Hintergrund. Für die durch wiederkehrende Essanfälle gekennzeichnete Binge Eating-Störung (BES) wurde die Kognitive Verhaltenstherapie (KVT) als Behandlungsmethode der Wahl etabliert. Zum Psychotherapieprozess, welcher das Therapieergebnis beeinflusst, ist jedoch wenig bekannt. Fragestellung. Da Untersuchungen zum Prozessaspekt der therapeutischen Adhärenz Unterschiede zwischen Patienten eines Therapeuten sowie zwischen verschiedenen Therapeuten belegen, soll der Einfluss von Patienten- und Therapeutenmerkmalen auf die therapeutische Adhärenz geprüft werden. Methode. In einer prospektiven, multizentrischen, randomisiert-kontrollierten Behandlungsstudie zum Wirksamkeitsvergleich von KVT und Internet-basierter angeleiteter Selbsthilfe (INTERBED) wurde die therapeutische Adhärenz in der KVT durch unabhängige Rater erfasst. Patienten- und Therapeutenmerkmale wurden mittels Interview und Selbstbericht erhoben. Ergebnisse. Soziodemografische Merkmale wie ein geringeres Bildungsniveau der Patienten und weibliches Geschlecht der Therapeuten wurden als signifikante Prädiktoren einer höheren therapeutischen Adhärenz identifiziert. Störungsspezifische Merkmale der Patienten waren nicht mit der therapeutischen Adhärenz assoziiert. Therapeutenmerkmale wie ein geringerer Ausbildungsgrad, eine geringere erlebte therapeutische Kompetenz und höhere Erwartungen sowie ein höheres emotionales Wohlbefinden der Therapeuten sagten eine höhere therapeutische Adhärenz vorher. Diskussion. Die etablierte hohe therapeutische Adhärenz erschien unabhängig vom Patienten, während einige Therapeutenmerkmale als Prädiktoren identifiziert wurden. Ungünstige Einflüsse auf die therapeutische Adhärenz bedürfen weiterer Erforschung und einer stärkeren Berücksichtigung in der Ausbildung von Therapeuten. / Background. Cognitive-behavioral therapy (CBT) has been established as the treatment of choice for binge-eating disorder (BED) which is characterized by recurrent binge eating episodes. However, only little is known about the impact of the psychotherapeutic process on treatment outcomes. Objectives. While studies concerning the process aspect of therapist adherence found differences between patients from one therapist as well as differences between therapists, the impact of patient and therapist characteristics on therapist adherence will be investigated. Methods. In a prospective multicenter randomized-controlled trial comparing CBT to Internet-based guided self-help (INTERBED), the therapist adherence to CBT was determined by independent raters. Patient and therapist characteristics were obtained via interview and self-report questionnaires. Results. Sociodemographic characteristics including lower education in patients and female sex in therapists were identified as predictors of higher therapist adherence. Disorder-specific characteristics of patients were not associated with the therapist adherence. Therapist characteristics including less postgraduate therapist training, lower self-rated therapeutic competence, and higher expectations as well as higher emotional well-being of therapists predicted higher therapist adherence. Conclusions. The high level of therapist adherence was mostly independent from patients, while some therapist characteristics were identified as predictors. Adverse impacts on therapist adherence should be investigated further and might be considered in therapeutic training.

Objective: Loss of control (LOC) eating is a salient indicator of eating disorder psychopathology in adolescents and is associated with marked distress. While research has focused on the relevance of episode size, clinical significance of LOC eating frequency has rarely been explored. Therefore, this study aimed at identifying LOC eating prevalence with respect to its recurrence and associated variables in a community-based sample. Method: Participants were 1643 adolescents, aged 12-20 years (62.4% female). Based on EDE-Q self-report, participants were categorized as those reporting recurrent (N = 156; 9.5%), non-recurrent (N = 226; 13.8%) and no LOC eating (N = 1261; 76.7%). Results: Adolescents with recurrent LOC eating reported clinically relevant and significantly greater eating disorder psychopathology, functional impairment and distress because of LOC eating, and a significantly higher body mass index (BMI, kg/m2) than adolescents with non-recurrent and those without LOC eating. Discussion: These results underline that LOC eating is a common eating behavior among adolescents in the community associated with clinical characteristics of eating disorders, and could therefore be a risk factor for developing full- or partial-syndrome eating disorders. Further research on the classification of eating disorders in adolescents with LOC eating and severity indicators is warranted.

Essstörungen sind prävalente psychische Störungen mit schwerwiegenden, oftmals langfristigen Auswirkungen auf die psychische und körperliche Gesundheit. Eine zunehmende Anzahl von klinischen Studien dokumentiert die Wirksamkeit verschiedener psychotherapeutischer Ansätze für spezifische Essstörungen. Im vorliegenden Themenheft 5 werden die Wirksamkeit von neuen Ansätzen zur Einzeltherapie und zur internet-basierten Rückfallprophylaxe, die Patientensicht auf die Therapie sowie die Relevanz von Faktoren des therapeutischen Prozesses bei verschiedenen Essstörungen beleuchtet. Weiterer Forschungsbedarf besteht insbesondere hinsichtlich des Prozesses und der Dissemination evidenzbasierter Psychotherapie für Essstörungen. / Eating disorders are prevalent psychiatric disorders with severe and longstanding 15 implications for mental and physical health. An increasing number of clinical studies documents the efficacy of certain psychotherapeutic approaches for specific eating disorders. This special issue addresses the efficacy of novel approaches in face-to-face individual therapy and Internet-based relapse prevention, patient views of treatment, and the relevance of therapeutic process factors for diverse eating disorders. Further research is particularly 20 warranted regarding the process and dissemination of evidence-based psychotherapy for eating disorders.

Objective: For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled. Method: Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified. Results: Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated. Discussion: As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

While cognitive-behavioral therapy (CBT) is the most well-established treatment for binge-eating disorder (BED), little is known about process factors influencing its outcome. The present study sought to explore the assessment of therapist adherence, its course over treatment, and its associations with patient and therapist characteristics, and the therapeutic alliance. In a prospective multicenter randomized-controlled trial comparing CBT to internet-based guided self-help (INTERBED-study), therapist adherence using the newly developed Adherence Control Form (ACF) was determined by trained raters in randomly selected 418 audio-taped CBT sessions of 89 patients (25% of all sessions). Observer-rated therapeutic alliance, interview-based and self-reported patient and therapist characteristics were assessed. Three-level multilevel modeling was applied. The ACF showed adequate psychometric properties. Therapist adherence was excellent. While significant between-therapist variability in therapist adherence was found, within-therapist variability was non-significant. Patient and therapist characteristics did not predict the therapist adherence. The therapist adherence positively predicted the therapeutic alliance. The ACF demonstrated its utility to assess therapist adherence in CBT for BED. The excellent levels of therapist adherence point to the internal validity of the CBT within the INTERBED-study serving as a prerequisite for empirical comparisons between treatments. Variability between therapists should be addressed in therapist trainings and dissemination trials.

Orientador: Wilza Carla Spiri / Resumo: Introdução: A prevalência da obesidade vem aumentando entre adultos em todo o mundo e está associada com aumento do risco de morbimortalidade, bem como redução da expectativa de vida com resultados negativos de saúde. Também associa-se a outras patologias como transtorno de ansiedade, comportamento compulsivo e desequilíbrio no comportamento do sono. Apesar da obesidade ser considerada uma patologia previnível, ainda existem grandes dificuldades associadas com a perda de peso e a sua manutenção através da modificação do estilo de vida no cenário atual, mostrando a necessidade de investigação de fatores que abordem não só o peso, mas também patologias e/ou sintomas associados. A terapia floral faz parte de um campo emergente de terapias vibracionais, e suas essências, feitas a partir de plantas silvestres, flores e árvores do campo, atuam harmonizando as emoções, e não tratando de condições físicas. Neste contexto, aparece como uma alternativa para o alivio do comportamento ansioso dos indivíduos, pois não há incompatibilidade com outros métodos de tratamento, e pode ser indicada a um grande número de pessoas em qualquer etapa da vida. Objetivo: Identificar se o tratamento com terapia floral altera o grau de ansiedade de indivíduos com sobrepeso ou obesidade, com consequente melhora no padrão de sono, redução nos sintomas de compulsão alimentar, redução na frequência cardíaca de repouso e melhora nos níveis de pressão arterial. Métodos: Ensaio Clínico Randomizado, paralelo, co... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: The prevalence of obesity is increasing among adults worldwide and is associated with an increased risk of morbidity and mortality, as well as a reduction in life expectancy with negative health outcomes. It is also associated with other pathologies such as anxiety disorder, compulsive behavior and imbalance in sleep behavior. Although obesity is considered a predictable pathology, there are still great difficulties associated with weight loss and its maintenance by modifying lifestyle in the current scenario, showing the need to investigate factors that address not only weight but also pathologies and / or associated symptoms. Floral therapy is part of an emerging field of vibrational therapies, and its essences, made from wild plants, flowers and field trees, work by harmonizing emotions, not by treating physical conditions. In this context, it appears as an alternative for the relief of the anxious behavior of individuals, as there is no incompatibility with other treatment methods, and can be indicated to a large number of people at any stage of life. Objective: To identify whether treatment with floral therapy changes the degree of anxiety of overweight or obese individuals, with consequent improvement in sleep pattern, reduction in binge eating symptoms, reduction in resting heart rate and improvement in blood pressure levels. Methods: Randomized, parallel, two-arm, double-blind, placebo-controlled, four-week clinical trial conducted at a public stitution ... (Complete abstract click electronic access below) / Doutor

Submitted by Suzimar de Fatima Benato Fusco (sbenato@gmail.com) on 2018-04-25T18:24:53Z No. of bitstreams: 1 tese_suzimar_fusco_2018.pdf: 3080060 bytes, checksum: 4575e04721f212bd817687282caf1fc2 (MD5) / Approved for entry into archive by ROSANGELA APARECIDA LOBO null (rosangelalobo@btu.unesp.br) on 2018-04-26T18:56:10Z (GMT) No. of bitstreams: 1 fusco_sfb_dr_bot.pdf: 3080060 bytes, checksum: 4575e04721f212bd817687282caf1fc2 (MD5) / Made available in DSpace on 2018-04-26T18:56:10Z (GMT). No. of bitstreams: 1 fusco_sfb_dr_bot.pdf: 3080060 bytes, checksum: 4575e04721f212bd817687282caf1fc2 (MD5) Previous issue date: 2018-02-28 / Introdução: A prevalência da obesidade vem aumentando entre adultos em todo o mundo e está associada com aumento do risco de morbimortalidade, bem como redução da expectativa de vida com resultados negativos de saúde. Também associa-se a outras patologias como transtorno de ansiedade, comportamento compulsivo e desequilíbrio no comportamento do sono. Apesar da obesidade ser considerada uma patologia previnível, ainda existem grandes dificuldades associadas com a perda de peso e a sua manutenção através da modificação do estilo de vida no cenário atual, mostrando a necessidade de investigação de fatores que abordem não só o peso, mas também patologias e/ou sintomas associados. A terapia floral faz parte de um campo emergente de terapias vibracionais, e suas essências, feitas a partir de plantas silvestres, flores e árvores do campo, atuam harmonizando as emoções, e não tratando de condições físicas. Neste contexto, aparece como uma alternativa para o alivio do comportamento ansioso dos indivíduos, pois não há incompatibilidade com outros métodos de tratamento, e pode ser indicada a um grande número de pessoas em qualquer etapa da vida. Objetivo: Identificar se o tratamento com terapia floral altera o grau de ansiedade de indivíduos com sobrepeso ou obesidade, com consequente melhora no padrão de sono, redução nos sintomas de compulsão alimentar, redução na frequência cardíaca de repouso e melhora nos níveis de pressão arterial. Métodos: Ensaio Clínico Randomizado, paralelo, com dois braços, duplo cego, placebo-controlado, de quatro semanas, realizado em uma instituição pública do estado de São Paulo - Brasil. Os participantes foram indivíduos sadios de ambos os sexos, com idade de 20 a 59 anos, alfabetizados, com sobrepeso ou obesidade pelos critérios da Organização Mundial da Saúde (IMC ≥ 25 Kg/m2) e com ansiedade moderada ou elevada pelos critérios do Inventário de Ansiedade-Estado (IDATE com Escore ˃ 34). Para a coleta de dados utilizou-se questionário sócio-demográfico e clínico, escala de ansiedade IDATE-ESTADO, Escala de Compulsão Alimentar Periódica (ECAP) e Questionário de Padrão do Sono de Pittsburg (PSQI), aferição da pressão arterial e eletrocardiograma, no momento inicial e após 4 semanas de tratamento. A análise estatística foi realizada calculando o delta para expressar a diferença das médias das medidas de desfecho entre os momentos de avaliação dentro de cada grupo estudado. Em seguida, utilizou-se o Teste de Mann-Whittney para a comparação entre grupos. Análise multivariada foi realizada utilizando modelos de regressão linear robusta simples e múltipla. Resultados: A coleta de dados ocorreu entre setembro de 2015 e janeiro de 2017 e a amostra foi constituída por 40 participantes no grupo placebo e 41 no grupo floral, principalmente pelo sexo feminino (92,5% e 90,2%), com idade média de 42,9 e 38,5 anos e IMC médio de 34,31 e 33,5 kg/m2 nos grupos placebo e floral respectivamente. A análise multivariada mostrou redução estatisticamente significante no grupo floral quando comparado ao grupo Placebo nas seguintes variáveis: IDATE (β=-0,190; p<0,001), PSQI (β=-0,160; p=0,027), ECAP (β=-0,226; p=0,001) e frequência cardíaca de repouso (β=-0,07; p=0,003). Conclusão: indivíduos tratados com terapia floral apresentaram redução de sintomas ansiosos, melhora no padrão de sono, redução nos sintomas de compulsão alimentar e diminuição na frequência cardíaca de repouso maior do que aqueles tratados com placebo. Esse resultado evidencia a importância e a necessidade de ações de saúde em prol da redução da ansiedade e sintomas associados em indivíduos com sobrepeso ou obesidade e fortalece a terapia floral como prática integrativa e complementar na área da saúde. / Introduction: The prevalence of obesity is increasing among adults worldwide and is associated with an increased risk of morbidity and mortality, as well as a reduction in life expectancy with negative health outcomes. It is also associated with other pathologies such as anxiety disorder, compulsive behavior and imbalance in sleep behavior. Although obesity is considered a predictable pathology, there are still great difficulties associated with weight loss and its maintenance by modifying lifestyle in the current scenario, showing the need to investigate factors that address not only weight but also pathologies and / or associated symptoms. Floral therapy is part of an emerging field of vibrational therapies, and its essences, made from wild plants, flowers and field trees, work by harmonizing emotions, not by treating physical conditions. In this context, it appears as an alternative for the relief of the anxious behavior of individuals, as there is no incompatibility with other treatment methods, and can be indicated to a large number of people at any stage of life. Objective: To identify whether treatment with floral therapy changes the degree of anxiety of overweight or obese individuals, with consequent improvement in sleep pattern, reduction in binge eating symptoms, reduction in resting heart rate and improvement in blood pressure levels. Methods: Randomized, parallel, two-arm, double-blind, placebo-controlled, four-week clinical trial conducted at a public stitution in the state of São Paulo - Brazil. Participants were healthy individuals of both sexes, aged 20-59 years, literate, overweight or obese according to World Health Organization criteria (BMI ≥ 25 kg / m2) and with moderate or high anxiety according to the criteria of the State - Trait Anxiety Inventory (STAI) (STAI with Score ˃ 34). Data were collected using a sociodemographic and clinical questionnaire, State - Trait Anxiety Inventory (STAI), Binge-Eating Scale (BES) and Pittsburgh Sleep Quality Index (PSQI), blood pressure and electrocardiogram and after 4 weeks of treatment. Statistical analysis was performed by calculating the delta to express the difference of means of outcome measures between the moments of evaluation within each group studied. Then, the Mann-Whittney test was used for the comparison between groups. Multivariate analysis was performed using simple and multiple robust linear regression models. Results: Data collection occurred between September 2015 and January 2017, and the sample consisted of 40 participants in the placebo group and 41 in the floral group, mainly female (92.5% and 90.2%), with age mean of 42.9 and 38.5 years and mean BMI of 34.31 and 33.5 kg / m2 in the placebo and floral groups, respectively. The multivariate analysis showed a statistically significant reduction in the floral group when compared to the placebo group in the following variables: IDATE (β = -0.190, p <0.001), PSQI (β = -0.160, p = 0.004), ECAP (β = -0.226; p = 0.001) and resting heart rate (β = -0.07, p <0.001). Conclusion: Individuals treated with floral therapy had reduced anxiety symptoms, improved sleep patterns, reduced binge eating symptoms, and decreased resting heart rate greater than those treated with placebo. This result evidences the importance and necessity of health actions in favor of the reduction of anxiety and associated symptoms in overweight or obese individuals and strengthens floral therapy as an integrative and complementary practice in the health area.

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

To evaluate psychological treatments for adolescent binge-eating disorder (BED), reliable information on therapeutic process factors is needed. This study examines therapist adherence and therapeutic alliance and their associations in cognitive-behavioural therapy (CBT) for adolescents with BED. In a randomised-controlled efficacy trial, adherence and alliance were objectively determined based on 247 audio-taped CBT sessions from a sample of N = 64 adolescents with BED. Variability of adherence and alliance, explained by treatment module, patient, and therapist were examined using multilevel modeling. Although adherence and alliance were excellent and unaffected by treatment module and therapist, there was significant between-patient variability for both concepts. Adherence was negatively associated with patient's treatment expectation. Alliance was negatively associated with the number of loss of control eating episodes and positively associated with adherence. Excellent adherence supported the internal validity of CBT for adolescent BED. Associations between process factors and patient characteristics demand adequate supervision in CBT.

To provide a comprehensive meta-analysis on the efficacy of psychological and medical treatments for binge-eating disorder (BED), including those targeting weight loss. Method: Through a systematic search before March 2018, 81 published and unpublished randomized-controlled trials (RCTs), totaling 7,515 individuals with BED (Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition [DSM–IV] and Fifth Edition [DSM–5]), were retrieved and analyzed using random-effect modeling. Results: In RCTs with inactive control groups, psychotherapy, mostly consisting of cognitive-behavioral therapy, showed large-size effects for the reduction of binge-eating episodes and abstinence from binge eating, followed by structured self-help treatment with medium-to-large effects when compared with wait-list. Pharmacotherapy and pharmacological weight loss treatment mostly outperformed pill placebo conditions with small effects on binge-eating outcome. These results were confirmed for the most common treatments of cognitive-behavioral therapy, self-help treatment based on cognitive-behavioral therapy, and lisdexamfetamine. In RCTs with active control groups, there was limited evidence for the superiority of one treatment category or treatment. In a few studies, psychotherapy outperformed behavioral weight loss treatment in short- and long-term binge-eating outcome and led to lower longer-term abstinence than self-help treatment, while combined treatment revealed no additive effect on binge-eating outcome over time. Overall study quality was heterogeneous and the quality of evidence for binge-eating outcome was generally very low. Conclusions: This comprehensive meta-analysis demonstrated the efficacy of psychotherapy, structured self-help treatment, and pharmacotherapy for patients with BED. More high quality research on treatments for BED is warranted, with a focus on long-term maintenance of therapeutic gains, comparative efficacy, mechanisms through which treatments work, and complex models of care.