Emotional processing following recovery from anorexia nervosa

"Don't talk to me like I am an illness": exploring patients' needs using the communication passport in an eating disorder service

PURPOSE

Social challenges are common in patients with eating disorders (ED). The presence of autistic characteristics often exacerbates social difficulties within this group, potentially affecting treatment outcomes. This study investigates the communication preferences, challenges, dislikes, and support needs of patients with ED, both with and without autistic traits, using a communication passport in a national inpatient ED service.

METHODS

An explorative qualitative analysis of 38 completed communication passports was conducted to investigate patients' communication preferences, sensory needs, struggles and dislikes, and areas of support required, paying particular attention to the distinct needs of patients with high levels of autistic traits.

RESULTS

The communication passport provided valuable insights into patients' communication preferences, sensory sensitivities, challenges, and support needed. Patients also used the passports to share information about their strengths, personal identity, and life beyond the hospital.

CONCLUSION

The communication passport fosters a deeper understanding of patients' needs and may support clinicians in care planning and communication strategies tailored to each patient's needs. Regular evaluation and updates are warranted to ensure its usability and accessibility by the wider care team.

ADRA2B and HTR1A: An Updated Study of the Biogenic Amine Receptors Reveals Novel Conserved Motifs Which Play Key Role in Mental Disorders

Mental disorders are strongly connected with several psychiatric conditions including depression, bipolar disorder, schizophrenia, eating disorder, and suicides. There are many biological conditions and pathways that define these complicated illnesses. For example, eating disorders are complex mental health conditions that require the intervention of geneticists, psychiatrists, and medical experts in order to alleviate their symptoms. A patient with suicidal ideation should first be identified and consequently monitored by a similar team of specialists. Both genetics and epigenetics can shed light on eating disorders and suicides as they are found in the main core of such investigations. In the present study, an analysis has been performed on two specific members of the GPCR family toward drawing conclusions regarding their functionality and implementation in mental disorders. Specifically, evolutionary and structural studies on the adrenoceptor alpha 2b (ADRA2B) and the 5-hydroxytryptamine receptor 1A (HTR1A) have been carried out. Both receptors are classified in the biogenic amine receptors sub-cluster of the GPCRs and have been connected in many studies with mental diseases and malnutrition conditions. The major goal of this study is the investigation of conserved motifs among biogenic amine receptors that play an important role in this family signaling pathway, through an updated evolutionary analysis and the correlation of this information with the structural features of the HTR1A and ADRA2B. Furthermore, the structural comparison of ADRA2B, HTR1A, and other members of GPCRs related to mental disorders is performed.

The Role of Emotion Regulation in Eating Disorders: A Network Meta-Analysis Approach

Background

Previous theoretical models and reviews have documented a strong connection between emotion dysregulation eating disorder (ED) psychopathology among the general and clinical populations. The aim of this review was to build on this previous work by conducting a network meta-analysis to explore associations between adaptive and maladaptive emotion regulation strategies and ED psychopathology trans-diagnostically across the ED spectrum to identify areas of emotion dysregulation that have the strongest association with symptomatology.

Methodology

A total of 104 studies were included in the meta-analysis and correlation coefficient representing the associations between specific emotion regulation strategies and ED symptomatology were extracted. We ran a Bayesian random effects network meta-analysis and the initial network was well-connected with each emotion regulation strategy being linked to at least one other strategy. We also conducted a network meta-regression to explore whether between-study differences in body mass index (BMI), age, and whether the sample consisted of solely female participants explained any possible network inconsistency.

Results

The network meta-analysis revealed that ruminations and non-acceptance of emotions were most closely associated with ED psychopathology. There was no significant network inconsistency but two comparisons approached significance and thus meta-regressions were conducted. The meta-regressions revealed a significant effect of BMI such that the associations between different emotion regulation strategies and ED symptomatology were weaker among those with low BMI.

Discussion

The present findings build on previous work and highlight the role of rumination and difficulties with accepting emotions as key emotion regulation difficulties in EDs. Additionally, the finding that the associations were weaker among ED patients with low BMI may point toward a complex relationship between ED behaviors and emotion regulation. Taken together, our findings call for interventions that target emotion regulation, specifically rumination and difficulties accepting emotions, in the treatment of EDs.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021249996, PROSPERO, identifier: CRD42021249996.

Intact neural and behavioral correlates of emotion processing and regulation in weight-recovered anorexia nervosa: a combined fMRI and EMA study

Altered emotion processing and regulation mechanisms play a key role in eating disorders. We recently reported increased fMRI responses in brain regions involved in emotion processing (amygdala, dorsolateral prefrontal cortex) in acutely underweight anorexia nervosa (AN) patients while passively viewing negatively valenced images. We also showed that patients' ability to downregulate activity elicited by positively valenced pictures in a brain region involved in reward processing (ventral striatum) was predictive of worse outcomes (increased rumination and negative affect). The current study tries to answer the question of whether these alterations are only state effects associated with undernutrition or whether they constitute a trait characteristic of the disorder that persists after recovery. Forty-one individuals that were weight-recovered from AN (recAN) and 41 age-matched healthy controls (HC) completed an established emotion regulation paradigm using negatively and positively valenced visual stimuli. We assessed behavioral (arousal) and fMRI measures (activity in the amygdala, ventral striatum, and dorsolateral prefrontal cortex) during emotion processing and regulation. Additionally, measures of disorder-relevant rumination and affect were collected several times daily for 2 weeks after scanning via ecological momentary assessment. In contrast to our previous findings in acute AN patients, recAN showed no significant alterations either on a behavioral or neural level. Further, there were no associations between fMRI responses and post-scan momentary measures of rumination and affect. Together, these results suggest that neural responses to emotionally valenced stimuli as well as relationships with everyday rumination and affect likely reflect state-related alterations in AN that improve following successful weight-recovery.

Social cognition in female adults with Anorexia Nervosa: A systematic review

Deficits in interpersonal and social functioning are well established in females with Anorexia Nervosa (AN), and are thought to be key features involved in the onset and maintenance of the disease. Growing literature suggests these may be attributed to poor social cognitive processes. This systematic review evaluates whether differences in social cognition exist in adult females with AN. A total of 32 studies that compared females with AN against a healthy control group using social cognitive measures and/or questionnaires were analysed. The majority of studies were deemed to have a low or moderate risk of bias. Overall, empathy appears to be intact in AN, however greater emotion regulation difficulties, elevated alexithymia and reduced emotional awareness are evident in AN. Findings relating to emotion recognition and emotional Theory of Mind were inconsistent. The nature of the task appeared to influence the domains of cognitive ToM and social perception, warranting further research. These findings are discussed within the broader context of social cognitive models and AN rehabilitation.

Emotional processing in recovered anorexia nervosa patients: A 15 year longitudinal study

OBJECTIVE

This 15 years longitudinal study aimed to examine whether difficulties in cognitive processing of emotions persisted after long-term recovery from anorexia nervosa (AN), and its link to anxiety and depression.

METHOD

Twenty-four females, who were tested longitudinally during their acute and recovered AN phases, and 24 healthy control (HC) women, were screened for anxiety, depression, alexithymia, emotion regulation difficulties (ER; only assessed in recovery phase), and completed an experimental task to analyse emotional experience.

RESULTS

In spite of significant improvement in alexithymia, anxiety, and depression with AN recovery, some emotion functioning difficulties did not normalize. The occurrence of comorbid anxiety and depression explained the reduced ability to identify, understand, and accept emotions in long-term recovery (relative to controls), but not the increased global difficulty in using ER strategies, which revealed a more stable nature of deficit. With recovery, negative emotions linked to situations addressing food and body weight are felt more intensely.

CONCLUSIONS

Managing emotions, especially the negative ones, remains a challenge for individuals recovered from AN. Under this circumstance, maladaptive eating behaviour can serve as an affect regulatory function, increasing the risk of relapse. Emotional education is an important avenue in protecting long-term AN relapse.

The Relationship between Emotional Intelligence, Obesity and Eating Disorder in Children and Adolescents: A Systematic Mapping Review

Eating and weight disorders often develop early in life and cause a long-standing significant health burden. Given the documented role of emotional intelligence (EI) in shaping the body image and predicting the onset of eating disorders, knowledge of the mechanisms involved in EI among youth is fundamental to designing specific interventions for screening and prevention of obesity and eating disorders (EDs). The present systematic mapping review was aimed to explore and quantify the nature and distribution of existing research investigating the impact of EI on EDs in young people. A systematic search for relevant articles was conducted using PubMed, Scopus, PsycINFO and Web of Science databases. The Appraisal tool for Cross-Sectional Studies (AXIS) was used to assess the included studies’ methodological quality. The included studies’ results were mapped based on stratification by age groups (children, preadolescents, and adolescents), population (clinical vs. non-clinical) and disordered eating outcomes. Nine studies were included, supporting the association between EI and body image dissatisfaction, ED risk and bulimic symptomatology, but not with anorexic symptoms. Research on children and clinical populations was scant. Further studies are needed to deepen the role of EI in the genesis and maintenance of EDs.

'Silencing the self' and women's mental health problems: A narrative review

In the context of women's mental health several propositions have been made to account for their increased susceptibility to certain psychiatric illnesses. However, given the topic's multifacetedness, no single explanation is found sufficient in itself. 'Silencing the Self' theory sheds new light on this issue because it acknowledges the importance of social and cultural processes. Besides with its relational perspective, it centers on the primacy of core relationships and its influence on a woman's mental health. Even though, since its inception three decades ago, the theory has been studied in relation to various psychological and physical disorders; it has hitherto received inadequate attention by scholars. Nonetheless, it has the potential to inform our understanding when formulating women's mental health issues. The aim of this review is to provide a comprehensive narrative account of the extant work on 'silencing the self' in relation to psychiatric illnesses like depression, eating disorder and premenstrual dysphoric disorder. It attempts to synthesize the work done till date, as a starting point for further investigation of unexamined areas.

Eating disorders

Eating disorders are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning. Disturbed attitudes towards weight, body shape, and eating play a key role in the origin and maintenance of eating disorders. Eating disorders have been increasing over the past 50 years and changes in the food environment have been implicated. All health-care providers should routinely enquire about eating habits as a component of overall health assessment. Six main feeding and eating disorders are now recognised in diagnostic systems: anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant-restrictive food intake disorder, pica, and rumination disorder. The presentation form of eating disorders might vary for men versus women, for example. As eating disorders are under-researched, there is a great deal of uncertainty as to their pathophysiology, treatment, and management. Future challenges, emerging treatments, and outstanding research questions are addressed.

Emotion regulation across eating pathology: A meta-analysis

The goal of this meta-analysis was to examine the associations between specific emotion regulation abilities (emotional awareness, emotional clarity) and strategies (acceptance of emotions, reappraisal, problem-solving, rumination, avoidance of emotions, and suppression), and eating pathology. A total of 96 studies and 239 effect sizes were included in the analysis. Relations between global and specific emotion regulation abilities and strategies and eating disorders and eating-related symptoms were examined. Results indicated medium-to-large effect sizes for the associations between adaptive emotion regulation and eating disorder and eating-related symptoms, and medium-to-large effect sizes for the associations between maladaptive emotion regulation and eating disorders and eating-related symptoms. In terms of specific emotion regulation strategies, large magnitude of associations were identified for the relations between lack of emotional awareness, clarity, acceptance, reappraisal, problem-solving, and eating disorders. Rumination, avoidance of emotions, and suppression also showed large associations with anorexia nervosa and bulimia nervosa. Overall, emotion regulation did not differ across eating disorders, a finding supporting the transdiagnostic character of emotion regulation problems in eating pathology. These findings have important theoretical and practical implications for prevention and intervention programs.

Residual eating disorder symptoms and clinical features in remitted and recovered eating disorder patients: A systematic review with meta-analysis

OBJECTIVE

In psychiatry, the presence of residual symptoms after treatment is linked to the definitions of remission and recovery. To identify the presence of residual eating disorder (ED) symptoms and associated non-ED clinical features in remitted and recovered EDs, the current systematic review with meta-analysis was performed.

METHOD

A systematic review was conducted on residual ED symptoms and non-ED clinical features including comorbid psychopathology, neurophysiological functioning, cognitive functioning, and quality of life in ED patients considered remitted or recovered. To examine residual ED symptoms, meta-analyses were performed while considering age, study quality, remission, and recovery criteria strictness as moderators. Sensitivity, publication bias, and heterogeneity analyses were also conducted.

RESULTS

The 64 studies selected for the systematic review underscored the presence of residual ED symptoms in anorexia nervosa (AN) and bulimia nervosa (BN), and impairments and deficits in the additional features examined. From the 64 studies, 31 were selected regarding residual ED symptoms in AN for meta-analysis. Large effect sizes indicated that remitted/recovered AN patients reported significantly lower body mass index (Hedges' g = -0.62[-0.77, -0.46]) and significantly greater symptomatology in terms of ED examination-questionnaire (Hedges'g = 0.86 [0.48,1.23]) and ED inventory (Hedges' g = 0.94[0.64,1.24]) than healthy controls, independently of remission and recovery criteria strictness, age, and study quality.

DISCUSSION

The presence of residual ED symptoms in AN is quantitatively supported, whereas the presence of residual ED symptoms in BN should be further investigated. Data on binge-eating disorder are missing. Future research should use consistent, multicomponent, and standardized comparable indicators of recovery.

'The body is a battleground for unwanted and unexpressed emotions': exploring eating disorders and the role of emotional intelligence

Emotional difficulties have been observed in individuals with eating disorders across awide range of studies, including poor interoceptive awareness, confusion of emotional states and difficulties with emotional language. Literature has linked these difficulties with emotional functioning as being an important factor related to the core aetiology ofeating disorders, however limited knowledge exists to how this impacts on professionalability to engage patients within treatment as a result of such dysfunction. Using aqualitative design this paper explores how facets of Emotional intelligence (EI) are related to the experience of an eating disorder. The study sampled a total of 32 participants with either a professional background working with eating disorders (n=27)or participants with personal lived experience (n=5), with a number of the participants (n=13) identified as having dual roles. The findings of the study show that aspects of EIsuch as emotional regulation and lack of an emotional language are considered to beat the core of the onset and maintenance of these disorders. Additional aspects of emotional awareness and expression were found to be related to treatment disengagement and difficulties. Building on previous literature, this paper found suchemotional deficits as a transdiagnostic issue rather than specifically anorexia nervosa. Furthermore, such dysfunction was seen by professionals to have a considerable impact on therapeutic relationships and successful treatment. These findings provide insight into the potential applications that EI may have in addressing aspects of theeating disorder to create better outcomes for treatment and intervention models.

Alexithymia and Treatment Outcome in Anorexia Nervosa: A Scoping Review of the Literature

Alexithymia is of great interest as an outcome predictor of recovery from anorexia nervosa, since it may interfere with both treatment compliance and patients' ability to benefit from the adopted interventions. For this reason, in the last years new treatment approaches targeting emotion identification, expression, and regulation have been applied and tested. Using the PRISMA methodology, we performed a scoping review of the literature about treatment outcome in anorexia nervosa, in terms of changes in alexithymia as assessed by its most commonly used self-report measure, the Toronto Alexithymia Scale (TAS). The Medline and Scopus databases were searched, and articles were included if matching the following criteria: dealing with patients affected by anorexia nervosa, without limits of age; involving the application of any kind of targeted therapy or treatment; assessing alexithymia and the effect of a treatment intervention on alexithymia, using the TAS. Ten studies were eventually included; overall, according to the selected studies, alexithymia levels often remain high even after specific treatment. Further research aimed at a deeper understanding of the actual impact of alexithymia on the outcome of anorexia, as well as exploring alternative treatment strategies for alexithymia in eating disorders (EDs), are warranted.

Are socio-emotional and neurocognitive functioning predictors of therapeutic outcomes for adults with anorexia nervosa?

BACKGROUND

Emotional, social, and neurocognitive factors are theorised to maintain anorexia nervosa (AN). Yet whether they predict outcomes or relate to clinical change remains unclear.

METHODS

Seventy-one consecutive adult outpatient eating disorder service referrals presenting with AN, who participated in a randomised controlled trial comparing 2 psychotherapies, were assessed for emotional processing, social cognition, and neurocognition pretherapy and posttherapy. Intention-to-treat analysis employed maximum-likelihood methods to model missing data. Baseline self-reported emotional processing, social cognitive, or neurocognitive task performance was entered into forward stepwise regression models with posttreatment clinical outcomes (weight, eating disorder psychopathology, psychosocial functioning) as dependent variables. Correlation analyses examined relationships between clinical and self-report/task score change.

RESULTS

Self-reported emotional avoidance (behavioural/cognitive avoidance, low acceptance) and submissive behaviour predicted clinical outcomes. Social cognitive (emotion recognition, emotional theory of mind) and neurocognitive performance (set-shifting, detail focus) had limited predictive ability.

CONCLUSIONS

Emotional avoidance and submissiveness may represent maintenance factors for AN.

Clinicians' views on working with anorexia nervosa and autism spectrum disorder comorbidity: a qualitative study

BACKGROUND

Anorexia nervosa (AN) and autism spectrum disorder (ASD) form a relatively common comorbidity, with poorer illness outcomes and poorer responses to treatments for AN compared to individuals without ASD. However, the treatment of this comorbidity remains poorly understood: no research to date has examined how clinicians currently approach treating AN/ASD. This study aimed to explore the experiences of clinicians working with comorbid AN/ASD using qualitative methods in order to identify areas for future improvement.

METHODS

Interviews with individual clinicians (n = 9) were carried out and explored using thematic analysis.

RESULTS

The findings suggest that many clinicians lack confidence in treating this comorbidity, which requires specific changes to treatment to accommodate the issues raised by comorbid ASD. At present, any adaptations to treatment are based on the previous experience of individual clinicians, rather than representing a systematic approach.

CONCLUSIONS

Further research is needed to empirically assess potential treatment modifications for this group and to establish guidelines for best clinical practice.

Perception of Peripersonal and Interpersonal Space in Patients with Restrictive-type Anorexia

This study examines whether the perception of peripersonal action-space and interpersonal social-space is modified in patients with restrictive-type anorexia in two experimental conditions using videos. First, participants stopped the video of an approaching stimulus when they felt the distance to be comfortable for interacting with it (first-person perspective). Second, participants stopped the video when an observed individual approaching a stimulus, or being approached by it, was at a comfortable distance (third-person perspective). In the first-person perspective, the results showed an estimation of peripersonal space that did not differ from controls when an object was approaching and an increase in interpersonal space compared with controls when a male or female individual was approaching. In the third-person perspective, both individual-object and individual-individual distances were larger in anorexic patients. These results indicate a specific deficit in adjusting interpersonal distances in both the first-person and third-person perspectives. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Effects of Intranasal Oxytocin on the Interpretation and Expression of Emotions in Anorexia Nervosa

Altered social-emotional functioning is considered to play an important role in the development and maintenance of anorexia nervosa (AN). Recently, there has been increasing interest in investigating the role of intranasal oxytocin in social-emotional processing. The present study aimed to investigate the effects of intranasal oxytocin on the interpretation and expression of emotions among people with AN. Thirty women with AN and 29 age-matched healthy women took part in the present study, which used a double-blind, placebo-controlled, cross-over design. The participants received a single dose of 40 IU of intranasal oxytocin in one session and a placebo spray in the other. Fifteen minutes after administration, the participants completed the Reading the Mind in the Eyes Test to assess the interpretation of complex emotions and mental states followed by a video task, which assessed expressions of facial affect when they were viewing humorous and sad film clips. The intranasal oxytocin did not significantly influence the expression or interpretation of emotions in the AN or healthy comparison groups. The AN group expressed significantly less positive emotion, spent more time looking away and reported experiencing a significantly more negative affect in response to the film clips. The finding that intranasal oxytocin had little to no effect on the interpretation or expression of emotions in either group supports the notion that the effects of oxytocin on social-emotional processing are not straightforward and may depend on individual and environmental differences, as well as the emotion being processed. Replication of these findings is necessary to explore the effect of timing on the effects of oxytocin before firm conclusions can be drawn. Nonetheless, these findings add to the steady accumulation of evidence that people with AN have reduced emotional expression and avoidance of emotionally provoking stimuli.

Emotion-focused treatments for anorexia nervosa: a systematic review of the literature

PURPOSE

The present review explores emotion-focused treatments for anorexia nervosa (AN).

METHODS

We conducted a systematic literature search across key databases (PsychINFO, PubMed/Medline, and Web of Science) prior to September 2015. Twenty studies were selected for systematic review.

RESULTS

The present review found initial evidence supporting the acceptability and feasibility of emotion-focused treatments for AN. Although preliminary results are promising, further controlled studies are necessary to establish the efficacy of emotion-focused treatments for AN.

CONCLUSIONS

Future controlled trials should compare emotion-focused treatments against each other and against other AN treatments. Future studies should also examine the mechanisms of action for the emotion-focused treatments and treatment moderators.

Diminished facial emotion expression and associated clinical characteristics in Anorexia Nervosa

This study aimed to investigate emotion expression in a large group of children, adolescents and adults with Anorexia Nervosa (AN), and investigate the associated clinical correlates. One hundred and forty-one participants (AN=66, HC= 75) were recruited and positive and negative film clips were used to elicit emotion expressions. The Facial Activation Coding system (FACES) was used to code emotion expression. Subjective ratings of emotion were collected. Individuals with AN displayed less positive emotions during the positive film clip compared to healthy controls (HC). There was no significant difference between the groups on the Positive and Negative Affect Scale (PANAS). The AN group displayed emotional incongruence (reporting a different emotion to what would be expected given the stimuli, with limited facial affect to signal the emotion experienced), whereby they reported feeling significantly higher rates of negative emotion during the positive clip. There were no differences in emotion expression between the groups during the negative film clip. Despite this individuals with AN reported feeling significantly higher levels of negative emotions during the negative clip. Diminished positive emotion expression was associated with more severe clinical symptoms, which could suggest that these individuals represent a group with serious social difficulties, which may require specific attention in treatment.

Intact social cognitive processes in outpatients with anorexia nervosa: a pilot study

OBJECTIVE

The aim of the study was to assess social cognition in community patients suffering from anorexia nervosa (AN) compared to healthy controls.

METHODS

25 women diagnosed with AN and 25 women matched for education level and age were involved in the study. Both subject groups were assessed using a set of validated experimental tasks, such as the facial expression recognition test, short recognition memory test for faces, 'Reading the mind in the eyes' test. Patients were assessed for symptoms of: eating disorder (the eating attitudes test-EAT-26), OCD (the Yale-Brown obsessive compulsive scale-Y-BOCS) and depression (Beck depression inventory-BDI). The research hypothesis indicated that patients suffering from anorexia represent no significant difference in social cognitive functioning in comparison to the healthy controls. These assessment scales were used to identify whether there are any problems according to social cognitive functioning especially emotion recognition and theory of mind (ToM). The primary outcome assessment was to identify social cognitive deficits in anorexic outpatients and secondary outcome was to verify whether these problems in emotional functioning found in women in acute phase of AN are state or trait effects.

RESULTS

Anorexic patients showed significantly higher scores on EAT-26, BDI and Y-BOCS. No significant differences were found in performance of social cognitive tests and facial perception test.

DISCUSSION

No marked alterations were found in social cognitive functioning in community patients with average body mass index (BMI) of 17.6. This may indicate that social cognition is a very complex construct to be reliably measured in anorexia nervosa considering relatively limited psychometric data for many social cognitive tasks. Further longitudinal studies are needed to untangle ongoing controversy whether social cognitive deficits in AN could be state or trait related.

Initial test of an emotional avoidance model of restriction in anorexia nervosa using ecological momentary assessment

It has been hypothesized that restrictive eating allows individuals with anorexia nervosa (AN) to avoid contact with negative emotions; however, this presumption has not been directly tested. In this study, we conducted an initial investigation examining whether restrictive eating serves an emotional avoidance function among individuals with AN. Females with AN (n = 118) reported on negative and positive affect, anxiety/tension, and eating behaviors at multiple time points daily over a 2-week period using ecological momentary assessment methodology. Affective patterns were compared using generalized estimating equation models between days in which participants reported either: (1) relatively high restriction (without binge eating); (2) relatively low restriction (without binge eating); (3) binge eating; or (4) no restriction or binge eating. We hypothesized that, if restriction were functioning to avoid negative affect, average negative affect and anxiety/tension, as well as average negative and positive affect lability, would be lower and average positive affect would be higher on days characterized by high levels of restriction compared to other eating patterns. Contrary to hypotheses: (1) average negative affect, anxiety/tension, and positive affect were not significantly different between days characterized by high restriction and those characterized by low or no restriction; (2) Negative affect and anxiety/tension lability were higher on days characterized by high restriction compared to no restriction or binge eating days; (3) Anxiety/tension lability was higher on days characterized by high versus low levels of restriction. This patterns of findings does not support an avoidance model of restrictive eating for individuals with AN.

Emotional Processing, Recognition, Empathy and Evoked Facial Expression in Eating Disorders: An Experimental Study to Map Deficits in Social Cognition

BACKGROUND

Difficulties in social cognition have been identified in eating disorders (EDs), but the exact profile of these abnormalities is unclear. The aim of this study is to examine distinct processes of social-cognition in this patient group, including attentional processing and recognition, empathic reaction and evoked facial expression in response to discrete vignettes of others displaying positive (i.e. happiness) or negative (i.e. sadness and anger) emotions.

METHOD

One hundred and thirty-eight female participants were included in the study: 73 healthy controls (HCs) and 65 individuals with an ED (49 with Anorexia Nervosa and 16 with Bulimia Nervosa). Self-report and behavioural measures were used.

RESULTS

Participants with EDs did not display specific abnormalities in emotional processing, recognition and empathic response to others' basic discrete emotions. However, they had poorer facial expressivity and a tendency to turn away from emotional displays.

CONCLUSION

Treatments focusing on the development of non-verbal emotional communication skills might be of benefit for patients with EDs.

Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A conceptual review of the empirical literature

Several existing conceptual models and psychological interventions address or emphasize the role of emotion dysregulation in eating disorders. The current article uses Gratz and Roemer's (2004) multidimensional model of emotion regulation and dysregulation as a clinically relevant framework to review the extant literature on emotion dysregulation in anorexia nervosa (AN) and bulimia nervosa (BN). Specifically, the dimensions reviewed include: (1) the flexible use of adaptive and situationally appropriate strategies to modulate the duration and/or intensity of emotional responses, (2) the ability to successfully inhibit impulsive behavior and maintain goal-directed behavior in the context of emotional distress, (3) awareness, clarity, and acceptance of emotional states, and (4) the willingness to experience emotional distress in the pursuit of meaningful activities. The current review suggests that both AN and BN are characterized by broad emotion regulation deficits, with difficulties in emotion regulation across the four dimensions found to characterize both AN and BN, although a small number of more specific difficulties may distinguish the two disorders. The review concludes with a discussion of the clinical implications of the findings, as well as a summary of limitations of the existing empirical literature and suggestions for future research.

Emotion generation and regulation in anorexia nervosa: a systematic review and meta-analysis of self-report data

This systematic review sought to examine the generation and regulation of emotion in people with Anorexia Nervosa (AN). Key databases (Medline, Embase, PsychINFO and Web of Science) were searched for peer-reviewed articles published by March 2015 yielding 131 studies relevant to emotion generation and emotion regulation (ER) processes as defined by Gross (1998). Meta-analyses determined pooled group differences between AN and healthy control (HC) groups. More maladaptive schemata were reported by people with AN than HCs, with largest pooled effects for defectiveness/shame (d=2.81), subjugation (d=1.59) and social isolation (d=1.66). Poorer awareness of and clarity over emotion generated and some elevated emotionality (disgust and shame) were reported. A greater use of 'maladaptive' ER strategies was reported by people with AN than HCs, alongside less use of 'adaptive' strategies. Pooled differences of particularly large effect were observed for: experiential avoidance (d=1.00), negative problem-solving style (d=1.06), external/social comparison (d=1.25), submissiveness (d=1.16), attention concentration (worry/rumination; d=1.44) and emotion suppression (d=1.15), particularly to avoid conflict (d=1.54). These data support the notion that emotion regulation difficulties are a factor in AN and support use of associated cognitive-affective models. The implications of these findings for further understanding AN, and developing models and related psychological interventions are discussed.

Self-evaluative and emotion processes linked with brooding rumination among adolescents

Rumination has been linked with a number of deleterious outcomes, though relatively little is known about self-evaluative and emotion processes by which it develops. The current investigation uses a prospective, longitudinal design and self-report measures to examine the role of contingent self-worth, perfectionism, negative emotion beliefs, and suppression of negative emotion in predicting the development of brooding and reflective forms of rumination among 168 adolescents (98 girls, 79.6% European-American) undergoing the transition to high school (Mage = 13.58). Results of structural equation modeling indicate that self-evaluative vulnerability (i.e., self-worth contingencies, perfectionism) and negative emotion beliefs, but not the suppression of negative emotion, predict brooding (but not reflective) rumination. The current study demonstrates how brooding is intertwined with views of self and core assumptions about emotion.

The neurobiology of eating disorders--a clinical perspective

OBJECTIVE

To provide a neurobiological basis of eating disorders for clinicians and to enlighten how comparing neurobiology and eating disorders with neurobiology of other psychiatric illnesses can improve treatment protocols.

METHOD

A selective review on the neurobiology of eating disorders. The article focuses on clinical research on humans with consideration of the anatomical, neural, and molecular basis of eating disorders.

RESULTS

The neurobiology of people with eating disorders is altered. Many of the neurobiological regions, receptors, and chemical substrates that are affected in other mental illnesses also play an important role in eating disorders. More knowledge about the neurobiological overlap between eating disorders and other psychiatric populations will help when developing treatment protocols not the least regarding that comorbidity is common in patients with EDs.

CONCLUSION

Knowledge about the underlying neurobiology of eating disorders will improve treatment intervention and will benefit from comparisons with other mental illnesses and their treatments.

Alexithymia in anorexia nervosa: the mediating role of depression

The role of depression in the expression of alexithymia in anorexia nervosa (AN) has been controversially explained and several variables that may mask or increase the presence of emotional difficulties have scant examination in previous studies. This study aims to analyze the associations between alexithymia and state variables, such as age, BMI, illness duration, treatment duration, and medication status in AN participants, and to test the mediating role of depression in emotional difficulties. The Toronto Alexithymia Scale (TAS-20) and the Zung Self-Rating Depression Scale were administrated to 160 females: 80 participants with AN and 80 healthy controls. High levels of alexithymia were not a function of state variables. The mediating role of depression differed by the alexithymia dimension, with total mediation found for the TAS-DDF and partial mediation found for the TAS-DIF. Alexithymia is a relevant feature throughout the spectrum of AN and does not seem to be related to developmental maturation and some clinical features. Depression is probably the variable that best accounts for the variance in alexithymia, but is not a complete explanation for the known cognitive-affective disturbances in AN. Specific emotional competencies require scrutiny during psychiatric treatment.

Emotional processing of infants displays in eating disorders

AIM

The aim of this study is to examine emotional processing of infant displays in people with Eating Disorders (EDs).

BACKGROUND

Social and emotional factors are implicated as causal and maintaining factors in EDs. Difficulties in emotional regulation have been mainly studied in relation to adult interactions, with less interest given to interactions with infants.

METHOD

A sample of 138 women were recruited, of which 49 suffered from Anorexia Nervosa (AN), 16 from Bulimia Nervosa (BN), and 73 were healthy controls (HCs). Attentional responses to happy and sad infant faces were tested with the visual probe detection task. Emotional identification of, and reactivity to, infant displays were measured using self-report measures. Facial expressions to video clips depicting sad, happy and frustrated infants were also recorded.

RESULTS

No significant differences between groups were observed in the attentional response to infant photographs. However, there was a trend for patients to disengage from happy faces. People with EDs also reported lower positive ratings of happy infant displays and greater subjective negative reactions to sad infants. Finally, patients showed a significantly lower production of facial expressions, especially in response to the happy infant video clip. Insecure attachment was negatively correlated with positive facial expressions displayed in response to the happy infant and positively correlated with the intensity of negative emotions experienced in response to the sad infant video clip.

CONCLUSION

People with EDs do not have marked abnormalities in their attentional processing of infant emotional faces. However, they do have a reduction in facial affect particularly in response to happy infants. Also, they report greater negative reactions to sadness, and rate positive emotions less intensively than HCs. This pattern of emotional responsivity suggests abnormalities in social reward sensitivity and might indicate new treatment targets.

Interpersonal dysfunction and affect-regulation difficulties in disordered eating among men and women

Although several studies suggest that negative affect and interpersonal problems serve as important contributors for eating-related problems, much of this research has been conducted among women and less is known about their roles in precipitating and maintaining eating problems among men. Previous studies with undergraduate men suggest that difficulties in emotion regulation are associated with disordered eating even after controlling for differences in body mass index (BMI) and negative affect. The present study sought to replicate these findings and extend them to assess any unique variance explained by problems in interpersonal functioning among both men and women. Participants were men (n=213) and women (n=521) undergraduates at a large Midwestern university who completed a demographic information form, the Eating Disorder Examination-Questionnaire (EDE-Q), the Difficulties in Emotion Regulation Scale (DERS), the Positive and Negative Affect Schedule, and the Inventory of Interpersonal Problems-Short Circumplex Form (IIP-SC). A series of hierarchical regression analyses indicated that DERS and IIP-SC significantly predicted EDE-Q global scores after controlling for variability in BMI and negative affect and that the results were similar for men and women. Our findings offer preliminary support for models that highlight emotional vulnerability and interpersonal problems for disordered eating for young adult men. Future research extending these findings among treatment-seeking samples and employing multi-method assessment would serve to further clarify the tenability of these theoretical models for both men and women.

A new service model for the treatment of severe anorexia nervosa in the community: the Anorexia Nervosa Intensive Treatment Team

Aims and method A community intensive treatment service for severe anorexia nervosa is described. The service is multidisciplinary but driven by a focus on psychological formulation. Psychological and dietetic interventions are grounded in a process of active risk management. Evaluations of safety, cost and acceptability of the service are described. Results Patients are highly satisfied with their care. A relatively low mortality rate for such a high-risk population was observed. In-patient bed use and costs were substantially reduced. Clinical implications There is a case for greater use of intensive community care for patients with severe anorexia nervosa, as it can be acceptable to patients, relatively safe and cost less than admission.

Study protocol: psychological and physiological consequences of exposure to mass media in young women - an experimental cross-sectional and longitudinal study and the role of moderators

BACKGROUND

Repeated exposure to thin beauty ideals is part of the daily routine. Exposure to thin ideals via mass media plays an important role in the development and maintenance of eating disorders (EDs), low self-esteem, depressive or anxious feelings in young females. It is important to elucidate the circumstances under which exposure to thin ideals develops its detrimental impact and to investigate whether these features are more pronounced in EDs than in other mental disorders also related to negative body image.

METHODS/DESIGN

We investigate the following key questions: (1) Does laboratory induced exposure to thin ideals (waiting room design) relate to impairments in terms of body image, affect and eating behavior and biological stress response (salivary alpha-amylase, salivary cortisol, heart rate and heart rate variability) in 18 to 35 year old female suffering from anorexia and bulimia nervosa (AN, BN) compared to female healthy controls and to a sample of females suffering from mixed mental disorders (depression, anxiety and somatic symptom disorder (SSD) disorders)? (2) How do moderators such as cognitive distortions ("Thought-Shape Fusion, TSF"), and correlates of emotion regulation (ER) moderate the influence of the exposure? (3) Are these characteristics amenable to change after treatment? Altogether 250 female participants including patients with AN, BN, depressive, anxiety and SSD disorders, and healthy women will be recruited in Switzerland and Germany.

DISCUSSION

The findings will provide knowledge about the role of moderators influencing the effects of exposure to thin ideals promoted by mass media in eating disorder (ED) patients, patients suffering from mixed mental disorders and healthy controls. Evaluating their differential susceptibility will contribute to a better understanding of the role of negative body image in the maintenance of not only symptoms of ED, but also of depression, anxiety and SSD. Additionally our results will shed light on the stability of effects in healthy controls as well as in the patient groups before and after treatment as usual. Findings foster the development of tailored interventions including a training in specific ER strategies as well as cognitive restructuring of distorted beliefs about the own body when confronted with thin ideals.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00005709. Date of registration: 6(th) of February, 2014.

Rank perception and self-evaluation in eating disorders

OBJECTIVES

Heightened sensitivity to social comparison and negative self-evaluation have been implicated in the development and maintenance of eating disorders (EDs). This study used behavioral tasks, as well as self-report measures, to examine processing of social rank-related cues and implicit self-concept in participants with EDs.

METHOD

Fifty healthy participants (HCs), 46 people with an ED, and 22 people recovered from an ED (REC) undertook an attentional bias task using social rank-related cues and an implicit self-evaluation task. In addition, they completed self-report measures of social comparison, submissive behavior, and shame.

RESULTS

People with EDs showed vigilance toward social rank-related stimuli and lower implicit positive self-evaluation than HCs. Self-report data confirmed the behavioral findings and showed that people with EDs had higher levels of unfavorable social comparison, submissive behaviors, and external and internal shame than HCs. People who had recovered from an ED showed an intermediate profile between the two groups.

DISCUSSION

People with EDs have heightened sensitivity to social rank-related cues and impaired self-evaluation at an automatic level of processing. Some of these biases remain in people who have recovered. Interventions which aim to remediate social threat sensitivity and negative bias about self and others might be of benefit in EDs.

The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA): Development, Key Features, and Preliminary Evidence

Anorexia nervosa (AN) is a severe mental disorder that affects mainly young females. In adults with a well-established form of the illness, it is hard to treat. In 2006, we proposed a maintenance model of AN, combining intra- and interpersonal factors and we have recently refined this model. The model encompasses four main maintaining factors (a thinking style characterized by rigidity, detail focus, and a fear of making mistakes; an avoidant emotion processing and relational style; positive beliefs about the use of anorexia for the person [pro-anorexia beliefs]; and a response of close others to the illness characterized by high expressed emotion and enabling of and accommodation to the illness). In this article, we describe how the model has been translated into a novel treatment for AN and the preliminary evidence supporting this. Implications for clinical practice and research are discussed.

Emotional facial expression in women recovered from anorexia nervosa

BACKGROUND

Recent models of anorexia nervosa (AN) have emphasised the importance of social and emotional difficulties as maintenance factors of the disorder, however, empirical data are limited. The aim of this study was to examine whether altered emotional facial expression, previously observed in people currently ill with anorexia nervosa, is limited to the ill state or present in people recovered from the illness.

METHODS

The sample consisted of 123 participants [49 AN, 21 recovered AN (RecAN) and 53 healthy controls (HC)]. Participants watched three films clips (amusing, neutral, sad) whilst their facial expressions were recorded and completed the positive and negative affect scale (PANAS) to record subjective experience. Facial expressions were subsequently coded for frequency of positive and negative expression and frequency of looking away.

RESULTS

In response to the amusing clip, AN participants showed significantly less positive expression than both HC and RecAN groups and both AN and RecAN showed more negative expression than HC with no difference between groups in looking away.In response to the sad clip there was no difference between groups in positive expression, but current AN participants showed significantly less negative expression than HC and looked away from the stimuli more than RecAN or HC.In terms of their subjective emotional experience, patients with current AN reported less positive emotion in response to both the amusing and the sad film clip. There was no difference between groups in subjective negative experience.

CONCLUSIONS

Alterations in facial expression are present in people currently ill with AN contributing to the social difficulties found in AN and potentially exacerbating resistance to treatment. Some alterations in facial expression are found in women with a past history of AN but not to the same extent as those shown in the currently ill group. Future studies need to use a wider range of stimuli involving different emotions to corroborate findings.

Video game therapy for emotional regulation and impulsivity control in a series of treated cases with bulimia nervosa

Although standard psychological treatments have been successful in treating several core features in eating disorders (ED), other characteristics such as emotional regulation or impulsivity appear to be more resistant to change. There is a growing body of evidence to support the efficacy of cognitive remediation for cognitive and emotional difficulties in ED. Playmancer/ Islands is a video game (VG) designed to specifically treat mental disorders, characterized by problems in impulse control. The objective of the game is to increase self-control over emotions, decision making and behaviours. The aim of this study is to describe the results from a consecutive series of nine bulimia nervosa patients who were treated with the VG in addition to cognitive behaviour therapy (CBT). The outcomes included clinical and psychopathological questionnaires, and physiological measures were obtained during the VG. Emotional regulation improved, heart rate variability increased, and respiratory rate and impulsivity measures reduced after the treatment. These findings suggest that VG training may enhance treatment for ED.

The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors

AIM

To describe the evidence base relating to the Cognitive-Interpersonal Maintenance Model for anorexia nervosa (AN).

BACKGROUND

A Cognitive-Interpersonal Maintenance Model maintenance model for anorexia nervosa was described in 2006. This model proposed that cognitive, socio-emotional and interpersonal elements acted together to both cause and maintain eating disorders.

METHOD

A review of the empirical literature relating to the key constructs of the model (cognitive, socio-emotional, interpersonal) risk and maintaining factors for anorexia nervosa was conducted.

RESULTS

Set shifting and weak central coherence (associated with obsessive compulsive traits) have been widely studied. There is some evidence to suggest that a strong eye for detail and weak set shifting are inherited vulnerabilities to AN. Set shifting and global integration are impaired in the ill state and contribute to weak central coherence. In addition, there are wide-ranging impairments in socio-emotional processing including: an automatic bias in attention towards critical and domineering faces and away from compassionate faces; impaired signalling of, interpretation and regulation of emotions. Difficulties in social cognition may in part be a consequence of starvation but inherited vulnerabilities may also contribute to these traits. The shared familial traits may accentuate family members' tendency to react to the frustrating and frightening symptoms of AN with high expressed emotion (criticism, hostility, overprotection), and inadvertently perpetuate the problem.

CONCLUSION

The cognitive interpersonal model is supported by accumulating evidence. The model is complex in that cognitive and socio-emotional factors both predispose to the illness and are exaggerated in the ill state. Furthermore, some of the traits are inherited vulnerabilities and are present in family members. The clinical formulations from the model are described as are new possibilities for targeted treatment.

Emotions in eating disorders: changes of anger control after an emotion-focused day hospital treatment

OBJECTIVE

Emotional states are key elements of eating disorders (EDs), with anger and aggressiveness playing an important role. This study aimed to investigate anger features in ED patients before and after an intensive day hospital (DH) specifically focused on emotions.

METHOD

Forty-one ED patients were admitted to our DH, which specifically includes emotion-focused activities. They completed self-reported questionnaires at the beginning and after the intervention: Eating Disorders Inventory-2, State-Trait Anger Expression Inventory (STAXI) and Beck Depression Inventory (BDI).

RESULTS

Anger Control (Axcon) subscale of STAXI decreased significantly, and both BDI and body mass index - in case of underweight patients - significantly improved after completion of DH. Axcon decrease correlated with BMI improvement. The majority of individuals showing good outcome reported also a significant improvement in Axcon levels.

DISCUSSION

This study provided preliminary data about the effectiveness - mainly in anger coping - of an emotion-focused DH.