Temporal associations between affective instability and dysregulated eating behavior in bulimia nervosa

A naturalistic examination of feeling fat: Characteristics, predictors, and the relationship with eating disorder behaviors

OBJECTIVE

Although literature implicates feeling fat in the maintenance of binge-spectrum eating disorders (EDs; e.g., bulimia nervosa, binge-ED), research in this area is small, nascent, and relies on retrospective self-report. The current study sought to understand the temporal pattern of feeling fat and its role as a precipitant and consequence of ED behaviors.

METHODS

Totally 106 treatment-seeking adults with binge-spectrum EDs completed 7-14-day ecological momentary assessments. They rated feeling fat, negative affect states, and reported on ED behaviors six times per day. Multilevel models evaluated whether feeling fat mediates prospective links between negative affect states and ED behaviors, assessed if negative affect states mediate the prospective association of feeling fat on ED behaviors, and examined the bidirectional prospective association between feeling fat and ED behaviors.

RESULTS

Feeling fat was highest in the early morning (6-8:59 a.m.). Individuals with binge-ED-spectrum EDs demonstrated greater variability in feeling fat than those with bulimia nervosa-spectrum EDs who had stable and high levels of feeling fat. Guilt, sadness, anxiety, and the overall NA at Time 2 mediated the prospective associations between at Time 1 feeling fat and Time 3 dietary restraint, actual dietary restriction, and compensatory exercise. There was a bidirectional prospective association between feeling fat and binge eating.

DISCUSSION

Feeling fat serves as a proximal predictor and mediator of the prospective association between guilt and binge eating. Feeling fat and binge eating mutually reinforce each other.

PUBLIC SIGNIFICANCE

Little is understood regarding the experience of feeling fat in natural environments among individuals with binge-spectrum eating disorders. We found that the risk for having the experience of feeling fat is high in the morning and evening. Feeling fat triggers guilt, anxiety, and sadness which in turn, increases engagement in dietary restraint/restriction and compensatory exercise. Feeling fat also triggers binge eating, and binge eating leads to feelings of fatness.

Daily instability in body dissatisfaction in individuals with and without eating disorders

Body dissatisfaction (BD) includes negative thoughts and feelings about one's body shape. Although typically assessed as a trait, BD has been found to fluctuate within a day. The present study examined whether daily instability in BD differs according to trait BD, eating disorder (ED) diagnosis, and engagement in maladaptive exercise. Participants with EDs (n = 166) and controls (n = 44) completed a self-report measure of trait BD and reported BD and engagement in maladaptive exercise five times daily for 14 days as part of an ecological momentary assessment protocol. BD instability was calculated as adjusted mean squared successive difference. On average across assessments, participants with EDs reported a 16% change in their BD ratings between consecutive assessments, which was significantly higher than the 12% change in controls. Trait BD was significantly inversely associated with BD instability in individuals with EDs, but not in controls. BD instability did not differ across ED diagnoses or between days with versus without maladaptive exercise. Findings suggest that BD is a dynamic state that varies within a day, especially in participants with EDs. Further research is needed to clarify whether this heightened instability in BD is a clinically relevant factor underlying ED symptoms.

Affect trajectories surrounding binge eating episodes and heavy drinking episodes in adults with binge-spectrum eating disorders

OBJECTIVE

The comorbidity of binge eating and heavy drinking (BE + HD) is concerning due to high prevalence and associated consequences. Affective pathways may maintain BE + HD, yet more micro-level research is needed. This study used ecological momentary assessment (EMA) to examine between-person and day-level relationships between positive and negative affect and binge eating or heavy drinking episodes in BE + HD.

METHODS

Participants (N = 53) were adults with binge-spectrum eating disorders who completed between 7 and 14 days of EMA prior to a treatment for binge eating.

RESULTS

Anxiety was highest on days with both binge eating and heavy drinking, while excitement and confidence were highest on days with only heavy drinking episodes for BE + HD. Global negative affect was relatively stable surrounding binge eating episodes. Guilt significantly increased prior to binge eating, and sadness significantly decreased following binge eating. Global positive affect significantly decreased prior to and stopped decreasing following heavy drinking episodes.

DISCUSSION

Results support binge eating being negatively reinforced by specific aspects of negative affect, while heavy drinking may be positively reinforced by global positive affect for individuals with BE + HD. Clinicians should incorporate interventions that focus on specific negative affect dimensions and that promote alternative rewarding activities besides heavy drinking.

Attachment, Mentalization, Emotion Dysregulation, and Empathy in Eating Disorders: Comparing Anorexic and Bulimic Patients

ABSTRACT

Eating disorders (EDs) represent a wide range of clinical symptoms related to food intake, body image, and weight issues, and include anorexia nervosa-restricting type (AN-R), anorexia nervosa-binge-purge type (AN-BP), and bulimia nervosa (BN). The aim was to investigate the characteristics of attachment, mentalization, emotion dysregulation, and empathy in a sample of 102 patients with EDs. A sample of 102 patients and therapists completed a series of measures for the assessment of ED pathology, mentalization, empathy, and emotion dysregulation. Pearson correlations and analysis of variance were used to test the characteristics of the variables among the groups. In relation to attachment and emotion dysregulation, no significant differences were found. In relation to mentalization, significant difference in good mentalization was found in AN-R subtype compared with the BN subtype. In relation to empathy, results showed significantly lower scores in BN subtype on affective empathy compared with the AN-BP subtype, and in AN-R subtype on cognitive empathy. Finally, we used Z-scores for each item ranked by value (higher to lower) to develop different clinical prototypes for each group. Our results point toward the clinical need to address the assessed variables, specifically mentalization, emotion dysregulation, and empathy, in the diagnosis and treatment of EDs.

Associations between affect dynamics and eating regulation in daily life: a preliminary ecological momentary assessment study

Disordered eating behaviors consistently associated with emotion regulation difficulties. However, most studies have focused on affect intensity without considering dynamic affective patterns. We examined these patterns in relation to daily overeating, loss of control eating (LOCE), dietary restraint, and food craving in young adults using ecological momentary assessment (EMA).Adults (N = 24) completed a 10-day EMA protocol during which they reported momentary affect and eating patterns. Generalized linear mixed-models examined each index in relation to eating variable.Higher PA instability (within-person) was associated with higher ratings of binge-eating symptoms (B = 0.15, SE = 0.06, p = 0.007). Lower NA differentiation (within-person) was associated with higher levels of food craving (B = -10.11, SE = 4.74, p = 0.033).Our results support previous findings suggesting that acute fluctuations in PA may increase risk of binge-eating symptoms. Further, inability to differentiate between momentary states of NA was associated with cravings. This study highlights the importance of examining multiple facets of NA and PA in relation to eating regulation.Trial registration: ClinicalTrials.gov identifier: NCT02945475.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of experimental medicine approaches for the development of novel psychiatric treatments based on orexin receptor modulation

Despite progress in understanding the pathological mechanisms underlying psychiatric disorders, translation from animal models into clinical use remains a significant bottleneck. Preclinical studies have implicated the orexin neuropeptide system as a potential target for psychiatric disorders through its role in regulating emotional, cognitive, and behavioral processes. Clinical studies are investigating orexin modulation in addiction and mood disorders. Here we review performance-outcome measures (POMs) arising from experimental medicine research methods which may show promise as markers of efficacy of orexin receptor modulators in humans. POMs provide objective measures of brain function, complementing patient-reported or clinician-observed symptom evaluation, and aid the translation from preclinical to clinical research. Significant challenges include the development, validation, and operationalization of these measures. We suggest that collaborative networks comprising clinical practitioners, academics, individuals working in the pharmaceutical industry, drug regulators, patients, patient advocacy groups, and other relevant stakeholders may provide infrastructure to facilitate validation of experimental medicine approaches in translational research and in the implementation of these approaches in real-world clinical practice.

Examining the Role of Body Image Instability in Young Adult Women: Conceptualization, Development, and Psychometric Evaluation of the Vacillating Body Image Scale (VBIS)

The current study conceptualized body image instability as a maladaptive tendency to vacillate between different self-perceptions of one's overall body image and developed a corresponding measure to assess body image instability. Results from a series of studies of young adult women demonstrated the validity, reliability, and utility of the Vacillating Body Image Scale (VBIS) as a meaningful measure of body image instability. In Study 1, we found that body image instability, as assessed by the VBIS, represents a unidimensional and reliable construct. In Study 2, we found evidence for both the convergent and discriminant validity of the VBIS in relation to other individual differences measures (i.e., self-concept schema, broad personality factors). In Study 3, the concurrent criterion validity of the VBIS was supported for young adult women in relation to a range of adjustment measures. Finally, in Study 4, we found consistent evidence for the incremental validity of the VBIS in predicting subsequent variations in eating disturbances, even after controlling for global self-esteem and self-concept instability. Overall, our findings offer promising support for our contention that body image instability, as measured by the VBIS, represents an important construct for understanding eating-related disturbances and other health outcomes in young adult women.

Novel digital methods for gathering intensive time series data in mental health research: scoping review of a rapidly evolving field

Recent technological advances enable the collection of intensive longitudinal data. This scoping review aimed to provide an overview of methods for collecting intensive time series data in mental health research as well as basic principles, current applications, target constructs, and statistical methods for this type of data.In January 2021, the database MEDLINE was searched. Original articles were identified that (1) used active or passive data collection methods to gather intensive longitudinal data in daily life, (2) had a minimum sample size of N ⩾ 100 participants, and (3) included individuals with subclinical or clinical mental health problems.In total, 3799 original articles were identified, of which 174 met inclusion criteria. The most widely used methods were diary techniques (e.g. Experience Sampling Methodology), various types of sensors (e.g. accelerometer), and app usage data. Target constructs included affect, various symptom domains, cognitive processes, sleep, dysfunctional behaviour, physical activity, and social media use. There was strong evidence on feasibility of, and high compliance with, active and passive data collection methods in diverse clinical settings and groups. Study designs, sampling schedules, and measures varied considerably across studies, limiting the generalisability of findings.Gathering intensive longitudinal data has significant potential to advance mental health research. However, more methodological research is required to establish and meet critical quality standards in this rapidly evolving field. Advanced approaches such as digital phenotyping, ecological momentary interventions, and machine-learning methods will be required to efficiently use intensive longitudinal data and deliver personalised digital interventions and services for improving public mental health.

Anhedonia in cognitive behavioral therapy for binge eating spectrum disorders

Anhedonia is theorized as being relevant to binge eating spectrum disorders (BESDs) by palatable foods substituting the pleasure typically obtained from day-to-day activities. The current study examined whether anhedonia is associated with eating pathology at baseline and whether it predicts cognitive behavioral therapy (CBT) outcomes alone and when controlling for non-anhedonia depression symptoms. Ninety-three individuals from two randomized controlled trials completed the Eating Disorder Examination and Beck Depression Inventory-II at pre-, mid-, and post-treatment. Results showed that anhedonia was positively associated with global eating pathology at baseline, and larger pre- to mid-treatment anhedonia and non-anhedonia reductions predicted larger pre- to post-treatment global eating pathology reductions, though the anhedonia association was no longer significant when controlling for non-anhedonia depression. Anhedonia appears to be related to global eating pathology in CBT for BESDs, but not loss of control eating. Further research is needed to elucidate the relationship between anhedonia and BESDs.

Co-occurring psychotic and eating disorders in England: findings from the 2014 Adult Psychiatric Morbidity Survey

BACKGROUND

Psychotic disorders and eating disorders are complex mental illnesses associated with increased mortality and functional impairment. This study aimed to investigate the co-occurrence and relationships between eating disorders and psychotic disorders and assess the mediation effect of mood instability.

METHODS

This study used data from the Adult Psychiatric Morbidity Survey (APMS) 2014, a general population-based survey in England. Participants (total N = 7546, female N = 4488, male N = 3058, mean age = 52.3 years) were categorised based on psychotic disorder status into the groups of probable psychosis, diagnosed psychosis, and healthy controls without psychosis. The dependent variable of this study was the presence or absence of an eating disorder, with mood instability as the mediator. Logistic regression and mediation analyses were conducted to assess the relationships between these variables.

RESULTS

Both probable and diagnosed psychoses were significantly related to the presence of an eating disorder, and mood instability was found to be a mediating variable with moderate effect.

CONCLUSION

The present study demonstrates a significant relationship between eating disorders and psychotic disorders in the English general population, indicating higher levels of co-occurrence between these two groups of disorders than when compared with healthy controls. The findings also suggest the relationship between eating and psychotic disorders is mediated, to an extent, by the presence of mood instability traits. Future research could extend the present study's findings through assessing whether specific eating disorders are more significantly related to psychotic disorders than others.

Eating disorders and the nine symptoms of borderline personality disorder: A systematic review and series of meta-analyses

OBJECTIVE

Eating disorders and borderline personality disorder have high rates of comorbidity. However, the extent to which individual BPD symptoms are elevated in patients with EDs is largely unknown. Meta-analyses examined: (1) which of the nine BPD symptoms are especially elevated in individuals with versus without EDs, (2) whether particular ED subtypes have elevated levels of certain BPD symptoms, and (3) which BPD symptoms remain unstudied/understudied in relation to EDs.

METHODS

We performed nine separate meta-analyses (one for each BPD symptom) to compare levels of symptoms in patients with EDs versus healthy controls. A total of 122 studies (range = 4-34 studies across symptoms) were included.

RESULTS

Affective instability was the BPD symptom most elevated, while anger was the BPD symptom least elevated, in patients with EDs compared to controls. When comparing effect sizes across ED subtypes, anorexia nervosa binge-eating/purging subtype had the largest effect sizes for the greatest number of BPD symptoms, while effect sizes for AN restrictive subtype were not significantly larger than those of other EDs for any BPD symptom. The least studied BPD symptoms were identity disturbance and interpersonal difficulties.

DISCUSSION

These meta-analyses suggest that certain symptoms of BPD play a more prominent role in the comorbidity between BPD and EDs than others. Targeting affective instability when treating cases of comorbid ED and BPD may be especially likely to ameliorate the negative outcomes related to this comorbidity. Future research should further investigate identity disturbance and interpersonal difficulties in the context of EDs.

PUBLIC SIGNIFICANCE

Having an eating disorder and borderline personality disorder is a common comorbidity associated with a severe clinical presentation. BPD is characterized by nine distinct symptoms. This research examined levels of individual BPD symptoms in patients with versus without EDs. Findings can guide researchers and clinicians towards studying and treating symptoms that may be most relevant for BPD-ED comorbidity and in turn, improve outcomes for these patients.

The Role of Affective Instability in Loss of Control Eating in Youth with Overweight/Obesity Across Development: Findings from Two EMA Studies

Affective instability is common during adolescence, but at high levels it is associated with a variety of internalizing and externalizing disorders, including eating disorders. Although most models focus on affective intensity as a mechanism for explaining eating disorders in adults, affective instability may be more developmentally relevant at predicting eating behaviors in youth. Using ecological momentary assessment, this manuscript explored the association between loss of control over eating (LOC), a key component of dysregulated eating in youth, and affective instability in youth with overweight/obesity in two separate studies, one with youth in middle childhood and early adolescence (Study 1: ages eight to 13) and one in youth in early through middle adolescence (Study 2: ages 12-17). Overall, there was no association between affective instability and LOC in Study 1, but in Study 2, age moderated the association between positive affective instability and LOC, such that greater between-person positive affective instability (i.e., relative to peers) was associated with lower average LOC for youth earlier in adolescence and higher average LOC for those later in adolescence. Negative affective instability was also associated with LOC in Study 2, such that on days when youth reported less within-person negative affective instability (i.e., relative to their own average), they also reported greater average LOC. Findings across the two studies indicate that the association between affective instability and LOC may not emerge until adolescence, and when it does, both positive and negative affective instability may be important to consider.

Volume and Connectivity Differences in Brain Networks Associated with Cognitive Constructs of Binge Eating

Bulimia nervosa (BN) and binge eating disorder (BED) are characterized by episodes of eating large amounts of food while experiencing a loss of control. Recent studies suggest that the underlying causes of BN/BED consist of a complex system of environmental cues, atypical processing of food stimuli, altered behavioral responding, and structural/functional brain differences compared with healthy controls (HC). In this narrative review, we provide an integrative account of the brain networks associated with the three cognitive constructs most integral to BN and BED, namely increased reward sensitivity, decreased cognitive control, and altered negative affect and stress responding. We show altered activity in BED/BN within several brain networks, specifically in the striatum, insula, prefrontal cortex (PFC) and orbitofrontal cortex (OFC), and cingulate gyrus. Numerous key nodes in these networks also differ in volume and connectivity compared with HC. We provide suggestions for how this integration may guide future research into these brain networks and cognitive constructs.

Do Patterns and Types of Negative Affect During Hospitalization Predict Short-Term Post-Discharge Suicidal Thoughts and Behaviors?

We still have little understanding of short-term predictors of suicidal thoughts and behaviors (STBs). Prior research links increased negative affect to STBs, but the vast majority of earlier work is limited by measuring negative affect at one time point and aiming to predict STBs months or years in the future. Recently, intensive longitudinal studies have shown that negative affect is associated with suicidal thoughts over relatively short, clinically useful time periods; however, the specific patterns and types of negative affect that predict STBs remain unclear. Using ecological momentary assessment (EMA) data from psychiatric inpatients hospitalized for suicide risk (N = 83), this study sought to test whether the patterns (means and variability) of two types of negative affect (anxiety/agitation and shame/self-hatred, which were derived from a larger EMA battery) during hospitalization predict STBs in the four weeks after discharge: an extremely high-risk time for suicidal behavior. The mean - but not the variability - of both anxiety/agitation and shame/self-hatred during hospitalization predicted the number of days with suicidal thoughts after discharge. The mean and the variability of shame/self-hatred - but not anxiety/agitation - predicted post-discharge suicide attempt. We discuss implications for assessment and treatment of suicidal individuals and propose key directions for future research.

Stress appraisal prospectively predicts binge eating through increases in negative affect

PURPOSE

Ecological momentary assessment (EMA) studies preliminarily support the transactional model of emotion regulation in eating disorders, such that heightened stress appraisal (i.e., the cognitive evaluation of an event's demands) results in increased negative affect (NA) and subsequent binge eating (BE). However, the temporal relationships between these variables and the magnitude of stress appraisal that is clinically significant require clarification. The current study aimed to extend previous research by (1) examining the temporal relationship between stress appraisal, changes in NA, and BE using three timepoints, (2) exploring what magnitude of momentary stress appraisal results in clinically significant increases in NA and BE, and (3) characterizing what stressors are associated with clinically significant stress appraisal.

METHODS

37 adult females completed an EMA protocol assessing momentary stressors, stress appraisal, NA, and BE over 2 week duration. Multilevel mediation models were used to test the study aims.

RESULTS

Momentary increases in stress appraisal significantly predicted binge eating through increases in NA. Stress appraisal ratings of 0.50 SD higher relative to one's average stress appraisal began to significantly predict the likelihood of BE through increases in NA, and the likelihood of BE occurrence increased with every 0.25 increments in momentary stress appraisal. Work/school stressors and interpersonal stressors were the most commonly endorsed stressors of clinically significant stress appraisal.

CONCLUSION

The current study supported the transactional model of emotion dysregulation in a binge eating sample and supports the use of momentary interventions at times of clinically significant stress appraisal to reduce BE risk.

LEVEL OF EVIDENCE

Level II, controlled trial without randomization.

Comparing Signal-Contingent and Event-Contingent Experience Sampling Ratings of Affect in a Sample of Psychotherapy Outpatients

Experience sampling methods are widely used in clinical psychology to study affective dynamics in psychopathology. The present study examined whether affect ratings (valence and arousal) differed as a function of assessment schedule (signal- versus event-contingent) in a clinical sample and considered various approaches to modeling these ratings. A total of 40 community mental health center outpatients completed ratings of their affective experiences over a 21-day period using both signal-contingent schedules (random prompts) and event-contingent schedules (ratings following social interactions). We tested whether assessment schedules impacted 1) the central tendency (mean) and variability (standard deviation) of valence or arousal considered individually, 2) the joint variability in valence and arousal via the entropy metric, and 3) the between-person differences in configuration of valence-arousal landscapes via the Earth Mover's Distance (EMD) metric. We found that event-contingent schedules, relative to signal-contingent schedules, captured higher average levels of pleasant valence and emotional arousal ratings. Moreover, signal-contingent schedules captured greater variability within and between individuals on arousal-valence landscapes compared to event-contingent schedules. Altogether, findings suggest that the two assessment schedules should not be treated interchangeably in the assessment of affect over time. Researchers must be cautious in generalizing results across studies utilizing different experience sampling assessment schedules.

A Pilot Study Using Frequent Inpatient Assessments of Suicidal Thinking to Predict Short-Term Postdischarge Suicidal Behavior

IMPORTANCE

The weeks following discharge from psychiatric hospitalization are the highest-risk period for suicide attempts. Real-time monitoring of suicidal thoughts via smartphone prompts may be more indicative of short-term risk than a single, cross-sectional assessment.

OBJECTIVE

To test whether modeling dynamic changes in real-time suicidal thoughts during psychiatric hospitalization can improve predictions of postdischarge suicide attempts vs using only baseline (ie, admission) data or using the mean level of real-time suicidal thoughts during hospitalization.

DESIGN, SETTING, AND PARTICIPANTS

In this prognostic study, 83 adults recruited from the inpatient psychiatric unit at Massachusetts General Hospital completed ecological momentary assessment surveys of suicidal thinking 4 to 6 times per day during hospitalization as well as brief follow-up surveys assessing suicide attempts at 2 and 4 weeks after discharge. Participants completed at least 3 real-time monitoring surveys. Inclusion criteria included hospitalization for suicidal thoughts and/or behaviors and English fluency. Data were collected from January 2016 to December 2018 and analyzed from January to December 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was suicide attempt in the month after discharge.

RESULTS

Of 83 participants (mean [SD] age, 38.4 [13.6] years; 43 [51.8%] male participants; 69 [83.1%] White individuals), 9 (10.8%) made a suicide attempt in the month after discharge. Mean cross-validated AUC for elastic net models revealed predictive accuracy was fair for the model using baseline data (area under the curve [AUC], 0.71; first to third quartile, 0.55-0.88), good for the model using the mean level of real-time suicidal thoughts during hospitalization (AUC, 0.81; first to third quartile, 0.67-0.91), and best for the model using dynamic changes in real-time suicidal thoughts during hospitalization (AUC, 0.89; first to third quartile, 0.81-0.97); this pattern of results held for other classification metrics (eg, accuracy, positive predictive value, Brier score) and when using different cross-validation procedures. Features assessing rapid fluctuations in suicidal thinking emerged as the strongest predictors of posthospital suicide attempts. A final set of models incorporating percentage missingness further improved both the mean (mean AUC, 0.93; first to third quartile, 0.90-1.00) and dynamic feature (mean AUC, 0.93; first to third quartile, 0.88-1.00) models.

CONCLUSIONS AND RELEVANCE

In this study, collecting real-time data about suicidal thinking during the course of hospitalization significantly improved short-term prediction of posthospitalization suicide attempts. Models including dynamic changes in suicidal thinking over time yielded the best prediction; features that captured rapid changes in suicidal thoughts were particularly strong predictors. Survey noncompletion also emerged as an important predictor of posthospitalization suicide attempts.

Momentary associations between positive affect dimensions and dysregulated eating during puberty in a diverse sample of youth with overweight/obesity

OBJECTIVE

The link between dysregulated positive affect and binge-eating behavior in youth with obesity is poorly understood. In addition, it is unclear how putative associations differ across developmental periods of rapid biological and emotional change, such as puberty, and in racial and ethnic minority youth, who are more likely to be overweight but are underrepresented in the literature.

METHOD

This study used a 2-week ecological momentary assessment protocol to examine independent and interactive effects of positive affect intensity/instability, and pubertal stage on two components of binge-eating behavior, loss of control eating (LOCE), and overeating.

RESULTS

Participants were 38 youth with overweight/obesity (ages 8-14 years; 78% African American/Hispanic). Positive affect instability was calculated using probability of acute change (PAC), representing the likelihood of extreme affective changes, and mean squared successive difference (MSSD), representing the average change in affect over successive recordings. There were no main effects of positive affect intensity on LOCE or overeating, but positive affect instability was negatively associated with overeating severity using both MSSD (p = .005) and PAC metrics (p = .001). However, moderation analyses including interactions with pubertal status revealed more extreme changes in positive affect (i.e., higher PAC) were related to greater overeating (p = .001) and LOCE severity (p = .043) in mid-late pubertal youth but not in pre-early pubertal youth.

DISCUSSION

Pubertal status may influence the association between disruptions in positive affect and dysregulated eating in youth, and positive affect instability may be important to consider in order to understand the emotional correlates of binge eating in youth with overweight/obesity.

Differences in Affective Dynamics Among Eating Disorder Diagnostic Groups

Emotion regulation theories suggest that affect intensity is crucial in the development and maintenance of eating disorders. However, other aspects of emotional experience, such as lability, differentiation, and inertia, are not as well understood. This study is the first to use ecological momentary assessment (EMA) to examine differences in several daily negative affect (NA) indicators among adults diagnosed with anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED). Using EMA data from three large studies, a series of linear mixed models showed that participants in the AN and BN groups experienced significantly greater NA intensity and better emotion differentiation than participants in the BED group. Alternatively, the BN group demonstrated significantly greater NA lability than the AN group and greater NA inertia than the BED group. These results suggest that several daily affective experiences differ among eating disorders diagnostic groups and have implications towards distinct conceptualizations and treatments.

The interplay between binge eating risk factors: Toward an integrated model

We aimed to assess the interplay between dietary restraint and emotion regulation (ER) difficulties as well as other well-known risk factors of binge eating in a community sample of women. Altogether 96 women (mean age 21.5 years; mean BMI 21.7) participated in the study using ecological momentary assessment. Structural equation modeling indicated that restraint and ER pathways are related yet operate independently in predicting binge eating in a unified model. ER difficulties moderated the effect of negative affect and fluctuations in negative affect in predicting binge eating while Neuroticism and preoccupation with body weight predicted binge eating indirectly.

Increased anticipatory brain response to pleasant touch in women remitted from bulimia nervosa

Bulimia nervosa (BN) is characterized by affective instability and dysregulated behaviors (binge eating, fasting, self-induced vomiting) that disrupt bodily homeostasis. Mechanisms underlying dysregulation in BN are unclear, although altered reward responsivity, anticipatory processing of environmental cues, and interoception (detection and integration of body-state signals to regulate behavior) have been implicated in BN pathophysiology. We aimed to determine whether BN is associated with ineffectively predicting body state or integrating predicted experience with actual experience by examining neural response to anticipation and experience of affective touch, a pleasant interoceptive stimulus that acts on sensory and emotional systems to guide behavior. During fMRI, we administered soft strokes to the palm and forearm in women remitted from BN (RBN; N = 23) and control women (CW; N = 25). A Group (RBN/CW) × Condition (anticipation/touch) interaction was found in the right dorsal caudate; both CW and RBN had increased activation during touch compared with anticipation, with RBN demonstrating marginally greater anticipatory response than CW. For RBN, those individuals who showed greater anticipatory response in the dorsal caudate also reported higher levels of harm avoidance. RBN individuals relative to CW showed greater activation in left putamen and insula during the anticipation but not when experiencing an affective touch. This increase during anticipation rather than the actual experience of the affective touch is consistent with a top-down preparatory process which is associated with harm avoidance and is similar to what has been observed in anxious individuals. This aberrant signal integration could disrupt feedback processing, serving to maintain disordered behavior.

Examining intra-individual variability in food-related inhibitory control and negative affect as predictors of binge eating using ecological momentary assessment

Binge eating presents in the context of several eating disorders (EDs) and has been shown to be associated with negative affectivity and inhibitory control deficits. While considerable ecological momentary assessment (EMA) work in EDs has demonstrated the importance of intra-individual variability in affect in predicting binge episodes, no research has considered how fluctuations in inhibitory control and negative affect together influence binge eating, or the extent to which these relationships may differ across ED diagnoses. Therefore, the present EMA study assessed the extent to which daily inhibitory control moderated momentary associations between negative affect and binge eating, and whether the presence of regular compensatory behaviors influenced these associations. Participants were 40 women reporting regular binge eating (anorexia nervosa binge-purge type [AN-BP], bulimia nervosa [BN], binge-eating disorder [BED]/subthreshold BED) who completed a 10-day EMA protocol that included measures of affect, eating, and a daily ambulatory Go/No-go task that included palatable food and neutral stimuli. Results of generalized estimating equations indicated greater between-person food-related inhibitory control deficits were associated with greater binge likelihood, and there was a three-way interaction between momentary negative affect, daily food-related inhibitory control, and compensatory behavior group. For individuals with BN or AN-BP, the relationship between momentary negative affect and subsequent binge eating was stronger on days characterized by reduced inhibitory control, whereas no main or interactive effects of negative affect or inhibitory control were observed for those with BED/subthreshold BED. Together these results demonstrate the importance of intra-individual variability in executive functioning and affective processes that underlie binge eating, as well as meaningful individual differences in these momentary associations.

Associations between physical activity and eating-disorder psychopathology among individuals categorised with binge-eating disorder and bulimia nervosa

OBJECTIVE

While physical activity (PA) is known to have positive effects on psychological and physical health, little is understood about the association between non-compensatory PA (ie, not compulsive or intended to control weight or shape) and psychopathology among individuals with eating-disorder features. The present study explored associations between non-compensatory PA and psychopathology among adults categorised with bulimia nervosa (BN) and binge-eating disorder (BED). We further explored the association between compensatory PA and psychopathology among those who engaged in that form of "purging."

METHOD

Participants were recruited through Mechanical Turk, an online recruitment platform. Individuals categorised with core features of BED (N = 138) and BN (N = 138) completed measures of eating-disorder psychopathology (Eating Disorder Examination - Questionnaire [EDE-Q] and Questionnaire on Eating and Weight Patterns - 5), depression (Patient Health Questionnaire - 2) and PA (both non-compensatory and compensatory, measured using the EDE-Q and Godin Leisure-Time Exercise Questionnaire).

RESULTS

Engagement in non-compensatory PA was associated with lower frequency of binge-eating episodes, lower overvaluation of shape/weight and lower dissatisfaction with shape/weight (Ps < .05). Engagement in compensatory PA was related to greater frequency of binge-eating episodes and greater restraint (Ps < .05).

DISCUSSION

Non-compensatory PA was associated with lower eating-disorder psychopathology. This suggests that PA is an important, though understudied, health behaviour among persons with features of BED and BN. Future research should examine the potential role of non-compensatory PA in interventions for individuals with core features of these eating disorders.

The interplay between self-regulation and affectivity in binge eating among adolescents

Binge eating among adolescents is associated with negative developmental outcomes. From a cognitive perspective, the role of impaired self-regulation is increasingly emphasized as an underlying factor in binge eating, whereas the affect regulation model proposes that affectivity is a key factor in explaining binge eating. Studies combining both perspectives are scarce, but necessary to add to the understanding of this pathological eating behavior. Therefore, the aim of the current study was to investigate unique and joint contributions of both factors in understanding binge eating among adolescents. Participants were 301 adolescents (10-17 years; 67.2% girls; M_age = 13.46 years; SD = 1.99) from the general community. Adolescents self-reported on different types of binge eating episodes (loss of control over eating in general, objective and subjective binge eating in particular), self-regulation (general self-regulation and inhibitory control) and affectivity (positive and negative). The parents were questioned about their children's self-regulatory capacities. Results revealed main effects of self-regulatory capacities (adolescent report) and negative affectivity in predicting objective binge eating. In addition, negative affectivity interacted with self-regulation (parent report) to predict objective binge eating, whereas positive affectivity interacted with self-regulation (adolescent report) to predict subjective binge eating. No significant effects were found for loss of control over eating specifically. Both self-regulation and affectivity each make unique as well as joint contributions to binge eating among adolescents, with results differing across types of binge eating episodes and informants. Theoretical and practical implications are discussed.

From Ecological Momentary Assessment (EMA) to Ecological Momentary Intervention (EMI): Past and Future Directions for Ambulatory Assessment and Interventions in Eating Disorders

PURPOSE OF REVIEW

Ambulatory assessment methods, including ecological momentary assessment (EMA), have often been used in eating disorders (EDs) to assess the type, frequency, and temporal sequencing of ED symptoms occurring in naturalistic environments. Relatedly, growing research in EDs has explored the utility of ecological momentary interventions (EMIs) to target ED symptoms. The aims of the present review were to (1) synthesize recent literature pertaining to ambulatory assessment/EMA and EMI in EDs, and (2) identify relevant limitations and future directions in these domains.

RECENT FINDINGS

With respect to ambulatory assessment and EMA, there has been substantial growth in the expansion of constructs assessed with EMA, the exploration of state- vs. trait-level processes, integration of objective and passive assessment approaches, and consideration of methodological issues. The EMI literature in EDs also continues to grow, though most of the recent research focuses on mobile health (mHealth) technologies with relatively minimal EMI components that adapt to momentary contextual information. Despite these encouraging advances, there remain several promising areas of ambulatory assessment research and clinical applications in EDs going forward. These include integration of passive data collection, use of EMA in treatment evaluation and design, evaluation of dynamic system processes, inclusion of diverse samples, and development and evaluation of adaptive, tailored EMIs such as just-in-time adaptive interventions. While much remains to be learned in each of these domains, the continual growth in mobile technology has potential to facilitate and refine our understanding of the nature of ED psychopathology and ultimately improve intervention approaches.

The use of a positive mood induction video-clip to target eating behaviour in people with bulimia nervosa or binge eating disorder: An experimental study

Recent theoretical models and empirical research have indicated that momentary negative affect increases the likelihood of binge eating episodes for individuals with bulimia nervosa and binge eating disorder. However, relatively little research has explored the potential for positive mood to serve a protective effect in reducing the likelihood of overeating behaviour in bulimia nervosa and binge eating disorder. The current study included 30 women with bulimia nervosa or binge eating disorder in a within-subjects crossover design. Following exposure to a video designed to induce food craving, we found that a positive mood vodcast was associated with significantly lower levels of negative mood and food consumption in a taste test meal, when compared to a neutral vodcast (p = 0.002). These findings support a role for decreasing negative mood in reducing the likelihood of binge eating behaviour in women with bulimia nervosa and binge eating disorder.

The potential of calibrated fMRI in the understanding of stress in eating disorders

Eating disorders (ED), including Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED), are medically dangerous psychiatric disorders of unknown etiology. Accumulating evidence supports a biopsychosocial model that includes genetic heritability, neurobiological vulnerability, and psychosocial factors, such as stress, in the development and maintenance of ED. Notably, stress hormones influence appetite and eating, and dysfunction of the physiological stress response has been implicated in ED pathophysiology. Stress signals also appear associated with food reward neurocircuitry response in ED, providing a possible mechanism for the role of stress in appetite dysregulation. This paper provides a review of some of the interacting psychological, behavioral, physiological, and neurobiological mechanisms involved in the stress response among individuals with ED, and discusses novel neuroimaging techniques to address potential physiological confounds of studying neural correlates of stress in ED, such as calibrated fMRI.

Associations of food addiction and nonsuicidal self-injury among women with an eating disorder: A common strategy for regulating emotions?

OBJECTIVE

We examined the association between lifetime nonsuicidal self-injury (NSSI), emotion regulation, and food addiction (FA) in women (n = 220) with eating disorders (ED) compared with (n = 121) healthy controls (HC).

METHOD

Participants were assessed via face-to-face interviews for ED diagnosis and lifetime NSSI. FA was assessed with Yale Food Addiction Scale 2.0 and emotion regulation using the Difficulty in Emotion Regulation Scale (DERS).

RESULTS

The prevalence of FA was significantly higher among women with an ED when compared with HC (75.9% vs. 4.1%, p < 0.001). Similarly, subjects presenting FA showed a high prevalence of lifetime NSSI, in both ED and HC (40.7% and 60.0%, respectively). Our predictive model revealed FA and DERS total scores as indicators of the presence of lifetime NSSI independent of group assignment, ED diagnosis, and age.

CONCLUSIONS

These findings suggest a shared aetiology between ED, NSSI, and FA, explained possibly in part by emotion-regulation deficits.

Emotion dysregulation and eating disorders-Associations with diagnostic presentation and key symptoms

OBJECTIVE

Emotion dysregulation seems involved in the development, maintenance, and outcome of eating disorders (EDs). The present study aimed to differentiate patients with EDs from a comparison group on emotion dysregulation, and to examine emotion dysregulation in relation to ED diagnostic presentation and ED symptoms.

METHOD

Participants, patients with EDs (N = 999) and a student comparison group (N = 252), completed the Difficulties in Emotion Regulation Scale and the Eating Disorder Examination Questionnaire. Patients were compared to the comparison group and compared by diagnosis regarding emotion dysregulation, and unique associations between emotion dysregulation aspects and ED symptoms were examined.

RESULTS

Patients reported greater general emotion dysregulation than the comparison group, especially poorer emotional awareness and clarity. There were very few diagnostic differences. In both patients and the comparison group, limited access to emotion regulation strategies was associated with cognitive ED symptoms, and presence of binge eating in the comparison group. In patients, poor emotional awareness and emotional non-acceptance were additionally associated with cognitive symptoms, and difficulties in impulse control and emotional non-acceptance were associated with binge eating.

DISCUSSION

Emotion dysregulation is an important transdiagnostic characteristic of ED. Results suggest interventions that enhance emotional awareness and acceptance, as well as emotion regulation skills training, in both ED treatment and prevention.

Emotion differentiation mediates the association between emotion regulation difficulties and caloric intake

Emotion differentiation is the ability to identify and label emotional experiences into discrete categories. The present study examined the influence of emotion regulation difficulties, emotion differentiation, and emotional state-specifically sad versus positive mood-on caloric intake in a laboratory setting. Undergraduate participants completed a series of questionnaires, including measures of emotion regulation difficulties and emotion differentiation, and then underwent a randomly assigned sad or positive mood induction. Afterwards, they participated in a taste test. Food was counted before and after the taste test to determine total caloric intake. Results showed that negative emotion differentiation was significantly inversely associated with overall caloric intake, such that low negative emotion differentiators ate more regardless of mood induction group. Positive emotion differentiation was not associated with caloric intake. Additional analysis found that negative emotion differentiation mediated the relation between emotion regulation difficulties and caloric intake. An alternative model found that emotion regulation difficulties did not mediate the relation between negative emotion differentiation and caloric intake. Our results suggest that reducing caloric intake among individuals with emotion regulation difficulties may involve incorporating strategies to specifically target the ability to differentiate between emotions.

Delay Discounting of Reward and Impulsivity in Eating Disorders: From Anorexia Nervosa to Binge Eating Disorder

Evidence points to eating disorder patients displaying altered rates of delay discounting (one's degree of preference for immediate rewards over larger delayed rewards). Anorexia nervosa (AN) patients are believed to have an increased capacity to delay reward, which reflects their ability to override the drive to eat. Contrarily, binge eating disorder (BED) patients are associated with a reduced predisposition to delay gratification. Here, we investigated monetary delay discounting and impulsivity in 80 adult women with EDs (56 AN and 24 BED), diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, and 80 healthy controls. AN-restrictive (AN-R) subtype patients showed less steep discounting rates than BED and AN-bingeing/purging subtype patients. Compared with healthy controls and AN-R patients, BED and AN-bingeing/purging patients presented higher delay discounting and positive and negative urgency levels. Our findings suggest that restriction in AN-R patients is associated with disproportionate self-control, whereas bingeing behaviours could be more driven by emotional states and impulsivity traits. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

A pilot open series of lamotrigine in DBT-treated eating disorders characterized by significant affective dysregulation and poor impulse control

BACKGROUND

There is little effective psychopharmacological treatment for individuals with eating disorders who struggle with pervasive, severe affective and behavioral dysregulation.

METHODS

This pilot open series evaluated lamotrigine, a mood stabilizer, in the treatment of patients with eating disorders who did not respond adequately to antidepressant medications. Nine women with anorexia nervosa- or bulimia nervosa-spectrum eating disorders in partial hospital or intensive outpatient dialectical behavior therapy (DBT)-based eating disorder treatment took lamotrigine for 147 ± 79 days (mean final dose = 161.1 ± 48.6 mg/day). Participants completed standardized self-report measures of emotion dysregulation and impulsivity after lamotrigine initiation and approximately biweekly thereafter. Mood and eating disorder symptomatology were measured at lamotrigine initiation and at time of final assessment.

RESULTS

Lamotrigine and concurrent DBT were associated with large reductions in self-reported affective and behavioral dysregulation (ps < 0.01). Eating disorder and mood symptoms decreased moderately.

CONCLUSIONS

Although our findings are limited by the confounds inherent in an open series, lamotrigine showed initial promise in reducing emotional instability and behavioral impulsivity in severely dysregulated eating-disordered patients. These preliminary results support further investigation of lamotrigine for eating disorders in rigorous controlled trials.