Publications by authors named "Ulrich Voderholzer"

170 Publications

Determining prognostic variables of treatment outcome in obsessive-compulsive disorder: effectiveness and its predictors in routine clinical care.

Eur Arch Psychiatry Clin Neurosci 2021 Jul 3. Epub 2021 Jul 3.

Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany.

The objectives of this study were to investigate the naturalistic effectiveness of routine inpatient treatment for patients with obsessive-compulsive disorder (OCD) and to identify predictors of treatment outcome. A routinely collected data set of 1,596 OCD inpatients (M = 33.9 years, SD = 11.7; 60.4% female) having received evidence-based psychotherapy based on the cognitive-behavioral therapy (CBT) in five German psychotherapeutic clinics was analyzed. Effect sizes (Hedges' g) were calculated for several outcome variables to determine effectiveness. Predictor analyses were performed on a subsample (N = 514; M = 34.3 years, SD = 12.2; 60.3% female). For this purpose, the number of potential predictors was reduced using factor analysis, followed by multiple regression analysis to identify robust predictors. Effect sizes of various outcome variables could be classified as large (g = 1.34 of OCD-symptom change). Predictors of changes in OCD and depressive symptoms were symptom severity at admission and general psychopathological distress. In addition, patients with higher social support and more washing compulsions benefited more from treatment. Subgroup analyses showed a distinct predictor profile of changes in compulsions and obsessions. The results indicate that an evidence-based psychotherapy program for OCD can be effectively implemented in routine inpatient care. In addition to well-established predictors, social support, and washing compulsions in particular were identified as important positive predictors. Specific predictor profiles for changes in obsessions and compulsions are discussed.
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http://dx.doi.org/10.1007/s00406-021-01284-6DOI Listing
July 2021

Bad mood food? Increased versus decreased food cue reactivity in anorexia nervosa and bulimia nervosa during negative emotions.

Eur Eat Disord Rev 2021 Jun 26. Epub 2021 Jun 26.

Department of Psychology, Division of Health Psychology, Paris-Lodron-University of Salzburg, Salzburg, Austria.

Objective: Emotion regulation difficulties in anorexia nervosa (AN) and bulimia nervosa (BN) might underlie bingeing and purging in BN, extreme fasting in AN, or combinations of these symptoms in binge-purge type AN. In this study, we tested for decreased food cue reactivity in response to negative emotions in AN, and the opposite pattern for BN. Furthermore, we explored subgroup differences (restrictive vs. binge-purging AN; history of AN in BN).

Method: Patients with AN (n = 41), BN (n = 39), and matched controls (n = 70) completed an emotional eating questionnaire. In a laboratory experiment, we induced negative emotions and measured food cue reactivity (pleasantness, desire to eat (DTE), and corrugator muscle activity).

Results: AN reported emotional undereating, while BN reported emotional overeating. In the laboratory task, BN showed increased DTE and an appetitive corrugator response during negative emotions, selectively towards high-calorie foods. AN showed generalized reduced cue reactivity to high-calorie food regardless of emotional state. This pattern appears to be characteristic of restrictive AN, while cue reactivity of both BN subgroups pointed towards emotional overeating.

Conclusions: The emotional over- versus undereating framework might help to explain bingeing and restricting along the anorectic-bulimic disorder spectrum, which calls for novel transdiagnostic theories and subgroup-specific treatments.
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http://dx.doi.org/10.1002/erv.2849DOI Listing
June 2021

Psychological consequences and differential impact of the COVID-19 pandemic in patients with mental disorders.

Psychiatry Res 2021 08 6;302:114045. Epub 2021 Jun 6.

Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany; Schoen Clinic Roseneck, Prien am Chiemsee, Germany; Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Freiburg, Germany.

Objective: People with mental disorders might be differentially affected by the COVID-19 pandemic. The aim of the current study was to evaluate the impact of the pandemic on patients with various psychiatric disorders who were admitted to inpatient treatment.

Methods: Five-hundred thirty-eight inpatients with mental disorders participated in a survey about psychological consequences of the pandemic between March-December 2020. We examined the perceived burden by restrictions and worries, changes in health care utilization, and helpfulness of coping strategies.

Results: More than 50% reported any worsening of symptoms, 40% stated increased need of therapeutic support. High rates of symptom deterioration were observed for depressive symptoms (>55%), anxiety (>40%), and sleeping behavior (>40%). Treatment impairment was stated by 27.9%. Patients with anxiety disorders were less affected by contact restrictions compared with eating disorders and depression. Patients with anorexia nervosa and post-traumatic stress disorder experienced higher helpfulness by daily structuring than patients with depression.

Discussion: About half of our sample of psychiatric patients experienced symptom deterioration due to the pandemic and about one quarter reported impairment of treatment modalities. Especially patients with eating disorders and depressive disorders were more frequently affected. The results indicate a needed improvement of treatment options during a pandemic.
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http://dx.doi.org/10.1016/j.psychres.2021.114045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180351PMC
August 2021

Mit Apps gegen Depression und Ängste - auch beim Hausarzt.

MMW Fortschr Med 2021 05;163(10):26-27

Schön Klinik Roseneck, 83209, Prien am Chiemsee, Deutschland.

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http://dx.doi.org/10.1007/s15006-021-9969-5DOI Listing
May 2021

Specialized post-inpatient psychotherapy for sustained recovery in anorexia nervosa via videoconference - study protocol of the randomized controlled SUSTAIN trial.

J Eat Disord 2021 May 19;9(1):61. Epub 2021 May 19.

Department of Psychosomatic Medicine und Psychotherapy, Medical University Hospital Tübingen, Eberhard Karls University Tübingen, Osianderstr. 5, 72076, Tübingen, Germany.

Background: A major barrier to long-term recovery from anorexia nervosa (AN) are early and frequent relapses after inpatient treatment. There is an urgent need for enhanced continuity of specialized care involving effective aftercare interventions and relapse prevention strategies in order to improve the long-term outcome for patients with AN.

Methods: SUSTAIN is a multi-center, prospective, randomized-controlled trial investigating the efficacy of a novel post-inpatient aftercare intervention for patients with AN as compared to optimized treatment-as-usual (TAU-O). The SUSTAIN aftercare intervention is based on the cognitive-interpersonal maintenance model of AN and specifically tailored to achieve sustained recovery in AN following inpatient treatment. The SUSTAIN aftercare intervention comprises 20 treatment sessions over eight months and will be predominantly delivered via videoconference to overcome discontinuity of care. TAU-O refers to routine outpatient psychotherapy as generally offered in the German health care system. A total number of 190 patients receiving inpatient or day-hospital treatment for AN will be randomized and assessed over a 14-month period following randomization including a 6 months follow-up. Minimum Body Mass Index (BMI) is 15 kg/m at trial inclusion. The primary efficacy endpoint is the change in BMI between baseline (T0) and end of treatment (T2) adjusted for baseline BMI. Key secondary outcomes comprise eating disorder and general psychopathology, quality of life, proportion of relapse and of weight restoration, and cost-effectiveness.

Discussion: The results of the present trial will provide evidence if the novel aftercare intervention fosters sustained recovery in patients affected by severe courses of AN.

Trial Registration: The SUSTAIN trial was prospectively registered on November 18, 2020, under the registration number DRKS00023372 at the German Clinical Trials Register ( https://www.drks.de/drks_web/ ) which is an acknowledged primary register of the World Health Organization ( http://apps.who.int/trialsearch/ ). Protocol version: 1.2.
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http://dx.doi.org/10.1186/s40337-021-00416-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8132489PMC
May 2021

Using network analysis to compare diagnosis-specific and age-specific symptom networks in eating disorders.

Int J Eat Disord 2021 May 5. Epub 2021 May 5.

Department of Psychiatry and Psychotherapy, University Hospital of Munich (LMU), Munich, Germany.

Objective: The network theory of mental disorders conceptualizes eating disorders (EDs) as networks of interacting symptoms. Network analysis studies in EDs mostly have examined transdiagnostic and/or mixed age samples. The aim of our study was to investigate similarities and differences of networks in adolescents and adults with anorexia nervosa (AN) or bulimia nervosa (BN).

Method: Participants were 2,535 patients (n = 991 adults with AN, n = 821 adolescents with AN, n = 473 adults with BN, and n = 250 adolescents with BN) who completed the Eating Disorder Inventory-2. Twenty-seven items were selected. Cross-sectional networks were estimated via Joint Graphical Lasso. Core symptoms were identified using strength centrality. Spearman correlations and network comparison tests (NCTs) were used to compare groups.

Results: Across diagnoses and ages, feeling ineffective, desire to be thinner, worries that feelings will get out of control, guilt after overeating as well as doing things perfectly emerged as most central symptoms. There were moderate to high correlations between symptom profiles (0.62-0.97, mean: 0.78) as well as high correlations between network structures (0.83-0.93, mean: 0.87) and network strengths (0.73-0.95, mean: 0.85). Global strength significantly differed in two of the six NCTs, and 2.5-10% of edges differed between networks.

Discussion: Considerable similarities in network structures and strengths across diagnoses and ages speak in favor of the transdiagnostic approach to EDs. Besides drive for thinness, ineffectiveness, emotion regulation difficulties, and perfectionism might be the most consistent factors in ED networks. These symptoms as well as their symptom connections should be especially focused in treatment regardless of age and diagnosis.
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http://dx.doi.org/10.1002/eat.23523DOI Listing
May 2021

Impact of comorbid borderline personality disorder on the outcome of inpatient treatment for anorexia nervosa: a retrospective chart review.

Borderline Personal Disord Emot Dysregul 2021 Mar 11;8(1). Epub 2021 Mar 11.

Schoen Clinic Roseneck, Prien am Chiemsee, Am Roseneck 6, D-83209, Prien am Chiemsee, Germany.

Background: Data on patients with anorexia nervosa (AN) and comorbid Borderline personality disorder (AN+BPD) are scarce. Therefore, we investigated (1) whether patients with AN and AN+BPD differ in characteristics related to admission to, discharge from, and course of specialized inpatient eating disorder treatment and (2) how comorbid BPD affects treatment outcome.

Method: One-thousand one-hundred and sixty inpatients with AN (97.2% female, 5.9% with comorbid BPD; mean age = 26.15, SD = 9.41) were administered the Brief Symptom Inventory (BSI), the Eating Disorder Inventory 2 (EDI-2), and the Global Assessment of Functioning (GAF) at admission and discharge. Data were extracted by a retrospective chart review of naturalistic treatment data. Age, sex, weekly weight gain, length of stay, and discharge characteristics were compared with independent t-tests and χ-tests. Changes in outcome variables, including body mass index (BMI), were analyzed with longitudinal multilevel mixed-effects models.

Results: No differences in age or sex were found between patients with AN and AN+BPD, but groups differed in previous inpatient treatments, BMI at admission, and frequency of at least one additional comorbidity with higher values for AN+BPD. Higher levels of disorder-specific and general psychopathology at admission were found for AN+BPD. Patients with AN showed statistically significant improvement in all examined variables, patients with AN+BPD improved in all variables except EDI-2 body dissatisfaction. Strongest improvements in patients with AN+BPD occurred in BMI (Cohen's d = 1.08), EDI-2 total score (Cohen's d = 0.99), EDI-2 interpersonal distrust (d = 0.84). Significant Group x Time Interactions were observed for BSI GSI, GAF, and EDI-2 body dissatisfaction, indicating a reduced benefit from inpatient treatment in AN+BPD. At discharge, no differences were found in weekly weight gain, BMI, length of stay, or discharge characteristics (e.g., ability to work, reason for discharge), however, patients with AN+BPD were more frequently treated with medication.

Conclusions: Patients with AN+BPD differ from patients with AN in that they show higher general and specific eating disorder psychopathology and only partially improve under specialized inpatient treatment. In particular, aspects of emotion regulation and core AN symptoms like body dissatisfaction and perfectionism need to be even more targeted in comorbid patients.
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http://dx.doi.org/10.1186/s40479-021-00149-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948359PMC
March 2021

Emotional eating across different eating disorders and the role of body mass, restriction, and binge eating.

Int J Eat Disord 2021 May 3;54(5):773-784. Epub 2021 Mar 3.

Department of Psychology, Centre for Cognitive Neuroscience, Paris-Lodron-University of Salzburg, Salzburg, Austria.

Objective: Different subtypes of eating disorders (ED) show dysfunctional eating behaviors such as overeating and/or restriction in response to emotions. Yet, systematic comparisons of all major EDs on emotional eating patterns are lacking. Furthermore, emotional eating correlates with body mass index (BMI), which also differs between EDs and thus confounds this comparison.

Method: Interview-diagnosed female ED patients (n = 204) with restrictive (AN-R) or binge-purge anorexia nervosa (AN-BP), bulimia nervosa (BN), or binge-eating disorder (BED) completed a questionnaire assessing "negative emotional eating" (sadness, anger, anxiety) and "happiness eating." ED groups were compared to BMI-matched healthy controls (HCs; n = 172 ranging from underweight to obesity) to exclude BMI as a confound.

Results: Within HCs, higher BMI was associated with higher negative emotional eating and lower happiness eating. AN-R reported the lowest degree of negative emotional eating relative to other EDs and BMI-matched HCs, and the highest degree of happiness eating relative to other EDs. The BN and BED groups showed higher negative emotional eating compared to BMI-matched HCs. Patients with AN-BP occupied an intermediate position between AN-R and BN/BED and reported less happiness eating compared to BMI-matched HCs.

Discussion: Negative emotional and happiness eating patterns differ across EDs. BMI-independent emotional eating patterns distinguish ED subgroups and might be related to the occurrence of binge eating versus restriction. Hence, different types of emotional eating can represent fruitful targets for tailored psychotherapeutic interventions. While BN and BED might be treated with similar approaches, AN-BP and AN-R would need specific treatment modules.
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http://dx.doi.org/10.1002/eat.23477DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252459PMC
May 2021

Facilitators and barriers in anorexia nervosa treatment initiation: a qualitative study on the perspectives of patients, carers and professionals.

J Eat Disord 2021 Feb 27;9(1):28. Epub 2021 Feb 27.

Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany.

Background: An early psychotherapeutic treatment of anorexia nervosa (AN) is crucial for a good prognosis. In order to improve treatment initiation, knowledge about facilitators and barriers to treatment is needed.

Objective: Against this background, we aimed to identify facilitators and barriers from the perspectives of patients, carers and professionals using a qualitative approach.

Method: To this end, semi-structured interviews were conducted in triads of female patients with AN aged 14 years and older at the beginning of their first psychotherapeutic treatment, their carers, and referring health care professionals. A modified Grounded Theory approach was used for analysis.

Results: In total, 22 interviews were conducted (n = 6 adults, n = 4 adolescents, 4 full triads). The duration of untreated AN ranged between 30 days and 25.85 years (M = 3.06 ± 8.01 years). A wide spectrum of facilitators and barriers within the patient, the social environment, the health care system and the society were identified. Most prominent factors were 'recognizing and addressing' by close others, 'waiting times and availability' and 'recommendations and referrals' by health care professionals. 'Positive role models for treatment' were perceived as a specific facilitative social influence. Facilitators were more frequently mentioned than barriers and most of the factors seem to hold potential for modifiability.

Conclusion: Overall, the findings suggest that early intervention approaches for AN should not only address patients and the health care system, but may also involve carers and successfully treated former patients.

Trial Registration: ClinicalTrials.gov Identifier: NCT03713541 .
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http://dx.doi.org/10.1186/s40337-021-00381-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7913310PMC
February 2021

Discrepancies Between Explicit Feelings of Power and Implicit Power Motives Are Related to Anxiety in Women With Anorexia Nervosa.

Front Psychol 2020 9;11:618650. Epub 2021 Feb 9.

Department of Clinical and Health Psychology, Ulm University, Ulm, Germany.

Background: Several studies identified low subjective feelings of power in women with anorexia nervosa (AN). However, little is known about implicit power motives and the discrepancy between explicit feelings of power and implicit power motives in AN.

Aim: The study investigated the discrepancy between explicit feelings of power and implicit power motives and its relationship to anxiety in patients with AN.

Method: Fifty-three outpatients and inpatients with AN and 48 participants without AN were compared regarding subjective feelings of power and anxiety. Explicit power [investigated with the Personal Sense of Power Scale (trait focus) and a visual analog scale (state focus)], implicit power motives [investigated with the Multi-Motive Grid (MMG)] and trait anxiety [measured with the State-Trait Anxiety Inventory (STAI)], were assessed.

Results: Explicit feelings of power (state and trait level) were lower in patients with AN compared to non-AN participants. No differences in implicit power motives were found when comparing the groups against each other. However, looking at the groups separately, women with AN had similar levels of implicit fear of losing power and hope for power, whereas woman without AN had significantly lower fear of losing power than hope for power. Focusing on discrepancies between powerful feelings and power motives, results were mixed, depending on the subscale of the MMG. Lastly, discrepancies between implicit power motives and explicit feelings of power were positively correlated with trait anxiety in AN patients.

Conclusion: These findings underline that individuals with AN display significantly lower explicit feelings of power, however, they show similar implicit power motives compared to individuals without AN. The discrepancy between explicit feelings of power and implicit power motives is related to anxiety in AN and may represent a vulnerability factor to illness maintenance.
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http://dx.doi.org/10.3389/fpsyg.2020.618650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901641PMC
February 2021

Orthorexia Nervosa-It Is Time to Think About Abandoning the Concept of a Distinct Diagnosis.

Front Psychiatry 2021 28;12:640401. Epub 2021 Jan 28.

Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany.

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http://dx.doi.org/10.3389/fpsyt.2021.640401DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876234PMC
January 2021

Unraveling the comorbidity of depression and anxiety in a large inpatient sample: Network analysis to examine bridge symptoms.

Depress Anxiety 2021 03 19;38(3):307-317. Epub 2021 Jan 19.

Department of Psychology, University of Greifswald, Greifswald, Germany.

Background: Comorbidities in mental disorders are often understood by assuming a common cause. The network theory of mental disorders offers an alternative to this assumption by understanding comorbidities as mutually reinforced problems. In this study, we used network analysis to examine bridge symptoms between anxiety and depression in a large sample.

Method: Using data from a sample of patients diagnosed with both depression and an anxiety disorder before and after inpatient treatment (N = 5,614, mean age: 42.24, 63.59% female, average treatment duration: 48.12 days), network models of depression and anxiety symptoms are estimated. Topology, the centrality of nodes, stability, and changes in network structure are analyzed. Symptoms that drive comorbidity are determined by bridge node analysis. As an alternative to network communities based on categorical diagnosis, we performed a community analysis and propose empirically derived symptom subsets.

Results: The obtained network models are highly stable. Sad mood and the inability to control worry are the most central. Psychomotor agitation or retardation is the strongest bridge node between anxiety and depression, followed by concentration problems and restlessness. Changes in appetite and suicidality were unique to depression. Community analysis revealed four symptom groups.

Conclusion: The estimated network structure of depression and anxiety symptoms proves to be highly accurate. Results indicate that some symptoms are considerably more influential than others and that only a small number of predominantly physical symptoms are strong candidates for explaining comorbidity. Future studies should include physiological measures in network models to provide a more accurate understanding.
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http://dx.doi.org/10.1002/da.23136DOI Listing
March 2021

The Burnout Phenomenon: A Résumé After More Than 15,000 Scientific Publications.

Front Psychiatry 2020 9;11:519237. Epub 2020 Dec 9.

Schön Klinik Roseneck, Prien am Chiemsee, Germany.

The "burnout" phenomenon, supposedly caused by work related stress, is a challenge for academic psychiatry both conceptually and professionally. Since the first description of burnout in 1974 until today, more than 140 definitions have been suggested. Burnout-symptomatology's main characteristic, the experience of exhaustion, is unspecific. Different development-models of burnout were proposed, assumed to depict a quasi-natural process. These could not be confirmed empirically. An expert consensus on the diagnostic criteria and the conceptual location, whether as an independent disorder or as a risk, could not be agreed on. Nevertheless, the phenomenon of burnout in the ICD-11 is considered to be categorized as a work-related disorder. Psychiatric research on the burnout-phenomenon ignores problems of definition resulting from different perspectives: It may meet societal expectations, but does not fulfill scientific criteria, and therefore is not suitable to establish an objective diagnosis and treatment. Parallel detection of ICD/DSM diagnoses from an expert perspective and subjective perturbation models are considered appropriate.
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http://dx.doi.org/10.3389/fpsyt.2020.519237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793987PMC
December 2020

Orthorexic tendencies in inpatients with mental disorders.

J Psychosom Res 2021 01 29;140:110317. Epub 2020 Nov 29.

Schoen Clinic Roseneck, Prien am Chiemsee, Germany; Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany; Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Freiburg, Germany.

Objective: Most research on orthorexia nervosa (ON)-the tendency to only eat foods that are perceived as healthy-has been based on non-clinical samples. Thus, we examined prevalence of and changes in orthorexic tendencies in a large sample of inpatients with mental disorders. Cross-sectional and longitudinal associations with body weight and eating disorder (ED) symptoms were tested in subgroups of inpatients with anorexia nervosa (AN) and bulimia nervosa (BN).

Methods: Inpatients (N = 1167) receiving disorder-specific treatment for disorders classified in the ICD-10 in F3, F4, or F5 completed the Düsseldorf Orthorexia Scale (DOS) at admission and a subset (N = 647) at discharge. ED patients completed the Eating Disorder Inventory-2 and their body weight and height was measured.

Results: Prevalence of ON was higher in ED patients than in all other groups, in which prevalence rates were similar to findings from the general population. Across ED groups, DOS scores decreased from admission to discharge, while there was no change in the other groups. In patients with BN, higher DOS scores related to lower BMI and predicted larger decreases in body dissatisfaction. Across ED groups, higher DOS scores related to higher body dissatisfaction and drive for thinness and predicted larger decreases in drive for thinness.

Conclusion: Our results highlight that ON is part of the ED spectrum. Associations with core ED symptoms question the suggested exclusive health focus on eating in ON and its potential as a distinct diagnosis. Rather, ON may represent a phenomenological subtype of restrictive EDs.
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http://dx.doi.org/10.1016/j.jpsychores.2020.110317DOI Listing
January 2021

Using bodily postures in the treatment of anorexia nervosa: Effects of power posing on interoception and affective states.

Eur Eat Disord Rev 2021 Mar 30;29(2):216-231. Epub 2020 Nov 30.

Department of Clinical and Health Psychology, Ulm University, Ulm, Germany.

Objective: Power posing involves the adoption of an expansive bodily posture. This study examined whether power posing could benefit individuals with anorexia nervosa (AN) and women with normal weight in regards to interoceptive ability and affective states.

Method: Participants included 50 inpatients and outpatients with AN as well as 51 normal-weight women. Interoceptive accuracy (IAcc), measured by the heartbeat tracking task and interoceptive sensibility (IS), measured by confidence ratings, were assessed at baseline, after a single power posing session and after 1 week of daily training. Also, the short-term effects of power posing on subjective feelings of dominance, pleasantness, and arousal were investigated.

Results: Both groups increased in their IAcc after one power posing session. Also, there was a significant main effect of time on feelings of dominance and pleasantness in the short-term. Women with AN displayed lower levels of IS, dominance, and pleasantness as well as higher levels of arousal than women without AN.

Discussion: These findings suggest that power posing has the potential to increase IAcc, subjective feelings of power and pleasant affect in the short-term. Further research should investigate which mechanisms foster the effectiveness of this intervention to tailor it to the needs of women with AN.
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http://dx.doi.org/10.1002/erv.2813DOI Listing
March 2021

Inpatient treatment of anorexia nervosa in adolescents: A 1-year follow-up study.

Eur Eat Disord Rev 2021 Mar 24;29(2):165-177. Epub 2020 Nov 24.

Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.

Objective: Inpatient treatment effectively increases body weight and decreases eating disorder symptoms in adolescents with anorexia nervosa (AN). However, there is a high risk of relapse within the first year after discharge, which calls for investigating long-term treatment success and its moderators.

Method: Female adolescent inpatients with AN (N = 142) were assessed, of which 85% participated at 1-year follow-up. Dependent variables were body mass index percentiles, eating disorder symptoms, depressive symptoms, compulsive exercise and life satisfaction.

Results: On average, body weight increased and eating disorder symptoms and depressive symptoms decreased from admission to discharge and remained stable at follow-up. Compulsive exercise decreased and life satisfaction increased from admission to discharge and even improved further at follow-up. Age, duration of illness, previous inpatient treatments, length of stay and readmission after discharge moderated changes in several outcome variables.

Conclusions: This study confirms the high effectiveness of inpatient treatment for adolescents with AN and demonstrates that treatment effects remain stable or even improve further within the first year after discharge. However, subgroups of patients (e.g., those with an older age, longer duration of illness, and previous inpatient treatments) require special attention during inpatient treatment and aftercare to prevent relapse.
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http://dx.doi.org/10.1002/erv.2808DOI Listing
March 2021

Obsessive-compulsive disorder during COVID-19: Turning a problem into an opportunity?

J Anxiety Disord 2021 01 5;77:102329. Epub 2020 Nov 5.

Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany; Schoen Clinic Roseneck, Prien am Chiemsee, Germany; Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Germany.

The COVID-19 pandemic has prompted global measures to prevent infection. Experts assume that it is particularly affecting people with obsessive-compulsive disorder (OCD), especially those with washing compulsions. Data, however, are currently lacking. 394 participants with OCD (n = 223 washers) participated in an online survey. Change in severity of OCD symptoms, reasons participants reported for the change (e.g., reduced mobility, reduced availability of cleaning products, economic factors, interpersonal conflicts), as well as participants' beliefs and experience associated with COVID-19 were assessed. 72 % of the participants reported an increase in OCD. This increase was significantly stronger in washers compared to non-washers. The worsening of symptoms was primarily associated with reduced mobility and interpersonal conflicts. Dysfunctional hygiene-related beliefs were significantly higher in washers than non-washers and were associated with greater symptom progression. Washers were more confident than non-washers about providing other people with helpful advice related to infection preventions. Washers, however, received more negative feedback from others in response to the advice they provided than non-washers. The majority of participants with OCD were negatively affected by the COVID-19 pandemic, and the negative effects were more pronounced in washers than in non-washers. Rapid interventions for OCD should be implemented to prevent long-term deterioration.
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http://dx.doi.org/10.1016/j.janxdis.2020.102329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644184PMC
January 2021

Practice-Based Evidence and Clinical Guidance to Support Accelerated Re-Nutrition of Patients With Anorexia Nervosa.

J Am Acad Child Adolesc Psychiatry 2021 05 27;60(5):555-561. Epub 2020 Sep 27.

Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Zucker School of Medicine at Hofstra/Northwell, Hempstead and The Zucker Hillside Hospital, New York. Electronic address:

Anorexia nervosa (AN) is characterized by underweight, and the primary goal of treatment is weight restoration. Treatment approaches (ie, hospitalization for weight recovery vs for medical stabilization) and settings (ie, medical/pediatric or psychiatric units) for patients with AN vary between and also within countries. Several specialized eating disorder units worldwide have established high-caloric refeeding (HCR) protocols for patients with AN. In observational studies, HCR shortens hospital stays and increases initial weight gain, the latter being associated with a favorable long-term prognosis. However, clinicians may still remain reluctant to accept this approach for fear of medical complications of HCR, including the risk of refeeding syndrome (RS). Research is building toward the development of evidence-based recommendations for safe and effective re-nutrition of underweight patients with AN. This focused review was based on clinical experience and describes 3 different protocols for nutritional management devised by experts from 3 different parts of the world (Australia, Germany, and the United States), in medical refeeding of patients with AN who have established HCR in their clinical units. In addition, and in order to understand energy requirements, empirical data on energy turnover of patients with AN from former metabolic studies are presented. To the best of our knowledge, there is no study reporting on HCR in a cohort of severely malnourished adolescents with AN (ie, with a mean body mass index [BMI] of <15 kg/m). Therefore, to provide information about the treatment of extremely malnourished patients with AN, we included a recently published HCR protocol for adults with a BMI of <13 kg/m..
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http://dx.doi.org/10.1016/j.jaac.2020.09.010DOI Listing
May 2021

Medical management of eating disorders: an update.

Curr Opin Psychiatry 2020 11;33(6):542-553

Schoen Clinic Roseneck, Prien.

Purpose Of Review: Eating disorders are associated with numerous medical complications. The aim of this study was to review recent progress in improving the medical management of patients with eating disorders.

Recent Findings: With close medical monitoring and electrolyte supplementation, accelerated refeeding protocols improve weight restoration without increasing the risk of refeeding syndrome. Olanzapine improves weight restoration better than placebo, without leading to adverse metabolic effects seen in individuals not in starvation. Alterations of the gut microbiome in anorexia nervosa have been demonstrated, but their clinical relevance remains unclear.

Summary: Medical complications of eating disorders may facilitate the first contact with health professionals and treatment initiation. Medical complications of anorexia nervosa generally occur due to starvation, malnutrition and their associated physiological effects, whereas medical complications of bulimia nervosa are generally due to purging behaviors. Most medical complications in patients with binge eating disorder are secondary to obesity. Most medical complications of eating disorders can be effectively treated with nutritional management, weight normalization and the termination of purging behaviors. In summary, eating disorders are associated with many medical complications that have to be carefully assessed and managed as early as possible to improve long-term outcomes.
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http://dx.doi.org/10.1097/YCO.0000000000000653DOI Listing
November 2020

Altered Interoceptive Awareness in High Habitual Symptom Reporters and Patients With Somatoform Disorders.

Front Psychol 2020 7;11:1859. Epub 2020 Aug 7.

Clinical Psychophysiology Laboratory, Institute for Health and Behaviour, University of Luxembourg, Esch-sur-Alzette, Luxembourg.

Altered interoception may play a major role in the etiology of medically unexplained symptoms (MUS). It remains unclear, however, if these alterations concern noticing of signals or if they are limited to the interpretation of signals. We investigated whether individuals with MUS differ in interoceptive awareness as assessed with the Multidimensional Assessment of Interoceptive Awareness (MAIA) questionnaire. Study 1: A total of 486 individuals completed the Screening for Somatoform Disorders (SOMS-2). Thirty-two individuals each of the upper and lower decile of the SOMS distribution (low symptom reporters/LSR, high symptom reporters/HSR) completed the MAIA. Study 2: MAIA scores of individuals diagnosed with somatoform disorder (SFD; = 26) were compared to individuals with major depressive disorder (MDD; = 25) and healthy controls (HC; = 26). HSR had lower scores than LSR on the MAIA scales Not-Distracting and Not-Worrying. The SFD and MDD groups showed lower scores than HC on the MAIA scales Not-Distracting, Self-Regulation, and Trusting. The MDD group scored lower than the other two groups on the scales Body Listening and Attention Regulation. There were no group differences on the scale Noticing. HSR, SFD, and MDD patients do not differ from HC in the awareness of noticing of interoceptive signal processing, whereas cognitive facets of interoception, such as distraction or self-regulation are differentially affected. This highlights the necessity of including specifically targeted interventions, which improve interoceptive awareness, in the prevention and treatment of SFDs.
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http://dx.doi.org/10.3389/fpsyg.2020.01859DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426478PMC
August 2020

Eating disorders in times of the COVID-19 pandemic-Results from an online survey of patients with anorexia nervosa.

Int J Eat Disord 2020 11 25;53(11):1791-1800. Epub 2020 Aug 25.

Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians-University, Munich, Germany.

Objective: The COVID-19 pandemic and the resulting public restrictions pose a psychological burden for humans worldwide and may be particularly detrimental for individuals with mental disorders. Therefore, the current study explored effects of the COVID-19 pandemic on eating disorder (ED) symptoms and other psychological aspects in former inpatients with anorexia nervosa (AN).

Method: One-hundred and fifty-nine patients with AN-discharged from inpatient treatment in 2019-completed an online survey on contact history with COVID-19, changes in ED symptoms and other psychological aspects, health care utilization, and strategies patients employed to cope during the pandemic.

Results: Approximately 70% of patients reported that eating, shape and weight concerns, drive for physical activity, loneliness, sadness, and inner restlessness increased during the pandemic. Access to in-person psychotherapies and visits at the general practitioner (including weight checks) decreased by 37% and 46%, respectively. Videoconference therapy was used by 26% and telephone contacts by 35% of patients. Patients experienced daily routines, day planning and enjoyable activities as the most helpful among the most used coping strategies.

Discussion: The COVID-19 pandemic poses great challenges to patients with AN. ED-related thoughts and behaviors may be used as dysfunctional coping mechanisms to regain control over the current circumstances. E-mental health interventions appear to be promising for supporting AN patients during these hard times. Furthermore, interventions addressing symptoms of depression and anxiety, as well as intolerance of uncertainty might help them manage their ED symptoms.
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http://dx.doi.org/10.1002/eat.23374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461418PMC
November 2020

Long-Term Follow-up of Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: Symptom Severity and the Role of Exposure 8-10 Years After Inpatient Treatment.

J Cogn Psychother 2020 08 26;34(3):261-271. Epub 2020 Jun 26.

Schoen Clinic Roseneck, Prien, Germany.

Obsessive-compulsive disorder (OCD) can be effectively treated by cognitive behavioral therapy (CBT) with exposure and response prevention (ERP). Yet, little is known about the long-term effects of inpatient CBT up to one decade after treatment. Thirty patients who had been treated with 12 weeks of intensive inpatient CBT with ERP were examined 8-10 years after their stay in hospital with regard to obsessive-compulsive symptoms, secondary outcomes, and use of healthcare services. Significant ( < .001) improvements in OC symptoms with medium and large effects compared to baseline on the Yale-Brown-Obsessive-Compulsive Scale (Y-BOCS) and on the Obsessive-Compulsive Inventory (OCI-R) could still be observed, with 20% of the patients reaching remission status. Continuation of exposure exercises after the inpatient stay was the sole significant factor for improved scores at follow-up. The results suggest that OCD does not necessarily take a chronic course. However, maintenance of exposure training seems to be crucial for sustained improvement.
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http://dx.doi.org/10.1891/JCPSY-D-20-00002DOI Listing
August 2020

Frequency and level of self-efficacy predict the effectiveness of therapist- and self-guided exposure in obsessive compulsive disorder.

Behav Cogn Psychother 2020 Nov 20;48(6):751-755. Epub 2020 Aug 20.

Schön Clinic Roseneck, Am Roseneck 6, 83209Prien am Chiemsee, Germany.

Background: While exposure and response prevention (ERP) is the most effective treatment for obsessive compulsive disorder (OCD), less is known about the specific mechanisms underlying symptom change after ERP.

Aims: We tested the hypothesis that the frequency of self- and therapist-guided ERP related to the extent of symptom reduction and that this link is mediated by increased self-efficacy.

Method: In a sample of 377 in-patients with a primary diagnosis of OCD receiving in-patient CBT, we assessed symptoms (YBOCS-SR) and self-efficacy (General Self-Efficacy Scale), before and after treatment, as well as the frequency of therapist- and self-guided ERP sessions.

Results: Patients with more therapist-guided ERP sessions during treatment showed more symptom reduction and the association of self-guided ERP on outcome was mediated by enhanced self-efficacy.

Conclusions: These findings highlight the importance of both therapist- and self-guided ERP sessions and suggest that therapists should conduct a sufficient number of ERP sessions to optimise treatment.
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http://dx.doi.org/10.1017/S1352465820000582DOI Listing
November 2020

Drawing the borderline: Predicting treatment outcomes in patients with borderline personality disorder.

Behav Res Ther 2020 Jul 17;133:103692. Epub 2020 Jul 17.

Philipps-University of Marburg, Department of Clinical Psychology and Psychotherapy, Gutenbergstraße 18, D-35032, Marburg, Germany.

Background: A routinely collected big data set was analyzed to determine the effectiveness of naturalistic inpatient treatment and to identify predictors of treatment outcome and discontinuation.

Methods: The sample included 878 patients with borderline personality disorder who received non-manualized dialectic behavioral therapy in a psychosomatic clinic. Effect sizes (Hedge's g) were calculated to determine effectiveness. A bootstrap-enhanced regularized regression with 91 potential predictors was used to identify stable predictors of residualized symptom- and functional change and treatment discontinuation. Results were validated in a holdout sample and repeated cross validation.

Results: Effect sizes were small to medium (g = 0.28-0.51). Positive symptom-related outcome was predicted by low affect regulation skills and no previous outpatient psychotherapy. Lower age, absence of work disability, high emotional and physical role limitations and low bodily pain were associated with greater improvement in functional outcome. Higher education and comorbid recurrent depressive disorder were the main predictors of treatment completion. The predictive quality of the models varied, with the best being found for symptom-related outcome (R = 18%).

Conclusion: While the exploratory process of variable selection replicates previous findings, the validation results suggest that tailoring treatment to the individual patient might not be based solely on sociodemographic, clinical and psychological baseline data.
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http://dx.doi.org/10.1016/j.brat.2020.103692DOI Listing
July 2020

Mortality in males as compared to females treated for an eating disorder: a large prospective controlled study.

Eat Weight Disord 2021 Jun 13;26(5):1627-1637. Epub 2020 Aug 13.

Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University (LMU), Nussbaumstraße 7, 80336, Munich, Germany.

Purpose: To report on the mortality of DSM-IV eating disorders and predictors of premature death in males compared to females after inpatient treatment.

Methods: Crude mortality rate (CMR) and standardized mortality ratio (SMR) were computed for a large sample of males aged at treatment 16-61 years [N = 66 anorexia nervosa (AN), 52 bulimia nervosa (BN), 70 eating disorder not otherwise specified (ED-NOS)] and females aged 14-65 years (N = 2066 AN, 1880 BN, 1350 ED-NOS). In addition, a survival analysis and Cox regression analyses for identifying predictors of death were computed.

Results: CMRs for males and females, respectively, were 15% and 5% in AN, 8% and 3% in BN, and 4% and 3% in ED-NOS. Compared to the general population, mortality was elevated in males with AN (SMR = 4.93) and in all female diagnostic groups (AN, BN, ED-NOS). No significant sex differences for SMR emerged in any diagnostic group. Compared to females with AN or BN, males with AN or BN showed a shorter survival time after onset (survival analysis). Being male, and having AN, increased the risk of premature death.

Conclusion: Mortality in inpatients with eating disorder is high, especially in AN. Males appear to have about the same outcome in terms of mortality as females with AN, BN, and ED-NOS. However, long-term survival was shorter in males with AN or BN compared to females. The need for intensive treatment in both males and females with an eating disorder remains an important issue.

Level Of Evidence: Level III, case-control analytic study.
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http://dx.doi.org/10.1007/s40519-020-00960-1DOI Listing
June 2021

Bulimia nervosa in times of the COVID-19 pandemic-Results from an online survey of former inpatients.

Eur Eat Disord Rev 2020 11 7;28(6):847-854. Epub 2020 Aug 7.

Department of Psychiatry and Psychotherapy, University Hospital (LMU), Munich, Germany.

Objective: The COVID-19 pandemic might pose special challenges to patients with eating disorders (EDs) by interfering with daily routines. The aim of this study was to investigate the impact of the current pandemic on patients with bulimia nervosa (BN).

Methods: Fifty-five former inpatients with BN completed an online survey on psychological consequences of the COVID-19 pandemic as well as on changes in health care utilisation and on the use and helpfulness of different coping strategies.

Results: Almost half of patients (49%) reported a deterioration of their ED symptomatology and 62% reported a reduced quality of life. The frequency of binge eating increased in 47% of patients and self-induced vomiting in 36%. Forty-six percent of patients stated a noticeable impairment of psychotherapy. Face-to-face psychotherapy decreased by 56% but videoconferencing therapy was only used by 22% of patients. Enjoyable activities, virtual social contacts with friends and mild physical activities were rated as the most helpful coping strategies among those most used.

Discussion: Approximately one half to two-thirds of former inpatients with BN experienced a negative impact of the crisis on their ED symptomatology and quality of life. In challenging times when face-to-face therapy options are restricted, e-health treatments such as videoconferencing therapy should be considered to ensure continuity of care.
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http://dx.doi.org/10.1002/erv.2773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436773PMC
November 2020

Predictors of outcome during inpatient psychotherapy for posttraumatic stress disorder: a single-treatment, multi-site, practice-based study.

Psychother Res 2021 04 7;31(4):468-482. Epub 2020 Aug 7.

Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Marburg, Germany.

The aims of this study were to determine the effectiveness of a routine clinical care treatment and to identify predictors of treatment outcome in PTSD inpatients. A routinely collected data set of 612 PTSD inpatients ( 42.3 years [ 11.6], 75.7% female) having received trauma-focused psychotherapy was analyzed. Primary outcome was the clinical symptom severity change score, secondary outcomes were assessed using functional, anxiety, and depression change scores. Hedges g-corrected pre-post effect sizes (ES) were computed for all outcomes. Elastic net regulation as a data-driven, stability-based machine-learning approach was used to build stable clinical prediction models. Hedges g ES indicated medium to large effects on all outcomes. The results of the predictor analyses suggested that a combined predictor model with sociodemographic, clinical, and psychometric variables contribute to predicting different treatment outcomes. Across the clinical and functional outcome, psychoticism, total number of diagnoses, and bronchial asthma consistently showed a stable negative predictive relationship to treatment outcome. Trauma-focused psychotherapy could effectively be implemented in a routine inpatient setting. Some important prognostic variables could be identified. If the proposed models of predictors are replicated, they may help personalize treatment for patients receiving routine clinical care.
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http://dx.doi.org/10.1080/10503307.2020.1802081DOI Listing
April 2021

The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis.

J Consult Clin Psychol 2020 Sep;88(9):829-843

Gordon F. Derner School of Psychology.

Objective: Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions 1 to 7.

Method: We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies.

Results: In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session.

Conclusion: The findings provide empirical evidence that in the early phase of therapy, symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000594DOI Listing
September 2020

Therapist-guided smartphone-based aftercare for inpatients with severe anorexia nervosa (SMART-AN): Study protocol of a randomized controlled trial.

Int J Eat Disord 2020 10 31;53(10):1739-1745. Epub 2020 Jul 31.

Department of Psychiatry and Psychotherapy, University Hospital of Munich (LMU), Munich, Germany.

Objective: Inpatient treatment for patients with anorexia nervosa (AN) is recommended in extreme or severe cases after failure of outpatient treatment and is highly effective. However, a number of patients show symptom increase and relapse after discharge. The aim of this study is to evaluate the efficacy of a therapist-guided smartphone-based aftercare intervention for inpatients with AN to support symptom stabilization.

Method: A total of 186 female patients with a DSM-5 diagnosis of AN (307.1) will be randomized either to receive a 16-week smartphone-based aftercare intervention with therapist feedback as add-on to treatment as usual (TAU) or TAU alone. Data will be assessed at discharge (= baseline, T0), after 16 weeks (= end of the aftercare intervention, T1) and after 10 months (= 6-month follow-up, T2). Primary outcome will be overall eating disorder symptomatology (Eating Disorder Examination Global score). Secondary outcome measures will include body mass index, depression, motivation to change, self-efficacy, patient satisfaction with and adherence to the smartphone-based aftercare intervention as well as rehospitalization rate.

Discussion: This study will be the first randomized controlled trial to examine a therapist-guided smartphone-based aftercare intervention for inpatients with AN. Results may reveal whether and to which extent this novel intervention can support symptom stabilization after inpatient treatment.
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http://dx.doi.org/10.1002/eat.23357DOI Listing
October 2020

Orthorexic tendencies in the general population: association with demographic data, psychiatric symptoms, and utilization of mental health services.

Eat Weight Disord 2021 Jun 29;26(5):1511-1519. Epub 2020 Jul 29.

Schoen Clinic Roseneck, Am Roseneck 6, 83209, Prien Am Chiemsee, Germany.

Purpose: Orthorexia nervosa (ON) is characterized by a preoccupation to eat healthily and restrictive eating habits despite negative psychosocial and physical consequences. As a relatively new construct, its prevalence and correlates in the general population and the associated utilization of mental health services are unclear.

Methods: Adults from the general population completed the Düsseldorf Orthorexia Scale (DOS), the Patient Health Questionnaire (PHQ), the Short Eating Disorder Examination (SEED).

Results: Five-hundred eleven (63.4% female) participants with a mean age of 43.39 (SD = 18.06) completed the questionnaires. The prevalence of ON according to the DOS was 2.3%. Considering only effects of at least intermediate size, independent samples t-tests suggested higher DOS scores for persons with bulimia nervosa (p < .001, Cohen's d = 1.14), somatoform syndrome (p = .012, d = .60), and major depressive syndrome (compared p < .001, d = 1.78) according to PHQ as well as those who reported to always experience fear of gaining weight (p < .001, d = 1.78). The DOS score correlated moderately strong and positively with the PHQ depression (r = .37, p < .001) and stress (r = .33, p < .001) scores as well as the SEED bulimia score (r = .32, p < .001). In multivariate logistic regression analyses, only PHQ depression scores were associated with past psychotherapeutic or psychiatric treatment (OR = 1.20, p = .002) and intake of psychotropic medication in the last year (OR = 1.22, p = .013).

Conclusions: The prevalence of ON was low compared to international studies but is in line with other non-representative German studies. Orthorexic tendencies related to general mental distress and eating disorder symptoms but were no independent reason for seeking treatment.

Level Of Evidence: Level V, cross-sectional descriptive study.
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http://dx.doi.org/10.1007/s40519-020-00961-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8128806PMC
June 2021
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