Während Leitlinien „Gold-Standards“ für die Psychotherapie bei bulimischen Essstörungen (Bulimia Nervosa und Binge-Eating-Störung) empfehlen, ist über psychotherapeutische Prozessfaktoren bei Essstörungen wenig bekannt. Ziel war es, mit Hilfe des etablierten Generic Model of Psychotherapy zur Systematisierung psychotherapeutischer Prozessfaktoren die aktuelle Literatur zum Einfluss dieser Faktoren auf den Therapieerfolg, operationalisiert als Symptomreduktion oder -remission, auf Basis einer systematischen Datenbanksuche zu sichten. Während der Einfluss des therapeutischen Settings nach bisheriger Forschungslage kaum Schlüsse hinsichtlich des Therapieerfolgs zulässt, konnte dieser durch spezifische Interventionen, frühe Symptomreduktionen und eine gute therapeutische Beziehung vorhergesagt werden. Weitere Forschung zu Prozessfaktoren bei bulimischen Essstörungen erscheint notwendig, um die praktische psychotherapeutische Arbeit zu unterstützen und Behandlungen effektiver gestalten zu können. / While guidelines recommend gold standards for psychotherapy in bulimic eating disorders (bulimia nervosa and binge eating disorder), less is known about psychotherapeutic process aspects. We aimed to summarize the current literature on the impact of process aspects on significant symptom reductions and/or abstinence as treatment outcome using the Generic Model of Psychotherapy. A systematic literature search was conducted. While effects of treatment settings can not yet be estimated, specific interventions, rapid response, and the therapeutic bond repeatedly predicted outcome. Process-outcome research in bulimic eating disorders will be necessary to support clinical practice and to enhance treatment efficacy.

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 Dissertation handelt von der Arbeit mit essgestörten Patientinnen und deren Unzufriedenheit mit dem eigenen Körper. Als Vergleichsgruppen wurden junge Mädchen aus der Sekundarstufe I und aus Sportvereinen untersucht. Die Ausführungen sind Resultat der langjährigen Beschäftigung mit den Themen Essstörungen (Anorexia nervosa, Bulimie u.a.) bei Mädchen in der Pubertät. Während meiner Tätigkeit als Kinder- und Jugendlichenpsychotherapeutin in einer Klinik für Essstörungen und in meiner Praxis für Psychotherapie offenbarte sich mir die dramatische Körper- und Gefühllosigkeit der erkrankten Mädchen. In vielen Therapiesitzungen fiel der Satz: Ich kann mich nicht fühlen, ich weiß nicht, wie sich mein Körper anfühlt. Der fehlenden Körperwahrnehmung wollte ich nachgehen und erkrankte, nicht-erkrankte und sportlich-aktive Mädchen u.a. hinsichtlich ihrer Einstellungen gegenüber dem eigenen Körper, ihrer familialen Beziehungen und ihrer sportlichen Aktivität befragen. Mit dieser qualitativen Körperuntersuchung und den gewonnenen Ergebnissen verfolge ich primär das Ziel, den Mädchen und Frauen zu helfen, die verzweifelt einen Ausweg suchen aus dem pathologischen Teufelskreis: Wie schlank muss ich sein, um geliebt zu werden" So gilt es einerseits, dem Bewusstsein Rechnung zu tragen, dass sich Modediktat, Schönheitsideal, Selbstwertproblematik nicht mit autoaggressiv-destruktiver Abmagerung lösen lässt. Andererseits braucht das Gesundheitswesen ausreichende finanzielle Mittel, um der hohen Sterblichkeitsrate bei Magersucht präventiv entgegenzuwirken. In diesem Sinne hoffe ich zu der Einsicht beizutragen, dass die Behandlung einer schweren Erkrankung wie Anorexia nervosa nicht ohne Psychotherapie, medizinische Betreuung, Ernährungstherapie und v.a. nicht ohne Körpertherapie prognostisch möglich ist. Die Arbeit zeigt, dass jegliches Fehlen von stärkender Körperwahrnehmung den Behandlungserfolg massiv in Frage stellt.

Die Binge-Eating-Störung (BES), als eigenständige Essstörung erstmals im Diagnostischen und Statistischen Manual psychischer Störungen DSM-5 definiert, ist durch wiederkehrende Essanfälle ohne gewichtskompensatorische Verhaltensweisen gekennzeichnet. Die breitere Definition in der avisierten International Classification of Diseases ICD-11 wird zu Veränderungen in Präsentation und Prävalenz dieser Störung führen. Die BES tritt vor dem Hintergrund einer komplexen, multifaktoriellen Ätiologie auf und geht mit einer erhöhten Essstörungs- und allgemeinen Psychopathologie, psychischen und körperlichen Komorbidität einschließlich Adipositas und verringertem Funktionsniveau einher. Trotz dieser Beeinträchtigungen wird die BES häufig weder diagnostiziert noch behandelt. Evidenzbasierte Therapien für die BES umfassen die Psychotherapie, wobei die Kognitive Verhaltenstherapie das etablierteste Verfahren darstellt, und die strukturierte Selbsthilfebehandlung. Andere Therapien wie die Pharmakotherapie, behaviorale Gewichtsreduktionstherapie und Kombinationstherapien erhielten in den aktuellen evidenzbasierten S3-Essstörungsleitlinien einen geringeren Empfehlungsgrad für spezielle Indikationen.

Background. Individuals with anorexia nervosa (AN) are often thought to show heightened selfcontrol and increased ability to inhibit desires. In addition to inhibitory self-control, antecedentfocused strategies (e.g., cognitive reconstrual—the re-evaluation of tempting situations) might contribute to disorder maintenance and enable disorder-typical, maladaptive behaviors. - Methods. Over a period of 14 days, 40 acutely underweight young female patients with anorexia nervosa (AN) and 40 healthy control (HC) participants reported their affect and behavior in selfcontrol situations via ecological momentary assessment during inpatient treatment (AN) and everyday life (HC). Data were analyzed via hierarchical analyses (linear and logistic modeling). - Results. Conflict strength had a significantly lower impact on self-control success in AN compared to HC. While AN and HC did not generally differ in the number or strength of self-control conflicts or in the percentage of self-control success, AN reported self-controlled behavior to be less dependent on conflict strength. - Conclusions. While patients with AN were not generally more successful at self-control, they appeared to resolve self-control conflicts more effectively. These findings suggest that the magnitude of self-control conflicts has comparatively little impact on individuals with AN, possibly due to the use of antecedent-focused strategies. If confirmed, cognitive-behavioral therapy might focus on and help patients to exploit these alternative self-control strategies in the battle against their illness.

Alterations in executive functions have repeatedly been found in individuals suffering from eating and weight disorders. However, less is known about how these cognitive processes might contribute to the etiology of the disorders, as large prospective population-based studies have been missing. Here, we comment on the results of Steegers et al. (2021), a study that helped to fill this gap with a focus on set-shifting abilities predicting symptoms of anorexia nervosa (AN) in children. The main goal of this commentary is to encourage further interpretation of the population-based data beyond its relevance to AN. More specifically, we discuss the role of impaired inhibition as a risk factor for weight gain and obesity.

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.

Background: Eating disorders are serious conditions associated with an impaired health-related quality of life and increased healthcare utilization and costs. Despite the existence of evidence-based treatments, access to treatment is often delayed due to insufficient health care resources. Internet-based self-help interventions may have the potential to successfully bridge waiting time for face-to-face outpatient treatment and, thus, contribute to overcoming treatment gaps. However, little is known about the feasibility of implementing such interventions into routine healthcare. The aim of this study is to analyze the effects and feasibility of an Internet-based selfhelp intervention (everyBody Plus) specifically designed for patients with Bulimia Nervosa, Binge Eating Disorder and other specified feeding and eating disorders (OSFED) on a waiting list for outpatient face-to-face treatment. The aim of this paper is to describe the study protocol. Methods: A multi-country randomized controlled trial will be conducted in Germany and the UK. N=275 female patients awaiting outpatient treatment will be randomly allocated either to the guided online self-help intervention “everyBody Plus” or a waitlist control group condition without access to the intervention. everyBody Plus comprises eight weekly sessions that cover topics related to eating and exercise patterns, coping with negative emotions and stress as well as improving body image. Participants will receive weekly individualized feedback based on their self-monitoring and journal entries. Assessments will take place at baseline, post-intervention as well as at 6- and 12-months follow up. In addition, all participants will be asked to monitor core eating disorder symptoms weekly to provide data on the primary outcome. The primary outcome will be number of weeks after randomization until a patient achieves a clinically relevant improvement in core symptoms (BMI, binge eating, compensatory behaviors) for the first time. Secondary outcomes include frequency of core symptoms and eating disorder related attitudes and behaviors, as well as associated psychopathology. Additional secondary outcomes will be the participating therapists' confidence in treating eating disorders as well as perceived benefits of everyBody Plus for patients. Discussion: To the best of our knowledge, this is the first randomized controlled trial examining the effects of Internet-based self-help for outpatients with eating disorders awaiting face-to-face outpatient treatment. If proven to be effective and successfully implemented, Internet-based self-help programs might be used as a first step of treatment within a stepped-care approach, thus reducing burden and cost for both patients and health care providers.

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