Anxiety and Disordered Eating

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.

Variables that explain disordered eating behaviors among women: the mediating role of body dissatisfaction

PURPOSE

To analyze the role of body dissatisfaction in the relationships of sociocultural influences, depression, and anxiety with disordered eating behaviors (DEB) in a sample of female Mexican university students.

METHODS

A nonrandom sample of 526 female Mexican university students aged 18 to 25 years completed the Questionnaire of Influence on the Aesthetic Model of Body Shape (CIMEC-26), the Hospital Anxiety and Depression Scale (HADS), the Body Shape Questionnaire (BSQ-8D) and the Eating Attitudes Test (EAT-26).

RESULTS

Through the mean model (χ2/df (5, n = 526) = 7.298, p = .199; NFI = .996; CFI = .999; RMSEA = .030; SRMR = .011), body dissatisfaction was found to mediate the relationships of influence of advertising, influence of social models and anxiety with DEB (restrictive dieting and bulimia). The variable with the most direct effect on restrictive dieting and bulimia was the influence of advertising. Body dissatisfaction partially mediated this relationship, as the influence of advertising had a significant direct effect on restrictive dieting and bulimia. The final model of direct and indirect effects explained 43% and 22% of the variance in restrictive dieting and bulimia, respectively.

CONCLUSION

The present study showed that body dissatisfaction partially mediated the relationships between influence of advertising, influence of social models, and anxiety with DEB among women. Thus, these variables should be taken into account in prevention and intervention programs targeting BED.

LEVEL V

Evidence obtained from a cross-sectional descriptive study.

LEVEL V

Evidence obtained from a cross-sectional descriptive study.

Clinical Characteristics of US Adolescents Hospitalized for Eating Disorders 2010-2022

BACKGROUND AND OBJECTIVES

Eating disorders (EDs) affect a substantial number of American adolescents, with an increasing number seeking care for EDs during the coronavirus disease 2019 pandemic. We assessed the prevalence and clinical characteristics of adolescents hospitalized with EDs during 2010 to 2022.

METHODS

We used data from a national database of 12 children's hospitals (PEDSnet). Adolescents aged 12 to 21 years hospitalized for ED, disordered eating, binge ED, anorexia nervosa, bulimia nervosa, avoidant-restrictive food intake disorder (ARFID), or other EDs were included. Patients with complex or chronic illness or with EDs hospitalized for another reason were excluded. We analyzed demographic data, clinical characteristics, cardiac manifestations, coexistence of psychiatric conditions, and hospital stay characteristics.

RESULTS

We included 13 403 hospitalizations by 8652 patients in this study. We found a gradual increase in hospitalizations for patients with EDs before the pandemic and a large increase during the pandemic. Mean age was 15.8 years with 85.9% described as female and 71.8% as white. Anorexia nervosa was the most common ED (57.5%), though hospitalization for patients with ARFID is increasing. Patients' median BMI percentage was 90.3%. Patients' malnutrition was classified as none (50.9%), mild (25.0%), moderate (18.6%), or severe (5.4%). Significant numbers of patients had a diagnosis of depression (58.5%) or anxiety (57.0%); 21.9% had suicidal thoughts. Nearly one-quarter (23.6%) required rehospitalization for ED treatment within 1 year.

CONCLUSIONS

Hospitalizations for EDs among American adolescents are increasing, with a spike during the coronavirus disease 2019 pandemic. Significant numbers of patients hospitalized with EDs have suicidal thoughts. Trends in patients with ARFID require monitoring.

Acoustics Features of Voice in Adolescent Females With Anorexia Nervosa

INTRODUCTION

The process of human voice production is a complex physiological and acoustic phenomenon that depends on many structural, physical, and hormonal factors, systemic diseases as well as emotional states. All these factors can be present in eating disorders. However, studies on eating disorders and voice problems have usually been evaluated in terms of bulimia. Chronic starvation and emotional problems in the course of anorexia nervosa (AN) appear to be under-researched, despite various biochemical, metabolic, and hormonal changes.

OBJECTIVE

The purpose of this study was to evaluate voice quality, specifically acoustic analysis, in adolescent female with AN from the point of view of the possible influence on the function and structure of the larynx, low body mass accompanying AN, as well as energy deficiency, hormonal and emotional disturbances.

MATERIALS AND METHODS

A total of 84 girls diagnosed with AN (Gr.A) (15.32 years, SD = 2.12; range 12-19, BMI = 14.11 ± 1.72) were assessed for the condition of the voice such as perceptual voice evaluation on the GRBAS scale, maximal phonation time (MPT), laryngoscopy, with special attention to voice acoustic analysis - Multi-Dimensional Voice Program (MDVP). The control group (Gr.C) included 62 girls without eating disturbances (aged 12-19, mean age 15.41 ± 2.40, BMI = 21.60 ± 1.92). Perceptual voice assessment, aerodynamic test MPT, and acoustic parameters were analyzed according to girls' age.

RESULTS

Total GRBAS scale was higher in girls with AN compared to the control group mainly for two parameters: breathiness (B) (P = 0.00015) and asthenia (A) (P < 0.05). The MPT for Gr.A was significantly shorter compared to Gr.C (15.40 ± 3.51 seconds vs. 23.19 ± 5.17 seconds) (P < 0.001), and a correlation of MPT values with the age of the adolescent female was observed: Spearman's coefficient for Gr.A = (-)0.5378, for Gr.C = 0.5516 (P = 0.0012). Acoustic analysis revealed the decrease in the basic frequency F0 in Gr.A compared to Gr.C (231.08 Hz vs. 242.30 Hz), and narrowing of the voice scale was observed, resulting mainly from a reduction in the upper limit. Significant differences were found for measures of frequency perturbations (Jita, Jitter, RPA, PPQ, sPPR), with Gr.A scoring significantly higher than Gr.C (P < 0.05 for all). Significant changes in voice acoustic analysis parameters were found with age. Negative correlations were found for measures of F0 for Gr.A to a much greater extent compared to Gr.C. Positive correlations were found with measures of tremor assessment (SPI, FTRI, ATRI) for Gr.A.

Validity and Consistency of the Arabic Version of the Eating Disorder Examination Questionnaire (EDE-Q) among Saudi Adults

The prevalence of eating disorders (EDs) is growing, and early screening is important to prevent related health complications. The Eating Disorder Examination Questionnaire (EDE-Q) has been widely used as a diagnostic tool to identify cases of EDs; however, a validated Arabic version of the tool is needed to help in the screening process of EDs. The aim of this study was to validate the Arabic version of EDE-Q. A cross-sectional study included a sample of 549 adults, who were recruited mainly from the four major provinces in Saudi Arabia. A forward–backward translation method was conducted, and then the tool was validated using the confirmatory factor analysis (CFA). The dataset was split for further convergent analysis using exploratory factor analysis (EFA) and CFA. The results of CFA from the main dataset did not support the four-factor original EDE-Q. The results of EFA from the first data-split suggested a three-factor EDE-Q-14 Arabic version. This was supported by the results of CFA of the second data-split. A total of five items were allocated in each shape and weight concern, and restraint component, with correlations ranging from 0.969 and 0.462 and from 0.847 to 0.437, respectively. A total of four items were allocated in eating concern, with correlations ranging from 0.748 to 0.556. The internal consistency of the global and the three subscales were high, with Cronbach’s α ranging from 0.762 to 0.900. Findings of the current study suggest that the Arabic version of the EDE-Q-14 is a valid and reliable tool to screen for EDs among adults in Saudi Arabia.

The mediating role of anxiety and depression between problematic social media use and bulimia nervosa among Lebanese university students

Background

Bulimia nervosa (BN) is a disorder that is characterized by binge eating and inappropriate compensatory behavior to control weight. The aim of this study was to evaluate the mediating role of anxiety and depression between problematic social media use (PSMU) and BN among a sample of Lebanese university students.

Methods

This cross-sectional study was carried out between July and September 2021; a total of 363 university students was recruited through convenience sampling. The PROCESS SPSS Macro version 3.4, model four was used to test the indirect effect and calculate three pathways. Pathway A determined the regression coefficient for the effect of PSMU on mental health issues (depression/anxiety); Pathway B examined the association between mental health issues on BN, and Pathway C’ estimated the direct effect of PSMU on BN. Pathway AB was used to calculate the indirect effect of PSMU on BN via depression/anxiety.

Results

Results showed that depression and anxiety partially mediated the association between PSMU and BN. Higher levels of PSMU were associated with more depression and anxiety; higher depression and anxiety were associated with more BN. PSMU was directly and significantly associated with more BN. When entering anxiety (M1) then depression (M2) as consecutive mediators in a first model, the results showed that only depression mediated the association between PSMU and bulimia. When taking depression (M1) then anxiety (M2) as consecutive mediators in a second model, the results showed that the mediation PSMU → Depression → Anxiety → Bulimia was significant. Higher PSMU was significantly associated with more depression, which was significantly associated with more anxiety, which was significantly associated with more bulimia. Finally, higher PSMU was directly and significantly associated with more bulimia

Conclusion

The current paper highlights the relationship that social media use has on BN and other aspects of mental health such as anxiety and depression in Lebanon. Future studies should replicate the mediation analysis conducted in the current study while taking into account other eating disorders. Additional investigations of BN and its correlates must strive to improve the comprehension of these associations’ pathways through designs that allow to draw temporal frameworks, in order to efficiently treat this eating disorder and prevent its negative outcomes.

Bulimia nervosa, an eating disorder, is characterized by an impulsive consumption of food in a short period of time, followed by behaviors that compensate the eating such as vomiting or excessive exercise in order to avoid weight gain. Individuals with problematic social media use were found to have higher levels of bulimia symptoms. Symptoms of bulimia can also be associated with both depression and anxiety. The aim of the current study was to examine the mediating role of anxiety and depression between problematic social media use and bulimia nervosa. The results of our study found that problematic social media use was directly associated with more bulimia nervosa and also associated with higher depression and anxiety, both of which were associated with bulimia nervosa. Tackling associated disorders may help reduce symptoms of bulimia nervosa. Clinicians should carefully examine these associations while assessing and implementing treatment plans.

Testing a Biobehavioral Model of Food Insecurity and Chronic Disease in Hispanic Older Adolescents

The biobehavioral model of food insecurity and chronic disease posits that stress perpetuates the cycle of food insecurity and chronic disease, in part, through changes in eating behaviors and weight gain. The current study conducted a preliminary test of the biobehavioral model in a sample of Hispanic older adolescents. It was hypothesized that older adolescents experiencing food insecurity would report greater depressive symptoms, which would be associated with more disordered eating, which would be associated with worse cardiometabolic indicators. Hispanic older adolescents (N = 113; 60% female; 15-21 years with mean age of 19.1; BMImean = 24.4) completed self-report baseline measures of food insecurity, depression, and disordered eating behaviors as part of a larger experimental study. Anthropometrics and body composition, blood pressure, heart rate, and resting metabolic rate were objectively measured. Hypotheses were tested using structural equation modeling. Experiencing food insecurity was associated with more disordered eating (b = 2.20, p = 0.032). Greater depressive symptoms were associated with more disordered eating (b = 0.28, p = 0.025) and worse cardiometabolic indicators (b = 0.15, p = 0.017). The full biobehavioral model, however, was not supported. Findings underscore the complex interaction of social and psychological functioning and physical health.

Analysis of Electrolyte Abnormalities in Adolescents and Adults and Subsequent Diagnosis of an Eating Disorder

IMPORTANCE

Eating disorders lead to increased mortality and reduced quality of life. While the acute presentations of eating disorders frequently involve electrolyte abnormalities, it remains unknown whether electrolyte abnormalities may precede the future diagnosis of an eating disorder.

OBJECTIVE

To determine whether outpatient electrolyte abnormalities are associated with the future diagnosis of an eating disorder.

DESIGN, SETTING, AND PARTICIPANTS

This population-level case-control study used provincial administrative health data for residents of Ontario, Canada aged 13 years or older from 2008 to 2020. Individuals without an eating disorder (controls) were matched 4:1 to individuals diagnosed with an incident eating disorder (cases) based on age and sex. Both groups had outpatient electrolyte measurements between 3 years and 30 days prior to index. Index was defined as the date of an eating disorder diagnosis in any inpatient or outpatient clinical setting for cases. Controls were assigned a pseudo-index date according to the distribution of index dates in the case population. Individuals with any prior eating disorder diagnosis were excluded. The data analyzed was from January 1, 2008, through June 30, 2020.

EXPOSURES

Any electrolyte abnormality, defined as abnormal test results for a composite of hypokalemia, hyperkalemia, hyponatremia, hypernatremia, hypomagnesemia, hypophosphatemia, metabolic acidosis, or metabolic alkalosis.

OUTCOMES AND MEASURES

Eating disorder diagnosis including anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified.

RESULTS

A total 6970 eligible Ontario residents with an eating disorder (mean [SD] age, 28 (19) years; 6075 [87.2%] female, 895 [12.8%] male) were matched with 27 878 age- and sex-matched residents without an eating disorder diagnosis (mean [SD] age, 28 [19] years; 24 300 [87.2%] female, 3578 [12.8%] male). Overall, 18.4% of individuals with an eating disorder had a preceding electrolyte abnormality vs 7.5% of individuals without an eating disorder (adjusted odds ratio [aOR], 2.12; [95% CI, 1.86-2.41]). The median (IQR) time from the earliest electrolyte abnormality to eating disorder diagnosis was 386 (157-716) days. Specific electrolyte abnormalities associated with a higher risk of an eating disorder were: hypokalemia (aOR, 1.98; 95% CI, 1.70-2.32), hyperkalemia (aOR, 1.97; 95% CI, 1.48-2.62), hyponatremia (aOR, 5.26; 95% CI, 3.32-8.31), hypernatremia (aOR, 3.09; 95% CI, 1.01-9.51), hypophosphatemia (aOR, 2.83; 95% CI, 1.82-4.40), and metabolic alkalosis (aOR, 2.60; 95% CI, 1.63-4.15).

CONCLUSIONS AND RELEVANCE

In this case-control study, individuals with an eating disorder were associated with a preceding outpatient electrolyte abnormality compared with matched controls. Otherwise unexplained electrolyte abnormalities may serve to identify individuals who may benefit from screening for an underlying eating disorder.

Recognising eating disorders in older people

Changes in eating behaviours, weight and mental health in older people may be related to psychological distress and indicate the presence of a diagnosable eating disorder, rather than 'anorexia of ageing'. Eating disorders in older people may be overlooked because signs and symptoms are assumed to be part of normal ageing. The role of nurses in the care of older people with eating disorders is likely to be detection, referral and support in accessing specialist intervention. This article offers an overview of eating disorders in older people and discusses why they may arise, why they may not be detected and how to recognise them. The authors describe a framework that nurses can use when assessing older people to determine whether they may have an eating disorder.

An fMRI study of cognitive regulation of reward processing in generalized anxiety disorder (GAD)

BACKGROUND

Cognitive regulation can affect the process of decision making. Generalized anxiety disorder (GAD) patients seem to have an impairment in cognitive regulation of reward processing concerning food stimuli. This study aims to explore the impact of GAD in cognitive regulation of food-related rewards.

METHODS

GAD patients (n=11) and healthy controls (n=15) performed a cognitive regulation craving task with food images while undergoing a functional magnetic resonance imaging (fMRI) acquisition. Between-group differences in functional connectivity were measured using dorsolateral prefrontal cortex (dlPFC) and ventromedial prefrontal cortex (vmPFC) seeds during cognitive regulation.

RESULTS

During cognitive regulation, there was a significant interaction for functional connectivity between the right dlPFC and bilateral vmPFC with the thalamus. GAD patients had lower functional connectivity for cognitive regulation conditions (distance and indulge) than for the non-regulated condition in these clusters, while control participants presented the opposite pattern. GAD group presented fixed food valuation scores after cognitive regulation.

CONCLUSIONS

GAD participants showed inflexibility while valuating food images, that could be produced by cognitive regulation deficits underpinned by functional connectivity alterations between prefrontal regions and the thalamus. These results show cognitive inflexibility and difficulty in the modulation of cognitive responses during decision making in GAD patients.

Eating disorder and social anxiety symptoms in Iranian preadolescents: a network analysis

PURPOSE

Network studies of eating disorder (ED) symptoms have identified central and bridge symptoms in Western samples, yet few network models of ED symptoms have been tested in non-Western samples, especially among preadolescents. The current study tested a network model of ED symptoms in Iranian preadolescents (ages 9 to 13), as well as a model of co-occurring social anxiety disorder (SAD) and ED symptoms.

METHOD

Preadolescent boys (n = 405) and girls (n = 325) completed the Children Eating Attitudes Test-20 and Social Anxiety Scale for Children. We estimated two network models (ED and ED/SAD networks) and identified central and bridge symptoms, as well as tested if these models differed by sex.

RESULTS

We found that discomfort eating sweets were the most central symptoms in ED networks. Concern over being judged was central in networks including both ED and SAD symptoms. Additionally, concern over being judged was the strongest bridge symptoms. Networks did not differ by sex.

CONCLUSION

Future research is needed to test if interventions focused on bridge symptoms (i.e., concern over being judged) as primary intervention points target comorbid ED-SAD pathology in preadolescents at risk for ED and SAD.

LEVEL OF EVIDENCE

Level III; Evidence obtained from well-designed observational study, including case-control design for relevant aspects of the study.

Exploring risk factors of food and alcohol disturbance (FAD) in U.S. college students

PURPOSE

Current research examining mental health and history of childhood trauma as risk factors of food and alcohol disturbance (FAD) is limited. College students may be at greater risk to engage in FAD behaviors because of the common co-occurrence of alcohol misuse and disordered eating behaviors within college populations. Therefore, the current study examined anxiety, depression, and adverse childhood experiences as possible risk factors of FAD behaviors in a college student sample.

METHODS

Two-hundred and seven undergraduate students from a large Midwest university completed a cross-sectional survey assessing history of adverse childhood experiences, depressive symptoms, anxiety symptoms, FAD behaviors, and frequency of alcohol use.

RESULTS

Current symptoms of generalized anxiety were significantly associated with engagement in FAD behaviors (Alcohol Effects subscale, β = 0.13, F(1, 204) = 4.10, p = 0.04; Bulimia subscale, β = 0.17, F(1, 204) = 6.19, p = 0.01; Diet and Exercise subscale, β = 0.19, F(1, 204) = 9.05, p < 0.01). Adverse childhood experiences were associated with engagement in FAD behaviors (Alcohol Effects subscale, β = 0.14, F(1, 204) = 4.27, p = 0.04). Current depressive symptoms were not significantly associated with FAD behaviors.

CONCLUSIONS

Study findings suggest that students who experience greater current symptoms of anxiety are at a greater risk to engage in FAD behaviors. Further understanding the role of anxiety in the development and maintenance of FAD behaviors may provide clinically useful information for the prevention and treatment of FAD behaviors. These findings highlight the need for further research to examine psychological distress as a risk factor for engagement in FAD behaviors longitudinally, in a larger, more diverse study sample.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Development and Psychometric Testing of the Suicidal Recovery Ability Scale (SRAS) for Assessing Individuals Who Have Attempted Suicide

Assessing the recovery ability of individuals who have attempted suicide is crucial for psychiatric health nurses. The purpose of this study was to develop and test a psychometric Suicidal Recovery Ability Scale (SRAS). Confirmatory factor analysis (CFA) indicated that three subscales with 15 items best fit the data. The global SRAS score showed significant negative correlation with the Beck Hopelessness Scale (BHS) score. The Cronbach's α and test-retest reliability scores for the global SRAS and the subscales all exceeded 0.70. Nurses can use the SRAS to assess the recovery ability of individuals who have attempted suicide and provide proper care to help them.

Social anxiety and associations with eating psychopathology: Mediating effects of fears of evaluation

Recent work suggests unique relations among features of social anxiety disorder and eating disorder pathology. Thus, it may be important to determine specific facets of social anxiety that account for the relation between it and eating disorders. Given the similarities in social-evaluative concerns in both sets of symptoms, we hypothesized that fears of both positive and negative evaluation would each independently account for the relationship between social anxiety symptoms and eating pathology among college females (N=167). Results were partially supportive of hypotheses. Fear of negative evaluation independently accounted for a significant portion of the relationship between social anxiety and each domain of eating pathology that was tested, which included Drive for Thinness, Body Dissatisfaction, and Bulimic Symptoms. Body mass index appeared to play a moderating role on the relationship between fear of negative evaluation and body dissatisfaction, but not drive for thinness or bulimia symptoms. Clinical implications including diagnostic and treatment considerations will be discussed.

Distributed circuits underlying anxiety

Anxiety is of paramount importance for animals, as it allows assessment of the environment while minimizing exposure to potential threats. Furthermore, anxiety disorders are highly prevalent. Consequently, the neural circuitry underlying anxiety has been a topic of great interest. In this mini review, we will discuss current views on anxiety circuits. We will focus on rodent anxiety paradigms, but we will also consider results from human neuroimaging and clinical studies. We briefly review studies demonstrating the central role that the amygdala and the bed nucleus of the stria terminals (BNST) play in modulating anxiety and present evidence showing how the bed nucleus uses different output pathways to influence specific features of anxiolysis. Lastly, we propose that several brain regions, such as the medial prefrontal cortex (mPFC) and the ventral hippocampus (vHPC), act in a coordinated fashion with the amygdala and BNST, forming a distributed network of interconnected structures that control anxiety both in rodents and humans.