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Crumby E, Penwell TE, Butler RM, Ortiz AML, Fitterman-Harris HF, Levinson CA. Does response to treatment differ between anorexia nervosa and atypical anorexia nervosa? Findings from two open series trials. J Affect Disord 2024; 365:451-458. [PMID: 39182520 DOI: 10.1016/j.jad.2024.08.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 08/21/2024] [Accepted: 08/22/2024] [Indexed: 08/27/2024]
Abstract
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.
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Affiliation(s)
- Emma Crumby
- Department of Psychological Sciences, University of Louisville, Louisville, KY, United States of America
| | - Taylor E Penwell
- Department of Psychological Sciences, University of Louisville, Louisville, KY, United States of America
| | - Rachel M Butler
- Department of Psychological Sciences, University of Louisville, Louisville, KY, United States of America
| | - Anna Marie L Ortiz
- Department of Psychological Sciences, University of Louisville, Louisville, KY, United States of America
| | - Hannah F Fitterman-Harris
- Department of Psychological Sciences, University of Louisville, Louisville, KY, United States of America
| | - Cheri A Levinson
- Department of Psychological Sciences, University of Louisville, Louisville, KY, United States of America.
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2
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Cusack CE, Hunt RA, Rae J, Christian C, Levinson CA. Experiential Avoidance During Mealtimes Among Individuals With Eating Disorders. Behav Ther 2024; 55:1084-1097. [PMID: 39174267 DOI: 10.1016/j.beth.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 03/13/2024] [Accepted: 04/02/2024] [Indexed: 08/24/2024]
Abstract
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.
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Butler RM, Christian C, Girard JM, Vanzhula IA, Levinson CA. Are within- and between-session changes in distress associated with treatment outcomes? Findings from two clinical trials of exposure for eating disorders. Behav Res Ther 2024; 180:104577. [PMID: 38850690 DOI: 10.1016/j.brat.2024.104577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 06/10/2024]
Abstract
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.
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Affiliation(s)
- Rachel M Butler
- University of Louisville, Department of Psychological and Brain Sciences, USA.
| | - Caroline Christian
- University of Louisville, Department of Psychological and Brain Sciences, USA
| | | | - Irina A Vanzhula
- Johns Hopkins School of Medicine, Department of Psychiatry & Behavioral Sciences, USA
| | - Cheri A Levinson
- University of Louisville, Department of Psychological and Brain Sciences, USA
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4
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Pictor LE, Laboe AA, Dillon K, Frank M, Gavuji M, Krawczyk A, Schaumberg K. A pilot randomized trial of the body advocacy movement: a novel, dissonance-based intervention designed to target fear of weight gain and anti-fat bias in young adults. Eat Disord 2024:1-20. [PMID: 38557300 DOI: 10.1080/10640266.2024.2332823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
The Body Advocacy Movement (BAM) is a novel, cognitive-dissonance-based intervention designed to target fatphobia and anti-fat bias as mechanisms to drive reductions in eating disorder (ED) risk. Previous dissonance-based programs (i.e. the Body Project; BP) have successfully targeted thin-ideal internalization as an intervention mechanism. As burgeoning research indicates that fatphobia and anti-fat bias may play a central role in the maintenance of ED pathology, a focused intervention designed to target these constructs could bolster prevention efforts. The aims of this pilot study include confirming acceptability and feasibility of BAM and developing preliminary estimates of its effects on intervention targets, along with benchmarking these effects against the BP intervention. BAM was found to be accepted by participants and feasible to facilitate in a peer-led model. Preliminary results from 50 participants (BAM: N = 26; BP: N = 24) reveal small-to-moderate pre-to-post intervention effects on fatphobia, anti-fat bias, thin-ideal internalization, and eating pathology, which dissipated at 8-week follow-up. The BAM intervention has the potential to supplement the existing suite of ED prevention programs by specifically targeting anti-fat bias, though additional testing in larger and more diverse samples is necessary to clarify its impact on both hypothesized risk mechanisms and ED outcomes.
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Affiliation(s)
- Lauren E Pictor
- Department of Psychiatry, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - A A Laboe
- Department of Psychiatry, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - K Dillon
- Department of Psychiatry, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - M Frank
- Department of Psychiatry, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - M Gavuji
- Department of Psychiatry, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - A Krawczyk
- Department of Psychiatry, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Katherine Schaumberg
- Department of Psychiatry, University of Wisconsin-Madison, Madison, Wisconsin, USA
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5
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Fitterman-Harris HF, Han Y, Osborn KD, Faulkner LM, Williams BM, Pennesi JL, Levinson CA. Comparisons between atypical anorexia nervosa and anorexia nervosa: Psychological and comorbidity patterns. Int J Eat Disord 2024; 57:903-915. [PMID: 38288579 PMCID: PMC11018480 DOI: 10.1002/eat.24147] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/12/2024] [Accepted: 01/12/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE Literature comparing "atypical" anorexia nervosa (atypical AN) and anorexia nervosa (AN) suggests these diagnoses share significant similarities in eating disorder (ED) pathology and psychiatric comorbidities. This study evaluated potential differences in ED pathology, psychiatric comorbidity, associated mechanisms (i.e., ED fears and perfectionism), and demographic factors (i.e., ethnicity and age) between individuals with atypical AN and AN. METHOD Data from seven protocols were combined for a total 464 individuals diagnosed with atypical AN (n = 215) or AN (n = 249). Between-group differences in ED severity and behaviors, psychiatric comorbidities, ED fears, perfectionism, and demographic factors were assessed using t-tests, Wilcoxon rank-sum tests, and Fisher's exact test. RESULTS Participants with atypical AN reported higher levels of overvaluation of weight and shape than those with AN. Participants with AN scored higher on food-related fears (anxiety about eating, food avoidance behaviors, and feared concerns) and fears of social eating, as well as obsessive-compulsive symptoms. Participants with AN were more likely to identify as Asian or Pacific Islander. No other statistically significant differences were found between groups for overall ED severity, ED behaviors, psychiatric comorbidities, general ED fears, perfectionism, or demographic factors. DISCUSSION Overall, results support previous literature indicating limited differences between individuals with atypical AN and AN, though individuals with atypical AN reported more overvaluation of weight and shape and those with AN reported higher food and social eating fears and obsessive-compulsive symptoms. Relatively few overall differences between atypical AN and AN highlight the importance of exploring dimensional conceptualizations of AN as an alternative to the current categorical conceptualization. PUBLIC SIGNIFICANCE This study assessed differences among individuals with atypical anorexia nervosa and anorexia nervosa in eating disorder severity and behaviors, comorbid psychiatric diagnoses, associated mechanisms, and demographic factors. Few differences emerged, though participants with atypical anorexia nervosa reported more overvaluation of weight and shape, while those with anorexia nervosa reported more food and social eating fears and higher obsessive-compulsive symptoms. Results support exploration of these diagnoses as a spectrum disorder.
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Affiliation(s)
| | - Yuchen Han
- Department of Bioinformatics and Biostatistics, University of Louisville
| | - Kimberly D. Osborn
- Department of Psychological and Brain Sciences, University of Louisville
- School of Community Health Sciences, Counseling and Counseling Psychology, Oklahoma State University
| | - Loie M. Faulkner
- Department of Psychological and Brain Sciences, University of Louisville
| | - Brenna M. Williams
- Department of Psychological and Brain Sciences, University of Louisville
| | - Jamie-Lee Pennesi
- Department of Psychological and Brain Sciences, University of Louisville
| | - Cheri A. Levinson
- Department of Psychological and Brain Sciences, University of Louisville
- Department of Pediatrics – Division of Child and Adolescent Psychiatry, University of Louisville
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6
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Sandoval-Araujo LE, Cusack CE, Ralph-Nearman C, Glatt S, Han Y, Bryan J, Hooper MA, Karem A, Levinson CA. Differentiation between atypical anorexia nervosa and anorexia nervosa using machine learning. Int J Eat Disord 2024; 57:937-950. [PMID: 38352982 PMCID: PMC11091846 DOI: 10.1002/eat.24160] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/21/2024] [Accepted: 01/22/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE Body mass index (BMI) is the primary criterion differentiating anorexia nervosa (AN) and atypical anorexia nervosa despite prior literature indicating few differences between disorders. Machine learning (ML) classification provides us an efficient means of accurately distinguishing between two meaningful classes given any number of features. The aim of the present study was to determine if ML algorithms can accurately distinguish AN and atypical AN given an ensemble of features excluding BMI, and if not, if the inclusion of BMI enables ML to accurately classify between the two. METHODS Using an aggregate sample from seven studies consisting of individuals with AN and atypical AN who completed baseline questionnaires (N = 448), we used logistic regression, decision tree, and random forest ML classification models each trained on two datasets, one containing demographic, eating disorder, and comorbid features without BMI, and one retaining all features and BMI. RESULTS Model performance for all algorithms trained with BMI as a feature was deemed acceptable (mean accuracy = 74.98%, mean area under the receiving operating characteristics curve [AUC] = 74.75%), whereas model performance diminished without BMI (mean accuracy = 59.37%, mean AUC = 59.98%). DISCUSSION Model performance was acceptable, but not strong, if BMI was included as a feature; no other features meaningfully improved classification. When BMI was excluded, ML algorithms performed poorly at classifying cases of AN and atypical AN when considering other demographic and clinical characteristics. Results suggest a reconceptualization of atypical AN should be considered. PUBLIC SIGNIFICANCE There is a growing debate about the differences between anorexia nervosa and atypical anorexia nervosa as their diagnostic differentiation relies on BMI despite being similar otherwise. We aimed to see if machine learning could distinguish between the two disorders and found accurate classification only if BMI was used as a feature. This finding calls into question the need to differentiate between the two disorders.
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Affiliation(s)
| | - Claire E. Cusack
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, KY
| | | | - Sofie Glatt
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, KY
| | - Yuchen Han
- Department of Biostatistics & Bioinformatics, University of Louisville, Louisville, KY
| | - Jeffrey Bryan
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, KY
| | | | - Andrew Karem
- Department of Computer Science & Engineering, University of Louisville, Louisville, KY
| | - Cheri A. Levinson
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, KY
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Butler RM, Crumby EK, Christian C, Brosof LC, Vanzhula IA, Levinson CA. Facing Eating Disorder Fears: An Open Trial Adapting Prolonged Exposure to the Treatment of Eating Disorders. Behav Ther 2024; 55:347-360. [PMID: 38418045 DOI: 10.1016/j.beth.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/31/2023] [Accepted: 07/15/2023] [Indexed: 03/01/2024]
Abstract
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.
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8
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Christian C, Butler RM, Burr EK, Levinson C. An Intensive time series investigation of the relationships across eating disorder-specific fear responses and behavior urges in partially remitted anorexia nervosa. J Anxiety Disord 2024; 102:102804. [PMID: 38128286 PMCID: PMC10923000 DOI: 10.1016/j.janxdis.2023.102804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/25/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
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.
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Affiliation(s)
- Caroline Christian
- University of Louisville, Department of Psychological & Brain Sciences, Louisville, KY, USA.
| | - Rachel M Butler
- University of Louisville, Department of Psychological & Brain Sciences, Louisville, KY, USA
| | - Emily K Burr
- University of Central Florida, Department of Psychology, Orlando, FL, USA
| | - Cheri Levinson
- University of Louisville, Department of Psychological & Brain Sciences, Louisville, KY, USA
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Fitterman-Harris HF, Davis GG, Bedard SP, Cusack CE, Levinson CA. Digital Mental Health Interventions: Differences in Diet Culture Intervention Framing. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 21:24. [PMID: 38248489 PMCID: PMC10815398 DOI: 10.3390/ijerph21010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/14/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024]
Abstract
Diet culture is a societal norm that ranks thin bodies as superior to other body types and has been associated with negative outcomes, such as eating disorders. Wellness has evolved into a term that is often used to promote diet culture messages. One possible way to combat diet culture is through single-session, digital mental health interventions (DMHIs), which allow for increased access to brief public health treatments. The framing of DMHIs is critical to ensure that the target population is reached. Participants (N = 397) were enrolled in a single-session DMHI, which was framed as either a Diet Culture Intervention (n = 201) or a Wellness Resource (n = 196). Baseline group differences in eating disorder pathology, body image, weight stigma concerns, fat acceptance, and demographic characteristics were analyzed. Across groups, participants reported moderately high eating disorder pathology, low-to-moderate levels of body dissatisfaction, moderate levels of fat acceptance, and either very low or very high weight stigma concerns. Participants in the Diet Culture Intervention group reported higher levels of fat acceptance than those in the Wellness Resource group (p < 0.001). No other framing group differences were identified, though post hoc analyses revealed differences based on recruitment source (i.e., social media versus undergraduate research portal). This study found that framing a DMHI as targeting diet culture or as a Wellness Resource can result in the successful recruitment of individuals at risk of disordered eating. Framing a DMHI as a Wellness Resource may increase recruitment of individuals with low levels of fat acceptance, which may be particularly important for dismantling diet culture, disordered eating, and weight stigma concerns. Future research should assess DMHI framing in other populations, such as men and adolescents.
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Affiliation(s)
- Hannah F. Fitterman-Harris
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY 40292, USA; (S.P.B.); (C.E.C.); (C.A.L.)
| | - Gabrielle G. Davis
- College of Education and Human Development, University of Louisville, Louisville, KY 40292, USA;
| | - Samantha P. Bedard
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY 40292, USA; (S.P.B.); (C.E.C.); (C.A.L.)
- Department of Psychology, University of Wyoming, Laramie, WY 82071, USA
| | - Claire E. Cusack
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY 40292, USA; (S.P.B.); (C.E.C.); (C.A.L.)
| | - Cheri A. Levinson
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY 40292, USA; (S.P.B.); (C.E.C.); (C.A.L.)
- Department of Pediatrics, Division of Child and Adolescent Psychiatry and Psychology, University of Louisville, Louisville, KY 40292, USA
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Forney KJ, Burton Murray H, Himawan L, Juarascio AS. Preliminary data that psychological treatment and baseline anxiety are associated with a decrease in postprandial fullness and early satiation for individuals with bulimia nervosa and related other specified feeding or eating disorder. Int J Eat Disord 2023; 56:2343-2348. [PMID: 37746867 PMCID: PMC10841224 DOI: 10.1002/eat.24068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Gastrointestinal symptoms, particularly postprandial fullness, are frequently reported in eating disorders. Limited data exist evaluating how these symptoms change in response to outpatient psychological treatment. The current study sought to describe the course of postprandial fullness and early satiation across psychological treatment for adults with bulimia nervosa and related other specified feeding or eating disorders and to test if anxiety moderates treatment response. METHODS Secondary data analysis was conducted on questionnaire data provided by 30 individuals (80% white, M(SD)age = 31.43(13.44) years; 90% female) throughout treatment and six-month follow-up in a pilot trial comparing mindfulness and acceptance-based treatment with cognitive-behavioral therapy for bulimia nervosa. Participants completed items from the Rome IV Diagnostic Questionnaire for Adult Functional Gastrointestinal Disorders and the State Trait Anxiety Inventory. RESULTS Postprandial fullness and early satiation both significantly decreased over time (ds = 1.23-1.54; p's < .001). Baseline trait anxiety moderated this outcome, such that greater decreases were observed for those with higher baseline anxiety (p = .02). DISCUSSION Results extend prior work in inpatient samples by providing preliminary data that postprandial fullness and early satiation decrease with outpatient psychological treatment for bulimia nervosa. Baseline anxiety moderated this effect for postprandial fullness. Future work should replicate findings in a larger sample and test anxiety as a mechanism underlying postprandial fullness in eating disorders. PUBLIC SIGNIFICANCE The current study found that common gastrointestinal symptoms (postprandial fullness and early satiation) decrease over the course of outpatient psychotherapy for adults with full and subthreshold bulimia nervosa. Postprandial fullness decreased more across time for those high in anxiety.
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Affiliation(s)
- K Jean Forney
- Department of Psychology, Ohio University, Athens, Ohio, USA
| | - Helen Burton Murray
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, Pennsylvania, USA
- Center for Neurointestinal Health, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lina Himawan
- Department of Psychology, Ohio University, Athens, Ohio, USA
| | - Adrienne S Juarascio
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, Pennsylvania, USA
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11
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Spix M, Melles H, Jansen A. From Bad to Worse: Safety Behaviors Exacerbate Eating Disorder Fears. Behav Sci (Basel) 2023; 13:574. [PMID: 37504021 PMCID: PMC10376478 DOI: 10.3390/bs13070574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/02/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023] Open
Abstract
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.
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Affiliation(s)
- Michelle Spix
- Department of Clinical Psychological Science, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Hanna Melles
- Department of Clinical Psychological Science, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Anita Jansen
- Department of Clinical Psychological Science, Maastricht University, 6229 ER Maastricht, The Netherlands
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12
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Melles H, Duijvis S, Jansen A. Inhibitory Learning during Exposure Treatment in Anorexia Nervosa: A Practical Guide. Behav Sci (Basel) 2023; 13:bs13050370. [PMID: 37232607 DOI: 10.3390/bs13050370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
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.
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Affiliation(s)
- Hanna Melles
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Stefanie Duijvis
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Anita Jansen
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
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13
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Butler RM, Williams B, Levinson CA. An examination of eating disorder fears in imaginal exposure scripts. J Affect Disord 2023; 326:163-167. [PMID: 36736788 DOI: 10.1016/j.jad.2023.01.121] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/25/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Rachel M Butler
- University of Louisville, Department of Psychological and Brain Sciences, United States of America.
| | - Brenna Williams
- University of Louisville, Department of Psychological and Brain Sciences, United States of America
| | - Cheri A Levinson
- University of Louisville, Department of Psychological and Brain Sciences, United States of America
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Fear of weight gain during cognitive behavioral therapy for binge-spectrum eating disorders. Eat Weight Disord 2023; 28:29. [PMID: 36879078 PMCID: PMC9988191 DOI: 10.1007/s40519-023-01541-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/12/2023] [Indexed: 03/08/2023] Open
Abstract
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.
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15
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Nicholas JK, Cusack CE, Levinson CA. Eating Disorder Symptom and Fear Change Trajectories During Imaginal Exposure Therapy: A Slope Network Analysis. Behav Ther 2023; 54:346-360. [PMID: 36858764 DOI: 10.1016/j.beth.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/13/2022] [Accepted: 09/22/2022] [Indexed: 11/25/2022]
Abstract
Eating disorders (EDs) are characterized by fears related to food, body image, and social evaluation. Exposure-based interventions hold promise for targeting a range of ED fears and reducing ED psychopathology. We investigated change mechanisms and optimal fear targets in imaginal exposure therapy for EDs using a novel approach to network analysis. Individuals with an ED (N = 143) completed up to four online imaginal exposure sessions. Participants reported ED symptoms and fears at pretreatment, posttreatment, and 6-month follow-up. We constructed networks of symptoms (Model 1), fears (Model 2), and combined symptoms and fears (Model 3). Change trajectory networks from the slopes of symptoms/fears across timepoints were estimated to identify how change in specific ED symptoms/fears related to change in other ED symptoms/fears. The most central changing symptoms and fears were feeling fat, fear of weight gain, guilt about one's weight/shape, and feared concerns about consequences of eating. In Model 3, change in ED fears bridged to change in desire to lose weight, desiring a flat stomach, following food rules, concern about eating with others, and guilt. As slope networks present averages of symptom/fear change slopes over the course of imaginal exposure therapy, further studies are needed to examine causal relationships between symptom changes and heterogeneity of change trajectories. Fears of weight gain and consequences of eating may be optimal targets for ED exposure therapy, as changes in these fears were associated with maximal change in ED pathology. Slope networks may elucidate change mechanisms for EDs and other psychiatric illnesses.
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Essayli JH, Forrest LN, Zickgraf HF, Stefano EC, Keller KL, Lane-Loney SE. The impact of between-session habituation, within-session habituation, and weight gain on response to food exposure for adolescents with eating disorders. Int J Eat Disord 2023; 56:637-645. [PMID: 36626314 PMCID: PMC9992286 DOI: 10.1002/eat.23894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/30/2022] [Accepted: 01/01/2023] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Jamal H Essayli
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
- Department of Psychiatry and Behavioral Health, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Lauren N Forrest
- Department of Psychiatry and Behavioral Health, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Hana F Zickgraf
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Emily C Stefano
- Bariatric and Weight Management Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kathleen L Keller
- Department of Nutritional Sciences, Pennsylvania State University, Pennsylvania, USA
- Department of Food Science, Pennsylvania State University, Pennsylvania, USA
| | - Susan E Lane-Loney
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
- Department of Psychiatry and Behavioral Health, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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Melles H, Jansen A. Transdiagnostic fears and avoidance behaviors in self-reported eating disorders. J Eat Disord 2023; 11:19. [PMID: 36782316 PMCID: PMC9926724 DOI: 10.1186/s40337-023-00745-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 02/02/2023] [Indexed: 02/15/2023] Open
Abstract
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.
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Affiliation(s)
- Hanna Melles
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Anita Jansen
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
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Christian C, Levinson CA. An integrated review of fear and avoidance learning in anxiety disorders and application to eating disorders. NEW IDEAS IN PSYCHOLOGY 2022. [DOI: 10.1016/j.newideapsych.2022.100964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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19
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Goldschmidt AB, Tortolani CC, Egbert AH, Brick LA, Elwy AR, Donaldson D, Le Grange D. Implementation and outcomes of home-based treatments for adolescents with anorexia nervosa: Study protocol for a pilot effectiveness-implementation trial. Int J Eat Disord 2022; 55:1627-1634. [PMID: 36324297 PMCID: PMC10018372 DOI: 10.1002/eat.23796] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Although family-based treatment (FBT) is considered a first-line treatment for adolescent anorexia nervosa (AN), it is underutilized in community settings and is unavailable to many families for a multitude of practical reasons (e.g., costs of treatment, transportation constraints). Adapting FBT interventions for delivery in home-based and community-based settings may reduce pragmatic barriers to treatment uptake and engagement. METHODS This pilot effectiveness-implementation trial will assess outcomes, implementation, and mechanisms of FBT adapted for the home setting (FBT-HB), delivered in the context of community-based behavioral health agencies. Adolescents with AN-spectrum disorders (n = 50) and their caregivers will be randomly assigned to either FBT-HB or home-based treatment as usual (TAU; integrated family therapy approach). Caregivers and adolescents will provide data on weight, eating, and putative treatment mechanisms, including caregiver self-efficacy and adolescent eating-related and weight-related distress. Implementation constructs of feasibility, acceptability, and appropriateness will be measured among providers and participating families. HYPOTHESES We expect that FBT-HB will be feasible, acceptable, and appropriate, and will outperform TAU in terms of improvements in adolescent weight and eating-related psychopathology. We further expect that caregiver self-efficacy and adolescent eating-related and weight-related distress, but not general distress, will show greater improvements in FBT-HB relative to TAU and will be associated with better adolescent weight and eating outcomes in FBT-HB. POTENTIAL IMPLICATIONS The proposed study has clear potential to advance scientific and clinical understanding of the real-world effectiveness of FBT for AN, including whether adapting it for the home setting improves its accessibility and effects on treatment outcome.
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Affiliation(s)
| | - Christina C. Tortolani
- Department of Counseling, Educational Leadership, and School Psychology, Rhode Island College, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University/The Miriam Hospital, Providence, RI, USA
| | - Amy H. Egbert
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University/The Miriam Hospital, Providence, RI, USA
| | - Leslie A. Brick
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University/The Miriam Hospital, Providence, RI, USA
| | - A. Rani Elwy
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University/The Miriam Hospital, Providence, RI, USA
| | - Deidre Donaldson
- Department of Family Medicine, Warren Alpert Medical School of Brown University/Gateway Healthcare, Providence, RI, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
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A model of self-criticism as a transdiagnostic mechanism of eating disorder comorbidity: A review. NEW IDEAS IN PSYCHOLOGY 2022. [DOI: 10.1016/j.newideapsych.2022.100949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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21
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Rodgers RF, Fischer LE, Murray SB, Franko DL. Integrating fear of fatness into sociocultural models of body image and eating concerns. Eat Behav 2022; 46:101653. [PMID: 35907363 DOI: 10.1016/j.eatbeh.2022.101653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 11/25/2022]
Abstract
To date, sociocultural models of body dissatisfaction and disordered eating have predominantly focused on the pursuit of thinness and have somewhat neglected sociocultural discourse and pressures that increase fear of fatness. Therefore, we tested a model to determine whether sociocultural pressures from media and interpersonal sources were associated with drive for thinness and fear of fatness. We also examined whether beliefs about the controllability of shape and weight were in turn associated with body dissatisfaction and disordered eating. A sample of N = 226 female undergraduate students in the U.S. completed an online survey assessing the variables of interest. After minor modification to the model pathways, the model provided a good fit to the data. Sociocultural influences to pursue thinness and fear fat related to body dissatisfaction and disordered eating through internalization of the thin-ideal and fear of fat. Together, these findings suggest that the pursuit of thinness and fear of fatness are distinct elements in etiologic models of body dissatisfaction and disordered eating. Additional work, including longitudinal research and studies among more diverse groups of individuals, is warranted to further clarify these relationships.
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Affiliation(s)
- Rachel F Rodgers
- APPEAR, Department of Applied Educational Psychology, Northeastern University, Boston, USA; Department of Psychiatric Emergency & Acute Care, Lapeyronie Hospital, CHRU Montpellier, France.
| | - Laura E Fischer
- APPEAR, Department of Applied Educational Psychology, Northeastern University, Boston, USA
| | - Stuart B Murray
- Department of Psychiatry and the Behavioral Sciences, University of Southern California, Los Angeles, CA, USA
| | - Debra L Franko
- APPEAR, Department of Applied Educational Psychology, Northeastern University, Boston, USA
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22
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Brown ML, Levinson CA. Core eating disorder fears: Prevalence and differences in eating disorder fears across eating disorder diagnoses. Int J Eat Disord 2022; 55:956-965. [PMID: 35567750 DOI: 10.1002/eat.23728] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Fear and anxiety are key maintaining factors for eating disorder (ED) pathology. Maladaptive fears lead to ED behaviors and avoidance, which provide temporary relief, but ultimately reinforce the fear and contribute to a cycle that maintains the ED. To date, fears of food and weight gain are the most explored fears underlying ED pathology. However, recently other important ED fears have been identified, including fears of social consequences and personal consequences. METHOD The current study (N = 229 individuals with an ED) aimed to better characterize ED fears. Specifically, this study examined which ED fears were most endorsed across and within ED diagnoses, and if there were differences in ED fears by diagnosis and by weight status. RESULTS Overall, fear of gaining weight was the most frequently endorsed fear, followed by fear of food, and fear of judgment. Individuals with anorexia nervosa (AN) most frequently endorsed fear of food, individuals with atypical AN and bulimia nervosa: fear of gaining weight, and those with other specified feeding and eating disorder: fear of judgment. Limited differences were found between diagnoses. When examining by weight category, participants with underweight most frequently endorsed fear of food, participants with normal weight: fear of gaining weight, and participants with overweight and obesity: fear of judgment. DISCUSSION These findings suggest ED fears are heterogenous. Given such high heterogeneity, this work highlights the importance of assessing for specific ED fears at the beginning of treatment, which could be used to deliver personalized exposure treatment. PUBLIC SIGNIFICANCE STATEMENT Eating disorders (EDs) are serious mental illnesses with high rates of medical and psychiatric comorbidities. Fear plays an important role in the development and maintenance of EDs. The present study found fear of food, weight gain, and judgment are the most frequently endorsed fears for individuals with EDs and found few differences in fears based on ED diagnosis. These findings highlight the importance of assessing individuals' specific ED fears for treatment.
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Affiliation(s)
- Mackenzie L Brown
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Cheri A Levinson
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, Kentucky, USA
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Disgust and Self-Disgust in Eating Disorders: A Systematic Review and Meta-Analysis. Nutrients 2022; 14:nu14091728. [PMID: 35565699 PMCID: PMC9102838 DOI: 10.3390/nu14091728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 12/10/2022] Open
Abstract
Disgust and self-disgust are aversive emotions which are often encountered in people with eating disorders. We conducted a systematic review and meta-analysis of disgust and self-disgust in people with eating disorders using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The systematic review of the literature revealed 52 original research papers. There was substantial heterogeneity regarding the research question and outcomes. However, we found 5 articles on disgust elicited by food images, 10 studies on generic disgust sensitivity, and 4 studies on self-disgust, and we proceeded to a meta-analytic approach on these studies. We found that women with eating disorders have significantly higher momentary disgust feelings in response to food images (1.32; 95% CI 1.05, 1.59), higher generic disgust sensitivity (0.49; 95% CI 0.24, 0.71), and higher self-disgust (1.90; 95% CI 1.51, 2.29) compared with healthy controls. These findings indicate the potential clinical relevance of disgust and self-disgust in the treatment of eating disorders.
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Butler RM, Heimberg RG. Imaginal Exposure for Disordered Eating Related Fears: An Initial Randomized Controlled Trial. Behav Modif 2022; 47:46-70. [PMID: 35440229 DOI: 10.1177/01454455221091783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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25
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Sala M, Vanzhula I, Roos CR, Levinson CA. Mindfulness and Eating Disorders: A Network Analysis. Behav Ther 2022; 53:224-239. [PMID: 35227400 DOI: 10.1016/j.beth.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/27/2022]
Abstract
Higher trait mindfulness may be protective against eating disorder (ED) pathology. However, little is understood about which specific mindfulness processes connect to specific ED symptoms. This study (N = 1,056 undergraduates) used network analysis at the symptom/process level to identify: (1) central nodes, or symptoms/processes with the greatest collective connection with all other symptoms/processes; and (2) bridge nodes, or symptoms/processes driving interconnection between mindfulness processes and ED symptoms. We conducted analyses both with and without food- and body-related mindfulness items. Central nodes included: describing how one feels in detail, expressing how one feels in words, and feeling guilty about eating due to shape/weight. Bridge nodes connecting higher mindfulness processes with lower ED symptoms included: the eating disorder symptom, being uncomfortable about others seeing one eat, and the mindfulness process, not criticizing oneself for having irrational/inappropriate emotions. Bridge nodes connecting higher mindfulness processes with higher ED symptoms included: noticing sensations of the body moving when walking and noticing how food/drinks affect thoughts, bodily sensations, and emotions. Findings suggest that future research should explore whether mindfulness-based interventions for EDs may be more effective by targeting mindfulness processes related to describing, expressing, and accepting emotions, accepting discomfort when eating with others, and reducing hyper-focus on and reactivity to food-and-body related sensations.
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Affiliation(s)
- Margaret Sala
- Ferkauf Graduate School of Psychology, Yeshiva University
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26
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Forney KJ, Jo JH, Pucci G, France CR. Validation of a test meal paradigm to experimentally manipulate meal-related fears: A registered report. Int J Eat Disord 2021; 54:2223-2228. [PMID: 34757654 DOI: 10.1002/eat.23637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/07/2022]
Abstract
Fear is central to conceptualizations of weight and shape-focused eating disorders. The current study will examine the reliability and validity of a test meal paradigm that varies perceptions of fat content to manipulate fear. Undergraduate women with elevated eating pathology (N = 96) will be randomized to one of three test meal conditions: two "low" fat yogurts, two "high" fat yogurts, or one "high" fat and one "low" fat yogurt. In actuality, all yogurts will have the same fat content. Supporting reliability, we hypothesize that self-reported fear and electrodermal activity (psychophysiological index of fear-related arousal) will exhibit good test-retest reliability over a 48-hr period in the "high" fat/"high" fat and "low" fat/"low" fat conditions. Supporting construct validity, self-reported fear and electrodermal activity will be elevated during the "high" versus "low" fat condition and responses to the "high" fat condition will correlate with fear of food, eating, and weight gain. Supporting discriminant validity, self-reported disgust and anger will be comparable in the "high" and "low" fat conditions and will exhibit weak correlations with trait measures of disgust and anger. This experimental paradigm will allow researchers to manipulate fear in order understand the mechanisms by which fear maintains eating pathology.
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Affiliation(s)
- K Jean Forney
- Department of Psychology, Ohio University, Athens, Ohio, USA
| | - Jenny H Jo
- Department of Psychology, Ohio University, Athens, Ohio, USA
| | - Gabriella Pucci
- Department of Psychology, Ohio University, Athens, Ohio, USA
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Levinson CA, Ralph-Nearman C, Brown ML, Gardner T, Cardi V, Treasure J, Purves K, Eley TC. A pilot randomized control trial of online exposure for eating disorders and mechanisms of change delivered after discharge from intensive eating disorder care: A registered report. Int J Eat Disord 2021; 54:2066-2074. [PMID: 34480773 PMCID: PMC9886130 DOI: 10.1002/eat.23603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 02/01/2023]
Abstract
More than 50% of individuals with an eating disorder (ED) will readmit to treatment within 6 months of treatment discharge and often due to persistent cognitive ED pathology. Interventions addressing unremitted cognitive ED pathology following discharge from intensive treatment are crucial to prevent readmission. Imaginal exposure therapy facilitates the approach of feared stimuli not accessible in everyday life (e.g., rapidly gaining weight). In the current pilot randomized control trial (RCT), participants will be randomly assigned to a five-session online imaginal exposure condition (n = 65) or a control online writing and thinking intervention (n = 65) within a month of discharge from intensive treatment. Exposure participants write about and imagine an ED fear and control participants will write about their ED generally. We will examine the feasibility and acceptability of the treatment conditions and whether imaginal exposure is more effective in preventing readmission than the control condition. We will test the efficacy of the imaginal exposure treatment in reducing ED symptoms and fears of food and weight gain, and whether fear learning is a mechanism of change related to ED pathology. Ultimately, this research will lead to the development of an easily deployable readmission prevention treatment based on fear conditioning targets.
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Affiliation(s)
- Cheri A. Levinson
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA
- Kings College London, Psychological Medicine, Academic Psychiatry and Social, Genetic and Developmental Psychiatry Centre, London, UK
| | - Christina Ralph-Nearman
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA
- Kings College London, Psychological Medicine, Academic Psychiatry and Social, Genetic and Developmental Psychiatry Centre, London, UK
| | - Mackenzie L. Brown
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA
- Kings College London, Psychological Medicine, Academic Psychiatry and Social, Genetic and Developmental Psychiatry Centre, London, UK
| | - Taylor Gardner
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA
- Kings College London, Psychological Medicine, Academic Psychiatry and Social, Genetic and Developmental Psychiatry Centre, London, UK
| | - Valentina Cardi
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA
- Kings College London, Psychological Medicine, Academic Psychiatry and Social, Genetic and Developmental Psychiatry Centre, London, UK
| | - Janet Treasure
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA
- Kings College London, Psychological Medicine, Academic Psychiatry and Social, Genetic and Developmental Psychiatry Centre, London, UK
| | - Kirstin Purves
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA
- Kings College London, Psychological Medicine, Academic Psychiatry and Social, Genetic and Developmental Psychiatry Centre, London, UK
| | - Thalia C. Eley
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA
- Kings College London, Psychological Medicine, Academic Psychiatry and Social, Genetic and Developmental Psychiatry Centre, London, UK
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Schaumberg K, Peters D, Ahrenholtz R, Crombie KM, Zhang R, Gorrell S. Registered report: A pilot investigation of acute exercise response among girls and young women with and without eating disorders. Int J Eat Disord 2021; 54:2057-2065. [PMID: 34323294 PMCID: PMC8595629 DOI: 10.1002/eat.23587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Driven exercise (DEx) is a serious and common feature of eating disorders (EDs), but current understanding of factors that give rise to and maintain DEx is limited. DEx may be reinforced through its effects on the threat reduction and reward systems. The current protocol is designed to evaluate acute psychobiological response to exercise among female participants (age 16-22) with and without EDs. METHOD Twenty medically-stable participants with restrictive-spectrum EDs and 20 healthy control (HC) participants will complete study screening and three task visits which will include two 30-minute bouts of aerobic exercise. RESULTS We aim to validate and demonstrate feasibility of two tasks capturing exercise response in this sample. Further, we will estimate the degree to which a bout of exercise impacts state body image, affect, and circulating concentrations of biological markers among participants, and we will examine whether the impact of exercise on psychological outcomes may differ across ED and HC groups. DISCUSSION Completion of this project will contribute to the conceptualization of DEx and how individuals' acute biological and affective responses to exercise contribute to risk for and maintenance of DEx.
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Affiliation(s)
- Katherine Schaumberg
- University of Wisconsin - Madison, Department of Psychiatry, 6001 Research Park Boulevard, Madison, Wisconsin, United States of America, 53719-1176
| | - Danielle Peters
- University of Wisconsin - Madison, Department of Psychiatry, 6001 Research Park Boulevard, Madison, Wisconsin, United States of America, 53719-1176
| | - Rachel Ahrenholtz
- University of Wisconsin - Madison, Department of Psychiatry, 6001 Research Park Boulevard, Madison, Wisconsin, United States of America, 53719-1176
| | - Kevin M. Crombie
- University of Wisconsin - Madison, Department of Psychiatry, 6001 Research Park Boulevard, Madison, Wisconsin, United States of America, 53719-1176
| | - Ruisu Zhang
- University of Wisconsin - Madison, Department of Psychiatry, 6001 Research Park Boulevard, Madison, Wisconsin, United States of America, 53719-1176
| | - Sasha Gorrell
- University of California - San Francisco, Department of Psychiatry and Behavioral Sciences, 401 Parnassus Avenue, San Francisco, California, United States of America, 94143
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Melles H, Spix M, Jansen A. Avoidance in Anorexia Nervosa: Towards a research agenda. Physiol Behav 2021; 238:113478. [PMID: 34058219 DOI: 10.1016/j.physbeh.2021.113478] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/15/2021] [Accepted: 05/26/2021] [Indexed: 01/27/2023]
Abstract
Anorexia Nervosa is a severe and disabling mental disorder and a huge challenge to treat. Intense fears of e.g., food, eating, weight gain and social evaluation are core features of anorexia nervosa and obstacles during treatment. The perceived threats trigger avoidance and safety behaviors like highly restrictive eating, strict eating rules, vomiting and body checking, to minimize feared outcomes. The role of avoidance in anorexia nervosa is however hardly studied experimentally. In the present article, the focus is on a new transdiagnostic research agenda featuring both basic and clinical experimental research into avoidance as a most important mechanism maintaining the eating disorder. Avoidance learning and the generalization of learned avoidance behaviors are discussed, as well as safety behaviors and the need for inhibitory learning as a treatment target during exposure therapy.
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Affiliation(s)
- Hanna Melles
- Clinical Psychological Science, Maastricht University, the Netherlands
| | - Michelle Spix
- Clinical Psychological Science, Maastricht University, the Netherlands
| | - Anita Jansen
- Clinical Psychological Science, Maastricht University, the Netherlands.
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30
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Levinson CA, Williams BM. Eating disorder fear networks: Identification of central eating disorder fears. Int J Eat Disord 2020; 53:1960-1973. [PMID: 32918319 DOI: 10.1002/eat.23382] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/28/2020] [Accepted: 08/28/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Eating-related fear and anxiety are hallmark symptoms of eating disorders (EDs). However, it is still unclear which fears are most important (e.g., food, weight gain), which has practical implications, given treatments for eating-related fear necessitate modifications based on the specific fear driving ED pathology. For example, exposure treatments should be optimized based on specific fears that maintain pathology. The current study (N = 1,622 combined clinical ED and undergraduate sample) begins to answer questions on the precise nature of ED fears and how they operate with other ED symptoms. METHOD We used network analysis to create two models of ED fears and symptoms. The first model consisted of ED fears only (e.g., fears of food, fears of weight gain) to identify which fear is most central. The second model consisted of ED fears and ED symptoms to detect how ED fears operate with ED symptoms. RESULTS We found fear of disliking how one's body feels due to weight gain, disliking eating in social situations, feeling tense around food, fear of judgment due to weight gain, and food anxiety were the most central ED fears. We also identified several bridge symptoms between ED fears and symptoms. Finally, we found that the most central ED fears predicted excessive exercise at two-month follow-up. DISCUSSION These data support the idea that consequences (i.e., judgment) associated with fears of weight gain and interoceptive fears are the most central ED fears. These data have implications for the future development of precision interventions targeted to address ED-related fear.
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Affiliation(s)
- Cheri A Levinson
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Brenna M Williams
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA
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Schaumberg K, Reilly EE, Gorrell S, Levinson CA, Farrell NR, Brown TA, Smith KM, Schaefer LM, Essayli JH, Haynos AF, Anderson LM. Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research. Clin Psychol Rev 2020; 83:101952. [PMID: 33221621 DOI: 10.1016/j.cpr.2020.101952] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/09/2020] [Accepted: 11/09/2020] [Indexed: 12/13/2022]
Abstract
Eating disorders (EDs) and anxiety disorders (ADs) evidence shared risk and significant comorbidity. Recent advances in understanding of anxiety-based disorders may have direct application to research and treatment efforts for EDs. The current review presents an up-to-date, behavioral conceptualization of the overlap between anxiety-based disorders and EDs. We identify ways in which anxiety presents in EDs, consider differences between EDs and ADs relevant to treatment adaptions, discuss how exposure-based strategies may be adapted for use in ED treatment, and outline directions for future mechanistic, translational, and clinical ED research from this perspective. Important research directions include: simultaneous examination of the extent to which EDs are characterized by aberrant avoidance-, reward-, and/or habit-based neurobiological and behavioral processes; improvement in understanding of how nutritional status interacts with neurobiological characteristics of EDs; incorporation of a growing knowledge of biobehavioral signatures in ED treatment planning; development of more comprehensive exposure-based treatment approaches for EDs; testing whether certain exposure interventions for AD are appropriate for EDs; and improvement in clinician self-efficacy and ability to use exposure therapy for EDs.
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Affiliation(s)
| | | | - Sasha Gorrell
- University of California, San Francisco, United States of America
| | - Cheri A Levinson
- University of Louisville, Department of Psychological & Brain Sciences, United States of America
| | | | - Tiffany A Brown
- University of California, San Diego, United States of America
| | - Kathryn M Smith
- Sanford Health, United States of America; University of Southern California, United States of America
| | | | | | - Ann F Haynos
- University of Minnesota, United States of America
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32
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Levinson CA, Christian C, Ram SS, Vanzhula I, Brosof LC, Michelson LP, Williams BM. Eating disorder symptoms and core eating disorder fears decrease during online imaginal exposure therapy for eating disorders. J Affect Disord 2020; 276:585-591. [PMID: 32794449 DOI: 10.1016/j.jad.2020.07.075] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/15/2020] [Accepted: 07/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Few evidence-based treatments for eating disorders (EDs) exist. Imaginal exposure therapy is a key component of effective treatment for anxiety disorders and post-traumatic stress disorder. However, imaginal exposure has not been systematically tested as a treatment for EDs. The current study aimed to develop and test online imaginal exposure as a treatment for EDs. METHODS The current study tested a four-week trial of online imaginal exposure for EDs (N = 229 participants with EDs recruited globally). Participants completed diagnostic interviews and four sessions of weekly online imaginal exposure, in which they wrote about and imagined a core ED fear (identified with a therapist). Participants completed measures of ED symptoms and fears (i.e., fear of weight gain, food) at pre-imaginal exposure, post-imaginal exposure, and six-month follow-up. Participants were recruited and participated in the protocol from November 2016 to October 2018. RESULTS All primary outcomes (ED symptoms, ED fears) significantly decreased at study completion and six-month follow-up with medium-to-large effect sizes. State anxiety across the exposure and follow-ups significantly decreased, specifically from initial sessions to follow-up. Worry, but not depression, significantly decreased. LIMITATIONS This study was an open case trial and did not include a control condition. CONCLUSIONS Significant decreases in ED symptoms and fears occurred during the course of imaginal exposure treatment. Online imaginal exposure is a feasible treatment for EDs and is associated with decreases in core ED symptomatology, which are comparable in magnitude to decreases seen from other evidence-based treatments. A future randomized-controlled trial is needed. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov identifier NCT03712748.
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Affiliation(s)
- Cheri A Levinson
- Department of Psychological and Brain Sciences, 317 Life Sciences, University of Louisville, 317 Life Sciences, Louisville, KY 40292, United States.
| | - Caroline Christian
- Department of Psychological and Brain Sciences, 317 Life Sciences, University of Louisville, 317 Life Sciences, Louisville, KY 40292, United States
| | - Shruti Shankar Ram
- Department of Psychological and Brain Sciences, 317 Life Sciences, University of Louisville, 317 Life Sciences, Louisville, KY 40292, United States
| | - Irina Vanzhula
- Department of Psychological and Brain Sciences, 317 Life Sciences, University of Louisville, 317 Life Sciences, Louisville, KY 40292, United States
| | - Leigh C Brosof
- Department of Psychological and Brain Sciences, 317 Life Sciences, University of Louisville, 317 Life Sciences, Louisville, KY 40292, United States
| | - Lisa P Michelson
- Department of Psychological and Brain Sciences, 317 Life Sciences, University of Louisville, 317 Life Sciences, Louisville, KY 40292, United States
| | - Brenna M Williams
- Department of Psychological and Brain Sciences, 317 Life Sciences, University of Louisville, 317 Life Sciences, Louisville, KY 40292, United States
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