Fear of negative evaluation and intolerance of uncertainty: Assessing potential internalizing correlates of eating disorder-related clinical impairment and differences across diagnostic presentations

The Hierarchical Taxonomy of Internalizing Dimensions for Eating Disorders model positions eating disorder (ED) symptoms on an internalizing dimension alongside anxiety and mood symptoms. Symptom dimensions falling under the internalizing subfactors of distress (e.g., social anxiety) and fear/avoidance (e.g., panic, compulsions, checking) may differentially guide treatment. We examined relations between fear of negative evaluation and intolerance of uncertainty (core features of social anxiety and obsessive-compulsive disorder, respectively) and ED-related impairment and potential diagnostic differences. We hypothesized that: (a) fear of negative evaluation and intolerance of uncertainty would be related to ED-related impairment, (b) the relation between fear of negative evaluation and impairment would be strongest among individuals with "binge-eating syndromes" (i.e., bulimia nervosa [BN], binge-eating disorder [BED]), and (c) the relation between intolerance of uncertainty and impairment would be strongest among individuals with "weight-phobic syndromes" (i.e., anorexia nervosa [AN], BN, atypical AN). Participants (N = 236) included children/adolescents and adults evaluated for outpatient ED treatment. Participants completed questionnaires and semi-structured diagnostic interviews. Greater fear of negative evaluation and greater intolerance of uncertainty were related to greater clinical impairment, and the strength of these relations depended on ED diagnosis. Fear of negative evaluation was related to impairment among individuals with AN and atypical AN, and intolerance of uncertainty was related to impairment for individuals with AN, BN, and atypical AN. We identified fear of negative evaluation and intolerance of uncertainty as correlates of clinical impairment, highlighting the potential utility of developing treatments to target these internalizing constructs, especially for individuals with weight-phobic syndromes.

An examination of adults with atypical anorexia nervosa at admission to treatment at higher levels of care: An attempt to increase diagnostic clarity

OBJECTIVE

Anorexia nervosa (AN) is a serious illness with a high mortality rate and multiple physiological complications. The vague definition of atypical AN allows for subjective interpretation. This retrospective study aimed to focus future research on the operational definition of atypical AN by examining four factors associated with atypical AN at admission to higher level of care treatment.

METHODS

Adults with atypical AN (n = 69) were examined within sample analyses among four groups: (1) >10% versus ≤10% weight loss; (2) weight loss within the previous 3 months versus >3 months; (3) engaging in purging behaviors versus absence of purging behaviors; and (4) endorsing versus not endorsing significant cognitive aspects of AN.

RESULTS

Patients with atypical AN endorsed elevated ED cognitions on the Eating Disorder Examination-Questionnaire and depressive symptoms; a lack of association was found between weight loss severity and weight loss time frame with depressive symptoms, eating concern, and restraint. Purging behavior was associated with a higher expected body weight percentage (%EBW) and dietary restraint, while greater AN cognitions were associated with a higher EBW and weight loss percentage. Few patients demonstrated bradycardia, hypophosphatemia, or amenorrhea.

DISCUSSION

This study demonstrated the severity of ED cognitions and depressive symptoms in this atypical AN sample and provided directions for future studies in the nosology of atypical AN. It may be important to distinguish between individuals with atypical AN who are purging and those who are not. Atypical AN was associated with a low frequency of physiological disturbances.

PUBLIC SIGNIFICANCE

This study provides further clarification regarding the operational definition of atypical AN; currently, a constellation of symptoms under Other Specified Feeding or Eating Disorders. This study was consistent with previous research in reporting severe eating disorder cognitions in adults with atypical AN, and noted the potential importance of distinguishing a purging distinction. A minority of patients in this study had physiological impairments.

Psychiatric medication use by Canadian adults prior to entering an outpatient eating disorders program: Types and combinations of medications, predictors of being on a medication, and clinical considerations

This study examined the proportion of Canadian adults who were on psychiatric medication prior to entering specialized outpatient care for an eating disorder, the types and combinations of medications taken, and predictors of being on a medication. A retrospective chart review of 223 adults with an eating disorder was conducted. A large proportion of the adults (61%) had been prescribed a psychiatric medication prior to entering specialized outpatient care. Of these adults, 74.6% were prescribed one medication and 24.3% were on a combination of two or more. Antidepressant and anti-anxiety medications were the most commonly prescribed (78%), while stimulant medications (2.1%), benzodiazepines (13.7%), and antipsychotics (10.7%) were also reported. Being at a higher weight status was a significant predictor of being on a psychiatric medication at intake assessment. Adults with comorbid depression were 2.68 times more likely to be on a psychiatric medication. Although the number of Canadian adults on psychiatric medication may well exceed the documented efficacy of these medications for eating disorders, psychopharmacological intervention could have been aimed at targeting comorbid conditions. Clinicians specializing in pharmacology and eating disorders may have an important role to provide psychoeducation to all providers.

Differences in severity of eating disorder symptoms between adults with depression and adults with anxiety

OBJECTIVES

Anxiety and depression are both considered maintaining factors for eating disorders (ED) but it is still unclear if one is more strongly associated with ED symptoms than the other. We examined differences in severity of ED symptoms among adults with either, both, or neither depression and anxiety.

METHODS

Volunteers (N = 3,780) to the project implicit mental health website ( https://implicit.harvard.edu/ ) self-reported their ED status (current ED: n = 374, past ED: n = 436; no ED: n = 2,970), their current depression/anxiety status, and their ED symptoms (using the Eating Attitudes Test). ANOVAs with post hoc comparisons were used to examine relationships between ED symptoms and comorbid depression/anxiety status among currently ill, recovered, and never ill individuals.

RESULTS

Participants without comorbidities had the least and participants with both comorbidities had the most severe ED symptoms (p = .021). Participants with anxiety alone had more severe ED symptoms relative to those with depression alone across groups (current ED: p = .024; past ED: p = .019; no EDs: p = .021).

DISCUSSION

These findings demonstrate, in contrast with an earlier study among youth with EDs (Hughes et al., 2013), that comorbid anxiety may be linked with more severe ED symptoms relative to comorbid depression. It is possible that anxiety serves as a maintaining factor for ED symptoms such that dieting and other ED-related behaviors may function to modulate symptoms of anxiety.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Depression, Anxiety and Eating Disorder-Related Impairment: Moderators in Female Adolescents and Young Adults

Adolescents and young adults, particularly females, are highly vulnerable to the development of anxiety disorders, depression, and eating disorders. Comorbid anxiety disorder or depression in eating disorders are associated with greater symptom severity, poorer prognosis, and burden of illness. Nonetheless, studies on what affects the relationship between anxiety, depression, and eating disorders in female at-risk samples are scarce. Using hierarchical linear modeling, the present study examined potential moderators to explain between-person differences in the association between anxiety, depression, and eating disorder-related impairment within 12- to 25-year-old females (N = 320). High impairment in anxiety/depression was associated with more severe eating disorder symptoms. Older age as well as greater impairment in mood dysregulation, self-esteem, and perfectionism were linked to more severe eating disorder symptomatology. Whereas mood dysregulation, self-esteem, and perfectionism had no statistically significant moderating effects, younger age appeared to augment the association of anxiety/depression and eating disorder symptomatology. Preventive care in particular needs to consider age-related effects as eating disorder symptoms are associated more strongly with symptoms of anxiety and depression in early adolescence.

Affective predictors of the severity and change in eating psychopathology in residential eating disorder treatment: The role of social anxiety

Despite evidence documenting relationships between eating disorder (ED) psychopathology, depression, and anxiety, little is known regarding how social anxiety is related to ED symptoms in treatment. Therefore this study examined associations between depression, general anxiety, social anxiety, and ED psychopathology at the beginning and end of treatment (EOT) among patients (N = 380) treated in a residential ED program. Participants completed measures of ED psychopathology and affective variables. Higher depression and general anxiety, but not social anxiety, were related to higher ED psychopathology at baseline. However, social anxiety emerged as a unique predictor of ED psychopathology at EOT such that participants with higher social anxiety evidenced less improvement in ED psychopathology. Findings suggest that social anxiety has specific relevance to treatment in EDs, which may reflect shared mechanisms and underlying deficits in emotion regulation.

Predictors of short-term outcome variables in hospitalised female adolescents with eating disorders

OBJECTIVE

Research in eating disorders (EDs) suggests that outcome variables other than that of the ED per se, such as the presence of comorbid disorders and overall functioning at follow-up, may influence the ED condition at that time. We sought to assess the factors potentially predicting these different outcome variables.

METHODS

Eighty-eight female adolescent in-patients with an ED were assessed on admission, discharge, and around one-year post-discharge using clinical interviews and self-rating questionnaires assessing ED and other relevant symptoms.

RESULTS

The mean body mass index (BMI) of patients with anorexia nervosa increased from admission to discharge and was maintained at follow-up. Twenty-eight patients were remitted at follow-up, whereas 48 and 12 patients had intermediate and poor ED-related outcome, respectively. Follow-up BMI was correlated with baseline BMI. Good ED-related outcome at follow-up according to accepted criteria was associated with more lifetime suicide attempts and more severe baseline ED symptomatology. Elevated psychiatric comorbidity at follow-up was associated with elevated baseline anxiety and with re-hospitalisation during the post-discharge follow-up period. Better academic/occupational functioning and social functioning at follow-up were associated with less lifetime suicide attempts, less re-hospitalisation and lower baseline anxiety.

CONCLUSIONS

In EDs, diverse factors may predict different outcome variables.

Sex differences in motivational responses to dietary fat in Syrian hamsters

Women are more likely than men to exhibit motivational disorders (e.g., anhedonia and anxiety) with limited treatment options, and to overconsume high-fat "comfort foods" to improve motivational disruptions. Unfortunately, neurobiological underpinnings for sex differences in motivational disruptions and their responses to dietary fat are poorly understood. To help bridge these fundamental knowledge gaps, we assessed behavioral and neurobiological responses to dietary fat in a hamster model of female-biased motivational lability. Relative to social housing, social separation reduced hedonic drive in a new behavioral assay, the reward investigational preference (RIP) test. Fluoxetine or desipramine treatment for 21, but not 7, days improved RIP test performance. Pharmacologic specificity in this test was shown by non-responsiveness to diazepam, tracazolate, propranolol, or naltrexone. In the anxiety-related feeding/exploration conflict (AFEC) test, social separation worsened latency to eat highly palatable food under anxiogenic conditions, but not in home cages. Social separation also reduced weight gain, food intake, and adiposity while elevating energy expenditure, assessed by caloric efficiency and indirect calorimetry. Furthermore, chronic high-fat feeding improved anhedonic and anxious responses to separation, particularly in females. In the motivation-influencing nucleus accumbens, females, but not males, exhibited a separation-induced anxiety-related decrease in Creb1 mRNA levels and an anhedonia-related decrease in ΔFosb mRNA levels. Consistent with its antidepressant- and anxiolytic-like effects on behavior, high-fat feeding elevated accumbal Creb1 and ΔFosb mRNA levels in females only. Another accumbal reward marker, Tlr4 mRNA, was elevated in females by high-fat feeding. These results show that social separation of hamsters provides a novel model of sex-dependent comorbid anhedonia, anxiety, and anorexia, and implicate accumbal CREB, ΔFosB, and TLR4. Moreover, the results validate a new assay for chronic antidepressant efficacy.