Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research

Does response to treatment differ between anorexia nervosa and atypical anorexia nervosa? Findings from two open series trials

BACKGROUND

No evidence-based treatments exist for atypical anorexia nervosa (AAN) and little is known about differences in response to treatment between anorexia nervosa (AN) and AAN. The purpose of this paper is to explore treatment outcomes in two pilot trials for those with AN and AAN.

METHODS

Study 1 (N = 127) examined treatment outcomes in a digital imaginal exposure trial and Study 2 (N = 34) examined outcomes in a personalized treatment trial. Participants with an active eating disorder (ED) were eligible and those with AN or AAN were included in these analyses. ED symptoms and ED-related fears were assessed at pre-treatment, post-treatment, and one and six-month follow-up. Linear mixed effects models explored treatment outcomes by diagnosis.

RESULTS

There were no significant differences in treatment response between diagnoses for most outcome measures. In Study 2, participants with AAN had a significant decrease in global ED symptoms across time, while AN did not.

LIMITATIONS

The samples were primarily white and female, limiting the generalizability of the studies. Additionally, due to limited consensus on "significant weight loss," a less conservative definition was used to diagnose AAN which may impact the results.

CONCLUSIONS

In general, those with AN and AAN may respond to treatment similarly, with some small differences. Digital exposure therapy may be effective treatments for both AN and AAN, especially for ED-related fears. Personalized treatment may be more effective for those with AAN than those with AN.

Anxiety and restrained eating in everyday life: An ecological momentary assessment study

BACKGROUND

Restrained eating has been related to psychological distress like anxiety and eating disorder symptomatology, but little is known about this relationship in daily life in non-clinical populations. We aimed to understand concurrent and temporal associations between momentary anxiety and restrained eating in everyday life within and across persons in a non-clinical sample, and examined whether this association remains after controlling for eating disorder symptomatology.

METHODS

We used a 10-day ecological momentary assessment (EMA) protocol. Participants (n = 123) completed a baseline survey with demographics and eating disorder symptomatology questions, and three EMA surveys per day reporting anxiety and restrained eating intentions. We applied mixed-effects and random intercept cross-lagged models to analyze the data.

RESULTS

Momentary anxiety and restrained eating were concurrently significantly positively associated within and between persons. When participants had more anxiety than was typical for them, they were more likely to intend to restrain eating, and people with overall higher anxiety symptoms tended to report greater restrained eating over the study period. These associations remained significant after adjusting for eating disorder symptomatology. There were no significant temporal cross-lagged effects. Anxiety-restrained eating association did not spill over into the next assessment window.

LIMITATIONS

The time window between prompts may have been too long to capture potential temporal effects, and we did not examine actual behavioral food restrictions.

CONCLUSION

Daily-life anxiety may be related to concurrent restrained eating intentions, above and beyond baseline eating disorder symptomatology. Research is needed exploring daily-life anxiety as a potential intervention target to address restrained eating.

Anxiety matters: a pilot lab study into food, weight, and virtual body exposure in anorexia nervosa

BACKGROUND

Anxiety is a core characteristic of anorexia nervosa and a potential target of exposure therapy, which requires a profound understanding of the patients' fears in order to be successful. The knowledge about fears in anorexia nervosa that should be targeted during exposure therapy can be enriched by laboratory research to the precise emotional and behavioral responses of anorexia nervosa patients when they are exposed to disorder relevant fear stimuli.

METHODS

In the laboratory, patients with anorexia nervosa (n = 15) and healthy controls (n = 51) were exposed to 1. their own body weight and a 10% higher body weight on the scale, 2. a standardized lab breakfast, and 3. five virtual bodies with different BMIs ranging from extreme underweight to lower healthy weight. The participants emotional (anxiety, disgust, satisfaction, acceptance) and behavioral responses (calorie consumption) were assessed. Patients with anorexia nervosa but not the healthy controls then received an intensive exposure treatment (~ 30 individual exposure sessions) targeting their individual fears, next to standard care. After the exposure treatment, it was investigated whether the patients' responses to the laboratory tasks changed.

RESULTS

Across all tasks, the patients reported more anxiety than healthy controls. The patients also consumed less calories during the breakfast and accepted the different body weights on the scale less than healthy controls. During the virtual body exposure, the patients' emotional responses did not differ per avatar but they reacted more negatively towards avatars with healthier weights than did healthy controls. After the exposure treatment, the patients reported less fears and they consumed more calories while their BMIs had increased. They were also more accepting of healthier weights.

CONCLUSIONS

Exposure to food-, body- and weight-related stimuli in the laboratory induces emotional reactions in patients with anorexia nervosa that are informative for the identification of exposure therapy treatment targets. In addition, exposure therapy targeting individual fears in patients with anorexia nervosa led to symptom reduction and is a promising intervention for the treatment of anorectic fears, though more research is needed to optimize its efficacy.

Experiential Avoidance During Mealtimes Among Individuals With Eating Disorders

The relationship between negative emotions and avoidance is widely theorized as a bidirectional cycle implicated in a range of psychopathology. Historically, research on this cycle has examined one type of negative emotion: anxiety. Yet, a broader range of internal experiences may be implicated in the maintenance of unhealthy avoidance cycles in psychopathology. This study examines prospective relationships among anxiety, guilt, physical discomfort, and experiential avoidance during mealtimes for individuals with eating disorders (EDs). Participants (N = 108) completed ecological momentary assessments four times a day for 25 days. We computed multilevel models to examine between- and within-person effects of negative emotions and physical discomfort on experiential avoidance. When including guilt and anxiety in one model, guilt, but not anxiety, explained the significant variance in experiential avoidance at the next meal. Mealtime physical discomfort and experiential avoidance evidenced reciprocal prospective relationships. Future research should test whether interventions targeting experiential avoidance and physical discomfort at mealtimes disrupt guilt.

Early change in gastric-specific anxiety sensitivity as a predictor of eating disorder treatment outcome

Eating disorders (EDs) are often accompanied by gastrointestinal (GI) distress. Anxiety sensitivity is the tendency to interpret sensations of anxiety as threatening or dangerous, and includes both broad physical symptoms (e.g., elevated heartrate) and GI-specific symptoms. Physical and GI-specific anxiety sensitivity may be important risk and maintaining factors in EDs. This study tested the hypothesis that greater reductions in both types of anxiety sensitivity during the first month of treatment would predict lower ED symptoms and trait anxiety at discharge and 6-month follow-up. Patients (n = 424) in ED treatment reported physical and GI-specific anxiety sensitivity, ED symptoms, and trait anxiety at treatment admission, 1-month into treatment, discharge, and 6-month follow-up. Analyses were conducted with hierarchical linear regression with imputation, controlling for relevant covariates. Results indicated that early reduction in GI-specific but not general physical anxiety sensitivity predicted both lower ED symptoms and lower trait anxiety at discharge and 6-month follow-up. These findings demonstrate the importance of GI-specific anxiety sensitivity as a potential maintaining factor in EDs. Developing and refining treatments to target GI-specific anxiety sensitivity may have promise in improving the treatment not only of EDs, but also of commonly co-morbid anxiety disorders.

Eating disorder risks and psychopathological distress in Italian high school adolescents

BACKGROUND

Psychopathological disorders are often comorbid diagnosis in eating disorders (EDs). We aimed to assess the presence of psychopathological traits and symptoms associated with EDs in an Italian high school adolescent population.

METHODS

A sample of high school adolescents was enrolled, and demographic and clinical data were collected. Two self-report questionnaires, the Eating Disorder Inventory-3 (EDI-3) and the Questionnaire for the Assessment of Psychopathology in Adolescence (Q-PAD), were administered.

RESULTS

548 adolescents (333 F/215 M; 16.89 ± 0.85 years) were included. Symptoms associated with EDs of clinical or high clinical concern were prevalent in a range of individuals, with percentages varying from 26.82% for body dissatisfaction to 51.83% for Interoceptive Deficits. The findings from the Q-PAD assessment indicated the presence of psychological distress, leading to discomfort or challenging situations requiring potential intervention in a percentage of adolescents ranging from 2.93% for psychosocial risks to 23.77% for anxiety. These percentages showed differences between genders (F > M, p < 0.001). Our study also highlighted an association between symptoms of EDs and lifestyle factors within families. We observed correlations between Q-PAD measures and EDI-3 scores, including a positive correlation between Q-PAD and EDI-3 body dissatisfaction (r = 0.7), Q-PAD interpersonal conflicts and EDI-3 interpersonal problems (r = 0.6) and a negative correlation between Q-PAD self-esteem and well-being and EDI-3 ineffectiveness Composite (r=-0.7).

CONCLUSIONS

a substantial prevalence of ED symptoms and psychological distress among high school adolescents were recorded. These conditions are interrelated, suggesting the importance of addressing them comprehensively. Early detection is essential to improve treatment outcomes and to implement preventive strategies.

Early reduction in anxiety sensitivity predicts greater reduction in disordered eating and trait anxiety during treatment for bulimia nervosa

OBJECTIVE

Anxiety sensitivity (AS), the trait-like fear of symptoms of anxiety, has been associated with eating disorder (ED) pathology broadly, bulimia nervosa (BN) symptoms specifically, and the anxiety disorders that are commonly comorbid with BN. AS, especially for physical symptoms specifically, maybe a risk and maintenance factor for BN and comorbid anxiety.

METHOD

Adult participants with BN (n = 44) in a clinical trial comparing CBT to mindfulness and acceptance-based treatment (MABT) reported ED symptoms, trait anxiety, and AS through treatment and follow-up. We predicted that greater early reduction (i.e., within the first month of treatment) in AS would predict greater reductions in ED symptoms and trait anxiety at post-treatment and follow-up.

RESULTS

Early reductions in AS for physical concerns predicted lower ED symptoms and trait anxiety at post-treatment but not follow-up. Exploratory analyses indicated that treatment groups did not differ in either early or total change in AS, controlling for baseline AS.

DISCUSSION

Early reductions in AS may be an important treatment target for BN, and may additionally support reductions in anxiety. Future research should identify which components of CBT and MABT best target AS, to deliver these components early in treatment, when they can have maximum effect.

PUBLIC SIGNIFICANCE

Anxiety sensitivity, the fear of symptoms of anxiety, is associated with eating disorders (ED). In this study, participants in treatment for bulimia nervosa reported ED symptoms, trait anxiety, and anxiety sensitivity through treatment and follow-up. Greater early reductions in anxiety sensitivity predicted lower ED symptoms and trait anxiety at post-treatment. Future research should identify which elements of treatment best target anxiety sensitivity, to deliver them early in treatment.

Examining co-occurring social anxiety in cognitive behavioral therapy for eating disorders: Does it change and does it moderate eating disorder outcomes?

OBJECTIVE

Eating disorders (EDs) often co-occur with social anxiety disorder (SAD). However, little research has examined the influence of SAD symptoms on ED treatment outcomes in the context of individual outpatient cognitive-behavior therapy for eating disorders (CBT-ED). It is plausible that SAD symptom severity could improve as a result of ED treatment, given the high overlap between EDs and SAD. We sought to test whether baseline SAD symptoms moderate early response to CBT-ED or post-treatment outcomes in CBT-ED, and the degree to which SAD symptoms improve during therapy despite SAD not being an explicit treatment target.

METHOD

ED clients (N = 226) aged ≥16 years were treated with CBT-ED. Outcomes were ED symptoms, clinical impairment, and SAD symptoms measured at baseline, session 5 and post-treatment.

RESULTS

Baseline SAD was a weak moderator of early and post-treatment ED symptoms and impairment. SAD symptoms improved moderately over treatment among clients who started with elevated levels of SAD symptomology.

DISCUSSION

Clients with EDs can experience good therapeutic outcomes regardless of their social anxiety severity at pre-treatment. SAD symptoms reduced over CBT-ED, but protocol enhancements such as exposure-based strategies that directly target co-occurring social-evaluative concerns may help achieve larger reductions in SAD symptoms.

PUBLIC SIGNIFICANCE

Eating disorders often co-occur with anxiety disorders such as social anxiety. We found people who had both social anxiety and an eating disorder benefited as much from eating disorder treatment as people who did not have social anxiety. People who were socially anxious became less anxious as a by-product of receiving eating disorder treatment. It may be possible to reduce social anxiety further by enhancing eating disorder treatment protocols.

A multi-modal assessment of fear conditioning in adolescent anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a pernicious psychiatric disorder which is principally characterized by a fear of weight gain. Notwithstanding the centrality of fear in the psychopathology of AN, controlled assessments of negative valence systems are lacking. Herein we assess fear conditioning in adolescent females with AN.

METHOD

Adolescent girls (Mage = 14.6 years, ±1.57) with DSM-5 diagnoses of AN (N = 25) and age-matched control girls (Mage = 14.8 years, ±1.46) with no DSM-5 diagnoses (N = 25) completed structured clinical interviews and participated in a classical three-phase Pavlovian fear conditioning paradigm. Participants with comorbid anxiety disorders were excluded. Skin conductance response (SCR) was measured, alongside self-reported fear, valence, and fear expectancy ratings.

RESULTS

Both groups demonstrated significant differential acquisition across all four measures. Regarding group comparisons, no differences emerged for self-reported fear, valence, and fear expectancy ratings during acquisition, although for SCR, those with AN demonstrated reduced physiological arousal relative to controls. Both groups demonstrated significant differential extinction for unconditioned stimuli (US) expectancy, self-report fear, and self-report valence. No statistically significant group differences were evident during extinction to the conditioned stimuli (CS)+, on any outcome measure. However, controls reported more positive valence to the CS- than those with AN.

CONCLUSIONS

Contrary to our hypotheses, our preliminary assessment did not find support for elevated fear responding among adolescent girls with AN with regards to fear acquisition or extinction. These data suggest that AN in adolescent girls may not be associated with a heightened propensity to acquire fear, but conversely, may suggest that exposure treatments for AN may be helpful, since extinction learning is intact in AN.

PUBLIC SIGNIFICANCE

AN is characterized by fear-related symptoms, including food and weight-related fear, and behavioral avoidance, yet controlled studies assessing fear learning are limited. Our preliminary assessment of adolescent AN indicates no abnormalities in fear learning among adolescents with AN. These findings may inform existing mechanistic models of AN psychopathology, and the development of exposure-based treatments for AN.

Food Addiction Screening, Diagnosis and Treatment: A Protocol for Residential Treatment of Eating Disorders, Substance Use Disorders and Trauma-Related Psychiatric Comorbidity

Food addiction, or ultra-processed food addiction (UPFA), has emerged as a reliable and validated clinical entity that is especially common in individuals seeking treatment for eating disorders (EDs), substance use disorders (SUDs) and co-occurring psychiatric disorders (including mood, anxiety and trauma-related disorders). The clinical science of UPFA has relied on the development and proven reliability of the Yale Food Addiction Scale (YFAS), or subsequent versions, e.g., the modified YFAS 2.0 (mYFAS2.0), as well as neurobiological advances in understanding hedonic eating. Despite its emergence as a valid and reliable clinical entity with important clinical implications, the best treatment approaches remain elusive. To address this gap, we have developed and described a standardized assessment and treatment protocol for patients being treated in a residential program serving patients with psychiatric multi-morbidity. Patients who meet mYFAS2.0 criteria are offered one of three possible approaches: (1) treatment as usual (TAU), using standard ED treatment dietary approaches; (2) harm reduction (HR), offering support in decreasing consumption of all UPFs or particular identified UPFs; and (3) abstinence-based (AB), offering support in abstaining completely from UPFs or particular UPFs. Changes in mYFAS2.0 scores and other clinical measures of common psychiatric comorbidities are compared between admission and discharge.

Telehealth-Delivered Radically Open Dialectical Behavior Therapy for Adolescents (RO DBT-A): A Pilot Mixed-Methods Study

OBJECTIVE

Disorders related to overcontrol frequently first appear during adolescence, are highly comorbid, and show limited treatment response, necessitating the adaptation of radically open dialectical behavior therapy (RO DBT; a transdiagnostic treatment targeting overcontrol) for adolescents (RO DBT-A). This study tested the preliminary efficacy of telehealth-delivered RO DBT-A in a heterogeneous clinical sample of youths.

METHODS

The sample consisted of 20 female participants ages 13-21 with elevated overcontrol; most were White (75%) and non-Hispanic/Latino (80%). RO DBT-A was provided over 20 weeks via skills group and individual sessions (N=13 participants). Participants seeking other treatment or no treatment formed the control group (N=7). Outcomes included self-reported symptoms and overcontrol. Follow-up interviews were analyzed by using inductive, contextualist thematic analysis to examine participant perceptions and reasons for dropout.

RESULTS

The RO DBT-A group showed significant improvements in depression (t=-1.78, df=10, p=0.011) and quality of life (QOL; Wilcoxon W=75, p=0.021) compared with the control group. From baseline to posttreatment, youths receiving RO DBT-A demonstrated significant improvements in maladaptive overcontrol (t=2.76, df=12, p=0.043), anxiety (t=2.91, df=12, p=0.043), depression (Wilcoxon signed rank V=82.5, p=0.043), and QOL (t=-3.01, df=12, p=0.043). Qualitative analysis revealed themes related to treatment barriers, facilitators, and timing.

CONCLUSIONS

The findings provide preliminary evidence supporting telehealth-delivered RO DBT-A in targeting overcontrol, decreasing symptomatology, and improving QOL in a heterogeneous clinical sample of youths. Qualitative follow-ups highlighted that dropout was driven by barriers related to therapy (e.g., structure- and therapist-related issues) and the timing of RO DBT-A compared with other treatments.

Are within- and between-session changes in distress associated with treatment outcomes? Findings from two clinical trials of exposure for eating disorders

OBJECTIVE

Imaginal exposure is a novel intervention for eating disorders (EDs) that has been investigated as a method for targeting ED symptoms and fears. Research is needed to understand mechanisms of change during imaginal exposure for EDs, including whether within- and between-session distress reduction is related to treatment outcomes.

METHOD

Study 1 tested four sessions of online imaginal exposure (N = 143). Study 2 examined combined imaginal and in vivo exposure, comprising six imaginal exposure sessions (N = 26). ED symptoms and fears were assessed pre- and posttreatment, and subjective distress and state anxiety were collected during sessions.

RESULTS

Subjective distress tended to increase within-session in both studies, and within-session reduction was not associated with change in ED symptoms or fears. In Study 1, between-session reduction of distress and state anxiety was associated with greater decreases in ED symptoms and fears pre-to posttreatment. In Study 2, between-session distress reduction occurred but was not related to outcomes.

CONCLUSIONS

Within-session distress reduction may not promote change during exposure for EDs, whereas between-session distress reduction may be associated with better treatment outcomes. These findings corroborate research on distress reduction during exposure for anxiety disorders. Clinicians might consider approaches to exposure-based treatment that focus on distress tolerance and promote between-session distress reduction.

Variation in care for inpatients with avoidant restrictive food intake disorder leads to development of a novel inpatient clinical pathway to standardize care

INTRODUCTION

There is limited evidence to guide management of patients with avoidant restrictive food intake disorder (ARFID) admitted for medical stabilization. We describe variations in inpatient care which led to the development of a multidisciplinary inpatient clinical pathway (ICP) to provide standardized management and examine differences after the ICP was implemented.

METHODS

A retrospective review of patients with ARFID admitted to Adolescent Medicine, Gastroenterology, and General Pediatrics at a single academic center was conducted. We compare hospital utilization and use of consulting services during the pre-ICP (2015-2017) and post-ICP (2018-2020) periods.

RESULTS

110 patients were admitted with ARFID (n = 57 pre- vs. n = 53 post-ICP). Most presented with moderate/severe malnutrition (63% pre vs. 81% post; p = 0.11) and co-morbid anxiety and/or depression (74% pre vs. 92% post; p = 0.01). There was some variation in use of enteral tube feeding by service in both periods (p = 0.76 and p = 0.38, respectively), although overall use was consistent between periods (46% pre vs. 58% post; p = 0.18). Pre-ICP, use of the restrictive eating disorder protocol differed across services (p < 0.001), with only AM using it. Overall, utilization of the restrictive eating disorder protocol decreased from 16% pre-ICP to 2% post-ICP (p = 0.02). There was variation by service in psychiatry/psychology (range 82-100% by service; p = 0.09) and social work consultations (range 17-71% by service; p = 0.001) during the pre-ICP period, though variation was reduced in the post-ICP period (p = 0.99 and p = 0.05, respectively). Implementation of the ICP led to improvements in these consultative services, with all patients in the post-ICP period receiving psychiatry/psychology consultation (p = 0.05) and an increase in social work consults from 44 to 64% (p = 0.03). Nutrition consults were consistently utilized in both periods (98% pre vs. 100% post; p = 0.33).

CONCLUSION

The ICP was developed to standardize inpatient medical stabilization for patients with ARFID. In this single center study, implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: there were improvements in the use of consulting services and a reduction in the use of the restrictive eating disorder protocol. The ICP demonstrates the potential to further standardize and improve care over time.

Evaluating the predictions of an interoceptive inference model of bulimia nervosa

OBJECTIVE

Bulimia nervosa (BN) is associated with loss-of-control (LOC) eating episodes that frequently occur in response to negative emotions. According to recent neurocomputational models, this link could be explained by a failure to accurately update beliefs about the body in states of high arousal. Specifically, these interoceptive inference models suggest that under-relying on signals from one's body about sensory experience ("low sensory precision") and/or over-relying on previously held beliefs ("excessively precise priors") lead to inaccurate perception and maladaptive behaviors. We conducted an initial test of these core predictions of the interoceptive inference model in BN using self-report measures.

METHODS

We compared women with BN (n = 30) and age-, BMI-, and full-scale IQ-matched controls (n = 31) on trust in sensory information from the body and two types of beliefs about what can be done to regulate high negative affect. Within the BN group, we tested interrelations among these measures and explored their associations with LOC eating frequency.

RESULTS

Compared with healthy controls, the BN group reported lower levels of trust in sensory information and stronger beliefs that once upset, there is little one can do, apart from eating, to self-regulate. These beliefs were associated with each other and with lower body trust. Beliefs about the uncontrollability of emotion were associated with more frequent subjective binge-eating episodes.

CONCLUSIONS

Findings provide initial support for the core predictions of an interoceptive inference account of BN: low trust in sensory information ("sensory precision") may promote an overreliance on maladaptive "prior beliefs" about the effects of eating on negative emotions, ultimately interfering with accurate updating of beliefs about other strategies that could regulate emotions and maintain LOC eating. Low body trust, strong expectations about emotions, and their neurocomputational underpinnings could be promising combined treatment targets for BN.

Testing the role of associative learning in evidence-based treatments for anorexia nervosa

Treatments for anorexia nervosa (AN) remain ineffective for many patients. Processes that can account for differential treatment outcomes remain mostly unknown. We propose that the field test the role of associative learning in current psychological treatments. We hold that this line of research could yield actionable information for understanding non-response and improving long-term outcomes. To make this argument, we define associative learning and outline its proposed role in understanding psychiatric disorders and their treatment. We then briefly review data exploring associative learning in AN. We argue that associative learning processes are implicitly implicated in existing treatments; by this rationale, baseline differences in learning may interfere with treatment response. Finally, we outline future research to test our hypotheses. Altogether, future research aimed at better understanding how associative learning may contribute to AN symptom persistence has the potential to inform novel directions in intervention research. PUBLIC SIGNIFICANCE: There is a pressing need to improve outcomes in treatments for anorexia nervosa (AN). We propose that individual differences in associative learning-the ability to form and update associations between cues, contexts, behaviors, and outcomes-may account for differential response to existing treatments. Undertaking this research could provide an understanding of how current treatments work and inform new approaches for those who may be at risk of poor outcomes.

Development and Validation of a Broad and Fear-Adaptable Measure of Fear Approach and Application to Common Eating Disorder Fears

Fear approach is a theorized mechanism of exposure treatment for anxiety-based disorders. However, there are no empirically established self-report instruments measuring the tendency to approach feared stimuli. Because clinical fears are heterogeneous, it is important to create a measure that is adaptable to person- or disorder-specific fears. The current study (N = 455) tests the development, factor structure, and psychometric properties of a self-report instrument of fear approach broadly and the adaptability of this measure to specific eating disorder fears (i.e., food, weight gain). Factor analyses identified a unidimensional, nine-item factor structure as the best fitting model. This measure had good convergent, divergent, and incremental validity and good internal consistency. The eating disorder adaptations retained good fit and strong psychometric properties. These results suggest that this measure is a valid, reliable, and adaptable measure of fear approach, which can be used in research and exposure therapy treatment for anxiety-based disorders.

When time worsens framing: a longitudinal analysis of the psychological effects of the COVID-19 pandemic in women with an eating disorder and their healthy sisters

The COVID-19 pandemic has profoundly affected individuals with eating disorders (ED), leading to an exacerbation of symptoms worldwide in 2020. However, there is a lack of longitudinal analyses of the psychological burdens experienced by this population. This study aims to longitudinally assess the psychological effects of the COVID-19 pandemic in people with ED and their healthy sisters (HS) 1 and 2 years after the onset of the crisis. A sample of 148 individuals, consisting of 73 with ED and 45 HS, was evaluated in spring 2021 and spring 2022 regarding their current psychological and behavioral states. Participants were also asked to reflect on their feelings and behaviors during the 2020 lockdown. General psychopathology, eating disorders, and trauma-related symptoms were evaluated using validated questionnaires. Both groups showed an overall improvement in psychopathological symptoms with time. Individuals with ED exhibited greater improvement compared to their HS, which may be attributed to their initially higher burden. Individuals with ED reported a negative reframe, characterized by internalizing negative emotions and behaviors related to the 2020 lockdown. This longitudinal evaluation revealed two distinct and contrasting effects. Both ED patients and their HS demonstrated psychological improvement over time. However, people with ED experienced a negative reframe that affected their memory of specific life events, subsequently affecting their psychological well-being. These findings shed light on the clinical severity observed in people with ED during these pandemic years.

Facing Eating Disorder Fears: An Open Trial Adapting Prolonged Exposure to the Treatment of Eating Disorders

Eating disorders (EDs) are maintained by core fears, which lead to avoidance behaviors, such as food avoidance or compensatory behaviors. Previously tested exposure-based treatments for EDs have generally focused on proximal outcomes (e.g., food), rather than addressing core fears (e.g., fear of weight gain and its consequences). The current study tested the feasibility and initial clinical efficacy of 10 sessions of imaginal and in vivo exposure for core ED fears (termed "Facing Eating Disorder Fears"), mainly fear of weight gain and its associated consequences. Participants were 36 adults with anorexia nervosa (AN), bulimia nervosa, or other specified feeding and eating disorders determined by semistructured diagnostic interviews. ED symptoms, fears, and body mass index (BMI) were assessed at pretreatment, posttreatment, and 1-month follow-up. Treatment involved 10 sessions of imaginal and in vivo exposure to ED fears in combination with in vivo exposures to feared and avoided situations as homework. ED symptoms and fears decreased from pre- to posttreatment and at 1-month follow-up. BMI increased significantly from pre- to posttreatment, particularly for those with AN. Effect sizes ranged from small to very large. ED symptoms and fears decreased and BMI increased following exposure. Increases in BMI occurred without any direct intervention on eating, suggesting that weight gain can be achieved without a specific focus on food during ED treatment. Facing Eating Disorder Fears may be a feasible stand-alone intervention for EDs. Future research must test comparative efficacy through randomized controlled trials.

An Intensive time series investigation of the relationships across eating disorder-specific fear responses and behavior urges in partially remitted anorexia nervosa

Anorexia nervosa (AN) is a serious and persistent psychiatric illness. Many individuals with AN cycle between stages of remission (i.e., relapse), with research documenting that cognitive remission generally lags behind nutritional/weight restoration. Yet, little is known about which mechanisms promote movement from partial remission in AN (defined as nutritional, but not cognitive, recovery) to full remission. Fear-based processes, including avoidance and approach behaviors, likely contribute to the persistence of cognitive-behavioral AN symptoms after nutritional restoration. The current study used intensive longitudinal data to characterize these processes during partial remission (N = 41 participants with partially remitted AN; 4306 total observations). We aimed to a) characterize frequency of fear-based processes in real-time, b) investigate associations across fear-based processes and behavioral urges, and c) test if real-time associations among symptoms differed across commonly feared stimuli (e.g., food, social situations). On average, participants endorsed moderate fear and avoidance, with weight-gain fears rated higher than other feared stimuli. Momentary fear, avoidance, approach, and distress were all positively associated with AN behavior urges at one time-point and prospectively. Central symptoms and symptom connections differed across models with different feared stimuli. These findings provide empirical support for the theorized fear-avoidance-urge cycle in AN, which may contribute to the persistence of eating pathology during partial remission. Fear approach may be associated with temporary increases in urges, which should be considered during treatment. Future research should explore these associations in large, heterogeneous samples, and test the effectiveness of exposure-based interventions during partial remission.

Elevated interoceptive deficits in individuals with eating disorders and self-injurious thoughts and behaviors: A replication and extension

INTRODUCTION

People with eating disorders (EDs) frequently report self-injurious thoughts and behaviors (SITBs). We aimed to replicate and extend findings demonstrating greater interoceptive deficits according to SITB severity. We predicted that interoceptive deficits would be greater among people with versus without lifetime SITBs and among those with multiple suicide attempts compared with single attempts or nonsuicidal self-injury. We also predicted that interoception would be increasingly impaired with greater current suicidality severity.

METHOD

Adults (N = 118) seeking ED treatment reported current and lifetime SITBs upon admission to treatment. We used planned contrasts to compare interoceptive deficits (self-reported using the Eating Disorders Inventory) by SITB and current suicidality groups (assessed by self-report and clinical interview).

RESULTS

Interoceptive deficits were greater among people with any SITB history compared to those without. People with multiple suicide attempts did not differ in interoceptive deficits from those with single attempts or only nonsuicidal self-injury. Interoceptive deficits were elevated among those with any current suicidality compared to those with no suicidal symptoms; interoceptive deficits did not differ according to severity of suicidality.

CONCLUSION

Among those with EDs, interoceptive deficits are elevated among those with concurrent SITBs. Interventions aimed at improving interoception may reduce the risk for SITBs.

Are central eating disorder network symptoms sensitive to item selection and sample? Implications for conceptualization of eating disorder psychopathology from a network perspective

Item selection is a critical decision in modeling psychological networks. The current preregistered two-study research used random selections of 1,000 symptom networks to examine which eating disorder (ED) and co-occurring symptoms are most central in longitudinal networks among individuals with EDs (N = 71, total observations = 6,060) and tested whether centrality changed based on which items were included in the network. Participants completed 2 weeks of ecological momentary assessment (five surveys/day). In Study 1, we obtained initial strength centrality values by estimating an a priori network using eight items with the highest means. We then estimated 1,000 networks and their centrality from a random selection of unique eight-item symptom combinations. We compared the strength centrality from the a priori network to the distribution of strength centrality estimates from the random-item networks. In Study 2, we repeated this procedure in an independent longitudinal dataset (N = 41, total observations = 4,575) to determine if our results generalized across samples. Shame, guilt, worry, and fear of losing control were consistently central across networks, regardless of items included in the network or sample. Results suggest that these symptoms may be important to the structure of ED psychopathology and have implications for how we understand the structure of ED psychopathology. Existing methods for item inclusion in psychological networks may distort the structure of ED symptom networks by either under- or overestimating strength centrality, or by omitting consistently central symptoms that are nontraditional ED symptoms. Future research should consider including these symptoms in models of ED psychopathology. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Orthorexia nervosa versus healthy orthorexia: Anxiety, perfectionism, and mindfulness as risk and preventative factors of distress

BACKGROUND

Orthorexia nervosa is a recently conceptualised pathological entity presenting as an obsessive focus on healthy eating with associated psychosocial impairment.

AIMS

The present study investigated the differential associations between orthorexia nervosa and healthy orthorexia with distress and impairment.

MATERIALS & METHODS

With a community sample (N = 268) multiple measures of orthorexia nervosa and health orthorexia were compared as explanatory variables in mediation structural equation modelling (SEM). Outcome variables assessed and investigated were psychological distress while demographic variables were controlled. The mediating roles of perfectionism and health anxiety on orthorexia nervosa were examined with further preventative mediation role of mindfulness on distress.

RESULTS

Distinctive to other eating disorders, gender showed no significant effects on orthorexia nervosa and healthy orthorexia. Signalling measurement issues for this disorder, the different measures of orthorexia nervosa resulted in mixed findings regarding body mass index and age. Findings supported perfectionism and health anxiety as risk factors, as well as mindfulness acceptance as a preventative factor in both orthorexia nervosa and healthy orthorexia. Orthorexia nervosa and healthy orthorexia assessed by most measures, contrary to the expectations, had significant positive associations with psychological distress indicated by stress, anxiety, and depression.

DISCUSSION & CONCLUSION

The complexity in differentiating orthorexia nervosa from healthy orthorexia calls for further investigation. This research effort should serve to substantiate the status of orthorexia nervosa as a distinct clinical disorder.

Testing anxiety and reward processing in anorexia nervosa as predictors of longitudinal clinical outcomes

Anorexia nervosa (AN) is a psychiatric disorder with a tenuous longitudinal course marked by a high risk of relapse. Previous studies suggest that aberrant threat perception and reward processing operate in many with AN, and may produce obstacles to treatment engagement; therefore, these could potentially represent predictors for longitudinal clinical outcomes. In this study, anxiety and reward symptoms, behaviors, and neural circuit connectivity were measured in intensively treated AN-restrictive subtype patients (n = 33) and healthy controls (n = 31). Participants underwent an fMRI experiment using a monetary reward task in combination with either overlapping individually tailored anxiety-provoking words or neutral words. Behavioral/psychometric measures consisted of reaction times on the monetary reward task and self-ratings on anxiety symptoms at study entry. We tested multimodal, multivariate models based on neural, behavioral, and psychometric measures of reward and anxiety to predict physiological (Body Mass Index; BMI) and psychological (eating disorder symptom severity) longitudinal outcomes in AN over six months. Our results indicated that higher anxiety symptom psychometric scores significantly predicted BMI reductions at follow-up. Untreated anxiety after intensive treatment could put individuals with AN at heightened risk for weight loss. This represents a potentially modifiable risk factor that could be targeted more aggressively to help reduce the chance of future clinical worsening.

Weight Suppression and Risk for Childhood Psychiatric Disorders

Weight suppression, defined as the discrepancy between an individual's highest historical weight and their current weight, has been implicated in the development and maintenance of eating disorders. Although weight suppression has also been found to impact mood, anxiety and suicidal behavior in patients with and without disordered eating, it has not been examined as a transdiagnostic risk factor for general psychopathology. The current study examined growth records of 281 children and adolescents (ages 7 to 17) newly diagnosed with psychiatric disorders to determine whether these children were more likely to be weight suppressed as compared to an age- and gender-matched control group. Findings suggest that weight suppression is related to an increased risk for anxiety disorders and externalizing disorders for males. These results underscore the need for psychiatric and behavioral health providers to review pediatric growth charts as a routine part of psychiatric evaluation. As weight restoration is a necessary precondition for eating disorder recovery, more research is necessary to determine if weight restoration can enhance treatments for psychiatric symptoms occurring in the context of weight suppression.

Relational attitudes in adolescent girls with and without a diagnosis of anorexia nervosa or atypical anorexia nervosa

BACKGROUND

People with eating disorders experience interpersonal difficulties, but little research explores relational attitudes in this population. We examined sense of relational entitlement towards parents, pathological concern, and psychological distress in adolescent girls with and without anorexia nervosa (AN) or atypical anorexia nervosa (AAN).

METHODS

Questionnaires assessing sense of entitlement towards parents, pathological concern, and symptoms of depression and anxiety were completed by 85 girls with and 100 girls without AN/AAN (mean age 15.06 ± 1.41). The AN/AAN group also completed a measure of ED pathology.

RESULTS

Eating pathology, pathological concern and symptoms of depression and anxiety were positively associated with both restricted and inflated sense of entitlement towards parents. AN/AAN participants scored significantly higher than controls on restricted and inflated sense of entitlement, pathological concern and symptoms of depression and anxiety. Restricted sense of entitlement and pathological concern partially mediation the association between AN/AAN and symptoms of depression and fully mediated the association between AN/AAN and anxiety. Within the AN/AAN group, pathological concern and symptoms of depression explained a large proportion of the variance in ED pathology.

CONCLUSIONS

Adolescent AN/AAN takes a heavy toll on emotional and social health, perhaps in part because crucial aspects of relational mutuality fail to develop. Teens with AN/AAN tend to over-focus on their parents' needs at the expense of their own needs. They also have impaired capacity to realistically appraise expectations from their parents, tending to feel over- and/or under-entitled to need fulfillment. These relational attitudes are associated with symptoms of depression and anxiety and should be addressed in therapy.

Measuring cognitions during exercise: Associations between thoughts and eating disorder behaviors over a 3-week ecological momentary assessment study

OBJECTIVE

Previous work has outlined cognitive beliefs about exercise in general, but very little is known about momentary cognitions while engaging in pathological exercise. The primary aim of this study was to explore thought content during exercise and to test whether these thoughts predicted later engagement in eating disorder behaviors. We also tested associations between thoughts and specific exercise activity.

METHOD

We monitored 31 women with clinically significant eating psychopathology for 3 weeks via ecological momentary assessment as they reported on their exercise and eating disorder behaviors, and thoughts about shape, weight, or calories during exercise. Thoughts were self-reported upon cessation of each exercise session.

RESULTS

Thinking about weight loss during exercise predicted later engagement in body-checking behaviors. Weight-bearing exercise was associated with a decreased likelihood of thinking about calories but an increased likelihood of thinking about shape during exercise.

DISCUSSION

These findings show that shape and weight thoughts are present during exercise and that their influence on eating disorder behaviors may exist on a much briefer time scale (i.e., within a day) than previous studies show. Clinically, future studies may seek to test interventions aimed at changing or restructuring cognitions during exercise to help shape adaptive exercise behavior during and after treatment.

PUBLIC SIGNIFICANCE

This is the first study measuring thoughts during pathological exercise in real-time among those with eating disorder psychopathology. The results show that thinking about weight loss during exercise might increase the likelihood of engaging in body-checking behaviors. Findings will inform the development of treatment approaches to help those in recovery from eating disorders re-engage with exercise.

Functions of disordered eating behaviors: a qualitative analysis of the lived experience and clinician perspectives

BACKGROUND

One method to improve treatment outcomes for individuals with eating disorders (EDs) may be understanding and targeting individuals' motives for engaging in DE behaviors-or the functions of DE behaviors. The goal of this study was to investigate and categorize the various functions of DE behaviors from the perspectives of adults who engage in DE behaviors and clinicians who treat EDs.

METHODS

Individuals who engage in DE behaviors (n = 16) and clinicians who treat EDs (n = 14) were interviewed, and a thematic analysis was conducted to determine key functions of DE behaviors.

RESULTS

Four main functions of DE behaviors were identified by the authors: (1) alleviating shape, weight, and eating concerns; (2) regulating emotions; (3) regulating one's self-concept; and (4) regulating interpersonal relationships/communicating with others.

CONCLUSIONS

Differences in participant responses, particularly regarding the relevance of alleviating shape and weight concerns as an DE behavior function, highlight the importance of individualized conceptualizations of DE behavior functions for any given client.

Neural representations of anxiety in adolescents with anorexia nervosa: a multivariate approach

Anorexia nervosa (AN) is characterized by low body weight, fear of gaining weight, and distorted body image. Anxiety may play a role in the formation and course of the illness, especially related to situations involving food, eating, weight, and body image. To understand distributed patterns and consistency of neural responses related to anxiety, we enrolled 25 female adolescents with AN and 22 non-clinical female adolescents with mild anxiety who underwent two fMRI sessions in which they saw personalized anxiety-provoking word stimuli and neutral words. Consistency in brain response patterns across trials was determined using a multivariate representational similarity analysis (RSA) approach within anxiety circuits and in a whole-brain voxel-wise searchlight analysis. In the AN group there was higher representational similarity for anxiety-provoking compared with neutral stimuli predominantly in prefrontal regions including the frontal pole, medial prefrontal cortex, dorsolateral prefrontal cortex, and medial orbitofrontal cortex, although no significant group differences. Severity of anxiety correlated with consistency of brain responses within anxiety circuits and in cortical and subcortical regions including the frontal pole, middle frontal gyrus, orbitofrontal cortex, thalamus, lateral occipital cortex, middle temporal gyrus, and cerebellum. Higher consistency of activation in those with more severe anxiety symptoms suggests the possibility of a greater degree of conditioned brain responses evoked by personally-relevant emotional stimuli. Anxiety elicited by disorder-related stimuli may activate stereotyped, previously-learned neural responses within- and outside of classical anxiety circuits. Results have implications for understanding consistent and automatic responding to environmental stimuli that may play a role in maintenance of AN.

Exploring Caloric Restriction in Inpatients with Eating Disorders: Cross-Sectional and Longitudinal Associations with Body Dissatisfaction, Body Avoidance, Clinical Factors, and Psychopathology

Reduction in food intake is an important feature of eating disorders (EDs). However, whereas self-reported cognitive control over food (i.e., dietary restraint) is commonly assessed, we are not aware of any study evaluating the actual reduction in caloric intake (i.e., caloric restriction, CR) and its relationships with psychopathological, clinical, and anamnestic factors in individuals with EDs. In this study, we quantified caloric intake, CR, and weight suppression in 225 ED inpatients and explored significant relationships with self-reported eating symptoms, body dissatisfaction, body avoidance, personality, and affective symptoms. For underweight inpatients (n = 192), baseline predictors of caloric intake and restriction at discharge were assessed through a data-driven approach. CR at admission was significantly related to eating symptomatology, state anxiety, and body image. In regression models, CR, higher BMI, binge-purging symptoms, and the interaction between weight suppression and CR were significantly related to body dissatisfaction. The best psychopathological predictors of caloric intake and restriction at discharge for underweight inpatients were perfectionistic concern over mistakes and state anxiety. These results suggest that caloric restriction is associated to relevant ED features and warrant for a multidimensional assessment of ED psychopathology.

From Bad to Worse: Safety Behaviors Exacerbate Eating Disorder Fears

When evaluating ambiguous situations, humans sometimes use their behavior as a source of information (behavior-as-information effect) and interpret safety behaviors as evidence for danger. Accordingly, we hypothesized that eating disorder safety behaviors (restrictive eating, body checking, etc.) might aggravate fear and anxiety in individuals with an eating disorder. The present study tested to what extent eating disorder safety behaviors increase threat perception in individuals with and without an eating disorder. For this, 108 individuals with a self-reported eating disorder diagnosis and 82 healthy controls rated the dangerousness of several short situations. The situations systematically varied in the presence of eating disorder safety behaviors and danger information. As expected, all participants perceived situations in which the protagonist executed an eating disorder safety behavior as more threatening than situations without a safety behavior. This 'behavior-as-information' effect was equally strong in individuals with and without an eating disorder. Additionally, safety behaviors strengthened threat perception more in safe situations than in dangerous situations. To conclude, the presence of eating disorder safety behavior can increase threat perception regardless of whether individuals have an eating disorder or not. This makes eating disorder safety behaviors a potential risk factor for the development and maintenance of eating disorder fears.

Can you learn to starve yourself? Inducing food avoidance in the laboratory

The restriction of energy intake is a central and persistent symptom of anorexia nervosa. Recent models of the disorder suggest that food restrictions are learned avoidance behaviours, which are acquired and maintained by classical and operant conditioning. The present study aims to test this learning model of food restriction. It investigates whether introducing negative consequences for the intake of tasty high-calorie food and introducing positive consequences for its avoidance can create food avoidance, increase fear of food, and decrease eating desires in healthy individuals. 104 women were randomly assigned to an experimental or control condition and completed an appetitive conditioning and avoidance learning task. While the experimental condition received money after avoiding the tasty high-calorie food item and heard an aversive sound after not avoiding food intake, the control condition never received these consequences. In the extinction phase, reward and punishment discontinued for both conditions. We measured avoidance frequency, mouse movements, fear, eating desires and stimulus liking. Participants in the experimental condition avoided the food more often than controls and showed increased fear, reduced eating desires and less liking for cues associated with food intake. These results support the notion that food avoidance behaviours, reduced eating desires and fear of food can be learned via classical and operant conditioning. Conditioning paradigms might be a useful tool to study the development and maintenance of food restriction in anorexia nervosa.

Predictors of Treatment Outcome in Eating Disorders: A Roadmap to Inform Future Research Efforts

PURPOSE OF REVIEW

With the current review, we provide a brief summary of recent literature that tests clinically observable characteristics at baseline that may impact treatment response, across eating disorder diagnoses. We then provide a critical discussion regarding how researchers may shift their approach to this research to improve treatment implications and generalizability of these findings.

RECENT FINDINGS

Recent work has broadly replicated prior findings suggesting a negative impact of lower weight status, poor emotion regulation, and early-life trauma on eating disorder treatment outcomes. Findings are more mixed for the relative contributions of illness duration, psychiatric comorbidity, and baseline symptom severity. Recent studies have begun to explore more specific domains of previously tested predictors (e.g., specific comorbidities) as well as previously neglected identity-related and systemic factors. However, recent research continues to use similar sampling techniques and approaches to analysis used in prior work. We propose that resolving remaining questions and illuminating predictors of treatment outcome in eating disorders requires a new approach to research sampling and study design. Suggested changes that can be applied within a traditional clinical trial framework may yield new insights with relevance across transdiagnostic eating disorder presentations.

Inhibitory Learning during Exposure Treatment in Anorexia Nervosa: A Practical Guide

Exposure therapy is known to be an effective intervention in the treatment of anxiety-related disorders. In eating disorders, such as anorexia nervosa, anxiety and avoidance are identified as maintenance factors. Therefore, they may constitute an important treatment target, suitable for the use of exposure therapy. Remarkably, exposure techniques to target fears and avoidance behaviors are not commonly used in the treatment of anorexia nervosa. We present a practical guide for the implementation of exposure therapy in the treatment of anorexia nervosa. We outline how exposure therapy is supposed to work according to the inhibitory learning model and how the exposure intervention can be designed for individuals with anorexia nervosa. Practical examples are provided through the case presentation of a patient with anorexia nervosa who completed 31 exposure sessions that focused on her fears of food, eating, weight, weight gain, their feared social consequences and the associated safety behaviors.

An examination of eating disorder fears in imaginal exposure scripts

OBJECTIVE

Eating disorders (EDs) are maintained by fear and anxiety, which lead to disordered eating behaviors thought to prevent the occurrence of feared outcomes. Fear of weight gain and food are among the most common fears present in the EDs. However, theory and clinical observation suggest that the feared consequences of eating or weight gain are diverse and individualized. Further research is needed to delineate specific fears underlying ED pathology.

METHOD

167 participants with any ED participated in an online four-session imaginal exposure intervention. Imaginal exposure scripts were rated by trained coders using items derived from the Eating Disorder Fear Interview to identify fears present. Frequencies of fears present in scripts were quantified.

RESULTS

Two-thirds of scripts mentioned fears of food and weight or body-related fears. In over half of scripts, fear of judgment and fear of loss of control were identified. Diagnostic differences were found, including that those with anorexia nervosa (AN) and bulimia nervosa (BN) had highest fears of food, whereas those with AN and other specified feeding and eating disorder (OSFED) had higher weight gain/body-focused fears.

LIMITATIONS

We were underpowered to make comparisons between ED diagnoses other than AN, BN, and OSFED.

CONCLUSIONS

Imaginal exposure scripts contained a large number of fears related to food, weight/shape, judgment, and loss of control, among others. These findings extend the current understanding of ED fears and provide evidence for the individualized and varied nature of fears. Identification of ED fears can further inform research on designing personalized, exposure-based treatment approaches.

Fear of weight gain during cognitive behavioral therapy for binge-spectrum eating disorders

PURPOSE

Fear of weight gain may play a central role in maintaining eating disorders (EDs), but research on the role of fear of weight gain during cognitive behavioral therapy (CBT-E) for binge-spectrum EDs is sparse. We examined changes in fear of weight gain during CBT-E for binge-spectrum EDs. We investigated whether fear of weight gain predicted loss of control (LOC) eating or weight change.

METHODS

Participants (N = 63) were adults of any gender recruited as part of a larger trial. Participants received 12 sessions of CBT-E, completed diagnostic assessments at pre-, mid-, and post-treatment, and completed brief surveys before sessions.

RESULTS

Fear of weight gain decreased across treatment, moderated by diagnosis. Those with bulimia nervosa spectrum EDs (BN-spectrum), compared to binge eating disorder, reported higher fear of weight gain at baseline and experienced a larger decrease in fear across treatment. Those reporting higher fear of weight gain at a given session experienced more frequent LOC episodes the following week. Fear of weight gain was not associated with session-by-session changes in BMI.

CONCLUSION

CBT-E results in decreases in fear of weight gain, but levels remain high at post-treatment, especially for those with BN-spectrum EDs. Future interventions should consider targeting fear of weight gain as a maintaining factor for LOC episodes TRIAL REGISTRATION: NCT04076553.

LEVEL OF EVIDENCE

Level II controlled trial without randomization.

The impact of between-session habituation, within-session habituation, and weight gain on response to food exposure for adolescents with eating disorders

OBJECTIVE

Exposure therapy is a promising treatment for eating disorders (EDs). However, questions remain about the effectiveness of exposure to feared foods during the weight restoration phase of treatment, and the importance of between-session and within-session habituation.

METHOD

We recruited 54 adolescents from a partial hospitalization program (PHP) for EDs which included daily food exposure. Throughout treatment, participants provided subjective units of distress (SUDS) ratings before and after eating a feared food, and completed measures of ED symptomatology.

RESULTS

Multilevel models found that pre-exposure SUDS decreased over time, providing some evidence that between-session habituation occurred. In contrast, the difference between pre-exposure and post-exposure SUDS did not decrease over time, indicating that within-session habituation did not occur. Weight gain predicted greater between-session habituation to feared foods, but did not predict within-session habituation. Between-session habituation, but not within-session habituation, predicted favorable treatment outcomes, including weight gain and improvements on the Children's Eating Attitudes Test and Fear of Food Measure.

DISCUSSION

Partial hospitalization programs that include daily exposure to feared foods may be effective at decreasing anxiety about foods for adolescents with EDs who are experiencing weight restoration. Further research is warranted to replicate our findings challenging the importance of within-session habituation, and to better understand between-session habituation and inhibitory learning as mechanisms of change when conducting food exposure for EDs.

PUBLIC SIGNIFICANCE

This study provides some evidence that PHPs that include food exposure may be useful for adolescents with EDs who are experiencing weight restoration. Between-session habituation, but not within-session habituation, predicted favorable treatment outcomes. Further research is needed to determine whether clinicians can disregard within-session habituation when conducting food exposure for EDs, and understand the importance of between-session habituation as a potential mechanism of food exposure.

Virtual Rejection and Overinclusion in Eating Disorders: An Experimental Investigation of the Impact on Emotions, Stress Perception, and Food Attitudes

(1) Background: the investigation of how interpersonal functioning affects eating psychopathology has been receiving increasing attention in the last decade. This study evaluates the impact of virtual social inclusion or ostracism on emotions, perceived stress, eating psychopathology, and the drive to binge or restrict in patients across the eating disorder spectrum. (2) Methods: a group of 122 adolescent and adult females with different eating disorder diagnoses were compared to 50 healthy peers with regards to their performance on, and responses to the Cyberball task, a virtual ball-tossing game. Each participant was randomly assigned to playing a social inclusion or a social exclusion block of the Cyberball task and completed self-report assessments of emotions, perceived stress and urge to restrict/binge before and after the task. (3) Results: patients with anorexia nervosa showed a more negative impact on psychological well-being evaluated with the need threat scale after the excluding block, while patients with bulimia nervosa reported more negative effects after the overincluding condition. Patients with binge eating disorder showed a reduction in specific negative emotions after the overincluding block, unlike all other participants. (4) Conclusions: findings show significant correlations between restraint thoughts in patients with bulimia nervosa and binge thoughts in patients with binge eating disorder after being exposed to the inclusion condition. Different reactions in cognitive and emotional states of patients with eating disorders after different interpersonal scenarios confirm the impact of inclusive or exclusive relationships on eating psychopathology, with specific and different responses across the eating disorder spectrum, that have been discussed, linked to their eating behavioral cognition.

Transdiagnostic fears and avoidance behaviors in self-reported eating disorders

BACKGROUND

Fears and avoidance behaviors are common symptoms of eating disorders. It was investigated whether different eating disorder diagnoses are equally characterized by similar fears and avoidance behaviors.

METHODS

Individuals with self-reported eating disorders (n = 250) and healthy controls (n = 95) completed online questionnaires assessing general fears, eating related fears, and avoidance behaviors.

RESULTS

All self-reported eating disorder diagnoses showed more eating related fears, general fears, and avoidance behaviors than healthy controls. Individuals with binge eating disorder showed less specific and general fears on some but by no means all scales, yet they showed less food avoidance behaviors than all other eating disorders and less eating restraint than anorexia nervosa and bulimia nervosa.

CONCLUSIONS

Eating related fears, general fears, and food avoidance behaviors were found to be transdiagnostic symptoms in self-reported eating disorders. Individuals with binge eating disorder also exhibit more fears and avoidance behaviors than healthy controls, but to a lesser extent than the other eating disorders. Specialized interventions targeting fears and avoidance may be promising add-on interventions not only in the treatment of anorexia nervosa, but in the treatment of all eating disorders.

Food-related aversion in a female sample of people with anorexia nervosa: Cognitive-behavioural correlates, somatic and subjective anxiety, and early experiences

OBJECTIVE

Food-related anxiety and avoidance are key features of anorexia nervosa, and among the most arduous maintaining processes to address in treatment. This study gathered information on the behavioural and cognitive correlates of food-related anxiety, including their associations with early experiences of aversive learning related to food, and more general anxiety.

METHODS

One-hundred and forty-four patients with anorexia nervosa were recruited from clinical services in Italy. They completed online questionnaires to assess food-related anxiety, eating disorder psychopathology, eating disorder safety behaviours and threat cognitions, early experience of aversive learning related to food, and somatic anxiety.

RESULTS

Experiences of food-related aversive learning were recalled by the majority of the sample (87.86%), with negative psychological consequences following eating being the most often reported (75%). Safety behaviours and threat cognitions related to the consequences of eating were also reported (14.29%-87.86%, and 36.43-90% respectively, depending on the behaviour/cognition). Eating disorder psychopathology was predicted by both somatic anxiety and negative psychological consequences following eating, whereas self-reported food anxiety was only predicted by somatic anxiety.

CONCLUSION

Findings validate an anxiety-based model of anorexia nervosa which establishes the role of safety behaviours, threat cognitions, early aversive learning experiences, and anxiety in the psychopathology of the illness. Exposure-based interventions have the potential to target these factors, and inhibit food-related fear.

Trait anxiety is associated with amygdala expectation and caloric taste receipt response across eating disorders

Anxious traits are elevated in eating disorders (EDs), are considered risk factors for ED development, and trait anxiety has been linked to ED psychopathology. How trait anxiety relates to ED neurobiology is not well understood. In this study 197 individuals across the ED spectrum (anorexia nervosa n = 91; other specified EDs n = 34; bulimia nervosa n = 56; binge ED n = 16), and 120 healthy controls were assessed for anxious traits and learned to expect and receive caloric or neutral taste stimuli during brain imaging. Amygdala sucrose expectation response differed across groups (Wilk's lambda = 0.945, p = 0.023), and was higher on the left in anorexia nervosa compared to healthy controls (p = 0.002). Expected sucrose receipt response across taste reward regions was not different between groups. In the ED sample, trait anxiety negatively moderated the relationship between amygdala expectation and right dorsal (p = 0.0062) and ventral (p = 0.0046) anterior insula receipt response. A subgroup analysis showed similar results for anorexia nervosa, and partially in bulimia nervosa. Across EDs, appetitive motivation correlated positively with bilateral orbitofrontal cortex, caudate head, and ventral striatal sucrose receipt response (r = 0.215 to 0.179, p = 0.002 to 0.012). Across the study sample, trait anxiety showed an inverted-U-shaped relationship with right (r = 0.147, p = 0.034) and left (r = 0.162, p = 0.016) amygdala expectation response. Amygdala sucrose expectation response is elevated in anorexia nervosa, correlates with sucrose receipt response, and this relationship is negatively moderated by trait anxiety across EDs. Trait anxiety may have an important role in how expectation drives taste stimulus receipt brain response and perhaps food approach in individuals with EDs.

Psychometric properties of the Italian body shape questionnaire: an investigation of its reliability, factorial, concurrent, and criterion validity

PURPOSE

This study was set up to investigate the reliability, factorial, concurrent, and criterion validity of the Italian version of the 34-item Body Shape Questionnaire (BSQ) and its shorter versions.

METHODS

The study included 231 patients diagnosed with an eating disorder and 58 putatively healthy people (comparison sample). The Italian BSQ-34 was administered to participants together with the Hamilton Depression Rating Scale and the Hamilton Anxiety Rating Scale. Information on body mass index, caloric intake at baseline, and the number of episodes of self-vomiting per week was also acquired.

RESULTS

Cronbach's alpha of BSQ-34 was 0.971 (95% confidence interval [CI] 0.965-0.976) in patients and 0.960 (0.944-0.974) in controls. Test-retest stability in patients (n = 69), measured with intraclass correlation coefficient, was 0.987 (0.983-0.991). Confirmatory factor analysis of the single-factor model yielded acceptable fit for all versions of the BSQ. On all BSQ versions, patients scored higher than controls with a large effect size when calculated as Cliff's delta. BMI and mean caloric intake at baseline had a stronger association with BSQ-34 than levels of anxiety and depression. The analysis with the receiver operating characteristics (ROC) curve showed that the BSQ-34 distinguished patients with an eating disorder from controls with good accuracy (Area Under the Curve = 86.5; 95% CI 82.2-90.7).

CONCLUSION

The Italian version of the BSQ possesses good psychometric properties, in both the long and the shortened versions, and it can be applied to measure body dissatisfaction for both clinical and research purposes.

LEVEL OF EVIDENCE

Level III, Evidence obtained from well-designed cohort or case-control analytic studies.

Validation of a shortened version of the Eating Attitude Test (EAT-7) in the Arabic language

BACKGROUND

Eating disorders are quite common around the world, disabling, and potentially lethal; but they remain so far under-captured and subject to substantial delays in treatment. We propose through this study to develop and validate a shortened version of the Eating Attitude Test (EAT) in the Arabic language among non-clinical Arabic-speaking Lebanese participants from the general population.

METHODS

1175 participants enrolled in this cross-sectional study, based on an online survey. The Eating Attitude Test-26 items, Drunkorexia Motives and Behaviors Scales and Lebanese Anxiety Scale were used to answer our objectives.

RESULTS

Our results confirmed validity and reliability of the questionnaire. Exploratory Factor Analyses showed that all items converged over a one-factor solution, with an excellent Cronbach's alpha (> 0.9). Confirmatory Factor Analyses found that the 7-item-version yielded excellent model fit. The instrument also revealed strong evidence of divergent validity, being highly correlated with measures of anxiety and drunkorexia motives and behaviors.

DISCUSSION

Findings provided evidence supporting that the Arabic seven-item one-factor structure of the scale (EAT-7) is valid, reliable, and can be used in clinical practice, preventive interventions and future eating disorders research in Arab settings.

Psychiatric Comorbidity Among Eating Disorders and Obsessive-Compulsive Disorder and Underlying Shared Mechanisms and Features: An Updated Review

Eating disorders (EDs) are highly comorbid with obsessive-compulsive disorder (OCD), with comorbidity rates as high as 41%. In the current review, we summarize the literature regarding the prevalence of ED-OCD comorbidity. We also identify and review the literature assessing shared features (i.e., shared characteristics or symptoms) and mechanisms (i.e., variables that may explain ED or OCD symptoms) of EDs and OCD. Potential shared features of EDs and OCD include age of onset, course of illness, obsessions, compulsions and ritualistic behaviors, and thought action fusion. Shared mechanisms that may explain ED-OCD comorbidity include genetic and neurobiological mechanisms, anxiety and fear, repetitive negative thinking, perfectionism, intolerance of uncertainty, distress tolerance, and impulsivity. Based on these shared features and mechanisms, a theoretical conceptualization of ED and OCD comorbidity is developed, and outline considerations for assessment, differential diagnosis, treatment, and future research regarding ED-OCD comorbidity are described.

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.

Imaginal Exposure for Disordered Eating Related Fears: An Initial Randomized Controlled Trial

Exposure therapy has been investigated as a treatment for eating disorders, but prior research has largely neglected core fears underlying the disorder such as rejection, abandonment, disgust, and loss of control. We tested the feasibility and acceptability of using imaginal exposure to target disordered eating related fears by randomizing participants (N = 47) with disordered eating to: imaginal exposure (IE), imaginal exposure preceded by a brief food exposure (IE + Food), or an assessment control. Participants attended two in-person visits and completed pretreatment, posttreatment, and one-month follow-up questionnaires. IE was rated more acceptable than IE + Food. Retention was high across conditions. Habituation occurred for subjective distress and believability of feared outcomes, suggesting that imaginal exposure effectively activates core fears. Distress tolerance and confidence in ability to change improved. Disordered eating symptoms, fears, preoccupations, and rituals decreased in all conditions, indicating that IE was not specifically responsible for improvement.

'In an otherwise limitless world, I was sure of my limit.'† Experiencing Anorexia Nervosa: A phenomenological metasynthesis

Anorexia Nervosa (AN) has the highest mortality rate of the mental disorders, with still less than 50% of affected individuals achieving recovery. Recent calls to bring innovative, empirical research strategies to the understanding of illness and its core psychopathological features highlight the need to address significant paucity of efficacious treatment. The current study brings a phenomenological approach to this challenge, synthesizing lived experience phenomena as described by qualitative literature. Fifty-three studies published between the years 1998 and 2021 comprising a total of 1557 participants aged 12-66 suffering from AN or sub-threshold AN are included. Reciprocal and refutational analysis generated six key third-order constructs: "emotion experienced as overwhelming," "identity," "AN as a tool," "internal conflict relating to Anorexia," "interpersonal communication difficulties" and "corporeality." Twenty-six sub-themes were identified, the most common being fear, avoidance, AN as guardian/protector, and AN as intertwined with identity. Some themes associated with current treatment models such as low self-esteem, need for social approval and feelings of fatness were less common. We highlight the significant role of intense and confusing emotion in AN, which is both rooted in and engenders amplified fear and anxiety. Restrictive eating functions to numb these feelings and withdraw an individual from a chaotic and threatening world whilst providing a sense of self around which to build an illness identity. Results have implications for therapeutic practice and overly protective weight and shape focused medical treatment models, which may serve to reinforce the disease.

The Good, the Bad, and the Ugly-Chances, Challenges, and Clinical Implications of Avoidance Research in Psychosomatic Medicine

Avoidance behaviors are shaped by associative learning processes in response to fear of impending threats, particularly physical harm. As part of a defensive repertoire, avoidance is highly adaptive in case of acute danger, serving a potent protective function. However, persistent or excessive fear and maladaptive avoidance are considered key factors in the etiology and pathophysiology of anxiety- and stress-related psychosomatic disorders. In these overlapping conditions, avoidance can increase the risk of mental comorbidities and interfere with the efficacy of cognitive behavioral treatment approaches built on fear extinction. Despite resurging interest in avoidance research also in the context of psychosomatic medicine, especially in conditions associated with pain, disturbed interoception, and disorders of the gut-brain axis, current study designs and their translation into the clinical context face significant challenges limiting both, the investigation of mechanisms involved in avoidance and the development of novel targeted treatment options. We herein selectively review the conceptual framework of learning and memory processes, emphasizing how classical and operant conditioning, fear extinction, and return of fear shape avoidance behaviors. We further discuss pathological avoidance and safety behaviors as hallmark features in psychosomatic diseases, with a focus on anxiety- and stress-related disorders. Aiming to emphasize chances of improved translational knowledge across clinical conditions, we further point out limitations in current experimental avoidance research. Based on these considerations, we propose means to improve existing avoidance paradigms to broaden our understanding of underlying mechanisms, moderators and mediators of avoidance, and to inspire tailored treatments for patients suffering from psychosomatic disorders.