A randomized, controlled pilot study of positive affect treatment adapted for anorexia nervosa

The current clinical approach to feeding and eating disorders aimed to increase personalization of management

Feeding and eating disorders (FEDs) are a heterogeneous grouping of disorders at the mind-body interface, with typical onset from childhood into emerging adulthood. They occur along a spectrum of disordered eating and compensatory weight management behaviors, and from low to high body weight. Psychiatric comorbidities are the norm. In contrast to other major psychiatric disorders, first-line treatments for FEDs are mainly psychological and/or nutrition-focused, with medications playing a minor adjunctive role. Patients, carers and clinicians all have identified personalization of treatment as a priority. Yet, for all FEDs, the evidence base supporting this personalization is limited. Importantly, disordered eating and related behaviors can have serious physical consequences and may put the patient's life at risk. In these cases, immediate safety and risk management considerations may at least for a period need to be prioritized over other efforts at personalization of care. This paper systematically reviews several key domains that may be relevant to the characterization of the individual patient with a FED aimed at personalization of management. These domains include symptom profile, clinical subtypes, severity, clinical staging, physical complications and consequences, antecedent and concomitant psychiatric conditions, social functioning and quality of life, neurocognition, social cognition and emotion, dysfunctional cognitive schemata, personality traits, family history, early environmental exposures, recent environmental exposures, stigma, and protective factors. Where possible, validated assessment measures for use in clinical practice are identified. The limitations of the current evidence are pointed out, and possible directions for future research are highlighted. These also include novel and emerging approaches aimed at providing more fine-grained and sophisticated ways to personalize treatment of FEDs, such as those that utilize neurobiological markers. We additionally outline remote measurement technologies designed to delineate patients' illness and recovery trajectories and facilitate development of novel intervention approaches.

Altered value-based decision-making in anorexia nervosa: A systematic review

Alterations in decision-making are considered core to anorexia nervosa (AN) phenomenology and may maintain illness through maladaptive choice behavior. This systematic review (n = 77) aimed to extend prior reviews beyond standard neuropsychological batteries by incorporating novel value-based choice tasks and computational methods. We organize findings across key factors, including: 1) illness state, 2) developmental stage, and 3) AN subtype, and highlight available neuroimaging findings. Differences in decision-making appear consistent during illness, including in weight-restored samples, but not in recovery and not in all domains. Differences are not consistently present in adolescence, although punishment sensitivity may be heightened; AN subtypes are not consistently distinguishable. Overall, decision-making varies by context and is influenced by reward/punishment processing, risk/uncertainty, and flexibility/control. Utilization of computational modeling methods, possibly increasing precision, highlight that, although raw behavior may not differ at recovery, latent decision-making processes appear impacted. Clinical interventions may benefit from consideration of context when working to shape choice behavior and from consideration of latent decision-making processes that influence how choices are made.

Reward responsivity and habit formation in the co-occurrence of restrictive eating and nonsuicidal self-injury

Dysfunctions in reward and/or habit formation have been proposed as factors contributing individually to the maintenance of restrictive eating and nonsuicidal self-injury (NSSI). However, despite the high comorbidity between these behaviors, the associations between reward and habit formation in their co-occurrence remains unclear. This study examined self-reported reward responsivity and habit strength among individuals with co-occurring restrictive eating and NSSI (Comorbid group; n = 108) and those with one behavior only (One-behavior group; n = 113). Hierarchical logistic regression analyses assessed the association between reward and habit features and the co-occurrence of restrictive eating and NSSI, accounting for the effects of impulsivity (a characteristic commonly considered to underlie co-occurring disordered eating and NSSI). Partial correlations examined the relationships between these features and the severity of eating disorder and NSSI symptoms, also controlling for impulsivity. Lower reward responsivity was associated with the co-occurrence of restrictive eating and NSSI, even after accounting for impulsivity (p = 0.017). In exploratory analyses, this relationship was no longer significant after accounting for self-reported depression. No significant associations were found regarding habit formation and restrictive eating and NSSI co-occurrence. Lower reward responsivity was linked to increased NSSI frequency and versatility in both groups and associated with severity of eating pathology in the Comorbid group (ps < 0.05). Our findings suggest that blunted reward responsivity may relate to the co-occurrence of restrictive eating, NSSI, and depressive symptoms, as well as the severity of restrictive eating and NSSI. Reward disturbances may serve as a crucial target in the treatment of multiple self-destructive behaviors.

Change in motivational bias during treatment predicts outcome in anorexia nervosa

OBJECTIVE

Reward and punishment sensitivity are known to be altered in anorexia nervosa (AN). Most research has examined these constructs separately although motivated behavior is influenced by considering both the potential for reward and risk of punishment. The present study sought to compare the relative balance of reward and punishment sensitivity in AN versus healthy controls (HCs) and examine whether motivational bias is associated with AN symptoms and treatment outcomes.

METHODS

Adolescents and adults with AN (n = 262) in a partial hospitalization program completed the Eating Disorders Examination Questionnaire (EDE-Q), Behavioral Inhibition System/Behavioral Activation System (BIS/BAS) scales, and Sensitivity to Punishment/Sensitivity to Reward Questionnaire (SPSRQ) at admission and discharge. HCs (HC; n = 90) completed the BIS/BAS and SPSRQ. Motivational Bias Scores were calculated to reflect the dominance of reward versus punishment sensitivity.

RESULTS

Individuals with AN demonstrated significantly greater bias toward punishment sensitivity than HC. In AN, a bias toward punishment was associated with higher EDE-Q Global score at admission. Change in motivational bias during treatment predicted EDE-Q Global scores, but not BMI, at discharge, with greater increases in reward sensitivity or greater decreases in punishment sensitivity during treatment predicting lower eating pathology. Similar findings were observed using the BIS/BAS and SPSRQ.

DISCUSSION

Change in motivational bias during treatment is associated with improved outcomes in AN. However, it appears that much of the change in motivational bias can be attributed to changes in punishment sensitivity, rather than reward sensitivity. Future research should examine the mechanisms underlying punishment sensitivity decreases during treatment.

PUBLIC SIGNIFICANCE

Sensitivity to reward and punishment may be important treatment targets for individuals with anorexia nervosa (AN). To date, most research has considered reward and punishment sensitivity separately, rather than examining their relationship to each other. We found that the balance of reward and punishment sensitivity (i.e., motivational bias) differs between healthy controls and those with AN and that this bias is associated with eating disorder symptoms and treatment outcome.