Improving prediction of eating-related behavioral outcomes with zero-sensitive regression models

Cannabis use and binge eating: Examining the relationship between cannabis use and clinical severity among adults with binge eating

Cannabis use is prevalent among individuals with binge eating (BE; i.e., the inability to control eating behavior). Yet, only two studies to date (both over 20 years old) have tested if cannabis use relates to clinical severity among BE samples. Characterizing the relationship between cannabis use, eating disorder (ED) severity, and other psychiatric symptoms in BE samples is necessary for informing screening and clinical recommendations. The present study characterized cannabis use among adults with BE and tested between-group and within-group relationships between cannabis use and eating disorder symptoms, alcohol consumption and symptoms, and depression symptoms. Participants (N = 165) were treatment-seeking adults with at least once weekly BE in the past 3 months who completed clinical interviews and self-report measures before treatment. Over 23% of participants reported cannabis use in the past 3 months, with most persons using cannabis reported using "once or twice" or "monthly." Most persons using cannabis reported cannabis-related symptoms. Persons using cannabis reported significantly greater alcohol consumption and were more likely to report alcohol-related symptoms compared to persons not using cannabis. No associations were observed between cannabis use, eating disorder symptoms, and depressions symptoms. These findings indicate that a notable subset of patients with BE use cannabis and experience cannabis-related problems, and that cannabis and alcohol use may be related for these individuals. Considering legal and sociocultural shifts in cannabis availability and prevalence, results from the present study support screening for cannabis and alcohol use patterns in patients with BE. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Does hopelessness predict treatment outcomes in adults with binge-spectrum eating disorders?

Using data from 165 adult participants who enrolled in four studies of cognitive-behavioral therapy (CBT) for binge-spectrum eating disorders (EDs), this secondary analysis examined 1) whether pretreatment hopelessness predicted posttreatment eating pathology, loss-of-control (LOC) eating frequency, and purging frequency; 2) whether treatment had an indirect effect on those outcomes through change in hopelessness; and 3) whether treatment had an indirect effect on hopelessness through those ED measures. The Eating Disorder Examination was used to assess overall eating pathology, LOC frequency, and purging frequency. Hopelessness was measured with one item from the Beck Depression Inventory-II. Regression models showed that pretreatment hopelessness predicted posttreatment LOC eating frequency but not overall eating pathology or purging frequency. Single-group tests of indirect effects showed no effect of reduction in hopelessness on reduction in ED symptoms, but there was an effect of reduction in ED symptoms on reduction in hopelessness.

Testing associations between assessments of cognitive flexibility and eating disorder symptoms in adolescent bulimia nervosa

OBJECTIVE

Cognitive rigidity, or difficulty adapting to changing demands, is commonly observed in anorexia nervosa. Less is known, however, about cognitive flexibility (CF) in bulimia nervosa (BN) and, particularly, adolescence. Clarifying this relation and best assessment practices may guide informed clinical decision-making. The current study compared how two measures of CF (i.e., Wisconsin Card Sort Task [WCST] and Trail Making Task [TMT]) relate to BN symptoms among adolescents.

METHODS

Data from a subsample (n = 78) of adolescents with BN were analyzed. Linear and hurdle regressions were used to compare the effects of WCST perseverative errors and TMT performance on Eating Disorder Examination Global Scores, objective binge episodes, and self-induced vomiting episodes (SVEs) at baseline and end-of-treatment (EOT).

RESULTS

Neither CF measure associated with baseline BN symptoms. TMT performance positively associated with the likelihood of engaging in SVEs at EOT (𝛽 = 0.47, p = 0.01, 95% confidence interval [CI] = [0.11-0.84]) and, among adolescents who endorsed ≥1 SVE at EOT, WCST perseverative errors (𝛽 = 0.05, p = 0.005, 95% CI = [0.01-0.08]) positively associated with SVE frequency at EOT.

DISCUSSION

The overall lack of associations between CF and outcomes suggests that cognitive rigidity may not be as relevant to the clinical profile of adolescent BN as for anorexia nervosa. In the few significant associations that emerged, the WCST and TMT uniquely predicted the severity of vomiting at EOT in this sample. Given the lack of CF deficits, future work should aim to test the role of other executive functions (e.g., impulsivity), in addition to CF, to determine which deficits are present in adolescent BN and may predict outcomes.

PUBLIC SIGNIFICANCE

Patients with eating disorders often have difficulties thinking flexibly, which may interfere with their recovery. We tested two ways of measuring flexible thinking in adolescents with BN. Overall, flexible thinking was not associated with symptom-level outcomes. However, less flexible thinking at the start of treatment predicted self-induced vomiting at EOT. If findings are replicable, then assessing and addressing flexible thinking could improve outcomes for adolescents with BN.

The role of habit in maintaining binge/purge behaviors: An ecological momentary assessment study

OBJECTIVE

Individuals with eating disorders transdiagnostically engage in binge eating (BE) and/or purging, despite life-threatening consequences. Little is known about factors that contribute to the persistence of these behaviors. This study explored whether habitual control over binge/purge (B/P) spectrum behaviors contributes to symptom persistence and whether negative reinforcement via reductions in negative affect is less influential in maintaining B/P behaviors that are under habitual control and are persistent.

METHOD

Women with BE and/or purging (N = 81) completed self-report measures assessing habit strength of BE and purging. Then, they completed a 14-day ecological momentary assessment (EMA) protocol during which they completed measures of negative affect, BE, and purging multiple times per day.

RESULTS

Habitual control over purging was associated with a greater frequency of purging during the EMA period. However, habitual control over BE was not associated with the severity of loss of control eating or the frequency of BE episodes. Habitual control did not moderate temporal relations between negative affect and B/P behaviors during the EMA period. However, exploratory analyses revealed that individuals with a longer duration of BE and greater habitual control over BE showed a less pronounced reduction in negative affect following BE.

DISCUSSION

Overall, these findings suggest that purging may be maintained by habitual stimulus-response learning. In addition, they support the possibility that reduction in negative affect may play a less prominent role in maintaining BE that is habitual and persistent.

PUBLIC SIGNIFICANCE

This study investigated whether habit contributes to the persistence of symptoms in women with binge/purge spectrum behaviors and whether negative reinforcement via reductions in negative affect is less influential in maintaining binge/purge behaviors that are under habitual control. The findings suggest that purging may be maintained through habit. This supports the potential utility of habit reversal interventions to decrease habitual purging.

Characterizing alcohol-related disordered eating behaviors in adults with binge eating

PURPOSE

Alcohol-related disordered eating behaviors (ADEBs; i.e., engagement in dietary restriction or excessive exercise before or after drinking alcohol to avoid weight gain) are associated with negative psychosocial and medical consequences. Previous research has primarily studied ADEBs among community samples. Individuals with clinically significant binge eating may also engage in ADEBs given high rates of alcohol use and inappropriate weight-control behaviors. The current study aimed to characterize the prevalence and psychological correlates (i.e., weight and shape concerns, alcohol consumption, binge eating frequency) of ADEBs among individuals with clinically significant binge eating.

METHODS

Participants were 166 treatment-seeking individuals who engaged in once weekly binge eating over the past three months. Participants completed a clinical interview to assess eating disorder symptoms and self-report measures of alcohol consumption patterns and ADEBs engagement.

RESULTS

Over one-fourth of participants endorsed at least one ADEBs in the past three months. Participants who endorsed ADEBs reported greater alcohol consumption than participants who drank alcohol but did not endorse ADEBs, after controlling for eating disorder diagnosis. Greater frequency of ADEBs was related to higher weight and shape concerns among individuals who endorsed ADEBs in the past three months. Presence of ADEBs and ADEBs frequency were not related to binge eating frequency.

CONCLUSION

Results suggest that clinicians treating individuals with binge eating who drink alcohol should screen for ADEBs and assess how ADEBs may contribute to an individual's eating pathology. Future research should assess the temporal relationship between alcohol use and ADEBs engagement, and study ADEBs in BN-spectrum samples.

LEVEL OF EVIDENCE

Level V, descriptive studies.

Characterizing changes in obsessive-compulsive symptoms over the course of treatment for adolescent bulimia nervosa

OBJECTIVE

Data suggest that obsessive-compulsive (OC) symptoms are commonly observed in adolescents with eating disorders and predict poorer treatment response. Further, emerging data among adults suggest that changes in OC symptoms relate to changes in eating disorder symptoms across treatment. Given evidence that early invention decreases risk for protracted illness, evaluating processes that may relate to treatment response will be useful in increasing the effectiveness of existing interventions. Therefore, the current investigation explored changes in general and eating disorder-specific OC symptoms throughout family-based treatment (FBT) and cognitive behavioral therapy (CBT) for bulimia nervosa (BN), as well as associations among these changes and eating disorder outcomes at follow-up.

METHOD

Participants (N = 110) received 18 sessions of FBT or CBT and completed measurements of general and eating disorder-specific OC symptoms at baseline, end-of-treatment, and 6- and 12-month follow-up.

RESULTS

Multilevel models indicated that across both treatments, there was no change in general OC symptoms, whereas all eating disorder-related OC symptoms decreased over treatment and follow-up. Exploratory analyses indicated that lower severity in discharge eating-disorder-specific OC symptoms contributed to lower eating pathology at follow-up.

DISCUSSION

Together, findings support the efficacy of both FBT and CBT in helping to reduce eating disorder-specific OC symptoms and suggest that adjunctive intervention may be required for ameliorating general OC symptoms in this population.

PUBLIC SIGNIFICANCE

BN is associated with significant increases in mortality and societal cost, and there is a pressing need for innovations within available treatments for young people with this disorder. In the current study, we explore the extent to which existing evidence-based treatments for adolescent BN are effective in targeting obsessive-compulsive symptoms, a known predictor of treatment response and common co-morbidity in this population.

Evaluating the use of lamotrigine to reduce mood lability and impulsive behaviors in adults with chronic and severe eating disorders

BACKGROUND

Gold-standard psychological and pharmacological treatments for bulimic-spectrum eating disorders only result in remission for around 50% of patients; patients with affective lability and impulsivity represent a subgroup with particularly poor outcomes. Both dialectical behavior therapy (DBT), a treatment for emotion dysregulation, and lamotrigine, a mood stabilizer, have demonstrated promise for targeting affective lability and impulsivity; however, data exploring the combination of these interventions remain limited.

OBJECTIVE

We followed a group of women with recurrent dysregulated eating behaviors (N = 62) throughout intensive DBT treatment and compared the symptom trajectory of those prescribed lamotrigine (n = 28) and those who were not (n = 34).

METHOD

Participants completed surveys every 2 weeks throughout treatment.

RESULTS

Group analyses suggested that all participants self-reported decreases in emotional reactivity, negative urgency, and symptoms of borderline personality disorder (BPD). The lamotrigine group reported greater elevations in BPD symptoms at baseline, but demonstrated steeper decreases in emotion and behavioral dysregulation than the non-matched comparison group. Within-subject analyses suggested that within the lamotrigine group, subjects reported greater decreases in symptoms following prescription of lamotrigine.

CONCLUSIONS

Findings provide initial data suggesting that lamotrigine could be useful as an adjunctive treatment for patients with affective lability and impulsivity.

LEVEL OF EVIDENCE

IV, time series without randomization.

The impact of COVID-19 on U.S. adolescents: loss of basic needs and engagement in health risk behaviors

Across the United States, the COVID-19 pandemic created myriad challenges for youth and families, including losses of basic needs which may be associated with increased use of maladaptive coping behaviors. In a sample of 2491 U.S. youth (ages 13-16), demographic differences in loss of basic needs and maladaptive coping were assessed using regression models. More than 21% of adolescents endorsed losing one or more basic needs (e.g., loss of access to food or shelter) and 83% endorsed use of maladaptive coping strategies (e.g., using drugs or alcohol; self-harming behaviors) during the COVID-19 pandemic. Although adolescents with both majority and minority identities reported losing basic needs and engaging in maladaptive coping behaviors, minoritized youth reported more basic needs losses (ps < 0.05) and greater reliance on maladaptive coping strategies (ps < .05) than their non-minoritized peers. Furthermore, adolescents who endorsed losing basic needs were more likely to also endorse engaging in maladaptive coping behaviors (p < .05). Healthcare providers and teachers must consider basic need losses while structuring emotional and behavioral supports for youth during and beyond the COVID-19 pandemic.

Emotion Dysregulation and Eating Disorder Symptoms: Examining Distinct Associations and Interactions in Adolescents

Emotion dysregulation has been posited as a key transdiagnostic factor of mental health difficulties, including eating disorders. However, how this transdiagnostic factor interacts with the disorder-specific factor of weight and shape concerns remains unclear. The current study examined whether emotion dysregulation is associated with eating disorder behaviors over and above the association between weight and shape concerns and whether these two factors interacted. The current study used data from two samples, a community sample of high school students (n = 2699), and a clinical sample of adolescents receiving outpatient treatment for an eating disorder (n = 149). Participants completed self-report measures on their eating behaviors, weight/shape concerns, and emotion dysregulation. Findings showed that emotion dysregulation had a unique association with engaging in binge eating and purging (community sample only). Weight and shape concerns were found to have a unique association with engaging in binge eating, fasting, purging, and driven exercise (community sample only). Additionally, weight and shape concerns moderated the association between emotion dysregulation and the probability of engaging in binge eating and driven exercise, whereby the strongest association between emotion dysregulation and these behaviors were observed among adolescents with the lowest levels of weight and shape concerns. Regarding the frequency of eating disorder behaviors, emotion dysregulation had a unique association with severity of binge eating and fasting. Weight and shape concerns were uniquely associated with severity of fasting and driven exercise (community sample only). Findings suggest that emotion dysregulation is a distinct factor of eating disorder behaviors among adolescents.

Appearance-ideal internalization, body dissatisfaction, and suicidality among sexual minority men

Sexual minority men (SMM) are disproportionately at risk for suicidality. Furthermore, SMM are at elevated risk for appearance-ideal internalization and body dissatisfaction, which are both associated with suicidality. Theoretical recommendations suggest including interaction terms between appearance-ideal internalization and body dissatisfaction when examining deleterious health outcomes. To test these interactions and examine whether appearance-ideal internalization or body dissatisfaction impart greater suicidality, the current study analyzed associations between specific forms of appearance-ideal internalization and suicidality among SMM, and whether body dissatisfaction moderated these associations. Participants were 171 SMM recruited for an eating disorder prevention program. Analyses examined the association between thin and muscular-ideal internalization with count of suicide risk, with body fat and muscularity dissatisfaction moderating these associations. Zero-inflated Poisson regressions revealed that the association between thin-ideal internalization and suicide risk was moderated by body fat dissatisfaction, such that thin-ideal internalization was associated with increased suicide risk at high levels of body fat dissatisfaction. Muscularity concerns were not significantly associated with suicidality, suggesting that thinness concerns may be more salient than muscularity for suicidality among SMM. Future research should replicate findings among larger SMM samples and extend the current design into non-SMM samples to examine if results generalize to other vulnerable populations.

Evaluating patterns of inconsistent and missing data on the eating disorders examination-questionnaire in a sample of treatment-seeking adults and adolescents

Missing or inconsistent responses on self-report assessments can have implications for the use of empirically validated measurements in research and clinical practice. However, literature on frequency and systematic patterns of missingness on common measures of eating pathology is lacking. The current study evaluated EDE-Q missing and inconsistent responding in a clinical eating disorders (EDs) sample (N = 739). Thirteen percent (13.4%; n = 99) of the sample failed to provide complete responses on the EDE-Q and 13.8% (n = 101) inconsistently responded to behavioral items of the EDE-Q. Males were more likely to provide missing data, and mean BMI was higher among individuals with missing responses. Inconsistent responders endorsed higher scores on several EDE-Q subscales, were younger, and were more likely to be Hispanic/Latinx. However, many of these differences were not significant following correction for multiple comparisons. Although our results indicated similar rates of missingness and inconsistency to past work in college samples, our results suggest that missing and inconsistent responding on the EDE-Q in clinical samples may not warrant specialized consideration within statistical analyses.

Factors associated with disordered eating behaviors and attitudes in older women

PURPOSE

The present study explored the potential factors associated with disordered eating behaviors and attitudes in older women.

METHODS

Women aged 60-75 years were recruited in the community (n = 203) and completed questionnaires. The Eating Disorder Examination-Questionnaire (EDE-Q) was used to evaluate disordered eating behaviors and attitudes. The independent variables were BMI, age, importance of appearance, importance of body competence, cognitive reappraisal, and fear of age-related appearance changes. Spearman correlation analyses and zero-inflated negative binomial regression models were used to analyze the data.

RESULTS

BMI was positively associated with EDE-Q restraint, EDE-Q eating concern, and EDE-Q frequency of objective binge-eating episodes. Importance of appearance was positively related to EDE-Q restraint, and fear of age-related appearance changes to EDE-Q eating concern and objective binge-eating episodes. Cognitive reappraisal was negatively associated with EDE-Q eating concern and excessive exercise in bivariate associations, but the relationships disappeared in the multivariate analyses.

CONCLUSIONS

BMI, importance of appearance, and fear of age-related appearance changes turned out to be positively associated with eating disordered behaviors and attitudes, similarly to what can be observed in middle-aged samples. However, the role of cognitive reappraisal was unclear and should be investigated further.

LEVEL OF EVIDENCE

Level V: cross-sectional descriptive study.

Impulsivity and anxiety-related dimensions in adults with bulimic-spectrum disorders differentially relate to eating disordered behaviors

While facets of both anxiety and impulsivity appear central to the development and maintenance of bulimia nervosa (BN), specific BN behaviors may be propagated by differing profiles of risk. The current study examined associations between dimensions of anxiety and impulsivity and BN symptoms (binge eating, vomiting, laxative misuse, driven exercise), both in terms of the presence of such behaviors and their frequency. Two hundred and four women (M_age = 25.7 years) who met DSM-IV criteria for full or subthreshold BN completed self-report measures of perfectionism (Frost Multidimensional Perfectionism Scale), anxiety (Spielberger Trait Anxiety Inventory), impulsivity (Barratt Impulsiveness Scale-11; Impulsive Behavior Scale), eating disordered behaviors (Eating Disorder Examination - Questionnaire), and associated psychiatric symptoms (Michigan Assessment Screening Test/Alcohol-Drug; Maudsley Obsessive-Compulsive Inventory). Factor analysis revealed multidimensional impulsive and anxiety-related traits (5 anxiety-related factors; 7 impulsivity-related factors). In zero-sensitive regression models, different facets of impulsivity evidenced association with the presence of binge eating (risk taking), laxative misuse (impulsive spending), and fasting (difficulty concentrating), along with the frequency of vomiting (long-term planning difficulties). In contrast, anxiety-related dimensions were only associated with driven exercise (high standards) and fasting (concern over mistakes, high standards, parental expectations). Overall, impulsive and anxiety-related factors and symptoms showed distinct associations with specific eating disorder behaviors, even among those with the same diagnosis.

Emotional Response Inhibition: A Shared Neurocognitive Deficit in Eating Disorder Symptoms and Nonsuicidal Self-Injury

Eating disorder (ED) symptoms often co-occur with non-suicidal self-injury (NSSI). This comorbidity is consistent with evidence that trait negative urgency increases risk for both of these phenomena. We previously found that impaired late-stage negative emotional response inhibition (i.e., negative emotional action termination or NEAT) might represent a neurocognitive mechanism for heightened negative urgency among people with NSSI history. The current study evaluated whether relations between negative urgency and ED symptoms similarly reflect deficits in this neurocognitive process. A total of 105 community adults completed an assessment of ED symptoms, negative urgency, and an emotional response inhibition task. Results indicated that, contrary to predictions, negative urgency and NEAT contributed independent variance to the prediction of ED symptoms, while controlling for demographic covariates and NSSI history. Worse NEAT was also uniquely associated with restrictive eating, after accounting for negative urgency. Our findings suggest that difficulty inhibiting ongoing motor responses triggered by negative emotional reactions (i.e., NEAT) may be a shared neurocognitive characteristic of ED symptoms and NSSI. However, negative urgency and NEAT dysfunction capture separate variance in the prediction of ED-related cognitions and behaviors, distinct from the pattern of results we previously observed in NSSI.

Behavioral inhibition moderates the association between overvaluation of shape and weight and noncompensatory purging in eating disorders

OBJECTIVE

The cognitive-behavioral therapy (CBT) model of eating disorders suggests that compensatory purging behaviors (e.g., self-induced vomiting, inappropriate laxative use) are primarily driven by binge eating. However, many individuals endorse purging in the absence of binge eating (i.e., noncompensatory purging [NCP]). Research is needed to understand why some individuals purge in the absence of objective or subjective binge-eating episodes.

METHOD

Given the importance of overvaluation of shape/weight in the CBT model, and the existing evidence linking temperamental characteristics like behavioral inhibition (i.e., the tendency to withdraw in response to threat cues) with purging in general, we tested whether behavioral inhibition moderated the relationship between overvaluation of shape/weight and NCP in a sample of individuals in a residential eating disorder treatment center (N = 143).

RESULTS

Overvaluation was more strongly related to NCP in individuals with high (relative to low) levels of behavioral inhibition. Among individuals low in behavioral inhibition, overvaluation predicted engagement in NCP to a much weaker extent.

DISCUSSION

For those high (relative to low) in behavioral inhibition, both emotional avoidance and overvaluation may be important targets in the treatment of NCP, particularly in the absence of binge eating.