Ulrich Voderholzer

Introduction: Physical exercise administered before or after exposure has been shown to have beneficial effects on treatment outcomes in anxiety- and trauma-related disorders. However, this approach has not yet been examined for obsessive-compulsive disorder (OCD). This randomized controlled trial investigated whether high-intensity exercise administered immediately after exposure therapy improves treatment outcomes in patients with OCD. Methods: Ninety-seven inpatients with OCD participated in an 8-week exposure-based treatment phase during inpatient care, comprising 2 sessions per week, and were randomly assigned to either high-intensity exercise (ExpoHI) or low-intensity control (ExpoLI) administered immediately after a standardized exposure and response prevention session. OCD severity was assessed using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at admission, discharge, and 6-month follow-up. The secondary outcomes included general psychopathological symptoms. Results: ExpoHI showed significantly greater reductions in Y-BOCS scores at discharge (between-group difference: −3.14 points, p = 0.009), corresponding to a moderate-to-large between-group effect size (Cohen’s d = 0.76), which was maintained at the 6-month follow-up (p = 0.030; Cohen’s d = 0.68). Responder rates at discharge were significantly higher in the ExpoHI group (85.4%) than in the ExpoLI group (61.2%) (p = 0.011), whereas remission rates did not differ between groups. ExpoHI also showed greater reductions in depressive symptoms at follow-up. Conclusions: High-intensity exercise immediately following exposure therapy produced greater reductions in obsessive-compulsive symptoms than the active control condition. These findings suggest that exercise may be a feasible adjunct for exposure-based treatment.

Background: Laboratory parameters and body weight are objective markers of physical stability in patients with severe and extreme anorexia nervosa. However, systematic analyses of trajectories during inpatient treatment with high-calorie refeeding and prophylactic phosphate supplementation remain limited in extremely underweight persons. Therefore, it is essential to gain a comprehensive understanding of changes in laboratory parameters, body mass index, and factors influencing these trajectories under this treatment approach in patients with severe and extreme anorexia nervosa, who are at particularly high risk of medical complications. Methods: Retrospective data of a six-week treatment period from 519 female inpatients of a specialized care unit with anorexia nervosa (body mass index at admission: M = 12.6 kg/m ² , SD = 1.35) were analyzed. Laboratory parameters (hemoglobin, thrombocytes, leukocytes, aspartate aminotransferase, alanine aminotransferase, creatine kinase, sodium, potassium, and phosphate) and body weight were assessed weekly. Results: More than one-third of patients showed leukopenia or hypertransaminasemia at admission. Most laboratory values and body mass index tended to ameliorate during the six-week treatment period. Lower body mass index at admission or longer illness duration was associated with larger changes in body mass index and several laboratory parameters (e.g., hemoglobin or aspartate aminotransferase). Conclusions: These findings provide a detailed characterization of laboratory changes during inpatient refeeding with prophylactic phosphate supplementation. The observed temporal patterns of laboratory stabilization may help inform individualized monitoring strategies and provide a basis for evaluating whether the frequency of routine laboratory testing can be tailored over a longer course of treatment according to clinical status and resolution of previous abnormalities. Furthermore, these findings may support the effectiveness and safety of inpatient refeeding protocols with prophylactic phosphate supplementation in patients with severe and extreme anorexia nervosa and an extremely low body mass index at admission (< 13 kg/m ² ).

Objective: The role of the therapeutic alliance (TA) in treatment outcomes of anorexia nervosa (AN) appears to be less substantial than in other disorders. However, the therapeutic process is a complex trajectory with many variables influencing each other. Hence, investigating motivation to change in the bidirectional interplay between TA and outcome among patients with AN may enhance the understanding of these processes. Method: In an exploratory analysis of longitudinal data from 173 inpatients with AN assessed at four time points in a specialized in‐patient clinic, the interplay of TA and its subscales with motivation was investigated using cross‐lagged panel models. Additionally, motivation was tested as a possible moderator and mediator of previously examined relationships between outcome and TA. Results: Autoregressive paths of TA and motivation were highly stable over the course of treatment, while residual covariances varied. Motivation showed moderate but significant cross‐lagged effects on subsequent TA, while TA had no effect on subsequent motivation. These associations were observed only when motivation was assessed with an exploratory measure of motivation. No mediation and moderation effect of motivation on relationships between TA and outcome was found. Discussion: Cross‐lagged analyses suggested that motivation preceded subsequent levels of TA, whereas TA did not predict subsequent motivation. Given the exploratory nature of the study, these findings should be considered hypothesis‐generating and require replication. Future research using more fine‐grained methodologies may help to further elucidate the longitudinal interplay between motivation and TA in patients with AN.

Objective: Individuals with high levels of orthorexic eating behavior (OEB) show a (pathological) fixation on healthy eating. Shared characteristics of OEB with individuals with anorexia nervosa (AN) raised debate over whether orthorexia nervosa constitutes a distinct disorder. Distinctions may lie in preference for and approach behavior toward foods differing in calorie content and healthiness. We expected reduced liking and weaker approach biases in AN and OEB compared with controls; specifically for high‐caloric foods in AN and for unhealthy foods in OEB. Method: Thirty‐five self‐reported AN, forty non‐AN individuals who scored > 30 on the Düsseldorf Orthorexia Scale (OEB), and 101 individuals with no eating disorder history (controls) completed liking ratings and an Approach‐Avoidance Task with food stimuli varying in calorie content (high vs. low) and, for high‐calorie items, healthiness (healthy vs. unhealthy). Results: Compared to controls, AN reported lower liking for all high‐caloric foods, while OEB reported lower liking only for high‐caloric, unhealthy foods. Accordingly, OEB also liked high‐caloric healthy foods more than AN. AN showed weaker approach bias than controls (mainly driven by high‐caloric unhealthy foods). OEB descriptively lay between both other groups, with no significant differences in approach bias to either. Conclusion: Explicit liking ratings distinguished AN from OEB aligning with their respective motivation to reduce high‐caloric versus unhealthy food intake. Reduced approach bias was specific to AN, possibly reflecting rapid engagement of approach‐avoidance responses to easy‐to‐categorize high‐caloric unhealthy foods. Contrary, health‐focused processing in OEB may require slower deliberations that are not captured by approach‐avoidance tasks.

Objective: To evaluate the efficacy of a 16‐week therapist‐guided, smartphone‐based aftercare intervention as an add‐on to treatment as usual (TAU) following inpatient treatment for anorexia nervosa (AN). Method: In this single‐center randomized clinical trial, 186 female inpatients with DSM‐5 AN (≥ 13 years; body mass index (BMI) ≥ 15.0 kg/m ² at discharge; smartphone access) were randomized to TAU plus smartphone‐based aftercare (intervention group, IG; n = 93) or TAU only (control group, CG; n = 93). The intervention used the Recovery Record app with individualized goals and therapist feedback of decreasing frequency over 16 weeks. Outcomes were assessed at discharge (T0), end of intervention (T1), and 6‐month follow‐up (T2) by blinded assessors, and were analyzed using linear mixed effect models (intention‐to‐treat). The primary outcome was the Eating Disorder Examination (EDE) global score; secondary outcomes included BMI, depressive symptoms, self‐reported eating disorder psychopathology, self‐efficacy, and stage of change. Results: At T1, there was no significant between‐group difference in EDE global score (mean difference, 0.12; 95% CI, −0.21 to 0.46), and results were similar at T2 (0.27; 95% CI, −0.13 to 0.67). Secondary outcomes did not differ clearly between groups. Intervention adherence was high (69.9% completed 16 weeks). Rehospitalizations occurred in 4.7% of participants by T1 and 26.4% by T2, without significant between‐group differences. Discussion: In a context of intensive TAU with rapid access to outpatient psychotherapy, adding therapist‐guided smartphone‐based aftercare did not yield additional short‐term symptom benefit after inpatient treatment for AN. Future work should refine digital aftercare and embed it more closely into blended treatment models. Trial Registration: ClinicalTrials.gov identifier: NCT04228939

Zwangsstörungen gehören mit einer Lebenszeitprävalenz von ca. 2-3% zu den häufigsten psy-chischen Störungen in der Bevölkerung. Expositionsverfahren stellen nach derzeitiger Stu-dienlage und den S3-Leitlinien das wirksamste Therapieverfahren in der Behandlung von Zwangserkrankungen dar. Trotzdem ist die leitlinienbasierte Versorgung insbesondere mit Expositionsverfahren von Zwangserkrankten besonders in der ambulanten Behandlungsreali-tät oftmals nicht gewährleistet und wird im therapeutischen Alltag nur unzureichend durchge-führt. Gründe hierfür sind der hohe Zeitaufwand und organisatorische Schwierigkeiten der Expositionsbehandlung, eine fehlende rechtliche Grundlage für die Delegation an Co-Therapeuten, die Sorge, dass Co-Therapeuten diese nicht effizient genug durchführen können und Risiken bergen könnten, die für den Patienten zu hoch sind. Erfahrungen mit Co-therapeutischen Konzepten liegen bisher hauptsächlich im stationären, kaum aber im ambulanten Bereich vor. Niedergelassene Psychotherapeuten können dabei nicht wie im stationären Kontext auf erfahrenes Pflegepersonal oder andere Co-Therapeuten zu-rückgreifen. Alternative Finanzierungsmodelle könnten eine ehrenamtliche Begleitung durch Co-Therapeuten oder geringfügige Vergütung im Falle von Psychologie-Studierenden oder PsychologInnen in Ausbildung sein. Auch Begleitung auf Basis von Soziotherapie, von Pflegeleistungen oder der Eingliederungshilfe wären denkbar. An rechtlichen Aspekten wären zu klären, ob Expositionsbehandlungen als Leistung unter den Approbationsvorbehalt fallen, welche Voraussetzungen ein Co-Therapeut erfüllen müsste und wie er angeleitet und supervidiert werden kann. Es wäre wünschenswert, dass Expositionsbehandlung in den Leistungskatalog der Soziotherapie aufgenommen würde, damit PsychotherapeutInnen sie verordnen können. Darüber hinaus sollte dafür gesorgt werden, dass Expositionsbehandlungen als delegationsfähige Leistung in den bestehenden Delegations-Vereinbarungskatalog der gesetzlichen Krankenversicherungen aufgenommen wird. Es besteht die Hoffnung, dass im Falle der Delegierbarkeit der Expositionsbehandlung an Co-Therapeuten der bisherigen Unterversorgung in der Behandlung Zwangserkrankter und der Behandlungsverzögerung entgegengewirkt werden kann.

Objective: Depressive symptoms are highly prevalent among people with eating disorders (ED). Although at the group level, depressive symptoms tend to improve alongside ED symptoms during treatment, many patients do not experience clinically meaningful reductions. Identifying at admission which patients are at risk for persistent depressive symptoms during ED treatment could support more personalized care and targeted treatment planning. Method: We analyzed routinely collected electronic health record data from 1412 persons receiving inpatient or day hospital ED treatment. Two outcomes were examined: (1) nonimprovement of depressive symptoms and (2) residual depression at discharge. Two machine learning (ML) models, namely elastic net regularized regression and extreme gradient boosting, were applied. Model performance was evaluated using standard classification metrics, feature importance, and decision curve analysis. Results: Nonimprovement was predicted poorly (AUC = 0.64–0.65), whereas residual depression was predicted adequately (AUC = 0.73–0.77). Important predictors included phobic anxiety, resilience, life satisfaction, and baseline depression. Decision curve analysis indicated that all models provided greater net benefit than treating all or no patients across clinically relevant thresholds. Conclusions: A substantial portion of patients continued to experience notable depressive symptoms despite specialized ED treatment. Although predictive performance was moderate, our findings demonstrate the potential of preregistered and transparent ML approaches in ED settings.

Objective: Several models of eating disorders (EDs) suggest that emotions and eating influence each other in a vicious cycle, producing part of the observed symptoms. However, no research tested whether such cycles exist across EDs. We therefore explored networks of prospective relationships between negative and positive emotions and eating-related behaviors (hunger, food craving, calorie intake, and binges) across EDs and healthy controls (HCs). Method: These variables were assessed six times a day for eight days in women with restrictive (AN-R, N = 29) and binge-purge (AN-BP, N = 26) Anorexia Nervosa, Bulimia Nervosa (BN, N = 42), and Binge-Eating Disorder (BED, N = 37), and in HCs ( N = 57). Prospective relationships were analyzed with modified vector-autoregressive networks. Results: Unlike HCs, ED groups showed many emotion-eating relationships. Calorie intake predicted subsequent increased negative or reduced positive affect in every ED, and so did binges in AN-BP, BN, and BED; post-binge negative affect was predicted to last up to 10 h. AN-R showed positive emotional eating, with more desire to eat and hunger during positive mood, while BED showed negative emotional eating, with worry predicting desire to eat and hunger, and irritation predicting calorie intake directly. Binges were not predicted by negative emotions, likely due to a long temporal distance between measurements. All EDs showed restriction-promoting feedback loops mediated by negative affect following calorie intake. In particular, AN-BP showed a panic-like cycle wherein a lack of hunger predicted worry, and this worry predicted a further reduction in hunger. Discussion: Post-eating dysphoria was present in all EDs, while restriction-promoting feedback loops were present in most EDs.

Objective: Compulsive exercise is a common behaviour among persons with eating disorders, particularly in those with anorexia nervosa (AN) and bulimia nervosa (BN). In the current study, we examined psychometric properties of a German version of the eight‐item Commitment to Exercise Scale (CES) with a four‐point scale response format. Method: Data of N = 2424 persons with AN and BN who completed the CES among other measures as part of the routine diagnostic assessment at admission to and discharge from inpatient treatment were analysed based on a preregistered protocol ( https://doi.org/10.17605/OSF.IO/Z2RYW ). Results: The CES had high internal consistency and a one‐factor structure with measurement invariance across age and diagnostic groups. Large correlations with other measures of compulsive exercise supported convergent validity and small‐to‐moderate correlations with other measures supported divergent validity. Scores on the CES were sensitive to change as they moderately decreased during inpatient treatment, with changes in compulsive exercise being larger in males and persons with AN that in females and persons with BN. Conclusions: The CES has sound psychometric properties in persons with AN and BN. Given its brevity, it may be favoured over lengthier instruments for assessing compulsive exercise in research and clinical practice.