005086., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Leptin, a hormone secreted by adipose tissue, appears to play a major role in the homeostasis of body weight and psychobiological processes associated with anorexia nervosa (AN). However, there is scarce data on its exact influence on this disorder, in particular data over time., Objective: The present study addresses whether leptin changes during inpatient treatment play a role for treatment outcome and psychological factors in underweight AN patients., Methods: In order to understand whether leptin's role differs in relation to AN severity, data were assessed from 11 patients with a very low BMI and a higher chronicity (high severity group; HSS; mean BMI at the beginning of the study = 13.6; mean duration of illness = 5.1 years) vs. nine with less severe symptoms (LSS; mean BMI = 16.2; mean duration of illness = 3.7 years). During the course of treatment, serum leptin concentrations were assessed weekly while weight (BMI) was assessed twice per week. Concomitantly, psychological variables were obtained by means of electronic diaries. Unconditional linear growth models were calculated to evaluate the temporal course of leptin in relation to BMI. For HSS patients, two phases of treatment (BMI < 16 and BMI ≥ 16 kg/m2) were investigated., Results: Leptin increased significantly with BMI in both groups of patients. For HSS patients, the increase of leptin in the first treatment phase did not predict later increases in BMI. Furthermore, the relationship of leptin and psychological factors was modulated by symptom severity. In HSS patients, higher leptin levels were associated with greater feelings of depression, anxiety, and stress whereas in LSS patients a higher leptin level showed the trend to be associated with lower psychological symptom burden., Conclusions: Our results suggest that leptin changes are differently associated with weight gain and psychological symptoms depending on the severity of starvation., Competing Interests: The authors have declared that no competing interests exist.

This study aimed to determine predictors of BMI and recovery for outpatients with anorexia nervosa (AN). Patients were participants of the ANTOP (Anorexia Nervosa Treatment of Out-Patients) trial and randomized to focal psychodynamic therapy (FPT), enhanced cognitive behavior therapy (CBT-E), or optimized treatment as usual (TAU-O). N=169 patients participated in the one-year follow-up (T4). Outcomes were the BMI and global outcome (recovery/partial syndrome/full syndrome) at T4. We examined the following baseline variables as possible predictors: age, BMI, duration of illness, subtype of AN, various axis I diagnoses, quality of life, self-esteem, and psychological characteristics relevant to AN. Linear and logistic regression analyses were conducted to identify the predictors of the BMI and global outcome. The strongest positive predictor for BMI and recovery at T4 was a higher baseline BMI of the patients. Negative predictors for BMI and recovery were a duration of illness >6 years and a lifetime depression diagnosis at baseline. Additionally, higher bodily pain was significantly associated with a lower BMI and self-esteem was a positive predictor for recovery at T4. A higher baseline BMI and shorter illness duration led to a better outcome. Further research is necessary to investigate whether or not AN patients with lifetime depression, higher bodily pain, and lower self-esteem may benefit from specific treatment approaches., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: The core symptoms of bulimia nervosa (BN) and binge eating disorder (BED) are recurrent episodes of binge eating. Despite negative psychological and physical consequences, BN/BED patients show uncontrollable approach tendencies towards food. This cognitive bias occurs at an early stage of information processing. Cognitive bias modification (CBM) directly targets such biases and has been shown to be effective in treating several mental disorders. In alcohol addiction, automatic action tendencies towards alcohol cues and relapse rates were successfully reduced by a specific form of CBM, termed approach bias modification. Based on these findings and data from a proof-of-concept study in people with high levels of food craving, CBM is considered a promising new treatment approach for BN/BED. Given the similarities between BN/BED and addictive disorders, the rationale for using approach bias modification appears to be particularly strong. The aim of the present study is to examine whether, compared to a sham training, computerised approach bias modification (10 sessions) can reduce binge-eating episodes in BN/BED patients from pre-treatment to follow-up. Additionally, we will investigate whether this CBM programme also reduces global eating disorder psychopathology, trait and cue-elicited food craving, food intake as well as approach and attentional bias towards visual food cues. Treatment acceptance will be determined by attrition rates and responses on a feedback form., Methods: This is a double-blind, randomised, placebo-controlled, parallel-group superiority trial with two parallel arms. A total of 54 BN/BED patients will be recruited. Approach bias towards food will be retrained by a computer task adopting an implicit learning paradigm. Patients in the control condition (sham) will conduct a similar task but will not be trained to avoid food cues. Methods against bias include public registration, randomisation by a central study office, standardisation of the treatments and blinding of assessors. Furthermore, the session number and duration will be equivalent in the two conditions., Discussion: This is the first registered randomised controlled trial of approach bias modification in a clinical BN/BED sample. Results from this study will provide an indication of the efficacy of approach bias modification training for BN/BED and the potential mechanisms of action underlying this treatment., Trial Registration: DRKS00010231 (retrospectively registered on 24 March 2016; first version).

Clinical observations and similarities to addiction suggest heightened reward sensitivity to food in patients with bulimic-type eating (BTE) disorders. Therefore, we investigated the expectation and receipt of food reward compared with monetary reward in patients with BTE. Fifty-six patients with BTE (27 patients with binge eating disorder and 29 with bulimia nervosa) and 55 matched healthy control participants underwent event-related functional magnetic resonance imaging while performing both food and monetary incentive delay tasks. BTE patients exhibited reduced brain activation in the posterior cingulate cortex during the expectation of food and increased activity in the medial orbitofrontal cortex, anterior medial prefrontal cortex and posterior cingulate cortex during the receipt of food reward. These findings were relevant to food because we found no significant group differences related to monetary reward. In the patients, higher brain activity in the medial orbitofrontal cortex during the receipt of food reward was related to higher levels of trait food craving and external eating. BTE patients exhibited increased hedonic processing during the receipt of food reward. These findings corroborate the notion that an altered responsiveness of the reward network to food stimuli is associated with BTE., (© The Author (2016). Published by Oxford University Press. For Permissions, please email: journals.permissions@oup.com.)

Objective: Building on recent models of anorexia nervosa (AN) that emphasize the importance of impaired social cognition in the development and maintenance of the disorder, the present study aimed at examining whether women with AN have more difficulties with inferring other people's emotional and nonemotional mental states than healthy women., Method: Social cognition was assessed in 25 adult women with AN and 25 age-matched healthy women. To overcome limitations of previous research on social cognition in AN, the processing of social information was examined in a more complex and ecologically valid manner. The Movie for the Assessment of Social Cognition (MASC) reflects complex real-life social interaction and allows for disentangling emotional and non-emotional mental state inference as well as different types of errors in mentalizing., Results: Women with AN showed poorer emotional mental state inference, whereas non-emotional mental state inference was largely intact. Groups did not differ in undermentalizing (overly simplistic theory of mind) and overmentalizing (overly complex or over-interpretative mental state reasoning). Performance in the MASC was independent of levels of eating disorder psychopathology and symptoms of depression and anxiety., Discussion: The findings suggest that AN is associated with specific difficulties in emotional mental state inference despite largely intact nonemotional mental state inference. Upon replication in larger samples, these findings advocate a stronger emphasis on socio-emotional processing in AN treatment. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:883-890)., (© 2016 Wiley Periodicals, Inc.)