Background: Although there is extensive evidence for the efficacy of online eating disorder (ED) prevention programs in clinical trials, these programs have rarely been adopted beyond the trial phase and offered to a wider audience. As risk factors for eating disorders are partly associated with overweight and overweight in turn is correlated to disordered eating, this study will offer a combined eating disorder prevention program which also promotes a balanced lifestyle to normal weight and overweight individuals alike. The efficacy of the program has been proven in previous trials. The study aims to evaluate the dissemination of a combined eating disorder prevention and health promotion program (everyBody) to women of all age groups and varying levels of ED risk status in the general population. Methods: A dissemination trial will be conducted in German-speaking countries, including 4160 women from the general population. Participants will be screened to exclude participants who are likely to have an ED. Eligible participants will be allocated to one of five program arms based on their BMI and respective ED symptoms. The guided program consists of 4 to 12 weeks of weekly sessions offering CBT-based exercises, psychoeducational material, self-monitoring, and group discussions. Outcomes will be assessed according to the RE-AIM model, including measures of effectiveness, reach, adoption, implementation, and maintenance of the program. Discussion/conclusions: This trial aims to disseminate a combined ED prevention and health promotion program in the general population, offering universal, selective and indicated prevention in one program. To our knowledge, it is the first trial to systematically evaluate dissemination efforts based on the RE-AIM model. This trial will be conducted as part of the EU-funded ICare (Integrating Technology into Mental Health Care Delivery in Europe) project.

As social beings, we are constantly confronted with psychosocial stressors (e.g., social evaluation, exclusion, achievement and / or performance; Dickerson & Kemeny, 2004; Kirschbaum et al., 1993; Pruessner et al., 2003), which significantly affect the neuroendocrine (HPAA) and autonomic (ANS) function (Chrousos, 2009; Foley & Kirschbaum, 2010; Mohammadi et al., 2019). In a prolonged fashion and in the lack of habituation, chronic stress leads to cortisol hypersecretion, posing a risk for the development of Hypothalamic-PituitaryAdrenal Axis (HPAA) hyporeactivity. At the same time, this represents a vulnerability for the development of somatic and psychiatric conditions (Chrousos, 2009; McEwan, 1998, 2004; Fries, et al., 2005; Heim et al., 2000; Herman et al., 2005). In this regard, response parameters of the HPAA (e.g., cortisol) and the ANS (e.g., Heart rate variability) are paramount in studying the relationship between reactivity and health/illness (Chrousos, 2009; McEwen, 1998). For example, individuals with psychiatric conditions, such as eating disorders (EDs), exhibit hyporesponsiveness of the stress networks, which is associated with dysregulated biomarkers (Het et al., 2020; Monteleone et al., 2010; 2018a, 2018b; Støving, 2019). Among EDs, Anorexia nervosa (AN) records the highest mortality rate (Arcelus et al., 2011; Erskine et al., 2016; Moskowitz & Weiselberg, 2017) and displays a range of ANS and HPAA irregularities, e.g., bradycardia, hypercortisolemia (Gibson et al., 2020; Giovinazzo et al., 2019; Katzmann, 2005; Mazurak et al., 2011; Miller et al., 2013; Sauro et al., 2008). Maintenance of underweight and fear of weight gain despite being underweight (BMI < 17.5 kg/m2) are typical characteristics (DSM-V, APA, 2013). Treatment outcomes are poor (Harbottle et al., 2008; Murray et al., 2019; Watson & Bulik, 2013) and the disease burden for patients and health care substantial (Schmidt et al., 2016). Therefore, innovative and effective treatments are urgently needed. Concerning onset and maintenance, psychosocial stress has been frequently investigated (Caglar-Nazali et al., 2014; Monteleone et al., 2011, 2018b; Wierenga et al., 2018). Patients commonly showed deficient social skills and higher negative affect accompanied by hyporesponsiveness to psychosocial stress (Het et al., 2015, 2020; Monteleone et al., 2011; 2018b; Putigiano et al., 2001; Vocks et al., 2007; Zonevylle-Bender et al., 2015). However, experimental and controlled studies on the neuroendocrine and autonomic reactivity are underrepresented and ambiguous in PAN. Accordingly, the following investigations address this research gap. Objectives and Method: In order to expand ED-specific data and foster understanding at the psychological and physiological level, the stress response to a psychosocial stressor was investigated in a sample of patients with anorexia nervosa (PAN) which was age- and gender-matched to healthy controls (HC), under highly14 standardized conditions. For this purpose, biomarkers such as salivary cortisol (Study 1), heart rate (HR) and heart rate variability (HRV; see Study 2/Table 1) were assessed in a crosssectional study design under two experimental conditions: 1) rest and 2) stress (see Figure 1/Study 1-2). In addition, psychological stress indicators (PASA, VAS, TICS) and symptoms were analyzed (e.g., SCL-K-9, BDI, EDI). Based on previous evidence, elevated cortisol levels and bradycardia at rest were expected in PAN (vs. HC). A stress hyporeactivity in the examined biomarkers was hypothesized in PAN (vs. HC). Additionally, a reduced sympathetic (SNS) and pronounced parasympathetic (PNS) activity and reactivity was assumed in PAN (vs. HC). Furthermore, a regulation of the HPAA functionality regarding total cortisol expression (AUCG) and reactivity with weight recovery in PAN was postulated. Secondarily, BMI (kg/m2) was analyzed in relation to the derived biomarkers and psychological measures of concern.

Background: Binge-eating disorder (BED) as a distinct eating disorder category and night eating syndrome (NES) as a form of Other Specified Feeding or Eating Disorders were recently included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Objectives: This study sought to investigate the prevalence of BED and NES and associations with various forms of non-normative eating behavior and psychopathology in prebariatric patients. Setting: Within a consecutive multicenter registry study, patients in six bariatric surgery centers in Germany were recruited. Methods: Overall, 233 prebariatric patients were assessed using the Eating Disorder Examination and self-report questionnaires. Assessment was unrelated to clinical procedures. Results: Diagnostic criteria for full-syndrome BED and NES were currently met by 4.3% and 8.2% of prebariatric patients, respectively. In addition, 8.6% and 6.9% of patients met subsyndromal BED and NES criteria, respectively. Comorbid BED and NES diagnoses were present in 3.9% of patients. In comparison to patients without any eating disorder symptoms, patients with BED and NES reported greater emotional eating, eating in the absence of hunger, and more symptoms of food addiction. Moreover, differences between patients with BED and NES emerged with more objective binge eating episodes and higher levels of eating concern, weight concern, and global eating disorder psychopathology in patients with BED. Conclusions: BED and NES were shown to be prevalent among prebariatric patients, with some degree of overlap between diagnoses. Associations with non-normative eating behavior and psychopathology point to their clinical significance and discriminant validity.

Study and treatment dropout and adherence represent particular challenges in studies on Internet-based interventions. However, systematic investigations of the relationship between study, intervention and patient characteristics, participation, and intervention outcomes in online-prevention are scarce. A review of participation in trials investigating a cognitive-behavioral, Internet-based, 8-week prevention program (StudentBodies™) for eating disorders, moderators of participation, and the impact of participation on the relationship of outcome moderators and outcomes was performed. Seven US and three German studies with a total of N = 1059 female participants were included. Two of the U.S. and one of the German trials explicitly addressed high risk samples in a selective prevention approach. Across studies, dropout rates ranged from 3% to 26%. The women who participated in the trials accessed on average between 49% and 83% of the assigned intervention content. None of the study characteristics (universal vs. selective prevention, incentives, country, participants' age) predicted adherence or study dropout. After adjusting for adherence, intervention outcomes (EDI Drive for Thinness and EDI Bulimia) were only moderated by participant's age, with smaller effects in one sample of adolescent girls. Adherence to StudentBodies™ proved to be high across a number of trials, settings and countries. These findings are promising, but it is likely that adherence will be distinctly lower in the general public than in research settings, and intervention effects will turn out smaller. However, the intervention is readily available at minimal cost per participant, and the public health impact may still be notable.

This study sought to examine risk and onset patterns in anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Women with AN (n=71), BN (n=66), BED (n=160) and non-psychiatric controls (n=323) were compared retrospectively on risk factors, symptom onset, and diagnostic migration. Eating disorder groups reported greater risk exposure than non-psychiatric controls. AN and BED differed on premorbid personality/behavioral problems, childhood obesity, and family overeating. Risk factors for BN were shared with AN and BED. Dieting was the most common onset symptom in AN, whereas binge eating was most common in BN and BED. Migration between AN and BED was rare, but more frequent between AN and BN and between BN and BED. AN and BED have distinct risk factors and onset patterns, while BN shares similar risk factors and onset patterns with both AN and BED. Results should inform future classification schemes and prevention programs.

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.

Die vorliegende Arbeit entwickelt einen Vorschlag für einen neuen, kompakteren Fragebogen mit dem Akronym „BaFEK-45“ zur Diagnostik von Essstörungen, der auf einer statistischen Analyse von Daten aus fünf bereits etablierten Fragebogen (ANIS, EAT – 26, FBeK, EDI – 2, EDES) mit einer Gesamtzahl von 231 Items basiert. Dabei wurden die Antworten von Patientinnen aus den 1990er- und 2000er-Jahren der Klinik und Poliklinik für Psychiatrie, Psychotherapie und Psychosomatik des Kindes- und Jugendalters der Universität Leipzig ausgewertet. Auf Grundlage zweier „Signalfragen“ zu Ess-Anfällen wurden die Fragebogen-Serien in drei Gruppen (anorektisch, bulimisch und grenzwertig) eingeteilt, daraufhin konnte eine Analyse zu den Unterschieden im Antwortverhalten zwischen eben diesen Gruppe vorgenommen werden. Nach einem auf dieser Analyse basierenden Auswahlverfahren wurden die verbliebenen Items einer mehrstufigen Faktorenanalyse und kritischen inhaltlichen Differenzierung unterzogen. An deren Ende steht der o.g. Vorschlag eines neuen Diagnostikinstruments, das sich aus 45 Fragen in fünf Skalen zusammensetzt.

Background: Binge-eating disorder (BED) as a distinct eating disorder category and night eating syndrome (NES) as a form of Other Specified Feeding or Eating Disorders were recently included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Objectives: This study sought to investigate the prevalence of BED and NES and associations with various forms of non-normative eating behavior and psychopathology in prebariatric patients. Setting: Within a consecutive multicenter registry study, patients in six bariatric surgery centers in Germany were recruited. Methods: Overall, 233 prebariatric patients were assessed using the Eating Disorder Examination and self-report questionnaires. Assessment was unrelated to clinical procedures. Results: Diagnostic criteria for full-syndrome BED and NES were currently met by 4.3% and 8.2% of prebariatric patients, respectively. In addition, 8.6% and 6.9% of patients met subsyndromal BED and NES criteria, respectively. Comorbid BED and NES diagnoses were present in 3.9% of patients. In comparison to patients without any eating disorder symptoms, patients with BED and NES reported greater emotional eating, eating in the absence of hunger, and more symptoms of food addiction. Moreover, differences between patients with BED and NES emerged with more objective binge eating episodes and higher levels of eating concern, weight concern, and global eating disorder psychopathology in patients with BED. Conclusions: BED and NES were shown to be prevalent among prebariatric patients, with some degree of overlap between diagnoses. Associations with non-normative eating behavior and psychopathology point to their clinical significance and discriminant validity.

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.