Dr. Cristin Runfola specializes in the treatment and research of eating disorders. Her research focuses on the epidemiology of dysregulated eating and weight concerns in underserved populations and her primary interest is in developing and testing the efficacy of clinical interventions designed to improve outcome for eating disorders. This work included developing protocols for delivering therapy in individual and couple-based formats either in person, online, or via video-conferencing. With grant funding, she co-developed couple based interventions for eating disorders (UNITE) and founded a peer to peer eating disorder educational initiative (EMBODY). Most recently, as lead-PI, she piloted a virtual reality based cue exposure therapy (VR-CET) for binge eating. Within Stanford Psychiatry’s Virtual Reality & Immersive Technology Program, she works with a group of interdisciplinary academics passionate and called upon to evaluate, innovate, and disseminate advances in the field of virtual and augmented reality technology in real world clinical settings. Dr. Runfola sees individuals with eating disorders in the outpatient setting and serves as a study therapist for various clinical trials. She has co-authored multiple peer-reviewed articles and book chapters and has presented her work both nationally and internationally. Dr. Runfola also teaches graduate courses in the Stanford University and Palo Alto University PsyD Consortium. She is engaged in advocacy and holds leadership positions within the Academy for Eating Disorders (AED).

Clinical Focus

  • Eating disorders
  • Couples
  • Clinical Psychology

Academic Appointments

  • Clinical Associate Professor, Psychiatry and Behavioral Sciences

Honors & Awards

  • Chairman’s Award for Clinical Innovation and Service, Stanford University (2022)
  • Clinician Scholarship Award, Academy for Eating Disorders (AED) (2015)
  • OTCF Award (for service and dedication to the UNC Center of Excellence for Eating Disorders), University of North Carolina at Chapel Hill (2012)
  • Martin S. Wallach Award for Outstanding Clinical Psychology Intern of the Year, University of North Carolina at Chapel Hill (2011)
  • Early Career Investigator Travel Fellowship Award, National Institute of Mental Health (NIMH) / Academy for Eating Disorders (AED) (2009)
  • Top Fundraising Award, National Eating Disorders Association (NEDA) (2009)
  • Superior Research Award, American Psychological Association (APA) (2008)
  • Fellowship Award, Pacific Graduate School of Psychology (2006 – 2008)
  • Undergraduate Service Award, San Diego State University (2006)
  • Exemplary Peer Advisor Award, San Diego State University (2006)
  • Golden Key International Honor Society, San Diego State University (2005 – 2006)
  • Phi Kappa Phi Honor Society, San Diego State University (2004 – 2006)
  • Psi Chi National Honor Society in Psychology, San Diego State University (2004 – 2006)
  • Deans list (all semesters), San Diego State University (2003 – 2006)

Boards, Advisory Committees, Professional Organizations

  • 2022 ICED Scientific Committee Member, Academy for Eating Disorders (2021 - Present)
  • Member, Association for Behavioral and Cognitive Therapies (ABCT) (2019 - Present)
  • Member, Association for Contextual Behavioral Science (ACBS) (2016 - Present)
  • Member, California Psychological Association (CPA) (2016 - Present)
  • Editorial Board, Eating Disorders: The Journal of Treatment and Prevention (2015 - Present)
  • Co-Chair, Membership Recruitment and Retention Committee, Academy for Eating Disorders (2013 - 2018)
  • Member, Binge Eating Disorder Association (BEDA) (2011 - Present)
  • Member, Academy for Eating Disorders (AED) (2005 - Present)

Professional Education

  • PhD Training: Palo Alto University/Pacific Graduate School of Psychology (2011) CA
  • Fellowship: University of North Carolina at Chapel Hill (2013) NC
  • Internship: University of North Carolina at Chapel Hill (2011) NC

Community and International Work

  • Embody Carolina: Providing Eating Disorder Support with Peer Education, North Carolina


    Eating Disorders

    Populations Served

    College Students



    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

Dr. Runfola's research focuses on the epidemiology of dysregulated eating and weight concerns in undeserved populations and her primary interest is in developing and testing the efficacy of clinical interventions designed to improve outcome for eating disorders.

With support from GFED, Dr. Runfola adapted the Uniting Couples in the treatment of Anorexia Nervosa (UCAN) therapy manual for couples in which one or both members have binge-eating disorder (UNITE) and recently completed pilot testing on this treatment. She is in the process of expanding this treatment for all couples affected by binge eating, and is submitting a grant to fund future work testing efficacy.


  • Enhancing Treatment for Binge-Eating Disorder with a Couple-Based Approach, University of North Carolina at Chapel Hill (1/1/2014 - Present)


    Chapel Hill, NC

  • Improving Detection and Treatment of Eating Disorders, University of North Carolina at Chapel Hill (2013 - 2015)


    Chapel Hill, NC

  • Developing and Pilot testing a Cognitive-Behavioral Couple Therapy (CBCT) Manual for Binge-Eating Disorder, University of North Carolina at Chapel Hill (2013 - 2015)


    Chapel Hill, NC

  • Anorexia Nervosa Genetics Initiative (ANGI), University of North Carolina at Chapel Hill (2011 - 2016)


    Chapel Hill, NC

  • Night Eating Syndrome in Pediatric Eating Disorders Patients, Palo Alto University (2010 - 2010)


    Palo Alto, CA

  • Uniting Couples in the treatment of Anorexia Nervosa (UCAN), University of North Carolina at Chapel Hill


    Chapel Hill, NC

  • Cognitive-Behavioral Therapy for Bulimia Nervosa (CBT4BN), University of North Carolina at Chapel Hill


    Chapel Hill, NC

All Publications

  • Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy. Journal of medical Internet research Brown, T., Nauman Vogel, E., Adler, S., Bohon, C., Bullock, K., Nameth, K., Riva, G., Safer, D. L., Runfola, C. D. 2020; 22 (4): e16386


    Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally.

    View details for DOI 10.2196/16386

    View details for PubMedID 32324145

  • Body dissatisfaction in adolescent boys. Developmental psychology Baker, J. H., Higgins Neyland, M. K., Thornton, L. M., Runfola, C. D., Larsson, H., Lichtenstein, P., Bulik, C. 2019


    Body dissatisfaction is a significant mental health symptom present in adolescent girls and boys. However, it is often either disregarded in adolescent boys or examined using assessments that may not resonate with males. The present study addresses these issues, examining the manifestation, etiology, and correlates of 3 facets of body dissatisfaction in adolescent boys. Adolescent male twins aged 16- to 17-years-old from the Swedish Twin Study of Child and Adolescent Development were included along with a female comparison group: 915 monozygotic and 671 dizygotic same-sex twins. Body dissatisfaction was defined using measures of height dissatisfaction, muscle dissatisfaction, and the body dissatisfaction subscale of the Eating Disorder Inventory (EDI-BD). We examined the prevalence of body dissatisfaction, whether the facets of body dissatisfaction were phenotypically and etiologically distinct, and associations with specific externalizing and internalizing symptoms. For boys, muscle dissatisfaction scores were greater than height dissatisfaction scores. Results also indicated that height and muscle dissatisfaction were phenotypically and etiologically distinct from the EDI-BD. Unique associations were observed with externalizing and internalizing symptoms: muscle dissatisfaction with symptoms of bulimia nervosa and the EDI-BD with internalizing symptoms, body mass index, and drive for thinness. The facets of body dissatisfaction were also largely distinct in girls and unique between-sex associations with externalizing and internalizing symptoms emerged. Overall, male-oriented aspects of body dissatisfaction are distinct from female-oriented aspects of body dissatisfaction. To capture the full picture of male body dissatisfaction, multiple facets must be addressed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

    View details for PubMedID 30985163

  • Interventions to Empower Adults with Eating Disorders and Their Partners around the Transition to Parenthood. Family process Sadeh-Sharvit, S. n., Sacks, M. R., Runfola, C. D., Bulik, C. M., Lock, J. D. 2019


    The transition to parenthood is perceived as a stressful life event, when parents experience an immense change of their psychological focus and a reorientation of roles and responsibilities in the family system. This process may be even more challenging in the presence of a parental eating disorder history. This paper reviews the impact of parental eating disorders on the parents, the couple relationship, and their child during the perinatal period. A parental eating disorder is associated with more negative expectations of parental efficacy as well as specific difficulties in couple communication over the child's feeding, shape, and weight. Providers who better understand the effects of an eating disorder on parental functioning can more effectively intervene early on. We also present couple- or parent-based, empirically supported interventions for adults with eating disorders and their partners in the prenatal and postnatal periods: Uniting Couples in the treatment of Anorexia Nervosa (UCAN) and Uniting couples In the Treatment of Eating disorders (UNITE) both enhance recovery from the eating disorder through a couple-based intervention; the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) incorporates the support of partners, when appropriate; Parent-Based Prevention (PBP) focuses on improving parental functioning and reducing risk of negative parental and child outcomes. Finally, we discuss the clinical implications of addressing parental eating disorders and encourage more research on these families.

    View details for DOI 10.1111/famp.12510

    View details for PubMedID 31799711

  • Parenting after Weight Loss Surgery: A Conceptual Model and Two Case Reports. Family process Gibbs, E. L., Runfola, C. D., Dickens, C. E., Welch, H. n., Safer, D. L., Sadeh-Sharvit, S. n. 2019


    The ways families approach eating, shape, and weight can result in stress for individual family members and challenge the overall functioning of the family. This is further complicated among families with a parent who has history of obesity or undergone weight loss surgery (WLS). Although WLS can positively impact other family members, it can also exacerbate conflicts regarding feeding and weight. Such conflicts can involve uncertainty regarding the extent to which the entire family should make the dietary changes recommended for the post-WLS parent. Conflict might also center on the appropriate level of concern regarding the children's risk of developing (or maintaining) obesity. This paper uses two case examples to describe the application of a specialized, time-limited intervention: Parent-Based Prevention following Bariatric Surgery (PBP-B). The program was developed to address the unique challenges and concerns that arise after, or are exacerbated by, WLS. Each detailed case example illustrates a common child-feeding challenge and the employment of key PBP-B strategies throughout the course of treatment. In the first case, the parent who had undergone WLS believed the family's current eating behaviors were the same as those that had led to her own overeating, obesity, and co-occurring psychiatric symptoms, while her husband disagreed. In the second case, both parents were concerned about their son's weight, yet due to their prior eating histories, they felt unable to construct boundaries around the feeding experience. Both cases follow families through the entire intervention and illustrate key points and challenges. These cases underscore the need for novel treatment modalities to support families following parental WLS.

    View details for DOI 10.1111/famp.12518

    View details for PubMedID 31826298

  • A pilot open trial of UNITE-BED: A couple-based intervention for binge-eating disorder. The International journal of eating disorders Runfola, C. D., Kirby, J. S., Baucom, D. H., Fischer, M. S., Baucom, B. R., Matherne, C. E., Pentel, K. Z., Bulik, C. M. 2018


    OBJECTIVE: To evaluate the feasibility, acceptability, and preliminary efficacy of a couple-based intervention for binge-eating disorder (BED), called UNiting couples In the Treatment of Eating disorders-BED edition (UNITE-BED).METHOD: In an open pilot trial, 11 couples in which one or both adult partners had a diagnosis of DSM-5 threshold or sub-threshold BED participated in 22 weekly sessions of UNITE-BED. Patients also received individual treatment, outside of the context of the trial. Couples completed measures on treatment satisfaction, eating disorder symptom severity, depression, anxiety, emotion regulation, and relational functioning at post-treatment and 3-month follow-up. Statistical analyses were conducted to identify change over the course of treatment.RESULTS: UNITE was feasible and acceptable to the majority of couples (9% dropout; high satisfaction ratings). Objective binge abstinence was 81.8% and subjective binge abstinence was 45.5% by post-treatment. Patient binge-eating symptomatology reduced over the course of treatment with results maintained at follow up. Patients' depression symptoms decreased and patients' emotion regulation improved at both time points.DISCUSSION: Including partners in treatment for BED may be beneficial. Results support further evaluation of the efficacy of couple-based interventions for BED in larger randomized-controlled trials.

    View details for PubMedID 30189106

  • Cost-Effectiveness of Internet-Based Cognitive-Behavioral Treatment for Bulimia Nervosa: Results of a Randomized Controlled Trial JOURNAL OF CLINICAL PSYCHIATRY Watson, H. J., McLagan, N., Zerwas, S. C., Crosby, R. D., Levine, M. D., Runfola, C. D., Peat, C. M., Moessner, M., Zimmer, B., Hofmeier, S. M., Hamer, R. M., Marcus, M. D., Bulik, C. M., Crow, S. J. 2018; 79 (1)


    To evaluate the cost-effectiveness of Internet-based cognitive-behavioral therapy for bulimia nervosa (CBT-BN) compared to face-to-face delivery of CBT-BN.This study is a planned secondary analysis of data from a randomized clinical trial. Participants were 179 adults (98% female, mean age = 28 years) meeting DSM-IV criteria for bulimia nervosa who were randomized to group face-to-face or group Internet-based CBT-BN for 16 sessions during 20 weeks. The cost-effectiveness analysis was conducted from a third-party payor perspective, and a partial societal perspective analysis was conducted to investigate cost-utility (ie, cost per gain in quality-adjusted life-years) and patient out-of-pocket travel-related costs. Net health care costs were calculated from protocol and nonprotocol health care services using third-party payor cost estimates. The primary outcome measure in the clinical trial was abstinence from binge eating and purging, and the trial start and end dates were 2008 and 2016.The mean cost per abstinent patient at posttreatment was $7,757 (95% confidence limit [CL], $4,515, $13,361) for face-to-face and $11,870 (95% CL, $6,486, $22,188) for Internet-based CBT-BN, and at 1-year follow-up was $16,777 (95% CL, $10,298, $27,042) for face-to-face and $14,561 (95% CL, $10,165, $21,028) for Internet-based CBT-BN. There were no statistically significant differences between treatment arms in cost-effectiveness or cost-utility at posttreatment or 1-year follow-up. Out-of-pocket patient costs were significantly higher for face-to-face (mean [95% CL] = $178 [$127, $140]) than Internet-based ($50 [$50, $50]) therapy.Third-party payor cost-effectiveness of Internet-based CBT-BN is comparable with that of an accepted standard. Internet-based dissemination of CBT-BN may be a viable alternative for patients geographically distant from specialist eating disorder services who have an unmet need for identifier: NCT00877786​.

    View details for PubMedID 29228517

    View details for PubMedCentralID PMC5837958

  • The Association between Symptom Accommodation and Emotional Coregulation in Couples with Binge Eating Disorder. Family process Weber, D. M., Fischer, M. S., Baucom, D. H., Baucom, B. R., Kirby, J. S., Runfola, C. D., Matherne, C. E., Bulik, C. M. 2018


    Intense negative emotions and maladaptive behavioral strategies to reduce emotional distress occur not only in patients with various forms of psychopathology but also in their committed partners. One common strategy to reduce distress is for partners to accommodate to the symptoms of the disorder, which reduces distress short term but maintains symptoms long term. Accommodation is believed to be motivated by the partner reacting behaviorally to the patient's emotions, but the emotions of the partner in this context have yet to be examined. This pilot study examined how partner accommodation related to specific patterns of emotional coregulation between patients with binge eating disorder (BED) and their partners, before and after a couple-based intervention for BED. Vocally encoded emotional arousal was measured during couples' (n = 11) conversations about BED. As predicted, partners' emotional reactivity to patients' emotional arousal was associated with high accommodation before treatment. Thus, partners may use accommodation as a strategy to reduce both the patients' and their own distress. After treatment, partners' arousal was no longer associated with the patients' emotional arousal; instead, partners showed greater emotional stability over time, specifically when accommodation was low. Additionally, patients were less emotionally aroused after treatment. Therefore, treatment may have decreased overall emotionality of patients and altered the association between accommodation and partners' emotional reactivity. If replicated, this understanding of the emotional context associated with accommodation in BED can inform couple-based treatment by targeting specific emotional precipitants of behaviors that maintain symptoms.

    View details for PubMedID 30229890

  • Potential Predictors of Injury Among Pre-Professional Ballet and Contemporary Dancers. Journal of dance medicine & science : official publication of the International Association for Dance Medicine & Science Yau, R. K., Golightly, Y. M., Richardson, D. B., Runfola, C. D., Waller, A. E., Marshall, S. W. 2017; 21 (2): 53-63


    Injuries occur frequently among ballet and contemporary dancers. However, limited literature exists on injuries to pre-professional dancers in the USA. The goals of this study were to 1. provide a descriptive epidemiology of the incidence of musculoskeletal injuries in an adolescent and young adult dance population and 2. identify parsimonious regression models that could be potentially used to predict injury incidence. The study was based at the University of North Carolina School of the Arts (UNCSA) from Fall 2009 to Spring 2015. An injury was defined as any event that caused a dancer to be seen at the UNCSA Student Health Services and caused the dancer to modify or curtail dance activity for at least 1 day. Injury rate ratios (IRRs) were calculated using negative binomial generalized estimating equations. Models predicting injury rates were built using forward selection, stratified by sex. Among 480 dancers, 1,014 injuries were sustained. Most injuries were to the lower extremity and the result of overuse. There were differences in upper extremity, lower extremity, and traumatic injury rates by demographic subgroups. Among females, the most parsimonious predictive model for injury rates included a self-reported history of depression, age at time of injury, and number of injuries sustained at UNCSA prior to the semester of current injury. Among males, the most parsimonious model was a univariate model with family history of alcohol or drug problems. Strategies for traumatic injury prevention among dancers should be both sex- and style-specific. No differences were observed in overuse injury rates by sex or style, suggesting that generic overuse prevention strategies may not need to be guided by these factors. It is concluded that strategies can be implemented to reduce and mitigate the consequences of injuries if not the injuries themselves.

    View details for DOI 10.12678/1089-313X.21.2.53

    View details for PubMedID 28535848

  • The Core Symptoms of Bulimia Nervosa, Anxiety, and Depression: A Network Analysis JOURNAL OF ABNORMAL PSYCHOLOGY Levinson, C. A., Zerwas, S., Calebs, B., Forbush, K., Kordy, H., Watson, H., Hofmeier, S., Levine, M., Crosby, R. D., Peat, C., Runfola, C. D., Zimmer, B., Moesner, M., Marcus, M. D., Bulik, C. M. 2017; 126 (3): 340-354


    Bulimia nervosa (BN) is characterized by symptoms of binge eating and compensatory behavior, and overevaluation of weight and shape, which often co-occur with symptoms of anxiety and depression. However, there is little research identifying which specific BN symptoms maintain BN psychopathology and how they are associated with symptoms of depression and anxiety. Network analyses represent an emerging method in psychopathology research to examine how symptoms interact and may become self-reinforcing. In the current study of adults with a Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) diagnosis of BN (N = 196), we used network analysis to identify the central symptoms of BN, as well as symptoms that may bridge the association between BN symptoms and anxiety and depression symptoms. Results showed that fear of weight gain was central to BN psychopathology, whereas binge eating, purging, and restriction were less central in the symptom network. Symptoms related to sensitivity to physical sensations (e.g., changes in appetite, feeling dizzy, and wobbly) were identified as bridge symptoms between BN, and anxiety and depressive symptoms. We discuss our findings with respect to cognitive-behavioral treatment approaches for BN. These findings suggest that treatments for BN should focus on fear of weight gain, perhaps through exposure therapies. Further, interventions focusing on exposure to physical sensations may also address BN psychopathology, as well as co-occurring anxiety and depressive symptoms. (PsycINFO Database Record

    View details for DOI 10.1037/abn0000254

    View details for Web of Science ID 000398740500007

    View details for PubMedID 28277735

  • CBT4BN: A Randomized Controlled Trial of Online Chat and Face-to-Face Group Therapy for Bulimia Nervosa PSYCHOTHERAPY AND PSYCHOSOMATICS Zerwas, S. C., Watson, H. J., Hofmeier, S. M., Levine, M. D., Hamer, R. M., Crosby, R. D., Runfola, C. D., Peat, C. M., Shapiro, J. R., Zimmer, B., Moessner, M., Kordy, H., Marcus, M. D., Bulik, C. M. 2017; 86 (1): 47-53


    Although cognitive-behavioral therapy (CBT) represents the first-line evidence-based psychotherapy for bulimia nervosa (BN), most individuals seeking treatment do not have access to this specialized intervention. We compared an Internet-based manualized version of CBT group therapy for BN conducted via a therapeutic chat group (CBT4BN) to the same treatment conducted via a traditional face-to-face group therapy (CBTF2F).In a two-site, randomized, controlled noninferiority trial, we tested the hypothesis that CBT4BN would not be inferior to CBTF2F. A total of 179 adult patients with BN (2.6% males) received up to 16 sessions of group CBT over 20 weeks in either CBT4BN or CBTF2F, and outcomes were compared at the end of treatment and at the 12-month follow-up.At the end of treatment, CBT4BN was inferior to CBTF2F in producing abstinence from binge eating and purging. However, by the 12-month follow-up, CBT4BN was mostly not inferior to CBTF2F. Participants in the CBT4BN condition, but not CBTF2F, continued to reduce their binge-eating and purging frequency from the end of treatment to the 12-month follow-up.CBT delivered online in a group chat format appears to be an efficacious treatment for BN, although the trajectory of recovery may be slower than face-to-face group therapy. Online chat groups may increase accessibility of treatment and represent a cost-effective approach to service delivery. However, barriers in service delivery such as state-specific license and ethical guidelines for online therapists need to be addressed.

    View details for DOI 10.1159/000449025

    View details for Web of Science ID 000390083600006

    View details for PubMedID 27883997

    View details for PubMedCentralID PMC5143175

  • Body image, aging, and identity in women over 50: The Gender and Body Image (GABI) study. Journal of women & aging Hofmeier, S. M., Runfola, C. D., Sala, M., Gagne, D. A., Brownley, K. A., Bulik, C. M. 2016: 1-12


    We conducted a qualitative study of 1,849 women over age 50 to capture the thoughts, feelings, and attitudes that women at middle age have about their bodies and the experience of aging. Via an open-ended question online survey, four primary themes emerged: (a) the physical and psychological experience of aging; (b) the injustices, inequities, and challenges of aging; (c) the importance of self-care; and (d) a plea for recognition of the need to maintain a contributory role in society. Results highlight the complexities of women's psychological and physical aspects of aging and point toward important topics worthy of further study in this growing population.

    View details for PubMedID 27399268

  • Familial Liability for Eating Disorders and Suicide Attempts Evidence From a Population Registry in Sweden JAMA PSYCHIATRY Yao, S., Kuja-Halkola, R., Thornton, L. M., Runfola, C. D., D'Onofrio, B. M., Almqvist, C., Lichtenstein, P., Sjolander, A., Larsson, H., Bulik, C. M. 2016; 73 (3): 284-291


    Suicide attempts are common in individuals with eating disorders. More precise understanding of the mechanisms underlying their concomitant occurrence is needed.To examine the association between eating disorders and suicide attempts and whether familial risk factors contribute to the association.A Swedish birth cohort including individuals born in Sweden between January 1, 1979, and December 31, 2001, was followed up from age 6 years to December 31, 2009 (N = 2,268,786). Information was acquired from Swedish national registers. All individuals were linked to their biological full siblings, maternal half siblings, paternal half siblings, full cousins, and half cousins. Data analysis was conducted from October 5, 2014, to April 28, 2015.Eating disorders were captured by 3 variables (any eating disorder, anorexia nervosa, and bulimia nervosa) identified by any lifetime diagnoses recorded in the registers. Suicide attempts were defined as any suicide attempts, including death by suicide, recorded in the registers. We examined the association between eating disorders and death by suicide separately, but the study was underpowered to explore familial liability for this association.Of 2,268,786 individuals, 15,457 females (1.40% of all females) and 991 males (0.09% of all males) had any eating disorder, 7680 females (0.70%) and 453 males (0.04%) had anorexia nervosa, and 3349 females (0.30%), and 61 males (0.01%) had bulimia nervosa. Individuals with any eating disorder had an increased risk (reported as odds ratio [95% CI]) of suicide attempts (5.28 [5.04-5.54]) and death by suicide (5.39 [4.00-7.25]). The risks were attenuated but remained significant after adjusting for comorbid major depressive disorder, anxiety disorder, and substance use disorder (suicide attempts: 1.82 [1.72-1.93]; death by suicide: 2.04 [1.49-2.80]). Similar results were found for anorexia nervosa (suicide attempts: crude, 4.42 [4.12-4.74] vs adjusted, 1.70 [1.56-1.85]; death by suicide: crude, 6.46 [4.38-9.54] vs adjusted, 2.67 [1.78-4.01]) and bulimia nervosa (suicide attempts: crude, 6.26 [5.73-6.85] vs adjusted, 1.88 [1.68-2.10]; death by suicide: crude, 4.45 [2.44-8.11] vs adjusted, 1.48 [0.81-2.72]). Individuals (index) who had a full sibling with any eating disorder had an increased risk of suicide attempts (1.41 [1.29-1.53]). The risk was attenuated for any eating disorder in more-distant relatives (maternal half siblings, 1.10 [0.90-1.34]; paternal half siblings, 1.21 [0.98-1.49]; full cousins, 1.11 [1.06-1.18]; half cousins, 0.90 [0.78-1.03]). This familial pattern remained stable after adjusting for the index individuals' eating disorders. Similar patterns were found for anorexia nervosa and bulimia nervosa.These results suggest an increased risk of suicide attempts in individuals with lifetime eating disorders and their relatives. The pattern of familial coaggregation suggests familial liability for the association between eating disorders and suicide. Psychiatric comorbidities partially explain this association, suggesting particularly high-risk presentations.

    View details for DOI 10.1001/jamapsychiatry.2015.2737

    View details for Web of Science ID 000371613500016

    View details for PubMedID 26764185

  • Eating disorders in midlife women: A perimenopausal eating disorder? MATURITAS Baker, J. H., Runfola, C. D. 2016; 85: 112-116


    Eating disorders afflict women across the lifespan with peak onset during critical or sensitive developmental periods of reproductive hormone change, such as puberty. A growing body of research supports the role of reproductive hormones, specifically estrogen, in the risk for eating disorders and related symptomatology in adolescence and young adulthood. Like puberty, perimenopause is characterized by estrogen change and may also present a window of vulnerability to eating disorder development. Here, we discuss the evidence that suggests perimenopause indeed may be a vulnerable period for the development or redevelopment of an eating disorder for midlife women. Drawing from what is known about the influence of estrogen on eating disorders at younger ages and from other psychiatric disorders with similar risk trajectories (i.e., perimenopausal depression), we describe a potential mechanism of risk for a perimenopausal eating disorder and how this can be explored in future research. Investigating vulnerability to perimenopausal eating disorders will clarify eating disorder etiology, identify reproductive stage-specific risk profiles, and guide future treatment directions.

    View details for DOI 10.1016/j.maturitas.2015.12.017

    View details for Web of Science ID 000370897300018

    View details for PubMedID 26857889

  • Sex- and Age-Specific Incidence of Healthcare-Register-Recorded Eating Disorders in the Complete Swedish 1979-2001 Birth Cohort INTERNATIONAL JOURNAL OF EATING DISORDERS Javaras, K. N., Runfola, C. D., Thornton, L. M., Agerbo, E., Birgegard, A., Norring, C., Yao, S., Rastam, M., Larsson, H., Lichtenstein, P., Bulik, C. M. 2015; 48 (8): 1070-1081


    To investigate the sex- and age-specific incidence of healthcare-register-recorded anorexia nervosa (AN) and other eating disorders (OED) in a complete birth cohort, and assess whether incidence varies by diagnostic period and (sub-) birth cohort.We used the actuarial method and Poisson models to examine the incidence of AN and OED from 1987 to 2009 (when individuals were 8-30 years old) for a cohort of 2.3 million individuals (48.7% female) born from 1979 to 2001 in Sweden, identified using Swedish registers.For both sexes, incidences of AN and OED increased considerably for diagnostic periods after 2000, but differed little by birth cohort. In 2009, AN incidence in the peak age category was 205.9 cases/100,000 persons (95% CI: 178.2, 233.5) for females (14-15 years), versus 12.8 cases/100,000 (95% CI: 5.6, 20.1) for males (12-13 years). OED incidence in the peak age category was 372.1 cases/100,000 (95% CI: 336.4, 407.9) for females (16-17 years), versus 22.2 cases/100,000 (95% CI: 13.3, 31.1) for males (14-15 years).Our finding of an increase in healthcare-register-recorded eating disorders for diagnostic periods after 2000 likely reflects improved detection and expanded register coverage in Sweden. The peak of eating disorder incidence in adolescence, which began unexpectedly early for AN in males, suggests the importance of vigilance for signs of AN in young boys and early primary prevention efforts. Waiting until later could miss critical windows for intervention that could prevent disorders from taking root.

    View details for DOI 10.1002/eat.22467

    View details for Web of Science ID 000367662500002

    View details for PubMedID 26769444

  • Couple-Based Interventions for Adults With Eating Disorders EATING DISORDERS Kirby, J. S., Runfola, C. D., Fischer, M. S., Baucom, D. H., Bulik, C. M. 2015; 23 (4): 356-365


    A significant number of adults with eating disorders fail to achieve relief from the disorder, with many dropping out of treatment or relapsing. The standard treatment remains individual therapy despite partners being negatively affected and typically wanting to help in an effective and loving way. We propose that couple-based interventions, which leverage the support of a partner and the relationship in treatment, may improve outcome and recovery rates for adults with eating disorders. In this article, we survey the empirical literature supporting the treatment of adults in a couple context and describe our existing and emerging couple-based interventions for eating disorders.

    View details for DOI 10.1080/10640266.2015.1044349

    View details for Web of Science ID 000356267600009

    View details for PubMedID 26010371

  • Prevalence and Clinical Significance of Night Eating Syndrome in University Students JOURNAL OF ADOLESCENT HEALTH Runfola, C. D., Allison, K. C., Hardy, K. K., Lock, J., Peebles, R. 2014; 55 (1): 41-48


    Most studies of night eating syndrome (NES) fail to control for binge eating, despite moderate overlap between the two conditions. Establishing the independent clinical significance of NES is imperative for it to be considered worthy of clinical attention. We compared students with and without NES on eating disorder symptomatology, quality of life, and mental health, while exploring the role of binge eating in associations.Students (N = 1,636) ages 18-26 years (M = 20.9) recruited from 10 U.S. universities completed an online survey including the Night Eating Questionnaire (NEQ), Eating Disorder Examination-Questionnaire (EDE-Q), Project Eating Among Teens, and the Health-Related Quality of Life-4. NES was diagnosed according to endorsement of proposed diagnostic criteria on the NEQ. Groups (NES vs. non-NES) were compared on all dependent variables and stratified by binge eating status in secondary analyses.The prevalence of NES in our sample was 4.2%; it decreased to 2.9% after excluding those with binge eating. Body mass index did not differ between groups, but students with NES were significantly more likely to have histories of underweight and anorexia nervosa. In students with NES, EDE-Q scores were significantly higher; purging, laxative use, and compulsive exercise were more frequent; quality of life was reduced; and histories of depression, attention-deficit/hyperactivity disorder, and self-injury were more common. Binge eating did not account for all of these differences; the presence of it and NES was associated with additive risk for psychopathology on some items.NES may be a distinct clinical entity from other DSM-5 eating disorders.

    View details for DOI 10.1016/j.jadohealth.2013.11.012

    View details for PubMedID 24485551

  • Self-image and suicide in a Swedish national eating disorders clinical register COMPREHENSIVE PSYCHIATRY Runfola, C. D., Thornton, L. M., Pisetsky, E. M., Bulik, C. M., Birgegard, A. 2014; 55 (3): 439-449


    Using a prospective design, to examine the relation between self-image (assessed using the Structural Analysis of Social Behavior) and suicide attempts/completions in women with anorexia nervosa-restricting type (ANR), anorexia nervosa-binge/purge type (ANBP), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (EDNOS); and to assess whether these self-image variables add unique predictive value to suicide when considering other baseline predictors.Women (N=2269) aged 12 to 45 (M=22.1) presenting to specialist eating disorders clinics in Sweden between 2005 and 2009 were identified through the Stepwise Eating Disorders Quality Register. Data on age, body mass index, eating disorder severity (Eating Disorder Examination-Questionnaire scores), psychiatric comorbidity, global assessment of functioning, and self-image were abstracted from Stepwise and included as baseline predictors or covariates. Suicide information (prior attempt and attempt/completion after Stepwise registration) was obtained from the National Patient Register and Cause of Death Register.Prevalence of detected suicide attempts/completions over the study period was 9.2%. Negative self-image variables were associated with prior suicide attempts in ANR and EDNOS and later suicide attempts/completions in women with BN. In a stepwise Cox proportional hazards model, only low self-affirmation predicted time to suicide attempts/completions in women with BN when accounting for age and prior suicide attempt.Assessing self-image might assist with identifying women with BN at elevated risk for suicide.

    View details for DOI 10.1016/j.comppsych.2013.11.007

    View details for Web of Science ID 000333661800006

    View details for PubMedID 24332388

  • NURTURE: Development and Pilot Testing of a Novel Parenting Intervention for Mothers with Histories of an Eating Disorder INTERNATIONAL JOURNAL OF EATING DISORDERS Runfola, C. D., Zucker, N. L., Von Holle, A., Mazzeo, S., Hodges, E. A., Perrin, E. M., Bentley, M. E., Ulman, T. F., Hoffman, E. R., Forsberg, S., Algars, M., Zerwas, S., Pisetsky, E. M., Taico, C., Kuhns, R. A., Hamer, R. M., Bulik, C. M. 2014; 47 (1): 1-12


    To describe the treatment development and pilot testing of a group parenting intervention, NURTURE (Networking, Uniting, and Reaching out To Upgrade Relationships and Eating), for mothers with histories of eating disorders.Based on focus group findings, extant research, and expert opinion, NURTURE was designed to be delivered weekly over 16 (1.5 h) sessions via an interactive web conferencing forum. It comprises four modules: (1) laying the foundation, (2) general parenting skills, (3) eating and feeding, and (4) breaking the cycle of risk. Pilot testing was conducted with three groups of 3-6 mothers (N = 13) who had children ages 0-3 years to determine feasibility (e.g., retention), acceptability (e.g., feedback questionnaire responses), and preliminary efficacy. Maternal satisfaction with NURTURE and changes in mother-child feeding relationship measures, maternal feeding style, maternal self-efficacy, and maternal psychopathology (eating disorder, depression, and anxiety symptoms) across three time points (baseline, post-treatment, 6-month follow-up) were examined. All outcomes were exploratory.The intervention was well tolerated with a 100% retention rate. Feedback from mothers was generally positive and indicated that the groups provided an engaging, supportive experience to participants. We observed changes suggestive of improvement in self-reported maternal self-efficacy and competence with parenting. There were no notable changes in measures of maternal feeding style or psychopathology.NURTURE is a feasible, acceptable, and potentially valuable intervention for mothers with eating disorder histories. Results of this pilot will inform a larger randomized-controlled intervention to determine efficacy and impact on child outcomes.

    View details for DOI 10.1002/eat.22178

    View details for Web of Science ID 000328152000001

    View details for PubMedID 23983082

  • Characteristics of Women with Body Size Satisfaction at Midlife: Results of the Gender and Body Image (GABI) Study JOURNAL OF WOMEN & AGING Runfola, C. D., Von Holle, A., Peat, C. M., Gagne, D. A., Brownley, K. A., Hofmeier, S. M., Bulik, C. M. 2013; 25 (4): 287-304


    This study characterizes the profile of women (N = 1,789) ages 50 and over who report body size satisfaction on a figure rating scale. Satisfied women (12.2%) had a lower body mass index and reported fewer eating disorder symptoms, dieting behaviors, and weight and appearance dissatisfaction. Interestingly, satisfied women exercised more than dissatisfied women, and weight and shape still played a primary role in their self-evaluation. Weight monitoring and appearance-altering behaviors did not differ between groups. Body satisfaction was associated with better overall functioning. This end point appears to represent effortful body satisfaction rather than passive contentment.

    View details for DOI 10.1080/08952841.2013.816215

    View details for Web of Science ID 000327927900002

    View details for PubMedID 24116991

  • Body Dissatisfaction in Women Across the Lifespan: Results of the UNC-SELF and Gender and Body Image (GABI) Studies EUROPEAN EATING DISORDERS REVIEW Runfola, C. D., Von Holle, A., Trace, S. E., Brownley, K. A., Hofmeier, S. M., Gagne, D. A., Bulik, C. M. 2013; 21 (1): 52-59


    To explore age differences in current and preferred silhouette and body dissatisfaction (current - preferred silhouette discrepancy) in women aged 25-89 years using figural stimuli [range: 1 (very small) to 9 (very large)]. Data were abstracted from two online convenience samples (N = 5868). t-tests with permutation-adjusted p-values examined linear associations between mean silhouette scores (current, preferred, discrepancy score) and age with/without stratification by body mass index (BMI). Modal current silhouette was 5; modal preferred silhouette was 4; mean discrepancy score was 1.8. There was no significant association between current silhouette and age, but a positive linear association between preferred silhouette and age remained after stratification by BMI. A significant inverse linear association of silhouette discrepancy score and age was found only prior to stratification by BMI. Body dissatisfaction exists in women across the adult life span and is influenced by BMI.

    View details for DOI 10.1002/erv.2201

    View details for Web of Science ID 000312245400009

    View details for PubMedID 22949165

  • Eating disorder symptoms and weight and shape concerns in a large web-based convenience sample of women ages 50 and above: Results of the gender and body image (GABI) study INTERNATIONAL JOURNAL OF EATING DISORDERS Gagne, D. A., Von Holle, A., Brownley, K. A., Runfola, C. D., Hofmeier, S., Branch, K. E., Bulik, C. M. 2012; 45 (7): 832-844


    Limited research exists on eating disorder symptoms and attitudes and weight and shape concerns in women in midlife to older adulthood. We conducted an online survey to characterize these behaviors and concerns in women ages 50 and above.Participants (n = 1,849) were recruited via the Internet and convenience sampling.Eating disorder symptoms, dieting and body checking behaviors, and weight and shape concerns were widely endorsed. Younger age and higher body mass index (BMI) were associated with greater endorsement of eating disorder symptoms, behaviors, and concerns.Weight and shape concerns and disordered eating behaviors occur in women over 50 and vary by age and BMI. Focused research on disordered eating patterns in this age group is necessary to develop age-appropriate interventions and to meet the developmental needs of an important, growing, and underserved population.

    View details for DOI 10.1002/eat.22030

    View details for Web of Science ID 000310271600003

    View details for PubMedID 22729743

  • Sleep problems are associated with binge eating in women INTERNATIONAL JOURNAL OF EATING DISORDERS Trace, S. E., Thornton, L. M., Runfola, C. D., Lichtenstein, P., Pedersen, N. L., Bulik, C. M. 2012; 45 (5): 695-703


    We examined the association among current self-reported sleep problems, lifetime binge eating (BE), and current obesity in women from the Swedish Twin study of Adults: Genes and Environment.Logistic regression analyses were used to evaluate these associations in 3,790 women aged 20-47 years.BE was reported by 244 (6.4%) women and was positively associated with not getting enough sleep (p < .015), sleeping poorly (p < .001), problems falling asleep (p < .001), feeling sleepy during work or free time (p < .001), and disturbed sleep (p < .001). These same sleep variables, as well as napping and being a night person, were also significantly associated with obesity. The associations between BE and sleep remained after accounting for obesity.This investigation offers empirical support for an independent association between sleep problems and BE, which is likely due to complex psychological, biological, neuroendocrine, and metabolic factors.

    View details for DOI 10.1002/eat.22003

    View details for Web of Science ID 000304993700009

    View details for PubMedID 22331832