Development and validation of the Detail and Flexibility Questionnaire (DFlex) in eating disorders

Enhancing emotional abilities in anorexia nervosa treatment: A rolling-group cognitive remediation and emotional skills training protocol

INTRODUCTION

Anorexia nervosa (AN) is characterised by limited remission rates and emotional dimensions are often neglected. Cognitive remediation and emotional skills training (CREST) protocol aims to address cognitive and emotional factors. This study evaluates the feasibility and effectiveness of a modified rolling-group CREST protocol in an inpatient setting.

METHODS

Quasi-experimental design evaluated CREST protocol in a rehabilitation programme. A total of 116 females diagnosed with AN were included, of whom 63 were included in the CREST protocol and 53 in the standard rehabilitation treatment. Various standardized measures were employed to assess psychopathology. Data collection occurred longitudinally, before and after CREST implementation.

RESULTS

No significant differences emerged between groups regarding changes in specific eating psychopathology. CREST group exhibited significant improvements in emotion regulation (p = 0.002) and social skills (p = 0.014), besides a reduction in alexithymia (p < 0.001) and cognitive rigidity (p = 0.013). Empathic features remained stable. Participants reported positive perceptions of the CREST intervention.

DISCUSSION

The study highlights the potential benefits of integrating emotional training within multidisciplinary intensive treatment for AN. Results emphasise the importance of treatment protocol with more affective and hot-cognition-related interventions, beyond weight-related psychopathology. Implementing a rolling-group CREST protocol in an inpatient setting showed promise in enhancing the emotional abilities of AN patients.

A clinical trial protocol of a single-session self-guided acceptance-based online intervention targeting food cravings as predictors of disordered eating in pregnant people

BACKGROUND

Pregnancy is a time of heightened risk for disordered eating behaviors, which are linked to adverse health outcomes in gestation, delivery, and the postpartum. These adverse outcomes may be partially mediated by greater rates of deviation from recommended weight gain trajectories, especially in those who engage in binge and loss of control (LOC) eating. Food cravings are powerful and highly modifiable triggers of binge and LOC eating in non-pregnant populations with preliminary evidence linking cravings to disordered eating behaviors in pregnancy as well. Acceptance-based approaches have been shown to be feasible and effective in reducing the adverse impact of cravings on behavior.

PURPOSE

To test the feasibility, acceptability, and preliminary efficacy of a single-session, self-guided, acceptance-based online workshop targeting food cravings as predictors of binge and LOC eating in pregnancy.

METHODS

We will conduct a pilot randomized controlled trial of a single-session, self-guided online acceptance-based workshop targeting food cravings in pregnancy. Pregnant individuals in the second trimester (n ≥ 74) endorsing current food cravings will be randomly assigned to the intervention or an untreated control group. The intervention group will participate in a one-hour workshop that imparts skills grounded in Acceptance and Commitment Therapy, including acceptance, defusion, and present-moment awareness. Both groups will complete comprehensive self-report assessments of primary outcomes and hypothesized mediators and moderators of intervention efficacy at baseline, one-month follow-up, and at full-term.

CONCLUSION

Results will inform integration of acceptance-based skills targeting food cravings into routine prenatal care to prevent adverse outcomes associated with disordered eating behaviors in pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT06129461; registered on November 10, 2023.

Cognitive Flexibility and Emotion Regulation in Eating Disorder Patients with Comorbid Generalized Anxiety and Posttraumatic Stress Symptoms

Research has found that difficulties in emotion regulation negatively impact mental health, whereas cognitive flexibility may promote stress resilience and positive mental health. Little is known about cognitive flexibility and emotion regulation in people with comorbid eating disorder (ED) and anxiety and stress disorders. A transdiagnostic ED population (N = 227 ) at an outpatient ED treatment facility completed several self-report instruments that measured cognitive flexibility, emotion regulation difficulties, posttraumatic stress disorder (PTSD) symptoms, and generalized anxiety disorder (GAD) symptoms upon admission. We investigated cognitive flexibility and emotion regulation differences for those with an ED without comorbidity and those with various combinations of comorbidity. In a one-way between-groups ANOVA, we investigated differences in cognitive flexibility for those with GAD, PTSD, neither, and both comorbidities. We found a statistically significant difference between these groups, with mean cognitive flexibility inventory scores being the lowest in the group with both comorbidities. However, when controlling for emotion regulation, a one-way between-groups ANCOVA indicated no significant differences in cognitive flexibility between comorbidity groups F ( 3 , 222 ) = 1.20 , p = . 31 Partial η 2 = . 02 . Though self-reported cognitive flexibility levels differ among ED patients with and without comorbidities, it appears that these differences are better explained by emotion regulation. Therefore, addressing emotion regulation early in treatment for all individuals with EDs, regardless of comorbidity. Further research is needed to understand the impact of treating emotion regulation on ED treatment engagement, dropout, and effectiveness.

Weak central coherence, cognitive rigidity and disordered eating in a community sample

Recent evidence has highlighted that a moderate degree of disordered eating has become the norm among the general population. While previous research has demonstrated that individuals with eating disorders exhibit heightened weak central coherence (i.e., attention to detail) and cognitive rigidity, and this plays a key role in the development and maintenance of the disorders, less is known about the relationship between disordered eating and these cognitive styles in subclinical community samples. A community sample of females completed self-report measures of weak central coherence, cognitive rigidity and eating disorder pathology. Unlike previous studies in the area, we first excluded participants with a diagnosis of eating disorder and then confined the analyses to those without clinically significant disordered eating. In line with the clinical literature, we found both cognitive rigidity and weak central coherence to correlate with severity and frequency of disordered eating behaviours and cognitions, suggesting the relationship also exists in subclinical samples. If replicated and expanded upon, these findings may bear important implications for the prevention and early identification of disordered eating in the community.

Validating and developing a shortened version of the detail and flexibility (DFlex) questionnaire for eating disorders, anxiety and depression

OBJECTIVE

To validate the original and a shortened version of the Detail and Flexibility (DFlex) Questionnaire.

METHOD

Confirmatory factor analyses, internal consistency, and discriminant validity estimates were conducted within individuals with a diagnosis of an eating disorder (ED) (n = 124), an anxiety disorder and/or depression (n = 219), and a community sample (n = 852) (Part 1). Convergent validity of the DFlex through comparisons with the Autism Spectrum Quotient, Wisconsin Card Sorting Task, and Group Embedded Figures Task was undertaken within a combined ED and community sample (N = 68). Test-retest reliability of the DFlex was also examined across 2 years in a community sample (N = 85) (Part 2).

RESULTS

The original factor structure of the DFlex was not supported. Hence, a shortened version, the DFlex-Revised, was developed. Good discriminant validity was obtained for the DFlex and DFlex-Revised, however, support for convergent validity was mixed. Finally, the 2-year test-retest reliability for the two DFlex versions was found to be low, suggesting potential malleability in construct over this timeframe.

CONCLUSIONS

Further research is needed to validate the DFlex in clinical and non-clinical populations using different neurocognitive tests. Test-retest, using varied time intervals, should also be assessed.

Adding executive function training to cognitive behavioral therapy for binge eating disorder: A pilot randomized controlled trial

Evidence-based treatments for binge eating disorder (BED), such as cognitive behavioral therapy (CBT) lead to successful outcomes only about half the time. Individuals with BED often have measurable deficits in executive function (EF) that may challenge adherence to or impact of cognitive behavioral intervention components. The aim of this study was to evaluate the impact of adding EF training to CBT by combining CBT with a compensatory cognitive training approach (EF-CBT). Participants were 32 adults with BED, overweight/obesity, and comorbid anxiety or depression who were randomly assigned to four months of group treatment in either standard CBT or EF-CBT. Outcomes were assessed at baseline, post-treatment, and at 2-month follow-up. Results showed that EF-CBT was feasible and acceptable, comparable to CBT. Both groups significantly decreased loss of control (LOC) days, clinical impairment, and depression at post-treatment and 2-month follow-up; though there were no differences between groups. Neither group significantly reduced anxiety or weight. Exploratory analyses found that participants with lower EF treated with EF-CBT were less likely to have LOC at post-treatment than those with lower EF treated with CBT. Higher self-monitoring rates during treatment were associated with lower LOC at post-treatment and participants with lower EF were more likely to self-monitor in the EF-CBT arm relative to the CBT arm. These findings suggest that EF-CBT is feasible, acceptable and efficacious, although larger scale research is needed. EF-CBT may be particularly suited for individuals with BED who have lower EF.

Acute Mood-Elevating Properties of Microdosed Lysergic Acid Diethylamide in Healthy Volunteers: A Home-Administered Randomized Controlled Trial

BACKGROUND

Microdosing psychedelic drugs is a widespread social phenomenon with diverse benefits claimed for mood and cognition. Randomized controlled trials have failed to support these claims, but the laboratory-based dosing in trials conducted to date may have limited ecological validity.

METHODS

Healthy male volunteers were randomized into lysergic acid diethylamide (LSD) (n = 40) and placebo (n = 40) groups and received 14 doses of either 10 μg LSD or an inactive placebo every 3 days for 6 weeks. First doses were given in a supervised laboratory setting, with other doses self-administered in a naturalistic setting. Results of safety data, blinding, daily questionnaires, expectancy, and pre-/postintervention psychometrics and cognitive tasks are presented here.

RESULTS

The most notable reported adverse event was treatment-related anxiety, which prompted the withdrawal of 4 participants from the LSD group. Daily questionnaires showed credible evidence (>99% posterior probability) of improved ratings of creativity, connectedness, energy, happiness, irritability, and wellness on dose days compared with nondose days, and these effects remained when controlling for preintervention expectancy. No questionnaire or cognitive task showed a credible change between baseline and 6-week assessment time points.

CONCLUSIONS

Microdosing LSD appears to be relatively safe in healthy adult men, notwithstanding a risk of anxiety. While microdosing elicited transient increases in scales associated with mood-elevating effects, it was not sufficient to promote enduring changes to overall mood or cognition in healthy adults. Future microdosing trials in clinical populations will require the use of active placebos to control for placebo effects and dose titration to adjust for interindividual variability in drug response.

Impact of virtual adjunctive cognitive remediation therapy on cognitive flexibility and treatment outcomes in comorbid anorexia nervosa and exercise dependence as quantified using novel biomarkers: A stage 1 registered report

OBJECTIVE

Anorexia nervosa (AN) is associated with significant individual mental and physical suffering and public health burden and fewer than half of patients recover fully with current treatments. Comorbid exercise dependence (ExD) is common in AN and associated with significantly worse symptom severity and treatment outcomes. Research points to cognitive inflexibility as a prominent executive function inefficiency and transdiagnostic etiologic and maintaining mechanism linking AN and ExD. This study will evaluate the initial efficacy of adjunctive Cognitive Remediation Therapy (CRT), which has been shown to produce cognitive improvements in adults with AN, in targeting cognitive inflexibility in individuals with comorbid AN and ExD. As an exploratory aim, this study also addresses the current lack of quick and cost-effective assessments of cognitive flexibility by establishing the utility of two proposed biomarkers, heart rate variability and salivary oxytocin.

METHOD

We will conduct a single-group, within-subjects trial of an established CRT protocol delivered remotely as an adjunct to inpatient or intensive outpatient treatment as usual (TAU) to adult patients (n = 42) with comorbid AN and ExD. Assessments, including self-report, neuropsychological, and biomarker measurements, will occur at three time points.

RESULTS

We expect CRT to increase cognitive flexibility transdiagnostically and consequently, along with TAU, positively impact AN and ExD compulsivity and symptom severity, including weight gain.

DISCUSSION

Findings will inform the development of more effective integrative interventions for AN and ExD targeting shared mechanisms and facilitate the routine assessment of cognitive flexibility as a transdiagnostic risk and maintaining factor across psychopathologies in clinical and research settings.

PUBLIC SIGNIFICANCE

Patients with anorexia nervosa often engage in excessive exercise, leading to harmful outcomes, including increased suicidal behavior. This study examines the preliminary efficacy of an intervention that fosters flexible and holistic thinking in patients with problematic eating and exercise to, along with routine treatment, decrease harmful exercise symptoms. This study also examines new biological markers of the inflexible thinking style thought to be characteristic of anorexia nervosa and exercise dependence.

Cognitive and Interpersonal Factors in Adolescent Inpatients with Anorexia Nervosa: A Network Analysis

The cognitive-interpersonal model of anorexia nervosa (AN) posits that cognitive and interpersonal traits contribute to the development and maintenance of AN. We investigated cognitive and interpersonal factors put forward by the model in a sample of 145 adolescent inpatients with AN using network analysis. Our main outcomes included core eating disorder symptoms, cognitive style, socio-affective factors, and mood symptoms. We estimated a cross-sectional network using graphical LASSO. Core and bridge symptoms were identified using strength centrality. Goldbricker was used to reduce topological overlap. The node with the highest strength centrality was Concern over Mistakes, followed by Eating Preoccupation, Social Fear, and Overvaluation of Weight and Shape. The nodes with the highest bridge strength were Concern over Mistakes, Doubt about Actions, Overvaluation of Weight and Shape, and Depression. Notably, both performance on a cognitive flexibility task and BMI were not connected to any other nodes and were subsequently removed from the final network. We provide partial support for the cognitive-interpersonal model while also supporting certain premises put forward by the transdiagnostic cognitive-behavioral model. The high centrality of Concern over Mistakes and Social Fear supports the theory that both cognitive and interpersonal difficulties contribute to AN, particularly in adolescence.

Protocol for the development and testing of the schiZotypy Autism Questionnaire (ZAQ) in adults: a new screening tool to discriminate autism spectrum disorder from schizotypal disorder

BACKGROUND

Autism spectrum disorder (ASD) and schizotypal disorder (SD) both have a heterogenous presentation, with significant overlaps in symptoms and behaviour. Due to elevated recognition and knowledge of ASD worldwide, there is a growing rate of referrals from primary health professionals to specialised units. At all levels of assessment, the differential diagnostic considerations between ASD and SD exert major challenges for clinicians. Although several validated screening questionnaires exist for ASD and SD, none have differential diagnostic properties. Accordingly, in this study, we aim to develop a new screening questionnaire, the schiZotypy Autism Questionnaire (ZAQ), which provides a combined screening for both conditions, while also indicating the relative likelihood of each.

METHODS

We aim to test 200 autistic patients and 100 schizotypy patients recruited from specialised psychiatric clinics and 200 controls from the general population (Phase 1). The results from ZAQ will be compared to the clinical diagnoses from interdisciplinary teams at specialised psychiatric clinics. After this initial testing phase, the ZAQ will be validated in an independent sample (Phase 2).

CONCLUSIONS

The aim of the study is to investigate the discriminative properties (ASD vs. SD), diagnostic accuracy, and validity of the schiZotypy Autism Questionnaire (ZAQ).

FUNDING

Funding was provided by Psychiatric Centre Glostrup, Copenhagen Denmark, Sofiefonden (Grant number: FID4107425), Trygfonden (Grant number:153588), Takeda Pharma.

TRIAL REGISTRATION

Clinical Trials, NCT05213286, Registered 28 January 2022, clinicaltrials.gov/ct2/show/NCT05213286?cond = RAADS&draw = 2&rank = 1.

Individual-Level Risk and Resilience Factors Associated with Mental Health in Siblings of Individuals with Neurodevelopmental Conditions: A Network Analysis

Siblings of individuals with neurodevelopmental conditions (NDCs) are exposed to unique family environments and experience a range of psychosocial risk and resilience factors. Networks of self-reported risk, resilience, and neuropsychiatric variables were estimated for siblings of individuals with (n = 235) and without (n = 480) NDCs (N = 715, mean age 22.40 years, 76% female, 74% White Caucasian). The NDC group reported more depressive (g = 0.39) and anxious (g = 0.43) symptoms than controls, and 71.5% of the NDC group reported at least one neuropsychiatric diagnosis compared to 36.9% of controls. Self-reported sleep and post-traumatic stress disorders were high amongst NDC siblings. Everyday executive functioning difficulties (cognitive inflexibility, hyperactivity/impulsivity) and emotion dysregulation were the most influential transdiagnostic risk factors for poorer functioning within the NDC group network.

Modifying an Open Science Online Grocery for parents of youth with anorexia nervosa: A proof-of-concept study

OBJECTIVE

For youth with anorexia nervosa (AN), remission requires high caloric goals to achieve weight restoration, consumption of a wide variety of calorically dense foods, and reintroduction of eliminated foods. Family-based treatment (FBT), the gold-standard treatment for youth with AN, empowers parents to renourish their child and restore them to health; yet, parents often report struggling with shifting meal planning and grocery shopping behaviors to focus on nutritional rehabilitation and weight restoration.

METHODS

This proof-of-concept study aimed to modify a simulated grocery store (Open Science Online Grocery [OSOG]) for parents of youth with AN and explore the acceptability and feasibility of its use as part of standard care. Study staff collaborated with six parent research partners to modify the OSOG prior to piloting it with participants. Participants were 10 parents of youth undergoing a first-time hospitalization for medical stabilization of AN or atypical AN. Parents completed a battery of measures and a semistructured interview assessing the acceptability and feasibility of OSOG.

RESULTS

Parents described the tool as credible and acceptable. Qualitative feedback highlighted common themes of caregiver burden, nutrition education, and acceptability of the tool.

DISCUSSION

Results point to the need for more work in supporting parents in Phase I of FBT.

PUBLIC SIGNIFICANCE

Families are instrumental in supporting youth to recover from anorexia nervosa. During treatment, parents are charged with selecting and serving their adolescent's meals, often requiring them to change grocery shopping and food preparation habits to meet their child's high caloric needs. Parents reported feeling overwhelmed by this task and noted struggling with learning different approaches to nourish their adolescent during an already stressful time. Collaboratively with parents, we modified a tool to support parents in shifting thier shopping habits, which they reported as being a helpful springboard in the early phase of treatment.

Evaluating thinking styles in adults with an eating disorder: Associations with life satisfaction, psychological symptoms, and treatment engagement

Cognitive weaknesses have been implicated as a vulnerability factor in the development and maintenance of eating disorders. Despite this, cognitive styles are not routinely assessed in adult outpatient eating disorder programs and little is known about how they may impact patients' functional outcomes, psychological symptoms, or treatment engagement. The aim of this study was to evaluate thinking styles (i.e., cognitive rigidity and attention to detail) among adults attending specialized outpatient treatment for an eating disorder and assess whether such styles were associated with participants' satisfaction with life, psychological symptoms, and engagement in the outpatient group therapy program. Demographic and physical health information was collected from 95 adults who were eligible for an outpatient program. Participants completed the Detail and Flexibility Questionnaire, Satisfaction with Life Scale, Beck Depression Inventory second edition, and Beck Anxiety Inventory. Elevated scores for cognitive rigidity and attention to detail were transdiagnostic rather than specific to eating disorder diagnoses. Cognitive rigidity and attention to detail were associated with lower satisfaction with life, and increased anxiety and depression. Cognitive styles of cognitive rigidity and attention to detail were not associated with engagement in treatment or treatment completion. Cognitive patterns may be important for clinicians to evaluate as part of routine outpatient care given that they occur transdiagnostically and are linked with psychological symptoms and functional outcomes for adults struggling with an eating disorder.

Group cognitive remediation therapy for children and adolescents in intensive day-patient treatment for anorexia nervosa: a feasibility study

Background

Cognitive Remediation Therapy (CRT) is an adjunct treatment targeting set-shifting (SS) and weak central coherence (CC) thought to play a role in maintaining anorexia nervosa (AN). This study aimed to test the feasibility of brief group CRT for young people with AN in a day-patient setting using neuropsychological assessment of SS and CC. It also explored the benefit for young people with Autism Spectrum Disorder (ASD) features.

Methods

Twenty female day-patients (12–18 years) with AN or Atypical AN completed neuropsychological assessment of SS (using the Wisconsin Card Sorting Task and the Brixton Spatial Anticipation Test) and of CC (using the Rey Osterrieth Complex Figures Task) pre and post 4 sessions of group CRT. Baseline ASD features and weight change pre and post were measured. Feasibility was assessed regarding the recruitment process, intervention feedback, suitability of neuropsychological assessment measures, and effect sizes.

Results

Study uptake was 95%, intervention retention was 91%, and group CRT was rated as acceptable. Medium to large effect size improvements were found across measures of SS (d_z = 0.44 to d_z = 0.90) and medium size improvements found in CC (d_z = 0.59). Young people with ASD features showed smaller to similar size improvements in SS and larger improvements in CC. There was a moderate (not significant) correlation with level of weight restoration.

Conclusions

Important study parameters have been estimated in order to plan a future definitive trial of brief group CRT in a day-patient setting using neuropsychological assessment. These findings also have implications for the use of brief group CRT in young people with ASD features.

Post-traumatic stress symptoms in parents of adolescents hospitalized with Anorexia nervosa

The current study was a planned secondary analysis to examine post-traumatic stress symptoms (PTSS) in parents of youth hospitalized for medical stabilization due to anorexia nervosa (AN). Questionnaires were administered to 47 parents (34 mothers, 13 fathers; 10 parental dyads) after admission; follow-up occurred at discharge and 4 weeks, 3 months, and 6 months post-discharge. PTSS were present in the majority of mothers (55.9%) and fathers (61.5%). PTSS were not associated with illness severity, but were associated with parental report of mood symptoms, avoidance, inflexibility, and symptom accommodation. Parental PTSS may negatively impact the adolescent rate of weight gain post-discharge. As hospitalization of a child for medical management of AN can be a traumatizing experience for parents, astute attention should be paid by medical staff to their needs. More work needs to be done to understand the impact of PTSS on parents of adolescents with AN.

Everyday flexibility and functional milestones in anorexia nervosa: survey results from a mixed community sample

PURPOSE

This study examined the relationship between self-reported cognitive-behavioral flexibility scores on the Eating Disorder Flexibility Index (EDFLIX) and objective social and occupational functional milestones in participants with a lifetime diagnosis of anorexia nervosa (AN). The Work and Social Adjustment Scale (WSAS) was included to compare objective and subjective measures.

METHODS

114 female adult participants with a current (53.5%) or past (46.5%) full or partial AN syndrome diagnosis completed an online survey which included functional milestone questions, the EDFLIX, WSAS, EDE-Q, and DASS-21.

RESULTS

Everyday flexibility scores were significantly associated with WSAS scores, but not functional milestones for the same domain. Lower flexibility was related to higher WSAS work impairment but was not associated with poor occupational outcomes. Lower flexibility was related to higher WSAS social impairment but was not associated with less frequent social contact with friends. Milestones across work, social and relationship areas were not significantly correlated, suggesting individuals have areas of strength and weakness across functional domains. In contrast, WSAS ratings indicated broad functional impairment.

CONCLUSION

Results from the milestones suggest self-reported cognitive-behavioral flexibility is not a strong determinant of everyday function. Results from the subjective WSAS function measure and the more objective functional milestones were not consistent. To obtain a more balanced assessment of everyday functioning in AN, both subjective and objective measures should be considered.

LEVEL OF EVIDENCE

Level III Case-control analytic study.

Experience-dependent reshaping of body gender perception

Protracted exposure to specific stimuli causes biased visual aftereffects at both low- and high-level dimensions of a stimulus. Recently, it has been proposed that alterations of these aftereffects could play a role in body misperceptions. However, since previous studies have mainly addressed manipulations of body size, the relative contribution of low-level retinotopic and/or high-level object-based mechanisms is yet to be understood. In three experiments, we investigated visual aftereffects for body-gender perception, testing for the tuning of visual aftereffects across different characters and orientation. We found that exposure to a distinctively female (or male) body makes androgynous bodies appear as more masculine (or feminine) and that these aftereffects were not specific for the individual characteristics of the adapting body (Exp.1). Furthermore, exposure to only upright bodies (Exp.2) biased the perception of upright, but not of inverted bodies, while exposure to both upright and inverted bodies (Exp.3) biased perception for both. Finally, participants' sensitivity to body aftereffects was lower in individuals with greater communication deficits and deeper internalization of a male gender role. Overall, our data reveals the orientation-, but not identity-tuning of body-gender aftereffects and points to the association between alterations of the malleability of body gender perception and social deficits.

Development of the dog executive function scale (DEFS) for adult dogs

Executive functions (EFs) are cognitive processes that are used to effortfully self-regulate behaviour and might be important for dogs’ success in working and pet roles. Currently, studies are assessing dogs’ EF skills through often laborious cognitive measures, leading to small sample sizes and lacking measures of reliability. A complementary method is needed. The aim of this study was to develop a dog executive function scale (DEFS) for adult dogs. Focus groups were held with people working with dogs professionally to refine a pool of items describing dog behaviours related to EF. A survey was distributed online to a convenience sample of N = 714 owners of adult dogs. Exploratory and confirmatory factor analysis identified six distinguishable factors named behavioural flexibility, motor inhibition, attention towards owner, instruction following, delay inhibition and working memory. These factors appear similar to factors identified in human EF scales. Working dogs exhibit higher EF scores on the DEFS than non-working dogs. Dogs sourced from breeders exhibited higher DEFS scores than dogs sourced from shelters, and the amount of training received positively correlated with dogs’ DEFS scores. The DEFS requires further validation with cognitive measures. The DEFS could then be used by researchers to complement assessment of dogs’ EF skills through cognitive measures or assess dogs’ EF skills in large samples.

Attention, flexibility, and imagery in misophonia: Does attention exacerbate everyday disliking of sound?

INTRODUCTION

Misophonia is an unusually strong aversion to everyday sounds, such as chewing, crunching, or breathing. Here, we ask whether misophonia might be tied to an unusual profile of attention (and related traits), which serves to substantially heighten an otherwise everyday disliking of sounds.

METHODS

In Study 1, we tested 136 misophonics and 203 non-misophonics on self-report measures of attention to detail, cognitive inflexibility, and auditory imagery, as well as collecting details about their misophonia. In Study 2, we administered the Embedded Figures task to 20 misophonics and 36 non-misophonics.

RESULTS

We first showed that the degree to which sounds trigger misophonia reflects the pattern by which they are (more mildly) disliked by everyone. This suggests that misophonia is scaffolded onto existing mechanisms rather than qualitatively different ones. Compared to non-misophonics, we also found that misophonics self-reported greater attention to detail, cognitive inflexibility, and auditory imagery. As their symptoms worsen, they also become more accurate in an attentional task (Embedded Figures).

CONCLUSIONS

Our findings provide a better understanding of misophonia and support the hypothesis that dispositional traits of attention to detail may be key to elevating everyday disliking of sound into the more troubling aversions of misophonia.

Cognitive flexibility, central coherence, and quality of life in anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) has consistently been found to be associated with poor cognitive flexibility and central coherence. These two cognitive functions have been considered important maintenance factors in AN and are addressed by specific treatment approaches such as cognitive remediation therapy. While there is clear empirical evidence that difficulties in such cognitive functions are related to impaired daily functioning in schizophrenia and bipolar disorder, this potential association has received only little attention in AN research so far. Therefore, the aim of this study was to examine potential relationships between weak cognitive flexibility, central coherence, and poor quality of life (QoL) in AN.

METHODS

Cognitive flexibility and central coherence were measured by both neuropsychological (i.e., performance based) and self-report measures alongside with self-reported QoL in a sample of 138 adult patients with AN.

RESULTS

Self-report but not performance based measures of cognitive flexibility and central coherence were associated with QoL. Weaker cognitive flexibility and central coherence were correlated with poorer QoL. These associations were independent of comorbid depression. The link between weak central coherence and poor QoL was particularly strong in patients with the restricting subtype of AN. The link between cognitive flexibility and QoL, however, was independent of AN subtype.

CONCLUSIONS

Weak cognitive flexibility and central coherence are associated with low QoL in AN, especially in patients with the restrictive subtype. However, this relationship is dependent on the method of measurement, where self-report measures seem to be more relevant than performance based measures.

Cognitive and Experienced Flexibility in Patients With Anorexia Nervosa and Obsessive Compulsive Disorder

OBJECTIVE

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) share a neuropsychological profile characterized by cognitive inflexibility as evident in set-shifting problems, and by strong detail focus. Clinically, both patient groups display a strong rigidity which may be explained by these neurocognitive difficulties. Cognitive inflexibility may hinder treatment uptake and help explain suboptimal treatment outcomes in both AN and OCD. This is the first study to compare clinical AN and OCD groups andto examine similarities and differences in cognitive flexibility. Specifically, this study aims to investigate neuropsychological outcomes and self-reported difficulties in both clinical groups and a control group, and explore associations between the different flexibility outcomes and illness.

METHOD

Two hundred participants (61 AN, 72 OCD and 67 HC) performed neuropsychological tasks on set-shifting abilities (Trail Making Task, Stroop color-word interference, Intradimensional-Extradimensional shift task), detail focus (Group Embedded Figures Test) and self-reported set-shifting abilities and attention to detail (DFlex).

RESULTS

Similarities between patient groups were found in terms of reduced set-shifting ability on the Trail Making Task and detail focus. Moreover, both patient groups self-reported more set-shifting problems but a less strong detail focus than HC, which in turn were not related to neuropsychological task outcomes in either of the groups. In both patient groups longer illness duration was associated to longer reaction times in the switching tasks and for both groups symptom severity was associated to higher experienced inflexibility and attention to detail.

CONCLUSION

Cognitive inflexibility processes are largely similar in patients with AN and OCD. Both patient groups report inflexibility, yet this is unrelated to neuropsychological outcomes. Illness duration seems to contribute to poorer set-shifting and higher illness severity is linked to more experienced inflexibility. Findings highlight the need for entangling different domains of cognitive flexibility and detail focus and examining self-report measures for a cohesive understanding of clinically relevant flexibility weaknesses in AN and OCD.

The longitudinal relationship between set-shifting at 4 years of age and eating disorder related features at 9 years of age in the general pediatric population

BACKGROUND

Individuals with anorexia nervosa (AN) tend to have rigid thoughts and behaviors regarding their body weight, body image, and eating habits. While a diagnosis of AN implies severe levels of impairment, AN traits can vary on a continuum within the population. However, little is known about how early markers of AN relate to rigid thought patterns and to what extent cognitive rigidity is already present in early childhood. We examined the association of set-shifting abilities as a measure of cognitive flexibility in preadolescents with AN-related features.

METHODS

Participants included 3,987 children participating in the Generation R Study, a Dutch population-based birth cohort. Set-shifting abilities (mother report) were assessed at 4 years of age, body mass index (BMI) was determined at 4 and 9 years and restrictive eating patterns (mother report) and body image (child report) were assessed at 9 years.

RESULTS

Lower set-shifting abilities at 4 years were associated with a lower BMI (β = -.44, p = 2.2 × 10^-4 ) in girls, and more restrictive eating (β = 0.15, p = 2.7 × 10^-6 ) in both boys and girls at 9 years of age. Moreover, set-shifting at age 4 was not associated with body image at age 9.

CONCLUSION

These findings contribute to the idea that the association between set-shifting problems and AN-related features are present early in childhood, prior to the typical range of the onset of eating disorders (EDs). Longitudinal studies that capture the peak age for the development of EDs will be important to assess whether early cognitive inflexibility is an early marker of AN.

Autistic characteristics in eating disorders: Treatment adaptations and impact on clinical outcomes

OBJECTIVE

Autistic people with eating disorders (EDs) may have special needs that are not met in standard ED treatment, raising the need for treatment adaptations to accommodate co-existing autism spectrum condition (ASC). Little is currently known about the nature of existing treatment options or adaptations for this population. We conducted a pre-registered systematic review to: (1) identify research articles describing existing interventions for patients with ED and comorbid ASC, and to critically review evidence of their clinical effectiveness and cost-effectiveness (Review 1); (2) review the impact of ASC comorbidity on ED clinical outcomes (Review 2).

METHOD

Peer-reviewed studies published until the end of December 2020 were identified through a systematic search of the electronic databases: Medline, Embase, PsycINFO, Web of Science, CINAHL, Scopus and Cochrane Library.

RESULTS

Only one clinical pathway of treatment adaptations (the 'PEACE' pathway) was identified in Review 1 with early evidence of cost-savings and favourable treatment outcomes. ASC characteristics were shown in Review 2 to have no direct impact on physical outcomes or ED symptoms, but could be associated with higher rates of comorbidities and greater use of intensive ED treatment. Additionally, patients with ASC characteristics may benefit more from individual sessions, rather than group sessions.

CONCLUSIONS

Any new treatments or treatment adaptations may not directly impact on ED symptoms, but may be better able to support the complex needs of the ASC population, thus reducing subsequent need for intensive treatment. Future research is warranted to explore evidence of clinical and cost-effectiveness of interventions for this population.

Neuropsychological and clinical findings of Cognitive Remediation Therapy feasibility randomised controlled trial in young people with anorexia nervosa

OBJECTIVE

Randomised controlled trial (RCT) in adults with anorexia nervosa (AN) showed that Cognitive Remediation Therapy (CRT) enhances cognitive flexibility, abstract thinking and quality-of-life. Despite inconsistent findings, CRT has the potential as an adjunct treatment for young people (YP) with AN. A feasibility RCT was conducted in an inpatient setting. The study will also consider the effect of CRT in YP with AN and autistic symptoms.

METHODS

Participants were randomly allocated to the Immediate or Delayed condition to receive individual CRT sessions, in addition to standard treatment. A repeated measures design was conducted.

RESULTS

Eighty participants were recruited. The neuropsychological measures were feasible for evaluating individual CRT in YP. Significant improvements in set-shifting and central coherence were found, with no main effect between immediate and delayed condition. Significant interactions were found between the condition, and autism spectrum condition (ASC) and No-ASC subgroup, with significant positive impact of CRT on set-shifting in the No-ASC subgroup. There was some evidence that for the No-ASC subgroup, CRT was more effective if delivered at the start of the treatment; and for the ASC subgroup, that CRT was more effective if delivered at the later stage of treatment.

CONCLUSIONS

These findings suggest that the overall positive effect of CRT in set-shifting and central coherence alongside standard treatment. They also indicate the importance of screening for the presence of ASC which could require tailored CRT.

Cognitive rigidity and heightened attention to detail occur transdiagnostically in adolescents with eating disorders

Cognitive inflexibility and attention to detail bias represent a promising target in eating disorder (ED) treatment. While prior research has found that adults with eating disorders exhibit significant cognitive inflexibility and heightened attention to detail, less is known about these cognitive impairments among adolescents, and across EDs transdiagnostically. To address this gap, adolescent females (N = 143) from a residential ED program with anorexia nervosa, bulimia nervosa, or other specified feeding or eating disorder completed the Detail and Flexibility Questionnaire (DFlex) and measures of ED and general psychopathology. Transdiagnostically, adolescents with EDs scored higher than an archival sample of healthy control adolescents on both cognitive rigidity (p < .001; Cohen's d = 1.92) and attention to detail (p < .001; Cohen's d = 1.16). These cognitive impairments were significantly associated with severity of eating pathology, and these relationships existed independent of age, duration of illness, or body mass index (BMI). Our findings suggest cognitive inflexibility and heightened attention to detail occur transdiagnostically in adolescents with eating disorders and are unlikely to be a scar of the disorder. Future prospective research is needed to determine whether these cognitive styles represent an endophenotype of eating disorders.

Cognitive remediation therapy for anorexia nervosa as a rolling group intervention: Data from a longitudinal study in an eating disorders specialized inpatient unit

Objective

Cognitive remediation therapy (CRT) has been proposed as an add‐on treatment approach that could increase the engagement in treatment of anorexia nervosa (AN) patients and reduce maintaining factors, but prior studies have evaluated CRT in individual and group settings, difficult protocols for rehabilitation settings. Our aim is to evaluate the CRT rolling protocol implementation in an inpatient specialised unit.

Methods

A historical longitudinal controlled study was designed to include 31 AN patients for the CRT program, and 28 AN patients treated as usual. The CRT rolling group was implemented in a multidisciplinary inpatient rehabilitation ward with both adolescent and adult patients and an 8‐weeks protocol. To evaluate the treatment implementation effect, different self‐administered questionnaires were used.

Results

The study found greater improvements of the CRT group in clinical symptomatology (p = 0.039), flexibility (p = 0.003), self‐confidence about the ability to change (p < 0.001), and less short‐term focus (p < 0.001), with no differences between restrictive and binge‐purging patients.

Conclusion

This study demonstrates that CRT rolling group protocol is feasible in an inpatient treatment setting and may improve a rehabilitation program's outcome. Our results have shown how CRT can influence cognitive styles considered AN maintenance factors, positively affecting both restrictive and binge‐purge type.

Cognitive remediation therapy (CRT) could be implemented in an inpatient setting with a rolling protocol

CRT improves flexibility, drive to change, and therapy engagement

No differences between restrictive or binge/purge subgroups

Both adolescent and adult patients improved their cognitive styles

A case report of a male patient receiving treatment for anorexia nervosa and comorbid obsessive compulsive disorder who was later diagnosed with nontuberculosis Mycobacterium

Cases of nontuberculous Mycobacterium (NTM) are on the rise across North America. This is the first clinical description of a 31-year old male patient in North America with Mycobacterium kansasii who met DSM-5 diagnostic criteria for anorexia nervosa (AN) and obsessive compulsive disorder (OCD), and who was engaged in specialized outpatient treatment of an eating disorder. The patient did not disclose at intake assessment that he was experiencing symptoms of a persistent cough, blood in his sputum, or that he was simultaneously being assessed outside of the eating disorders program for NTM until he had a positive smear for Mycobacterium kansasii in March 2017. The patient made progress in treatment in his weight status and some psychological symptoms despite the concurrent NTM symptoms. However, later treatment attendance was negatively impacted by the side effects of his medication regime for NTM and careful follow-up was required to monitor for potential interactions between his treatment for NTM and psychiatric medication. This case report provides an initial window into clinicians' ability to treat a patient with a concurrent eating disorder and an NTM infection and lessons learned in the process. LEVEL OF EVIDENCE: Level V: Opinions of respected authorities, based on descriptive studies, clinical experience, or reports of expert committees.

Cognitive Remediation Therapy Does Not Enhance Treatment Effect in Obsessive-Compulsive Disorder and Anorexia Nervosa: A Randomized Controlled Trial

BACKGROUND

Guideline-recommended therapies are moderately successful in the treatment of obsessive-compulsive disorder (OCD) and anorexia nervosa (AN), leaving room for improvement. Cognitive inflexibility, a common trait in both disorders, is likely to prevent patients from engaging in treatment and from fully benefiting from existing therapies. Cognitive remediation therapy (CRT) is a practical augmentation intervention aimed at ameliorating this impairing cognitive style prior to disorder-specific therapy.

OBJECTIVE

To compare the effectiveness of CRT and a control treatment that was not aimed at enhancing flexibility, named specialized attention therapy (SAT), as add-ons to treatment as usual (TAU).

METHODS

In a randomized controlled multicenter clinical trial, 71 adult patients with OCD and 61 with AN were randomized to ten twice-weekly sessions with either CRT or SAT, followed by TAU. Patients were evaluated at baseline, post-CRT/SAT, and after 6 and 12 months, with outcomes being quantified using the Yale-Brown Obsessive Compulsive Scale for OCD and the Eating Disorder Examination Questionnaire for AN.

RESULTS

Across study groups, most importantly CRT+TAU was not superior to control treatment (SAT)+TAU in reducing OCD and AN pathology. Contrary to expectations, SAT+TAU may have been more effective than CRT+TAU in patients being treated for OCD.

CONCLUSIONS

CRT did not enhance the effect of TAU for OCD and AN more than SAT. Unexpectedly, SAT, the control condition, may have had an augmentation effect on TAU in OCD patients. Although this latter finding may have been due to chance, the effect of SAT delivered as a pretreatment add-on intervention for adults with OCD and AN merits future efforts at replication.

The relationship between tendency to attend to detail, sensory sensitivity, and affective response to food cues - A registered report

Understanding the underlying drivers of food choice remains a challenge and has highlighted the need for measures that capture data over and above that offered by self-reporting tools. Consequently, a growing body of research has set out to interpret facial responses to food cues to offer a greater insight into the emotional responses that may drive food acceptance. However, interpreting facial responses is challenging, as there are numerous factors that may influence affective response to foods, including expectation, context, and individual differences. Existing findings suggest there is a link between autistic traits and sensory sensitivities; research highlights further links between sensory sensitivities and eating behaviour, and autistic traits and eating behaviour, with a body of research focusing on the autistic trait attention to detail (ATD). As such, the current study aimed to examine rapid facial activity in response to foods cues while capturing these individual differences present in the general population. This study found no evidence to suggest facial responses to food pictures were linked with attention to detail or hyper-sensitivity. The findings did support a general link between self-reported pleasantness ratings of viewed foods and activity of facial muscles. Post-hoc analyses suggested scoring on the social skills sub-scale of the Autism Quotient (AQ) was associated with levator activity while viewing pictures low in pleasantness. This study offers a greater understanding of variations, at the individual level, which are associated with affective response to foods, and may help to inform the development of tools that set out to predict food acceptance.

MDLSD: study protocol for a randomised, double-masked, placebo-controlled trial of repeated microdoses of LSD in healthy volunteers

BACKGROUND

Regular ingestion of sub-hallucinogenic doses of psychedelics, referred to as "microdosing", has gained increasing popularity and attention in the press and in online forums, with reported benefits across multiple cognitive and emotional domains. Rigorously controlled studies to date, however, have been limited in scope and have failed to produce results comparable to those reported in the grey literature.

METHODS

Eighty healthy male participants will receive 14 doses of placebo or 10 μg lysergic acid diethylamide orally every 3rd day over a 6-week treatment protocol. A battery of personality, creativity, mood, cognition, and EEG plasticity measures, as well as resting-state fMRI imaging, will be administered at baseline and at the end of the protocol. Creativity, mood, and plasticity measures will additionally be assessed in the acute phase of the first dose. Daily functioning will be monitored with questionnaires and a wearable sleep and activity tracker.

DISCUSSION

This study will rigorously examine the claims presented in the microdosing grey literature by pairing a comparable dosing protocol with objective measures. Potential therapeutic implications include future clinical trials to investigate microdosed psychedelics as a standalone treatment or as an augmentation of psychotherapy in the treatment of depression, addiction, eating disorders, obsessive-compulsive disorders, and palliative care.

TRIAL REGISTRATION

ACTRN12621000436875 . Registered on 19 February 2021.

Are poor set-shifting and central coherence associated with everyday function in anorexia nervosa? A systematic review

BACKGROUND

There is increasing interest in associations between cognitive impairments and clinical symptoms in Anorexia Nervosa (AN), however, the relationship with everyday function is unclear. The current review synthesizes existing data regarding associations between scores on tests of set-shifting and central coherence and functional outcome measures for individuals with AN.

METHOD

A systematic electronic database search yielded 13 studies which included participants with current or lifetime AN where scores on a neuropsychological test of set-shifting or central coherence were directly or indirectly compared to a functional outcome measure.

RESULTS

Associations between set-shifting and central coherence performance measures and functional outcomes were limited in number and noted only in adult or mixed-age cohorts. Associations were noted at subscale level, suggesting they are specific in nature. In younger cohorts, assessments of executive functioning in everyday life appear sensitive to cognitive-behavioral flexibility issues.

CONCLUSIONS

Associations between cognitive performance and functional outcome have not been as systematically assessed in AN as in other psychiatric disorders. Key factors to address in future research include: (a) the use of function measures which are sensitive to both the level of impairment, and specific rather than general impairments (b) the ecological validity of measures, (c) the task impurity problem, especially in regard to cognitive flexibility assessment, and (d) the need to measure both cognitive deficits and strengths, because tests of specific cognitive processes may underestimate the ability to function in daily life due to compensatory strategies.

Joint Hypermobility and Clinical Correlates in a Group of Patients With Eating Disorders

Background: The ability to move joints beyond the normal range of motion is called Joint Hypermobility (JHM). JHM has been associated with a plethora of physical problems and is a frequent sign of hereditary disorders of connective tissue. Neuropsychiatric conditions such as eating disorders (ED) have also been related to JHM. However, little is known about the clinical profile of people with ED and JHM. The aim of this study was to explore JHM in patients with ED and to compare the clinical characteristics of hypermobile ED patients with non-hypermobile ED patients. Method: Fifty-three outpatients diagnosed with ED were assessed using the Beighton score for JHM, the Eating Disorders Inventory 2, the Eating Disorder Examination, and the Detail and Flexibility Questionnaire. Information relating to patients' psychiatric and somatic comorbidities/symptoms was also collected. Results: Using the traditional Beighton score's cutoff of ≥4, 41.5% of the sample presented with JHM. Our results indicate that compared with non-hypermobile ED patients, those with JHM are significantly younger, suffer at a greater extent from joint pain and easy bruising, have a shorter duration of the ED, and have lower scores for cognitive rigidity. In addition, for those with anorexia nervosa, the restricting subtype represents a significantly lower proportion of hypermobile ED patients compared to non-hypermobile ED patients. Multivariate analyses showed that cognitive rigidity, age, and duration of the ED could predict the JHM status in this sample. Conclusion: These results suggest that JHM is frequent in patients with ED and is accompanied by signs of tissue fragility. Patients with ED and JHM seem to present a specific profile characterized by less cognitive rigidity and restricting behavior in the case of anorexia nervosa. Further research is needed in order to confirm these results.

Subjective cognitive rigidity and attention to detail: A cross-cultural validation of the Detail and Flexibility Questionnaire (DFlex) in a French clinical sample

Introduction: People diagnosed with Anorexia Nervosa (AN) are at risk for poor cognitive flexibility and excessive attention to detail. These difficulties are traditionally quantified using neuropsychological tests. These tests do not capture the subjective repercussions of these cognitive styles. The Detail and Flexibility Questionnaire (DFlex) has been specifically developed to measure these repercussions. The aim of this study was to evaluate the psychometric properties of the French version of this scale (F-DFlex) and to adapt it if needed. Methods: The instrument factor structure, internal consistency, convergent, and discriminant validity were assessed in a sample of 107 French women AN inpatients. For convergent validity, associations between F-DFlex scores, perceived levels of autistic traits (Autism Quotient questionnaire - AQ) and eating disorders symptomatology (Eating Disorder Examination Questionnaire - EDE-Q), as well as neuropsychological evaluations (Wisconsin Card Sorting Test - WCST, Rey Complex Figure - RCF) were tested. Discriminant validity was assessed by comparing F-DFlex scores of the patients with a chronic versus non-chronic illness. Results: The results of the exploratory factorial analysis led to the removal of four items. Internal consistency indices of this shortened version were good. Correlation coefficients directions and values between F-DFlex factors and relevant AQ Switching and Detail subscores were satisfactory, indicating good convergent validity. F-DFlex Rigidity scores were associated with the WCST percentage of perseverative errors, but the F-DFlex Attention to Detail scores were not associated with the RCF central coherence index. F-DFlex scores were associated with the severity of eating disorders symptomatology independently of BMI, illness duration, or anxiety, and depression. Conclusion: This study indicates good psychometric properties of this new version of the DFlex. The F-DFlex appears as a promising self-report screening tool of important cognitive dimensions for use in clinical management of people diagnosed with AN.

Cognitive flexibility in acute anorexia nervosa and after recovery: A systematic review

Difficulties in cognitive flexibility-the ability to adapt effectively to changes in the environment and/or changing task demands-have been reported in anorexia nervosa (AN). However, findings are inconsistent across studies and it remains unclear which specific aspects of cognitive flexibility patients with AN may struggle with. This systematic review aimed to synthesise existing research on cognitive flexibility in AN and clarify differences between patients with acute AN, patients who are weight-restored and patients who are fully recovered from AN. Electronic databases were searched through to January 2020. 3,310 papers were screened and 70 papers were included in the final review. Although adults with acute AN performed worse in perceptual flexibility tasks and self-report measures compared to HCs, they did not exhibit deficits across all domains of cognitive flexibility. Adolescents with acute AN did not differ to HCs in performance on neurocognitive tasks despite self-reporting poorer cognitive flexibility. Overall, significant differences in cognitive flexibility between acute and recovered participants was not evident, though, the findings are limited by a modest number of studies. Recovered participants performed poorer than HCs in some neurocognitive measures, however, results were inconsistent across studies. These results have implications for the assessment of cognitive flexibility in AN and targeted treatment approaches.

Impulsivity and compulsivity in anorexia and bulimia nervosa: A systematic review

This study aimed to systematically appraise cross-sectional research that compared the cognitive performance of individuals in the acute phase of BN and/or AN to HCs on measures of impulsivity and compulsivity. The results of the systematic review showed support for the trans-diagnostic approach to eating disorders. There was no strong evidence to support the characterisation of AN as high in compulsivity (and low in impulsivity), nor to support the characterisation of BN as high in impulsivity (and low in compulsivity). There appeared to be mixed findings for both impulsivity and compulsivity across AN and BN. Results were highly variable due to the heterogeneous tasks used, and lack of replication across studies. There was no consensus amongst the included studies on the most appropriate task and/or outcome measures that should be used to study the constructs of impulsivity and compulsivity.

Cognitive Remediation Interventions in Autism Spectrum Condition: A Systematic Review

BACKGROUND

Autism spectrum condition (ASC) is a lifelong neurodevelopmental condition characterized by difficulties in social cognition and heterogeneity of executive function which are suggested to be underpinned by neurobiological, prenatal and genetic factors. Cognitive remediation (CR) interventions are frequently used to address cognitive characteristics and improve cognitive and general functioning. However, the evidence is limited for ASC. This systematic review is the first to provide a narrative synthesis of all studies of CR interventions and ASC. The review aimed to delineate the development of research in this area in both adolescents and adults, with implications for clinical practice and future research.

METHOD

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. The literature was reviewed using the PubMed, PsycINFO, Web of Science, Scopus and Embase from inception to 1st April 2020. Out of 1,503 publications, a total of 13 papers were identified as being relevant for the review.

RESULTS

The 13 studies meeting the inclusion criteria were: four randomized control trials (RCTs); two non-randomized control trials, four case series, two feasibility studies and one case study. A narrative synthesis of the data suggested that CR interventions are potentially effective in improving social cognition and cognitive functioning in ASC. RCTs supported the efficacy of CR interventions in improving social cognition and executive functioning. Non-randomized control trials provided evidence for the effectiveness of social cognition remediation interventions in ASC. Case series and a case study have also supported the feasibility of CR interventions, including reflections on their adaptation for ASC populations and the positive feedback from participants.

CONCLUSIONS

CR interventions are potentially effective in improving social cognition and cognitive functioning in ASC. However, the generalizability of the included empirical studies was hampered by several methodological limitations. To further strengthen understandings of the effectiveness of CR interventions for ASC, future RCTs are needed with larger sample sizes in exploring the long-term effectiveness of CR interventions, using age-appropriate valid and reliable outcome measures. They should also consider the heterogeneity in neuropsychological functioning in ASC and the mediating and moderating mechanisms of the CR intervention for ASC.

Evaluation of the Psychometric Properties of the Five Facet of Mindfulness Questionnaire

Objective

The Five Facet of Mindfulness Questionnaire (FFMQ) is widely used to assess mindfulness. The present study provides a psychometric evaluation of the FFMQ that includes item response theory (IRT) analyses and evaluation of item characteristic curves.

Method

We administered the FFMQ, the Beck Depression Inventory-II, the Ruminative Response Scale, and the Emotion Regulation Questionnaire to a heterogenous sample of 240 community-based adults. We estimated internal consistency reliability, item-scale correlations, categorical confirmatory factor analysis, and IRT graded response models for the FFMQ. We also estimated correlations among the FFMQ scales and correlations with the other measures included in the study.

Results

Internal consistency reliabilities for the five FFMQ scales were 0.82 or higher. A five-factor categorical model fit the data well. IRT-estimated item characteristic curves indicated that the five response options were monotonically ordered for most of the items. Product-moment correlations between simple-summated scoring and IRT scoring of the scales were 0.97 or higher.

Conclusions

The FFMQ accurately identifies varying levels of trait mindfulness. IRT-derived estimates will inform future adaptations to the FFMQ (e.g., briefer versions) and the development of future mindfulness instruments.

Intolerance of uncertainty and eating disorder behaviour: Piloting a consumption task in a non-clinical sample

BACKGROUND AND OBJECTIVES

Intolerance of uncertainty (IU) is a transdiagnostic process contributing to the maintenance of anxiety disorders, and is a potential target for treatment. Recent literature has investigated IU as a cognitive process underpinning pathological fear and anxiety in Anorexia Nervosa (AN). The current study was designed to examine trait and state IU, and their relationship to restrictive eating disorder symptoms, anxiety, worry, cognitive rigidity and eating behaviour.

METHODS

A sample of undergraduate women (N = 85) completed measures of eating disorder symptoms, IU, cognitive rigidity and worry. Participants were randomised to complete an eating task under one of two conditions: the "certain" condition received a high-calorie meal and nutritional information, while the "uncertain" condition received the meal alone. During the meal, state IU and state anxiety were examined at three time-points (baseline, pre-eating, post-eating).

RESULTS

Trait IU was correlated with cognitive rigidity, worry, global eating disorder symptoms, and, in particular, dietary restraint. No differences emerged between conditions with respect to eating-related anxiety, or amount of food eaten. Controlling for condition and eating disorder symptoms, state IU predicted pre-eating anxiety. Beyond the contribution of condition, BMI and eating disorder symptoms, state IU predicted consumption, specifically greater dietary restriction.

LIMITATIONS

The study employed a non-clinical sample.

CONCLUSIONS

IU may be implicated in a rigid cognitive style, the anxiety response to energy-dense food, and restrictive eating behaviour. Should these findings be replicated in a clinical sample, then IU might emerge as an adjunctive treatment target for AN.

Individual cognitive remediation therapy benefits for patients with anorexia nervosa and high autistic features

Cognitive remediation therapy (CRT) is an increasingly implemented intervention in psychiatric conditions. The majority of randomized treatment trials in psychiatry reports cognitive improvements resulting in better functional outcomes in CRT groups. This brief report from the national inpatient treatment programme for eating disorders demonstrates cognitive performance task–based improvements in patients with high and low autistic characteristics. This preliminary study shows feasibility and benefits of individual CRT in patients who have autism spectrum disorder features.

Harm minimization in severe and enduring anorexia nervosa

For many sufferers of anorexia nervosa, the time course is long, and the prospect of disability and family burden great. This is all too often the case, even with early diagnosis and treatment. The term severe and enduring anorexia nervosa has been applied to these survivors. Yet, a majority of patients do eventually recover and, even where this is not the case, adaptive medical stability and function can be maintained despite alarming dilapidation. Managing the years of illness so as to have the best outcome physically and psychologically, even where full weight recovery does not occur, or has not yet occurred, is the topic of this article. Literature pertaining to harm minimization in chronic, severe, enduring, and long-standing anorexia nervosa was selectively reviewed using an Ovid data base and Google Scholar. The authors' own clinical experience over almost four decades in public and private hospital and community settings has also informed much of what has been written. The authors would like to think that it is possible to do better than the familiar injunction (variously attributed to Hippocrates, Galen, and others) of 'primum non nocere'-although this is a good place to start.

General and Eating Disorder Specific Flexibility: Development and Validation of the Eating Disorder Flexibility Index (EDFLIX) Questionnaire

Findings from studies investigating cognitive flexibility in eating disorders (EDs) are inconsistent, and although neuropsychological tests are commonly used to measure these skills, they may not be particularly effective in predicting everyday functioning. Also, extant studies have largely focused on flexibility in anorexia nervosa (AN), with assessments targeting general rather than specific flexibility, and cognitive, rather than behavioral flexibility. Knowledge regarding ED specific flexibility and flexibility in bulimia nervosa (BN) and binge eating disorder (BED) is still scarce. The aim of this study was to develop and validate a novel measure assessing general and ED specific flexibility in a diagnostically diverse sample, and in healthy controls (HCs). A sample of 207 adult individuals with EDs (55% AN, 29% BN, 16% BED) and 288 HCs responded to an online, 51-item, pilot questionnaire on ED specific and general flexibility. In addition, participants completed the shift subscale from the Behavior Rating Inventory of Executive Function Adult version (BRIEF-A), and the Eating Disorder Diagnostic Scale (EDDS). A principal component analysis (PCA) in the clinical sample yielded a 36-item, three-factor solution capturing general flexibility, flexibility related to food and exercise, and flexibility concerning body shape and weight. Results showed that the measure had good to excellent internal consistency, and good convergent validity. A confirmatory factor analysis (CFA) using data from HCs revealed good fit indexes, supporting the original factor solution. A receiver operating characteristics analysis (ROC) demonstrated excellent accuracy in distinguishing scores from those with and without EDs. A cutoff score of 136 yielded the most balanced sensitivity and specificity. Significant differences in general and ED specific flexibility were found between individuals with and without EDs. Overall, HCs achieved the highest flexibility scores, followed by those with BED, BN, and AN. In sum this novel measure, the Eating Disorder Flexibility Index (EDFLIX) questionnaire, was found to be reliable and valid in the assessment of cognitive and behavioral flexibility, with results offering support for the conceptual distinction between general and ED related flexibility. The study also provides strong evidence for the discriminant validity of the EDFLIX with results revealing significant differences in flexibility in people with and without EDs. In addition, significant differences in flexibility also emerged when comparing diagnostic groups, indicating the utility of the assessment instrument for classification purposes.

Feasibility of group Cognitive Remediation Therapy in an adult eating disorder day program in New Zealand

OBJECTIVE

To explore the feasibility of integrating group Cognitive Remediation Therapy (gCRT) into an eating disorder day program in Auckland, New Zealand.

METHOD

A consecutive series of 28 patients took part over an 8-month period in the context of a service audit. Main outcome measures were the Detail and Flexibility Questionnaire (DFlex) and qualitative feedback from patients.

RESULTS

Significant shifts in self-report inefficient cognitive style were observed pre/post gCRT with large effect sizes (Cohen's d_av) for both cognitive rigidity and attention to detail outcomes. Patient feedback was positive, with themes of enjoyment, increased insight, and positive social interaction/esteem boosting in the context of the group emerging.

CONCLUSIONS

Support for the acceptability, adaptation, expansion, practicality, and limited-efficacy testing of gCRT in an Australasian day program setting has been found, suggesting integration of this module into existing day treatment programs is merited. Larger scale trials may help delineate the clinical characteristics of good responders.

Cognitive remediation therapy (CRT) as a pretreatment intervention for adolescents with anorexia nervosa during medical hospitalization: a pilot randomized controlled trial protocol

BACKGROUND

Anorexia nervosa (AN) is a severe psychiatric condition characterized by low body weight, fear of weight gain/becoming fat and/or behavior that interferes with weight gain, and body disturbance. Though there have been recent advances in the treatment of AN, there continues to be an urgent need to increase treatment options. Cognitive remediation therapy (CRT) has been successfully used as an adjunctive treatment for individuals with AN. In this study, we pilot the use of CRT plus an innovative parent involvement component as a pre-treatment intervention on a medical unit. We hypothesize that adding CRT with parent involvement to a standard hospital stay is feasible, acceptable by patients and staff, and may improve treatment outcomes post-hospitalization.

METHODS/DESIGN

This is a pilot randomized controlled trial with three arms. Participants are adolescents aged 12-18 with AN; 60 participants will be included. They are randomized into one of three groups: treatment as usual (TAU, standard care at Children's Hospital of Philadelphia), CRT + contact control (known as "Family Fun Time"), and CRT + Teach the Parent. Intervention will occur on an inpatient basis. Follow-up will be outpatient and will continue until 6 months post-discharge. Psychosocial, neurocognitive, and behavioral measures will be collected throughout the study, and group differences will be evaluated at 4 weeks, 3 months, and 6 months post-discharge. The study will take place at The Children's Hospital of Philadelphia.

DISCUSSION

This pilot randomized controlled trial will inform feasibility of the integration of a pre-treatment intervention into a medical hospital stay for AN. We will assess recruitment procedures, treatment administration, and participant retention. Finally, a comprehensive assessment battery will be evaluated. Secondary goals are to conduct a preliminary evaluation of whether or not CRT with parent involvement increases rate of weight gain and treatment engagement and decreases parental accommodation of symptoms post-discharge. If successful, this pilot study will inform a larger controlled trial fully powered to examine the secondary goals.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02883413.

Inflexible daily behaviour is associated with the ability to control an automatic reaction in autism spectrum disorder

Inflexible behaviours in people with autism spectrum disorder (ASD) broadly obstruct social communication. Meanwhile, flexibility implicates cognitive control to resolve socially conflicting situations; however, it remains unclear how people with ASD behave in the face of these conflicts in this respect. We used the ultimatum game (UG) and the implicit-association test (IAT) to examine goal-directed/economic flexibility, both of which involve conflict and cognitive control. In addition, we used the Detail and Flexibility Questionnaire (DFlex) to measure inflexible everyday behaviour with diminished cognitive control and attention shifting. We observed the decreased flexibility in participants with ASD (DFlex and IAT); further, their IAT scores positively correlated with DFlex. However, in the UG, contrary to our prediction, participants with ASD accepted unfair offers more frequently than TD. These results suggest that assessing the automatic/attention processing level with the IAT could be a useful approach to study behavioural flexibility among ASD compared with the UG, which might comprise multiple response strategies besides economic rationality. Overall, the severity of inflexible daily behaviours in people with ASD may be associated with a reduced flexible attitude at an automatic level, altered attention processing and decreased cognitive control.

Cognitive remediation therapy (CRT) in a specialist inpatient eating disorder service for children and adolescents: CAN-CRT study protocol for a pilot randomised controlled trial

INTRODUCTION

Research on treatments for young people (YP) with anorexia nervosa (AN) is scarce. Evidence supports the use of cognitive remediation therapy (CRT) to improve central coherence and set-shifting, inefficiencies that can negatively impact on prognosis.

OBJECTIVE

The study aims to evaluate the feasibility of individual CRT in an inpatient setting for YP aged 10-18 years with AN and to qualitatively examine YP's and their parents experiences.

METHOD

In a single-centre, pilot, randomised controlled trial, 80 patients aged 10-18 years with AN will be randomly allocated to the immediate or delayed CRT group, in addition to standard treatment. A repeated measures design will be conducted across 3 time points.

DISCUSSION

The data will provide evidence regarding the feasibility of individual CRT in YP with AN, informing directions of further development of CRT. The study is in preparation for a definitive randomised controlled trial. The aim of this manuscript is to describe the study protocol.