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Objectives The ICEpop Capability Measure for Adults (ICECAP-A) assesses 5 capabilities (stability, attachment, autonomy, achievement, and enjoyment) that are important to one’s quality of life and might be an important addition to generic health questionnaires currently used in economic evaluations. This study aimed to develop a Dutch tariff of the Dutch translation of the ICECAP-A. Methods The methods used are similar to those used in the development of the UK tariff. A profile case best–worst scaling task was presented to 1002 participants from the general Dutch population. A scale-adjusted latent class analysis was performed to test for preferences of ICECAP-A capabilities and scale heterogeneity. Results A 3-preference class 2-scale class model with worst choice as scale predictor was considered optimal and was used to calculate the resulting tariff. Results indicated that the capabilities stability, attachment, and enjoyment were considered more important aspects of quality of life than autonomy and achievement. Additionally, improving capabilities from low to moderate levels had a larger effect on quality of life than improving capabilities that were already at a higher level. Conclusions The ICECAP-A tariffs found in this study could be used in economic evaluations of healthcare interventions in The Netherlands.

OBJECTIVE: Many individuals with an eating disorder do not receive appropriate care. Low-threshold interventions could help bridge this treatment gap. The study aim was to evaluate the effectiveness of Featback, a fully automated online self-help intervention, online expert-patient support and their combination. METHOD: A randomized controlled trial with a 12-month follow-up period was conducted. Participants aged 16 or older with at least mild eating disorder symptoms were randomized to four conditions: (1) Featback, a fully automated online self-help intervention, (2) chat or email support from a recovered expert patient, (3) Featback with expert-patient support and (4) a waiting list control condition. The intervention period was 8 weeks and there was a total of six online assessments. The main outcome constituted reduction of eating disorder symptoms over time. RESULTS: Three hundred fifty five participants, of whom 43% had never received eating disorder treatment, were randomized. The three active interventions were superior to a waitlist in reducing eating disorder symptoms (d = -0.38), with no significant difference in effectiveness between the three interventions. Participants in conditions with expert-patient support were more satisfied with the intervention. DISCUSSION: Internet-based self-help, expert-patient support and their combination were effective in reducing eating disorder symptoms compared to a waiting list control condition. Guidance improved satisfaction with the internet intervention but not its effectiveness. Low-threshold interventions such as Featback and expert-patient support can reduce eating disorder symptoms and reach the large group of underserved individuals, complementing existing forms of eating disorder treatment. PUBLIC SIGNIFICANCE STATEMENT: Individuals with eating-related problems who received (1) a fully automated internet-based intervention, (2) chat and e-mail support by a recovered individual or (3) their combination, experienced stronger reductions in eating disorder symptoms than those who received (4) usual care. Such brief and easy-access interventions play an important role in reaching individuals who are currently not reached by other forms of treatment. ispartof: INTERNATIONAL JOURNAL OF EATING DISORDERS vol:55 issue:10 pages:1361-1373 ispartof: location:United States status: published

Objective: The primary aim was assessing the cost-effectiveness of an internet-based self-help program, expert-patient support, and the combination of both compared to a care-as-usual condition. Method: An economic evaluation from a societal perspective was conducted alongside a randomized controlled trial. Participants aged 16 or older with at least mild eating disorder symptoms were randomly assigned to four conditions: (1) Featback, an online unguided self-help program, (2) chat or e-mail support from a recovered expert patient, (3) Featback with expert-patient support, and (4) care-as-usual. After a baseline assessment and intervention period of 8 weeks, five online assessments were conducted over 12 months of follow-up. The main result constituted cost-utility acceptability curves with quality-of-life adjusted life years (QALYs) and societal costs over the entire study duration. Results: No significant differences between the conditions were found regarding QALYs, health care costs and societal costs. Nonsignificant differences in QALYs were in favor of the Featback conditions and the lowest societal costs per participant were observed in the Featback only condition (euro16,741) while the highest costs were seen in the care-as-usual condition (euro 28,479). The Featback only condition had the highest probability of being efficient compared to the alternatives for all acceptable willingness-to-pay values. Discussion: Featback, an internet-based unguided self-help intervention, was likely to be efficient compared to Featback with guidance from an expert patient, guidance alone and a care-as-usual condition. Results suggest that scalable interventions such as Featback may reduce health care costs and help individuals with eating disorders that are currently not reached by other forms of treatment. Public significance statement Internet-based interventions for eating disorders might reach individuals in society who currently do not receive appropriate treatment at low costs. Featback, an online automated self-help program for eating disorders, was found to improve quality of life slightly while reducing costs for society, compared to a do-nothing approach. Consequently, implementing internet-based interventions such as Featback likely benefits both individuals suffering from an eating disorder and society as a whole.

Most of the network approaches in eating disorders found the highest degree of centrality for symptoms related to weight and shape concerns. However, longitudinal analyses are scarce and may increase our insight of the complex characteristics and dynamics over time. In the current study, an alternative non-linear method to perform longitudinal network analyses, the dynamic time warp approach, was used to examine whether robust dimensions of eating disorder psychopathology symptoms could be found based on the individual dynamic interplay of eating disorder symptoms co-occurrence patterns in time.The study sample included a naturalistic cohort of patients (N = 255) with all eating disorder subtypes who were assessed with the eating disorder examination questionnaire (EDE-Q) at a minimum of four times during treatment. Dynamic time warp analyses yielded distance matrices within each individual patient, which were subsequently aggregated into symptom networks and dimensions at the group level.Aggregation of the individual distance matrices at the group level yielded four robust symptom dimensions: 1. restraint/rules, 2. secret eating/fasting, 3. worries/preoccupation, and 4. weight and shape concern. The items 'fear of weight gain' and 'guilt' were bridge symptoms between the dimensions 1, 3 and 4.Dynamic time warp could capture the within-person dynamics of eating disorder symptoms. Sumscores of the four dimensions could be used to follow patients over time. This approach could be applied in the future to visualize eating disorder symptom dynamics and signal the central symptoms within an individual and groups of patients.Level III: evidence obtained from well-designed cohort or case-control analytic studies. .

Background:Research into mental disorders has found mental imagery to be a maintaining factor for psychological distress. However, studies investigating mental imagery in eating disorders are scarce.Aim:The aim of the present study was to compare spontaneous mental imagery related to eating, weight and/or appearance and intrusive prospective imagery in women with an eating disorder with female healthy controls.Methods:Spontaneous mental imagery and intrusive prospective imagery were assessed in adult women with an eating disorder (n = 29) and in female healthy controls (n = 32) using a semi-structured interview and the Impact of Future Events Scale, respectively.Results:In comparison with healthy controls, the spontaneous mental images in individuals with an eating disorder involved more sensory modalities (U = 156.50, p < .001, r = –.51), were more vivid (t (52) = 2.04, p = .047, d = .55), negative (U = 103.00, p < .001, r = –.62), and anxiety provoking (U = 158.50, p < .001, r = –.49), and were experienced with a lower sense of control (U = 215.00, p = .009, r = –.36). The emotional impact of intrusive prospective imagery (U = 105.00, p < .001, r = –.66) was also higher in individuals with an eating disorder, as was the number of negative prospective images (U = 283.00, p = .016, r = –.31).Conclusions:Our findings are consistent with previous research on mental imagery in other psychiatric disorders, and provide possibilities for incorporating imagery-based techniques in treatment interventions.

BACKGROUND Economic costs of mental disorders for society are huge. Internet-based interventions are often coined as cost-effective alternative to usual care, but evidence is mixed. OBJECTIVE The aim was to review the literature on cost-effectiveness of eHealth interventions for mental disorders compared to usual care and to provide an estimate of the monetary benefits of such interventions compared to usual care. METHODS A systematic review and meta-analysis of (1) randomized controlled trials that (2) included participants with symptoms of mental disorders, (3) investigated a telephone or internet-based intervention, (4) included a control condition in the form of treatment as usual, psychological placebo, waiting list control or bibliotherapy, (5) reported outcomes on both quality of life and costs and (6) were published in English, was conducted. Electronic databases PubMed (including Medline), Embase, Emcare, PsycINFO, Web of Science and The Cochrane Library were searched. Data on risk of bias, quality of the economic evaluation, quality-of-life adjusted life years (QALYs) and costs were extracted from included studies and the incremental net benefit (INB) was calculated and pooled. RESULTS The search yielded 6226 abstracts and 37 studies with 14,946 participants were included. Quality of economic evaluations of included studies was rated to be moderate and risk of bias was high. A random-effects approach was maintained. Analyses suggested internet interventions to be slightly more effective than usual care in terms of QALY gain, Hedges’ g=.052 (95% CI .010; .094, P=.016), and equally expensive, Hedges’ g=.002 (95% CI -.080; 0.84, P=.96). The pooled INB was $255, (95% CI $91; $419, P=.002), favoring eHealth interventions over usual care. Perspective of the economic evaluation and targeted mental disorder moderated results. CONCLUSIONS Findings indicate that cost-effectiveness of e-mental health interventions compared to a care-as-usual approach is likely, but generalizability to new studies is poor given the substantial heterogeneity. This is the first study in the area of mental health to pool cost-effectiveness outcomes in an aggregate-data meta-analysis. CLINICALTRIAL Prospero registration https://www.crd.york.ac.uk/PROSPERO/; registration number: CRD42019141659.

Several studies have shown that obsessive-compulsive disorder (OCD), eating disorders (ED), autism spectrum disorders (ASD) and body dysmorphic disorder (BDD) share obsessive-compulsive (OC) symptoms and often co-occur, which could be seen as indicative of a common etiological basis. In addition, they also appear to have similarities in executive functioning. The present study investigated disorder-specific symptoms and executive functioning as a possible joint factor in individuals with OCD (n=53), BDD (n=95), ED (n=171) and ASD (n=73), and in healthy controls (n=110). The participants completed online questionnaires measuring OCD, ED, ASD and BDD related symptoms as well as executive functioning. The clinical groups were first compared to the healthy controls. Subsequently, a network analysis was performed only with the OC-groups. This network approach assumes that psychopathological disorders are the result of causal symptom interactions. As expected, the healthy controls reported less severe symptoms compared to the OC patient groups. The network analysis suggested that the executive functioning skill set shifting/attention switching and the ASD symptoms, social and communication skills were the most central nodes in the model. Difficulty with cognitive flexibility and social factors are central in OC-spectrum disorders and may be perpetuating factors and thus a relevant focus of treatment.

Purpose The ICEpop CAPability measure for Adults (ICECAP-A) assesses five capabilities that are important to one’s well-being. The instrument might be an important addition to generic health questionnaires when evaluating quality of life extending beyond health. This study aimed to conduct a psychometric assessment of the Dutch translation of the ICECAP-A. Methods Construct validity of the instrument was assessed in two ways. First, by measuring correlations with the EQ-5D-5L questionnaire and a measure of self-efficacy and, second, by investigating the ability to distinguish between groups known to differ on the construct the ICECAP-A means to capture. Additionally, test–retest reliability was evaluated. Results In total, 1002 participants representative of the general Dutch population completed an online survey. For test–retest reliability, 252 participants completed the same questionnaire 2 weeks later. The ICECAP-A indicated moderate to strong correlations with the EQ-5D-5L and a strong correlation with self-efficacy. Furthermore, it was capable of differentiating known groups. Moreover, results indicated adequate test–retest reliability with an intraclass correlation coefficient of 0.79. Conclusion In summary, results suggest adequate test–retest reliability and construct validity and indicate that the ICECAP-A might be of added value, especially when considering areas outside of the traditional health intervention model.

IntroductionWith the rise of camera phones, selfie-taking has become a normative part of our modern culture. However, little is known about how this behavior may relate to eating disorder (ED) characteristics, particularly in those who already have eating disorder symptoms of clinical severity. The current study investigated how selfie-posting and selfie-taking with no intention of posting online (offline selfies) were related to ED symptoms.MethodA total of 152 females (average age 22.44 years) with ED symptoms of clinical severity completed self-report questionnaires measuring selfie-frequency (online and offline), frequency of non-selfie photo posting, social networking site use, body dissatisfaction, body checking, ED symptom severity, self-esteem and body avoidance. Responses were collected via an ED social community.ResultsNo direct relationship, or indirect association via body dissatisfaction, was found between selfie behavior and ED symptom severity. However, the more offline selfies an individual took, the more frequently they body checked, and this, in turn, was related to greater ED symptom severity.ConclusionsThese results suggest that offline selfies may be a modern form of body checking. Our findings are the first to imply that offline selfie-taking may be a problematic behavior and a potential maintenance factor for individuals with severe ED symptoms.

Patients with complex and severe eating disorders often receive a number of ineffective or/and insufficient treatments. Direct referral of these patients to highly specialized tertiary treatment facilities in an earlier stage of the disorder is likely to be more (cost)-effective. The aim of the study was to develop a decision tool that aids clinicians in early identification of these patients. After identification of criteria that were indicative of severity and complexity of eating disorder psychopathology by means of a systematic review of literature and consultation of a focus group, a Delphi method was applied to obtain consensus from experts on the list of relevant criteria. Finally, the decision tool was validated in clinical practice, and cut-off criteria were established. The tool demonstrated good feasibility and validity to identify patients for highly specialized tertiary care. The final decision tool consisted of five criteria that can easily be implemented in clinical practice. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Background: E-mental health has become increasingly popular in interventions for individuals with eating disorders (EDs). It has the potential to offer low-threshold interventions and guide individuals to the needed care more promptly. Featback is such an Internet-based intervention and consists of psychoeducation and a fully automated monitoring and feedback system. Preliminary findings suggest Featback to be (cost-)effective in reducing ED symptomatology. Additionally, e-mail or chat support by a psychologist did not enhance theeffectiveness of Featback. Support by an expert patient (someone with a lived experience of an ED) might be more effective, since that person can effectively model healthy behavior and enhance self-efficacy in individuals struggling with an ED. The present study aims to replicate and build on earlier findings by further investigating the (cost-)effectiveness of Featback and the added value of expert-patient support.Methods: The study will be a randomized controlled trial with a two-by-two factorial design with repeatedmeasures. The four conditions will be (1) Featback, in which participants receive automated feedback on a short monitoring questionnaire weekly, (2) Featback with weekly e-mail or chat support from an expert patient, (3) weekly support from an expert patient, and (4) a waiting list. Participants who are 16 years or older and have at least mild self-reported ED symptoms receive a baseline measure. Subsequently, they are randomized to one of the four conditions for 8 weeks. Participants will be assessed again post-intervention and at 3, 6, 9, and 12 months follow-up. The primary outcome measure will be ED psychopathology. Secondary outcome measures are experienced social support, self-efficacy, symptoms of anxiety and depression, user satisfaction, intervention usage, and help-seeking attitudes and behaviors.Discussion: The current study is the first to investigate e-mental health in combination with expert-patient support for EDs and will add to the optimization of the delivery of Internet-based interventions and expert-patient support.Trial registration: Netherlands Trial Register, NTR7065. Registered on 7 June 2018.Keywords: Eating disorders, Internet, Internet-based, E-mental health, Intervention, Treatment, Prevention, Expert patient, Peer support, Cost-effectiveness

Background: Major Depressive Disorder (MDD) in adolescence has a high prevalence and risk of disability, but current treatments show limited effectiveness and high drop-out and relapse rates. Although the role of distressing experiences that relate to the development and maintenance of MDD has been recognized for decades, the efficacy of a trauma-focused treatment approach for MDD has hardly been studied.Objective: To determine the effectiveness of eye movement desensitization and reprocessing (EMDR) therapy as a stand-alone intervention in adolescents diagnosed with MDD. We hypothesized that reprocessing core memories related to the onset and maintenance of MDD using EMDR therapy would be associated with a significant decrease in depressive and comorbid symptoms.Method: We recruited 32 adolescents (12–18 years) fulfilling DSM-IV criteria for mild to moderate-severe MDD from an outpatient youth mental health care unit. Treatment consisted of six weekly 60-min individual sessions. Presence or absence of MDD classification (ADIS-C), symptoms of depression (CDI), symptoms of posttraumatic stress (UCLA), anxiety (SCARED), somatic complaints (CSI), and overall social-emotional functioning (SDQ) were assessed pre and post-treatment and 3 months after treatment.Results: 60.9% of the adolescents completing treatment no longer met DSM-IV criteria for MDD after treatment anymore, and 69.8% at follow-up. Multilevel analyses demonstrated significant posttreatment reductions of depressive symptoms (CDI: Cohen’s d = 0.72), comorbid posttraumatic stress, anxiety and somatic complaints, while overall social-emotional functioning improved. These gains were maintained at 3-month follow-up (Cohen’s d = 1.11). Severity of posttraumatic stress reactions significantly predicted the posttreatment outcome; however, duration of MDD, number of comorbid disorders, or having a history of emotional abuse, emotional neglect or physical neglect were not predictive for outcome.Conclusions: This is the first study suggesting that EMDR therapy is associated with a significant reduction of depressive symptoms and comorbid psychiatric problems in adolescents with mild to moderate-severe MDD.

Objective To investigate the cost-utility of the internet-based intervention “Featback” provided with different levels of therapist support, in comparison to a waiting list. Method This economic evaluation was conducted from a societal perspective and was part of a randomized controlled trial in which participants (N = 354) with self-reported ED symptoms were randomized to: (1) 8 weeks of Featback, consisting of psychoeducation and a fully automated monitoring- and feedback system, (2) Featback with low-intensity (weekly) therapist support, (3) Featback with high-intensity (three times a week) therapist support, and (4) a waiting list. Participants were assessed at baseline, postintervention, and 3-month follow-up. Cost-utility acceptability curves were constructed. Results No significant differences between the study conditions were found regarding quality-adjusted life-years (P = 0.55) and societal costs (P = 0.45), although the mean costs per participant were lowest in the Featback condition with low-intensity therapist support (€1951), followed by Featback with high-intensity therapist support (€2032), Featback without therapist support (€2102), and the waiting list (€2582). Featback seemed to be cost-effective as compared to the waiting list. No clear preference was found for Featback with or without therapist support. Discussion A fully automated Internet-based intervention for ED symptoms with no, low-, or high-intensity therapist support represented good value for money when compared to a waiting list. This finding may have important implications for clinical practice, as both the unguided- and guided intervention could allow for more efficient care and widespread dissemination, potentially increasing the accessibility and availability of mental health care services for individuals with ED symptoms. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1068–1076)

Background Identifying predictors of psychological outcome for patients with eating disorders may improve the effectiveness of treatment. Patients with different pre-treatment characteristics and symptoms may benefit from different therapies. This study aimed to identify potential predictors of treatment outcome in a large naturalistic cohort of patients with an eating disorder. Method The study sample included patients (N = 1153) with all types of eating disorders who were receiving residential, day, or outpatient treatment. Remission was defined by means of four different indicators based on the Eating Disorder Examination-Questionnaire global score: 1. achieving reliable change; 2. showing a 50% reduction in baseline symptom severity; 3. reaching the clinical significance cut-off point; and 4. a combination of indicators 2 and 3. Potential predictor variables were investigated in univariate and multivariate Cox regression models. Results Different predictors were found for the four outcome criteria. Patients with high levels of interpersonal distrust at baseline were less likely to have achieved reliable change in eating disorder psychopathology. Higher self-esteem and less body dissatisfaction at baseline was independently associated with a symptom reduction of more than 50% and/or reaching the clinical significance cut-off point. Contrary to our expectations, no differences in outcome were found between the eating disorder subtypes. Discussion Clinically, it is important to reduce the risk of poor outcome and to achieve a rapid response in treatment using an intervention designed for this purpose, such as shared decision making or an intervention directed at self-esteem or body image, which may act as a catalyst for change. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016)

Executive functions are a set of cognitive processes that are necessary for the cognitive control of behavior. They play a role in mediating self-control, self-regulation and decision-making. It has been suggested that the inability to control eating behavior in binge eating disorder (BED) may indicate deficits in executive functioning. This may be worsened by depressive symptoms. The aim of the present study was to compare executive functioning of patients with BED and no-to-mild depressive symptoms (n = 25), patients with BED and moderate-to-severe depressive symptoms (n = 66), and healthy controls (Body Mass Index n = 56), matched on age, educational level and gender. The participants were assessed by means of neuropsychological tests and questionnaires. The neuropsychological tests did not show significant differences in executive functioning between the groups. However, eating disorder psychopathology and depressive symptoms are associated with self-reported difficulties in executive functioning in daily life. A self-report questionnaire which evaluates the functional, real-world impact of executive dysfunction expressed in everyday activities seems to be more useful in this population than neuropsychological tests. This study highlights the importance of taking depressive symptoms into account when studying executive functioning in patients with (binge) eating disorders.

Purpose of review This review compares the literature on cognitive remediation therapy (CRT) for eating disorders with findings in the field of schizophrenia, and discusses future directions for CRT for eating disorders. Recent findings First studies using a randomized controlled trial design show the added value of CRT for eating disorders. Patients reported lessened symptoms and further improvements in quality of life and cognitive flexibility. Furthermore, the acceptability of the intervention was good and attrition rates for CRT itself were low. Research into the use of cognitive remediation for schizophrenia is extensive and the results on global cognition appeared to be robust at post-treatment and durable at follow-up, with small to medium effect sizes. Recent articles within the field of schizophrenia emphasize the necessity of intrinsic motivation to translate cognitive gains into actual changes in everyday life. Summary A next step is to examine the impact of CRT for eating disorders on motivation. It is also important to focus on the transdiagnostic use of CRT, considering the overlap in cognitive inefficiencies between eating disorders. Another important step may be to develop effective personalized methods of CRT by taking into account individual differences in cognitive processes most relevant to improvement in outcome.

The Risk factors for Binge Eating Disorder in Overweight (REO) questionnaire is a screening tool for nutritionists to discriminate between individuals with obesity with and without Binge Eating Disorder (BED). The first study tested the discriminative ability of the REO and identified an optimal cut-off value. In the second study this cut-off value was used to identify individuals with and without BED from a sample of individuals with obesity visiting a nutritionist and compared clinical and personality characteristics with a group of individuals officially diagnosed with BED. Results showed that the REO has a sensitivity of 95.1%, specificity of 81.5%, a good internal consistency of α = .96, and an exploratory factor analysis showed four underlying factors of the REO that explained a total variance of 63.7%. Characteristics of individuals with BED symptoms identified by the REO and those officially diagnosed with BED were comparable and differed from individuals with obesity without BED symptoms. By screening individuals with obesity with the REO those presenting with BED symptoms are more easily identified, and can be referred to psychological treatment facilities for further assessment and appropriate treatment.

The purpose of the present review is to provide a summary of the research findings on emotion regulation in Binge Eating Disorder (BED). Negative emotions and maladaptive emotion regulation strategies play a role in the onset and maintenance of binge eating in BED. Anger and sadness, along with negative emotions related to interpersonal experiences (i.e., disappointment, being hurt or loneliness), seem to be particularly relevant. Individuals with BED have a tendency to suppress and ruminate on their unwanted emotions, which leads to increased psychopathological thoughts and symptoms. Compared to healthy controls, they use adaptive strategies, such as reappraisal, less frequently. Evidence concerning the causal relation between negative affect and binge eating is inconclusive and still very limited. While experimental studies in a laboratory setting lack ecological validity, ecological momentary assessment studies offer more promise at unraveling the causal relationship between emotions and binge eating. Increases in negative affect are found to be antecedents of binge eating in BED. However, there seems to be less support for the possibility that binge eating serves as a means to alleviate negative affect. Finally, BED seems to be related to other forms of maladaptive emotion regulation strategies, such as substance abuse and self-harm.

This study investigated moderators of intervention response in a fully automated Internet-based monitoring and feedback intervention (‘Featback’) with different levels of therapist support for individuals with eating disorder (ED) symptoms. This study was part of a randomized controlled trial comparing four conditions: 1) Featback, 2) Featback with low-intensity (weekly) therapist support, 3) Featback with high-intensity (three times a week) therapist support, and 4) a waiting list. A total of 273 participants completed baseline and post-intervention assessments. The outcome measure was ED psychopathology. Model-based recursive partitioning was applied. Baseline levels of ED psychopathology were found to moderate intervention response. Specifically, in terms of improvement in symptoms of anorexia nervosa, participants with higher baseline levels of anorectic psychopathology showed better outcomes in the waiting list condition and the Featback conditions with low- and high-intensity therapist support in comparison with Featback without therapist support. In terms of improvement in symptoms of bulimia nervosa, participants with mild to moderate bulimic symptoms had better outcomes in the Featback conditions compared with the waiting list. Thus, the fully automated Internet-based intervention with and without therapist support may be particularly suitable in improving mild to moderate bulimic psychopathology, whereas the intervention without therapist support may be less effective in improving severe anorectic psychopathology. Further investigating differential intervention responses is important, as this could help to optimize the delivery and dissemination of E-health interventions and therapist support, which in turn could help moving toward personalized (E-)care.

Introduction Many individuals with eating disorder problems seek information and support online. There are however numerous websites that promote eating disordered behaviors. The website and e-community ‘Proud2Bme’ was developed as a healthy alternative for pro-eating disorder websites, providing a safe, positive, and pro-recovery focused environment. It offers a wide array of information and personal stories, as well as platforms for interaction such as a forum and chat. The first aim of this study was to investigate whether, and to what extent, empowering processes and outcomes are experienced by participants on Proud2Bme. The second aim was to examine correlates of empowering processes and outcomes. Methods Participants ( n = 311) were recruited via an online survey on Proud2Bme. Correlations were examined and T -tests and ANOVAs were conducted. Results Exchanging information, finding recognition, and sharing experiences were the empowering processes most often reported by participants. The most pronounced empowering outcome was feeling better informed. To a smaller degree, increased help-seeking behavior, increased optimism and control over the future, and increased confidence in treatment and the relationship with the therapist were reported. Lower levels of general empowerment, younger age, and more interactive usage patterns of the website were positively associated with the experience of empowering processes and outcomes. Discussion Offering a platform where individuals can share their experiences and find recognition might be one of the most important ingredients for successful e-health initiatives aimed at improving patient empowerment. Moreover, in the field of eating disorders specifically, such initiatives offer a healthy alternative to the harmful and negative effects of pro-eating disorder websites.

PURPOSE: This study investigates self-injury from the perspective of patients with anorexia nervosa. DESIGN AND METHODS: A phenomenological design was used. Twelve patients participated. Data were collected using a semi-structured interview guide. FINDINGS: Participants display self-injurious behavior predominantly in situations when they are forced to eat. They are terrified of gaining weight and use self-injurious behavior to cope with their anxiety. Self-injury is envisioned as a technique to regain control of their own eating pattern without bothering anyone. They feel shame for not controlling their emotions more constructively. PRACTICE IMPLICATIONS: Healthcare professionals should systematically observe signals and explore less harmful strategies that help to regulate overwhelming feelings.

Objective To review the literature regarding internet-based treatment of eating disorders (ED). Method Relevant studies were identified by searching electronic databases (including Medline, Embase, PsycInfo, and Web of Science). Eligible studies evaluated an internet-based treatment for ED, or an ED treatment that included at least one internet-based component. Results Twenty-one studies were included. Methodological quality varied. Internet-based treatments were superior to waiting lists in reducing ED psychopathology, frequency of binge eating and purging, and in improving (ED-related) quality of life. Internet-based treatment was more effective for individuals with less comorbid psychopathology, binge eating as opposed to restrictive problems, and individuals with binge eating disorder as opposed to bulimia nervosa. Higher levels of compliance were related to more improvements in ED symptoms. Study dropout ranged from 5.3 to 76.8%. Inclusion of face-to-face assessments and therapist support seemed to enhance study compliance. Overall, the internet can be considered an acceptable vehicle for delivering ED treatment. Discussion Future research should determine the utility of internet-based treatment by comparing them to face-to-face treatment. Research should furthermore focus on unraveling predictors and mediators of treatment outcome, compliance, and dropout, respectively. Studies with good methodological quality are needed with reports according to CONSORT guidelines. © 2013 by Wiley Periodicals, Inc. (Int J Eat Disord 2013; 46:539–552)

Patients with complex and severe eating disorders often receive a number of ineffective or/and insufficient treatments. Direct referral of these patients to highly specialized tertiary treatment facilities in an earlier stage of the disorder is likely to be more (cost)-effective. The aim of the study was to develop a decision tool that aids clinicians in early identification of these patients. After identification of criteria that were indicative of severity and complexity of eating disorder psychopathology by means of a systematic review of literature and consultation of a focus group, a Delphi method was applied to obtain consensus from experts on the list of relevant criteria. Finally, the decision tool was validated in clinical practice, and cut-off criteria were established. The tool demonstrated good feasibility and validity to identify patients for highly specialized tertiary care. The final decision tool consisted of five criteria that can easily be implemented in clinical practice. Copyright © 2017 John WileySons, Ltd and Eating Disorders Association.

Identifying predictors of psychological outcome for patients with eating disorders may improve the effectiveness of treatment. Patients with different pre-treatment characteristics and symptoms may benefit from different therapies. This study aimed to identify potential predictors of treatment outcome in a large naturalistic cohort of patients with an eating disorder.The study sample included patients (N = 1153) with all types of eating disorders who were receiving residential, day, or outpatient treatment. Remission was defined by means of four different indicators based on the Eating Disorder Examination-Questionnaire global score: 1. achieving reliable change; 2. showing a 50% reduction in baseline symptom severity; 3. reaching the clinical significance cut-off point; and 4. a combination of indicators 2 and 3. Potential predictor variables were investigated in univariate and multivariate Cox regression models.Different predictors were found for the four outcome criteria. Patients with high levels of interpersonal distrust at baseline were less likely to have achieved reliable change in eating disorder psychopathology. Higher self-esteem and less body dissatisfaction at baseline was independently associated with a symptom reduction of more than 50% and/or reaching the clinical significance cut-off point. Contrary to our expectations, no differences in outcome were found between the eating disorder subtypes.Clinically, it is important to reduce the risk of poor outcome and to achieve a rapid response in treatment using an intervention designed for this purpose, such as shared decision making or an intervention directed at self-esteem or body image, which may act as a catalyst for change. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:863-873).

A new report from the King’s Fund entitled Bringing Together Physical and Mental Health: a New Frontier for Integrated Care not only reviews the case for integration, but also provides real practical examples of how it has been achieved. Importantly, the report describes both the barriers to and facilitators of its successful implementation on the basis of interviews of those involved. The barriers are many and not all will be overcome simply by colocation of services (colocation is not integration). They include deeply ingrained cultural factors in the workforce that reinforce division and the separate organisational and payment systems for physical and mental health care. Key facilitators to achievement of integration include strong leadership for change at both clinical and board level and a willingness to innovate in the relevant organisations. Policy developments in various countries, including the new models of care introduced by the National Health Service Five Year Forward View in England and the growth of accountable care organisations in the USA have the exciting potential to facilitate integration of physical and mental health care. However, this integration will only happen if psychiatrists and other professionals now actively engage with these developments and use them as opportunities to advocate for and lead new forms of collaborative or even integrated working. The idea of so-called parity of esteem for patients’ mental and physical health care, which has been successfully championed by the Royal College of Psychiatrists, has achieved considerable influence. Indeed, in England, the Health and Social Care Act 2012 created a new legal responsibility for the National Health Service to deliver parity of esteem between physical and mental health, something that the Government has pledged to achieve by 2020. However, interpretations of parity of esteem vary. One interpretation is simply for existing mental health services to be as well funded and provide as good care as existing physical health services. Although this interpretation is an important ambition, the report from the King’s Fund7 raises sights much higher than this ambition to a vision in which mental health care is not only as good as physical care is, but is also delivered as part of all health and care services. This challenge should be addressed and the opportunity seized if we are to repair the harm caused by 100 years of separation.

This study aimed to review the emerging findings regarding E-health interventions for eating disorders and to critically discuss emerging issues as well as challenges for future research. Internet-based cognitive behavioral therapy and guided self-help have demonstrated promising results in terms of reducing eating disorder psychopathology. Emerging findings also suggest that E-health interventions reach an underserved population and improve access to care. The use of smartphone applications is becoming increasingly popular and has much potential although their clinical utility and effectiveness is presently unknown and requires investigation. Important challenges include the diagnostic process in E-health interventions, the optimization of E-health within existing health care models, and the investigation and implementation of blended care. More high-quality research is needed to bring the field forward and to determine the place for E-health in our health care service delivery systems.

Body dysmorphic disorder (BDD), an abnormal preoccupation with perceived defects in one or more body parts, and eating disorders (ED) share several essential clinical features, making it sometimes difficult to differentiate between the two disorders. The aims of this study were to assess the prevalence of BDD in patients with ED and to compare characteristics of ED patients with and without BDD.We measured dysmorphic appearance concerns and behaviors, ED symptoms, general psychopathology, and quality of life in 158 patients seeking treatment for ED.Forty-five percent screened positive for BDD. Patients with both disorders (ED + BDD) had significantly more dysmorphic appearance concerns, had more psychopathology, and were dissatisfied with a larger number of body parts than patients with ED only. The differences remained significant even after correcting for severity of eating disorder psychopathology.This finding suggests that BDD is a distinct comorbid disorder in almost half of the patients with ED. It is thus important to recognize and treat the manifestation of BDD in patients with both disorders. Given that the treatment of BDD is different from that of ED, it is important to recognize BDD.

Sad people may indulge in fattening snacks because they believe that eating will repair their mood. To test whether (1) changes in expectations and mood had an effect on caloric intake and (2) depressive symptoms moderated caloric intake, 73 women with binge eating disorder were randomly assigned to a condition in which expectations about food and emotion were either confirmed or disconfirmed. Subsequently they were shown either an upsetting or an amusing movie clip followed by a taste task. Contrary to our expectations, there were no differences in the four conditions: participants in all four conditions ate comparable amounts of calories. Manipulation of expectations or mood had no effect on caloric intake. However, higher baseline expectations that food is pleasurable and useful as a reward resulted in a higher caloric intake after positive mood induction. Non-depressed individuals ate less after a negative mood induction than did depressed individuals. Interestingly, they also ate less than the group of individuals, depressed and not, whose mood was positively induced. Non-depressed individuals seem to use healthier coping strategies: negative affect signals that the environment poses a problem. Positive affect on the other hand signals that the environment is benign, and thus makes people less vigilant about food intake.

Overeating may be a consequence of the suppression of negative emotions, by depleting self-control resources. This experiment investigated whether (a) there is a causal relationship between the suppression of negative emotions, negative mood, and overeating in people with binge eating disorder (BED) and whether (b) this relationship is increased in depressed people with BED. Sixty-six women with (full and sub-threshold) BED were shown an upsetting movie and then asked either to suppress their emotions or to react naturally. Subsequently, everyone participated in a taste task. After a decline, initial mood before watching the movie was restored after eating. Depressive symptomatology was positively correlated with caloric intake. Within the clinically depressed (Beck Depression Inventory-score > 19) BED group, those who were most affected by the negative mood induction consumed the most calories. No differences were found between the two conditions with regard to caloric intake. No interaction effect was found between depressive symptoms and mood suppression. The hypothesis that suppression of negative emotion leads to overeating in (depressed) binge eaters was not born out. Overeating may serve as a means to (temporary) repair negative mood.

Executive functions play an important role in problem-solving and self-control. Set-shifting is an aspect of executive functioning and represents cognitive flexibility. The inability to control eating in Binge Eating Disorder (BED) may imply deficits in set-shifting which could be exacerbated by negative mood and depressive symptoms. The aim of the study was to test whether there is a causal relationship between set-shifting ability, changes in mood and loss of control over eating in BED. Seventy-five participants diagnosed with BED were randomly assigned to a negative or neutral mood induction. Set-shifting abilities, depressive symptoms, current mood and loss of control over eating were assessed. Having depressive symptoms and poorer set-shifting abilities resulted in a more negative mood after a negative mood induction, whereas this was not observed in the neutral mood induction. Post-hoc analyses revealed that individuals with poorer set-shifting abilities and more changes in negative mood, experienced more feelings of loss of control over eating than individuals whose set-shifting abilities were better and whose mood did not change. The results suggest that both depressive symptoms and deficits in set-shifting abilities may decrease an individual's ability to handle negative affect and increase loss of control over eating in individuals with BED.

This study compared maladaptive core beliefs of eating-disordered groups (full and subthreshold syndrome) and healthy controls and investigated the association between eating disorder symptoms and core beliefs. Participants were compared on self-report measures of core beliefs (YSQ) and eating disorder psychopathology (BITE). Anorexia nervosa (AN; both subtypes) and bulimia nervosa (BN) patients had significantly more core beliefs than healthy controls. Binge eating disorder (BED) patients had intermediate scores between AN and BN on the one hand and healthy controls on the other hand. No correlation was found between core beliefs and frequency of binge eating. Frequency of vomiting, laxative misuse and fasting was positively associated with all domains of core beliefs. Patients with eating disorders have some core beliefs which are not directly related to eating, weight or shape. Frequency of purging and fasting behaviors is associated with more severe maladaptive core beliefs. Our data demonstrate the importance of identifying purging and fasting as significant clinical markers.

Pro-ana is de naam van een online groepering die (vooral) bestaat uit jongeren met problemen die zich actief manifesteren op internetfora, chats en websites. Daar wordt informatie geboden en er vindt interactie plaats die vooral gericht is op de promotie, ondersteuning en onderhoud van eetstoornisgebonden gedrag. In deze bijdrage gaan we nader in op de aard en functie van Pro-ana, wie deze online groepering nu precies bezoeken en wat de risico’s zijn.

The role of changes in ego- and exocentric spatial relationships on perceptual judgements about visual displacement was investigated in this study. Subjects were asked to indicate whether a dot in a test stimulus was displaced compared to a dot in a reference stimulus. Subjects were given explicit instructions to report displacement relative to themselves (egocentric) or relative to a circle surrounding the dot (exocentric). Four types of test stimuli were used in which object-circle (exocentric) and object-observer (egocentric) relations were systematically varied. It was found that for test stimuli that reveal conflicting ego- and exocentric spatial information, subjects performed poorly in both instruction conditions. This suggests that ego- and exocentric representations cannot be used independently and are probably interconnected.

To review the literature regarding internet-based treatment of eating disorders (ED).Relevant studies were identified by searching electronic databases (including Medline, Embase, PsycInfo, and Web of Science). Eligible studies evaluated an internet-based treatment for ED, or an ED treatment that included at least one internet-based component.Twenty-one studies were included. Methodological quality varied. Internet-based treatments were superior to waiting lists in reducing ED psychopathology, frequency of binge eating and purging, and in improving (ED-related) quality of life. Internet-based treatment was more effective for individuals with less comorbid psychopathology, binge eating as opposed to restrictive problems, and individuals with binge eating disorder as opposed to bulimia nervosa. Higher levels of compliance were related to more improvements in ED symptoms. Study dropout ranged from 5.3 to 76.8%. Inclusion of face-to-face assessments and therapist support seemed to enhance study compliance. Overall, the internet can be considered an acceptable vehicle for delivering ED treatment.Future research should determine the utility of internet-based treatment by comparing them to face-to-face treatment. Research should furthermore focus on unraveling predictors and mediators of treatment outcome, compliance, and dropout, respectively. Studies with good methodological quality are needed with reports according to CONSORT guidelines.

The first aim of this study was to provide norms for the Eating Disorder Examination Questionnaire (EDE-Q) in a diverse and large clinical sample of individuals with an eating disorder (ED), and a general population sample without an ED. Norms for individuals with obesity without an ED were also provided, as a more relevant comparison group for individuals with binge eating disorder. The second aim was to investigate the discriminative validity of the EDE-Q. A sample of females with an ED (N=935), women from the general population without an ED (N=235), and obese females without an ED (N=321) completed the EDE-Q. Explorative factor analyses did not support the theorized four subscales of the EDE-Q. Norms for EDE-Q global scores were provided for each of the three samples. Within the ED sample, norms were provided separately for patients with different ED diagnoses. Receiver operating characteristic analyses showed the EDE-Q global score to be highly accurate in discriminating individuals with an ED from those without, and moderately accurate in discriminating individuals with binge eating disorder from those with obesity. The presented norms contribute to a more accurate interpretation of EDE-Q scores, providing an index of the severity level of ED psychopathology. Furthermore, these norms can be used to assess clinical significant change during treatment. In addition, this study demonstrates that the EDE-Q, when using its global score, is a valid instrument to assess levels of ED psychopathology.

Objective: Although Binge Eating Disorder (BED) is associated with obesity and unstable weight and the diagnosis was originally predicated with the obese in mind, obesity is not a criterion for BED. In fact, BED is not uncommon in nonobese individuals. The aim of this study was to compare the psychopathology of obese (BMI >30) and nonobese individuals (BMI < 30) with BED. Method: Within a group of 174 individuals diagnosed with BED, 51 (29%) were classified as nonobese and 123 (71%) as obese. The Eating Disorder Examination (EDE) and Beck Depression Inventory (BDI) were administered to assess eating disorder psychopathology and depressive symptoms. Results: The nonobese BED group was significantly younger and was less likely to receive treatment. The obese group had more concerns about weight and reported more objective binge eating episodes. No differences were found on any other subscales of the EDE or BDI. Discussion: Our main finding was that there are more similarities than differences between the nonobese and obese individuals with BED. The severity of the psychopathology does not seem to be related to BMI. More awareness of the existence of nonobese individuals with BED is needed. Early detection and treatment may prevent the development of overweight and it's consequences. © 2011 by Wiley Periodicals, Inc. (Int J Eat Disord 2012)

A randomized controlled trial ( N =52) was conducted comparing cognitive–behavioral therapy with a waiting list control group to identify mediators and predictors of treatment outcome. Reduction of weight concerns mediated abstinence of binge eating at post-treatment. Abstinence was marginally mediated by changes in eating and shape concerns, depressive symptoms and global severity of general psychopathology. Neither treatment outcome nor status at 1-year follow-up could be predicted by severity of eating disorder, comorbid psychopathology or maladaptive core beliefs at baseline or at post-treatment. The only predictor for abstinence at both post-treatment and 1-year follow-up was the coping style palliative reacting: higher scores predicted less favorable outcomes. Lower expression of emotions at post-treatment predicted more reduction of eating disorder psychopathology at follow-up. No other patient characteristics allowing treatment–patient matching could be identified.

Both the skin and the brain develop from the same ectoderm and it is thought, therefore, that dermatoglyphics are informative for early disturbances in brain development in schizophrenia. This study was aimed at investigating the differences in both digital and palmar dermatoglyphic indices between twins discordant for schizophrenia and control twins. Furthermore, the significance of dermatoglyphic indices in relation to other determinants of brain development with regard to the susceptibility to schizophrenia was investigated. Data on dermatoglyphic indices of the hand and the palm were obtained from 21 same-sex discordant and 37 same-sex control twins. For 19 discordant and 25 control twins, there was also data available on brain volumes. Non-genetic intra-uterine circumstances early in pregnancy (10-13 weeks of gestation) are associated with a susceptibility to schizophrenia, since both the twins with schizophrenia and the unaffected co-twins showed more fluctuating asymmetry of the finger ridges (P0.01), and marginally higher absolute finger ridge counts (P=0.06) than control twin pairs. Fluctuating asymmetry of the finger ridges was as important as whole brain and left hippocampal volumes in differentiating twins with a high susceptibility to schizophrenia from those with a low susceptibility.

Background: Social phobia frequently occurs in the general population but is probably underreported due to comorbid disorders which mask the social phobia. Another reason might be that patients do not consult their general pratitioner due to embarrassment or an estimation of their condition. There are several treatments available for social phobia, but not enough is known about the efficacy of the different treatments strategies. Methods: A retrospective, medical record-based study was carried out in four outpatient clinics specializing in treatment of anxiety disorders to investigate the characteristics of 64 patients with a DSM-IV axis diagnosis of social phobia who seeked help for their problems. Therapies for social phobia within these clinics and differences between these clinics were evaluated. Results: Men with a high educational level tended to seek more help and comorbid disorders tended to cause more impairment in functioning. Further, there is a large delay between onset and therapy attendance (mean 14 years). Finally, there was consistency in the treatment of social phobia in these four clinics which consisted of cognitive behavioral therapy and / or medication. Limitations: The study is retrospective and based on medical records which means there was no objective measurement of the effectiveness of the therapies. Conclusions: Seventy-five percent of patients improved after treatment independent of the kind of therapy, the occurrence of comorbid disorders and the type of social phobia. © 2001 Elsevier Science B.V. All rights reserved.

Binge eating disorder (BED) is a new proposed eating disorder in the DSM-IV. BED is not a formal diagnosis within the DSM-IV, but in day-to-day clinical practice the diagnosis seems to be generally accepted. People with the BED-syndrome have binge eating episodes as do subjects with bulimia nervosa, but unlike the latter they do not engage in compensatory behaviours. Although the diagnosis BED was created with the obese in mind, obesity is not a criterion. This paper gives an overview of its epidemiology, characteristics, aetiology, criteria, course and treatment. BED seems to be highly prevalent among subjects seeking weight loss treatment (1.3-30.1%). Studies with compared BED, BN and obesity indicated that individuals with BED exhibit levels of psychopathology that fall somewhere between the high levels reported by individuals with BN and the low levels reported by obese individuals. Characteristics of BED seemed to bear a closer resemblance to those of BN than of those of obesity.A review of RCT's showed that presently cognitive behavioural treatment is the treatment of choice but interpersonal psychotherapy, self-help and SSRI's seem effective. The first aim of treatment should be the cessation of binge eating. Treatment of weight loss may be offered to those who are able to abstain from binge eating.

The authors assessed the effects of nutritional deficiency during the first trimester of pregnancy on brain morphology in patients with schizophrenia.Nine schizophrenic patients and nine healthy comparison subjects exposed during the first trimester of gestation to the Dutch Hunger Winter were evaluated with magnetic resonance brain imaging, as were nine schizophrenic patients and nine healthy subjects who were not prenatally exposed to the famine.Prenatal famine exposure in patients with schizophrenia was associated with decreased intracranial volume. Prenatal Hunger Winter exposure alone was related to an increase in brain abnormalities, predominantly white matter hyperintensities.Nutritional deficiency during the first trimester of gestation resulted in an increase in clinical brain abnormalities and was associated with aberrant early brain development in patients with schizophrenia. Stunted brain development secondary to factors that affect brain growth during the first trimester of gestation may thus be a potential risk factor for developing schizophrenia.

Background: Several Internet-based interventions for eating disorders have shown their effectiveness. Still, there is a need to refine such interventions given that most existing programs seem to be limited by their static ‘one-size-fits-all’ approach. ‘Featback’, an Internet-based intervention for symptoms of eating disorders provides a more individualized approach. It consists of several components (psychoeducation, a fully automated monitoring and feedback system, and support from a coach), which can be matched to participants’ needs and preferences. Until now, it is unclear whether online self-help interventions for eating disorders with support are more effective than those without. The aims of the current study are i) to examine the relative effectiveness of (the different components of) Featback; ii) to examine predictors, moderators and mediators of intervention responses; iii) to report on practical experiences with Featback; and iv) to examine the cost-effectiveness of Featback. Methods/design: Individuals aged 16 years or older, with mild to severe eating disorder symptoms will be randomized to one of the four study conditions. In condition one, participants receive the basic version of Featback, consisting of psychoeducation and a fully automated monitoring and feedback system. In conditions two and three, participants receive the basic version of Featback supplemented with the possibility of infrequent (weekly) or frequent (three times a week) e-mail, chat, or Skype support from a coach, respectively. The fourth condition is a waiting list control condition. Participants are assessed at baseline, post-intervention (8 weeks), and at 3- and 6-month follow-up (the latter except for participants in the waiting list control condition). Primary outcome measures are disordered eating behaviors and attitudes. Secondary outcome measures are (eating disorder-related) quality of life, self-stigma of seeking help, self-esteem, mastery and support, symptoms of depression and anxiety, repetitive negative thinking, motivation to change, user satisfaction, compliance, and help-seeking attitudes and behaviors. Discussion: This study aims to provide more insight into the (cost-) effectiveness of Internet-based interventions for eating disorders, particularly those with and without professional support, as well as different levels of support. Trial registration: NTR3646