Could repetitive negative thinking interfere with corrective learning? The example of anorexia nervosa

Virtual food exposure with positive mood induction or social support to reduce food anxiety in anorexia nervosa: A feasibility study

OBJECTIVE

Aversive emotions toward food and the consequences of eating are at the core of anorexia nervosa. Exposure therapy is effective to reduce anxiety and avoidance toward feared stimuli. Based on the inhibitory learning framework, this study examined the feasibility to induce social support or positive mood to enhance the impact of a single session virtual food exposure on food-related anxiety in anorexia nervosa.

METHOD

One hundred and forty-five patients were randomized to: (1) virtual food exposure (i.e., baseline condition), (2) virtual food exposure plus positive mood induction (i.e., positive mood condition), or (3) virtual food exposure plus social support (i.e., social support condition). They completed self-report assessments of anxiety toward virtual foods, general anxiety, positive mood, social support, and hunger, before and after virtual food exposure. Number of eye gazes and touches toward foods were recorded during the virtual reality exposure.

RESULTS

Patients had lower levels of anxiety toward virtual foods in the positive mood condition, compared to the baseline condition [F(2,141)  = 4.36, p = .015; medium effect size]. They also touched food items more often in the baseline condition. No other significant changes were found.

DISCUSSION

Virtual food exposure enhanced by positive mood induction seems a feasible approach to strengthen the impact of food exposure in anorexia nervosa.

PUBLIC SIGNIFICANCE

This research contributes to the understanding of how patients with anorexia nervosa can be supported to overcome fear and anxiety around food. Virtual reality enables patients to expose themselves to difficult situations (e.g., kitchen with foods of various calorie contents) while experiencing positive stimuli, such as a loving and kind pet or a supportive avatar.

Mindfulness on Rumination in Patients with Depressive Disorder: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective: To systematically evaluate the effectiveness of mindfulness-based interventions (MBIs) on rumination among patients with depression and their efficacy across countries and year of publication and control conditions. Methods: Web of Science Core Collection, Medline, BIOSIS Citation Index, KCI-Korean Journal Database, SciELO Citation Index, PubMed, Cochrane Library, and Embase were searched to include randomized controlled trials of MBIs for depressive rumination that met the criteria. The Rumination Scale was used as the primary outcome indicator; Depression, mindfulness, and anxiety indexes were selected as the secondary outcome indicators. An evaluation of bias risk was conducted to identify possible sources of bias based on methodological and clinical factors. RevMan5.3 software was used to perform a meta-analysis of the extracted data. Results: Nineteen studies with 1138 patients were included. Meta-analysis showed that MBIs could significantly reduce rumination levels in patients with depression (standardized mean difference (SMD) = −0.46; 95% confidence interval (CI): −0.58, −0.34; p < 0.001), notably improve depression (SMD = −0.58; 95% CI: −0.83, −0.32; p < 0.001), enhance mindfulness ability (SMD = 0.95; 95% CI: 0.57, 1.32; p < 0.001), and reduce the anxiety of patients with depression (SMD = −0.45, 95% CI: −0.62, −0.27; p < 0.001). MBIs conducted in Asia improved rumination better than studies in Europe and North America (SMD = −2.05 95% CI: −4.08, −0.01; p < 0.001) but had no greater effect than behavior activation on depression. The interventions carried out in the past 5 years were significantly better than earlier studies in improving mindfulness levels (SMD = 2.74; 95% CI: 0.81, 4.66; p = 0.005). Conclusions: MBIs are effective in the treatment of depression as they produce pleasant improvement in rumination and depression, decrease the degree of anxiety, and enhance mindfulness levels compared to controls. In newer forms of MBIs, regional differences need to be considered when designing the intervention program. More large, high-quality randomized controlled studies are needed to confirm the conclusion that the effectiveness of MBIs has differences in terms of the trial area and year of publication.

Rumination Derails Reinforcement Learning with Possible Implications for Ineffective Behavior

How does rumination affect reinforcement learning-the ubiquitous process by which we adjust behavior after error in order to behave more effectively in the future? In a within-subject design (n=49), we tested whether experimentally manipulated rumination disrupts reinforcement learning in a multidimensional learning task previously shown to rely on selective attention. Rumination impaired performance, yet unexpectedly this impairment could not be attributed to decreased attentional breadth (quantified using a "decay" parameter in a computational model). Instead, trait rumination (between subjects) was associated with higher decay rates (implying narrower attention), yet not with impaired performance. Our task-performance results accord with the possibility that state rumination promotes stress-generating behavior in part by disrupting reinforcement learning. The trait-rumination finding accords with the predictions of a prominent model of trait rumination (the attentional-scope model). More work is needed to understand the specific mechanisms by which state rumination disrupts reinforcement learning.

Decentering predicts attenuated perseverative thought and internalizing symptoms following stress exposure: A multi-level, multi-wave study

While research identifies a growing list of risk factors for anxiety and depression, it is equally important to identify potential protective factors that may prevent or reduce vulnerability to developing internalizing psychopathology. We hypothesized that forms of perseverative thinking, such as rumination and worry, act as mechanisms linking negative life experiences and prospective symptoms of anxiety and depression. More specifically, we investigated whether decentering, the meta-cognitive capacity to adopt a distanced perspective toward one's thoughts and feelings, serves as a protective factor at various points along this mediational pathway. A sample of 181 undergraduate students were recruited and assessed at five time points over a 12-week period. Multilevel modeling indicated that decentering was associated with an attenuated impact of (1) negative events on prospective depressive symptoms; (2) negative events on prospective brooding, and (3) brooding, pondering and worry on prospective internalizing symptoms. Multilevel moderated mediation analyses provided partial support for the hypothesis that perseverative thinking would mediate the longitudinal associations between negative life events and internalizing symptoms, with decentering attenuating risk at several connections of the indirect pathways. The strongest support was provided for moderated mediation models in which decentering was associated with attenuated relationships between negative events, brooding, and symptoms of depression. This study is the first to elucidate the role of decentering as a protective factor against anxiety and depressive symptoms at different points in the path from stress to perseverative thought to internalizing symptoms. Decentering therefore may be a critical target for clinical intervention to promote resilience against anxiety and depression.

The role of rumination and positive beliefs about rumination in eating pathology

PURPOSE

General and eating disorder (ED)-specific ruminations have been identified as key factors that may contribute to eating pathology. Positive beliefs about rumination (e.g., "Ruminating helps me to prevent future mistakes") may impact this association. However, the effect of positive beliefs about rumination on the links between rumination and ED symptom severity has not been investigated. This study sought to clarify relations between rumination and ED symptom severity and to evaluate the potential moderating effect of positive beliefs about rumination on these associations.

METHODS

During a laboratory visit, undergraduate participants (N = 473, M_Age = 18.90 ± 2.27, M_BMI = 23.45 kg/m² ± 4.31, 54.8% female) completed an online battery of questionnaires assessing general and ED-specific ruminative processes (e.g., brooding, reflection), positive beliefs about rumination, and global ED symptoms. Hierarchical multiple regression analyses assessed the unique contributions of specific ruminative processes, and the moderating effect of positive beliefs on associations between ruminative processes and ED symptom severity.

RESULTS

Hierarchical multiple regression results suggest that, after controlling for gender and BMI, ED-specific brooding, b = 1.32, SE = 0.13, β = 0.46, p < 0.0001, and reflection, b = 1.44, SE = 0.33, β = 0.19, p < 0.0001, accounted for unique variance in ED symptom severity. Moderation model results indicate that, at low levels of general reflection, b = - 0.06, SE = 0.02, β = - 0.51, p = 0.003, and ED-specific reflection, b = - 0.15, SE = 0.03, β = - 0.59, p < 0.0001, increased positive beliefs about rumination were associated with greater ED symptom severity.

CONCLUSION

Findings suggest ED-specific rumination accounts for ED symptom severity above and beyond general rumination, and that rumination-related expectancies influence the association between reflection and ED symptom severity.

LEVEL OF EVIDENCE

Level III, evidence obtained from a well-designed cohort study.

The ecological validity of trait-level rumination measures among women with binge eating symptoms

PURPOSE

Cognitive rumination is a transdiagnostic construct that has been increasingly studied in the context of eating disorders (EDs). While this literature has consistently linked trait-level general and ED-specific forms of rumination to ED psychopathology, it is not clear whether trait-level measures are independently related to symptoms in daily life. Therefore, the present study used ecological momentary assessment (EMA) to assess the ecological validity of trait measures of general rumination and ED-specific rumination, and assess the degree to which ruminative brooding and reflection were differentially related to relevant momentary affective, cognitive, and behavioral processes.

METHODS

Forty women completed baseline measures (Ruminative Response Scale [RRS] and Ruminative Response Scale for Eating Disorders [RRSED]) followed by a 10-day EMA protocol.

RESULTS

Generalized estimating equations indicated trait-level ED-specific rumination was related to momentary general and ED-specific rumination, and trait-level general and ED-specific rumination were related to momentary affect and concentration difficulties. Trait-level general rumination was related to momentary self-discrepancy, while higher trait-level ED-specific rumination was related to greater loss of control eating, overeating, and body dissatisfaction. Lastly, trait levels of ruminative brooding, compared to reflection, were more consistently related to maladaptive momentary symptoms (i.e., general rumination, negative affect, concentration problems, body dissatisfaction).

CONCLUSION

Together these findings support the ecological validity of the RRSED and identify shared and unique momentary correlates of the RRS and RRSED. Results also highlight the importance of measuring and addressing trait- and state-level ruminative processes that are both general and specific to ED psychopathology in research and clinical work.

LEVEL OF EVIDENCE

Level V, observational descriptive study.

Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research

Eating disorders (EDs) and anxiety disorders (ADs) evidence shared risk and significant comorbidity. Recent advances in understanding of anxiety-based disorders may have direct application to research and treatment efforts for EDs. The current review presents an up-to-date, behavioral conceptualization of the overlap between anxiety-based disorders and EDs. We identify ways in which anxiety presents in EDs, consider differences between EDs and ADs relevant to treatment adaptions, discuss how exposure-based strategies may be adapted for use in ED treatment, and outline directions for future mechanistic, translational, and clinical ED research from this perspective. Important research directions include: simultaneous examination of the extent to which EDs are characterized by aberrant avoidance-, reward-, and/or habit-based neurobiological and behavioral processes; improvement in understanding of how nutritional status interacts with neurobiological characteristics of EDs; incorporation of a growing knowledge of biobehavioral signatures in ED treatment planning; development of more comprehensive exposure-based treatment approaches for EDs; testing whether certain exposure interventions for AD are appropriate for EDs; and improvement in clinician self-efficacy and ability to use exposure therapy for EDs.

A naturalistic investigation of cognitive-affective dysfunction in anorexia nervosa: The role of inefficiency

OBJECTIVE

Research has shown that rumination and negative affect are elevated in patients with anorexia nervosa (AN), but the underlying origins remain unclear. Drawing from the theoretical framework of the Goal Progress Theory of rumination, we propose that heightened feelings of "inefficiency" (i.e., low self-efficacy) in AN might play an important role in these dysfunctional cognitive-affective processes.

METHOD

Thirty-two weight-recovered participants with a history of AN and 32 healthy control participants filled out questionnaires regarding rumination and affect six times a day over a period of 2 weeks via ecological momentary assessment in real-life.

RESULTS

Analyses via hierarchical as well as conceptual process modeling suggest that while inefficiency is generally associated with more rumination and negative affect, additional amplifying mechanisms between these variables exist specifically in recovered participants with a history of AN.

DISCUSSION

Inefficiency as a core aspect of AN appears to trigger dysfunctional cognitive-affective processes which may contribute to vulnerability for AN.

Intolerance of uncertainty moderates the relationship between high personal standards but not evaluative concerns perfectionism and eating disorder symptoms cross-sectionally and prospectively

Two dimensions of perfectionism related to eating disorder (ED) symptoms are evaluative concerns and high standards. Evaluative concerns are consistently linked with ED symptoms, whereas there are conflicting results regarding high standards and ED symptoms. High standards are unrelated to ED symptoms in some studies and are linked to higher ED symptoms in others. Intolerance of uncertainty (IU) may influence the relation between high standards and ED symptoms; individuals elevated in both IU and high standards may find it distressing to be uncertain about future situations for fear of not living up to high expectations and use ED behaviors to cope with such uncertainty. In the current study (N = 216), we explored whether IU moderates the relationships between high standards and evaluative concerns and ED symptoms, both cross-sectionally and prospectively across two weeks. IU significantly moderated high standards and ED symptoms both cross-sectionally and across time while accounting for baseline ED symptoms, but did not moderate the relationship between evaluative concerns and ED symptoms. Higher standards were associated with greater ED symptoms in individuals higher, but not lower in IU. These findings suggest high standards may only contribute to ED symptoms when individuals are also high in IU.