Ross D. Crosby

Objective: To evaluate moderators and predictors of response to cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) for binge‐eating disorder (BED). Method: Moderators/predictors of treatment outcome, central to CBT and to DBT treatment, were chosen from an aggregated dataset of two clinical outcome studies with non‐random allocation to treatment groups ( N = 203). Both studies compared DBT‐BED ( n = 71) to a more intensive outpatient CBT program (CBT+, n = 132) in individuals with BED. Generalized linear models examined moderators and predictors of objective binge‐eating (OBE) frequency at end of treatment (EOT) and six‐month follow up (FU). Results: Baseline shape/weight overvaluation, shape concerns and low self‐esteem significantly predicted and moderated reductions in OBE frequency at EOT whereas difficulty in identifying feelings predicted and moderated outcome at FU. Emotional eating predicted outcome at FU (medium effect) and moderated outcome at EOT (large effect). Depression levels predicted, but not moderated, treatment outcome at both EOT and FU. For shape/weight overvaluation, shape concerns and low self‐esteem, low levels were related to fewer reductions in outcome in DBT‐BED than in CBT+. Individuals with the highest levels of emotional eating and difficulty identifying feelings showed more decrease in OBE episodes with DBT‐BED than with CBT+ at EOT and FU respectively. Discussion: Findings suggest that BED treatment outcomes could be enhanced by matching individuals with certain symptom presentations to treatment overall, and to DBT‐BED or CBT+ specifically. DBT‐BED may be a promising alternative to CBT+ for those with more severe psychopathology.

Background: Loss of control eating is more likely to occur in the evening and is uniquely associated with distress. No studies have examined the effect of treatment on within-day timing of loss of control eating severity. We examined whether time of day differentially predicted loss of control eating severity at baseline (i.e. pretreatment), end-of-treatment, and 6-month follow-up for individuals with binge-eating disorder (BED), hypothesizing that loss of control eating severity would increase throughout the day pretreatment and that this pattern would be less pronounced following treatment. We explored differential treatment effects of cognitive-behavioral guided self-help (CBTgsh) and Integrative Cognitive-Affective Therapy (ICAT).Methods: Individuals with BED (N = 112) were randomized to receive CBTgsh or ICAT and completed a 1-week ecological momentary assessment protocol at baseline, end-of-treatment, and 6-month follow-up to assess loss of control eating severity. We used multilevel models to assess within-day slope trajectories of loss of control eating severity across assessment periods and treatment type.Results: Within-day increases in loss of control eating severity were reduced at end-of-treatment and 6-month follow-up relative to baseline. Evening acceleration of loss of control eating severity was greater at 6-month follow-up relative to end-of-treatment. Within-day increases in loss of control severity did not differ between treatments at end-of-treatment; however, evening loss of control severity intensified for individuals who received CBTgsh relative to those who received ICAT at 6-month follow-up.Conclusions: Findings suggest that treatment reduces evening-shifted loss of control eating severity, and that this effect may be more durable following ICAT relative to CBTgsh.

ObjectiveEmerging research indicates that skills acquisition may be important to behavior change in cognitive behavior therapy (CBT) for eating disorders. This study investigated whether skills use assessed in real time during the initial 4 weeks of CBT-based day treatment was associated with momentary eating disorder behavior change and rapid response to treatment.MethodsParticipants with DSM-5 bulimia nervosa or purging disorder (N = 58) completed ecological momentary assessments (EMA) several times daily for the first 28 days of treatment. EMA assessed skills use, the occurrence of binge eating and/or purging, and state negative affect. Rapid response was defined as abstinence from binge eating and/or purging in the first 4 weeks of treatment.ResultsGreater real-time skills use overall, and use of "planning ahead," "distraction," "social support," and "mechanical eating" skills in particular, were associated with a lower likelihood of engaging in binge eating or purging during the same period. After controlling for baseline group differences in overall difficulties with emotion regulation, rapid and non-rapid responders did not differ in overall skills use, or skills use at times of higher negative affect, during the EMA period.DiscussionMomentary use of skills appears to play an important role in preventing binge eating and purging, and certain skills appear to be particularly helpful. These findings contribute to the literature elucidating the processes by which CBT treatments for eating disorders work by providing empirical evidence that skills use helps to prevent binge eating and purging behaviors.Public SignificanceIndividuals with eating disorders learn new skills during treatment to help them improve their symptoms. This study shows that for people with eating disorders, using skills helps prevent eating disorder behaviors in the moment. Certain skills may be particularly helpful, including planning ahead, distracting activities, support from others, and focusing on eating meals and snacks regardless of how one is feeling. These findings help us better understand how treatments work.

Objective: Prominent theories of binge‐eating (BE) maintenance highlight dietary restriction as a key precipitant of BE episodes. Consequently, treatment approaches for eating disorders (including binge‐eating disorder; BED) seek to reduce dietary restriction in order to improve BE symptoms. The present study tested the hypothesis that dietary restriction promotes BE among 112 individuals with BED.Methods: Participants completed a 7‐day ecological momentary assessment (EMA) protocol before and after completing 17 weeks of either Integrative Cognitive‐Affective Therapy or guided self‐help cognitive behavioral therapy. Analyses examined whether dietary restriction on 1 day of the baseline EMA protocol predicted risk for BE later that same day, and on the following day. Changes in dietary restriction over the course of treatment were also evaluated as a predictor of change in BE from pre‐treatment to post‐treatment. Baseline dietary restraint was examined as a moderator of the above associations.Results: Dietary restriction did not predict BE later the same day, and changes in restriction were not related to changes in BE across treatment, regardless of baseline dietary restraint levels. Restriction on 1 day did predict increased BE risk on the following day for individuals with higher levels of dietary restraint, but not those with lower levels.Discussion: These findings challenge the assumption that dietary restriction maintains BE among all individuals with BED. Rather, results suggest that dietary restriction may be largely unrelated to BE maintenance in this population, and that reducing dietary restriction generally does not have the intended effect on BE frequency.

Importance Breast cancer (BC) death rates have not improved for American Indian/Alaska Native (AI/AN) women, whereas, it has significantly decreased for non-Hispanic White (White) women. Objective Delineate the differences in patient and tumor characteristics among AI/AN and Whites with BC, and its impact on age and stage at diagnosis as well as overall survival (OS). Methods Hospital-based, cohort study using the National Cancer Database to identify female AI/AN and Whites diagnosed with BC between the years 2004 and 2016. Results BC in 6866 AI/AN (0.3%) and 1,987,324 Whites (99.7%) were studied. The median age at diagnosis was 58 for AI/AN and 62 for Whites. AI BC patients traveled double the distance for treatment, lived in lower median income zip codes, had a higher percentage of uninsured, higher comorbidities, lower percentage of Stage 0/I, larger tumor size, greater number of positive lymph nodes, higher proportion of triple negative and HER2-positive BC than Whites. All the above comparisons were significant, pp=0.023). After adjustment of all covariates, OS was not different (HR=1.038, 95%CI=0.902–1.195, p=0.601). Conclusion There were significant differences in patient/tumor characteristics among AI/AN and White BC which adversely impacted OS in AI/AN. However, when adjusted for various covariates, the survival was similar, suggesting that the worse survival in AI/AN is mostly the impact of known biological, socio-economic, and environmental determinants of health.

Objective: To evaluate whether the results of a quasi‐randomized study, comparing dialectical behavior therapy for binge‐eating disorder (DBT‐BED) and an intensive, outpatient cognitive behavior therapy (CBT+) in individuals with BED, would be replicated in a nonrandomized study with patients who more closely resemble everyday clinical practice.Method: Patients with (subthreshold) BED (N = 175) started one of two group treatments: DBT‐BED (n = 42) or CBT+ (n = 133), at a community eating disorder service. Measures of eating disorder pathology, emotion regulation, and general psychopathology were examined at end of treatment (EOT) and at 6‐month follow‐up using generalized linear models with multiple imputation.Results: Both treatments lead to substantial decreases on primary and secondary measures. Statistically significant, medium‐size differences between groups were limited to global eating disorder psychopathology (d = −.62; 95% CI = .231, .949) at EOT and depressive symptoms at follow‐up (d = −.45; 95% CI = .149, 6.965), favoring CBT+. Dropout of treatment included 15.0% from CBT+ and 19.0% from DBT‐BED (difference nonsignificant).Discussion: Decreases in global eating disorder psychopathology were achieved faster with CBT+. Overall, improvements in DBT‐BED were comparable to those observed in CBT+. Findings of the original trial, favoring CBT+ on the number of OBE episodes, emotional dysregulation and self‐esteem at EOT, and on eating disorder psychopathology and self‐esteem at follow‐up, were not replicated. With similar rates of treatment dropout and about half of the therapy time used in CBT+, DBT‐BED can be considered a relevant treatment for BED in everyday clinical practice.Public Significance: In this effectiveness study, dialectical behavior therapy (DBT) resulted in clinically relevant improvements in individuals with binge eating disorder. Changes were broadly comparable to those of cognitive behavior therapy (CBT), the current treatment of choice. Although CBT resulted in decreases in eating disorder psychopathology faster, there was a trend toward relapse in CBT at 6‐month follow‐up. Therefore, the less costly DBT‐program can be considered a relevant treatment in clinical practice.

We examined the moderating role of posttraumatic stress disorder (PTSD) in the association between trauma and impulsive behaviors. Adult women (N = 97) with a history of childhood sexual abuse (CSA; n = 26), rape in adulthood (n = 21), both CSA and adult rape (n = 25), or no history of sexual trauma (n = 25) completed self-report questionnaires. PTSD symptoms were positively associated with self-harm and with stealing and accident proneness, but not with sexual impulsivity. Trauma group had no independent associations with impulsive behaviors. PTSD reexperiencing symptoms interacted with trauma group such that reexperiencing symptoms were positively associated with self-harm for the two trauma groups that included CSA but not for the control and adult rape–only groups. Overall, results indicate that PTSD symptoms—more so than the occurrence of trauma itself—associate with impulsive behavior. Results highlight the importance of assessing posttraumatic symptomatology, and not just trauma occurrence, when aiming to prevent or treat impulsive behaviors.

The acquired preparedness (AP) model of eating disorder (ED) risk suggests transaction between impulsive traits and eating expectancies, though there remains a lack of research investigating distinct facets of impulsivity within this framework. This study examined how different facets of impulsivity moderate associations between eating expectancies and binge-eating severity in daily life. Women with binge-eating symptoms (N = 40) completed surveys followed by 10 days of ecological momentary assessment (EMA). Generalized estimating equations examined the independent and interactive effects of impulsivity facets and eating expectancies on EMA-measured binge-eating severity. Significant interactions were found between eating expectancies and emotional and behavioral impulsivity, but not a cognitive facet. Results suggest that among women high in emotional impulsivity, those with greater eating expectancies report higher binge-eating severity. Conversely, among those with lower behavioral impulsivity, those with lower eating expectancies report lower binge-eating severity. Future prospective work is needed with non-clinical samples.