Anxiety-related processes in anorexia nervosa and their relation to eating disorder pathology, depression and anxiety

Analysis of symptom clusters amongst adults with anorexia nervosa: Key severity indicators

This study used cluster analysis to explore clinically relevant subgroups of adult patients with anorexia nervosa (AN). Patients were clustered based on their body mass index (BMI), eating disorder symptomatology, anxiety and depression symptoms and autistic characteristics. The difference between clusters in work and social functioning, duration of illness, bingeing and purging behaviour, previous hospitalisations and number of comorbidities was also investigated. Two meaningful clusters emerged: a higher symptoms cluster with more severe eating pathology, anxiety, depression, and more autistic traits, and a second cluster with lower symptoms. BMI did not make major contributions to cluster formation. The higher symptoms cluster also reported lower self-efficacy to change, more previous hospitalisations, comorbid diagnoses, binge eating and purging behaviours and use of psychotropic medication. Our findings suggest that weight alone may not be a significant severity indicator amongst inpatients with AN, and targeted treatment of AN should consider a broader range of symptom severity indicators.

Assessing cognitive flexibility in anorexia nervosa using eye tracking: A registered report

OBJECTIVE

Cognitive flexibility research in anorexia nervosa (AN) has primarily focused on group differences between clinical and control participants, but research in the general population utilizing the mixed pro- anti-saccade flexibility task has demonstrated individual differences in trait anxiety are a determinant of switching performance, and switching impairments are more pronounced for keypress than saccadic (eye-movement) responses. The aim of the current research is to explore trait anxiety and differences in saccadic and keypress responding as potential determinants of performance on flexibility tasks in AN.

METHOD

We will compare performance on the mixed pro- anti-saccade paradigm between female adult participants with a current diagnosis of AN and matched control participants, observing both saccadic and keypress responses while controlling for trait anxiety (State - Trait Anxiety Inventory) and spatial working memory (Corsi Block Tapping Test). Associations with eating disorder-related symptoms (Eating Disorder Examination Questionnaire), flexibility in everyday life (Eating Disorder Flexibility Index), and the Clinical Perfectionism Questionnaire will also be assessed.

RESULTS

Data which controls for individual differences in trait anxiety and assesses flexibility at both the task- and response-set level may be used to more accurately understand differences in performance on cognitive flexibility tasks by participants with AN.

DISCUSSION

Clarifying the effects of trait anxiety on flexibility, and differences between task- and response-set switching may advance our understanding of how cognitive flexibility relates to flexibility in everyday life and improve translation to therapeutic approaches.

PUBLIC SIGNIFICANCE STATEMENT

This research will compare performance on a flexibility task between participants with anorexia nervosa (AN) and controls while observing their eye-movements to examine whether trait anxiety and type of response (eye-movement and keypress) are associated with performance. This data may improve our understanding of why participants with AN perform more poorly on cognitive flexibility tasks, and how poor cognitive flexibility relates to eating disorder-related issues with flexibility in everyday life.

Broad and Narrow Transdiagnostic Risk Factors in Eating Disorders: A Preliminary Study on an Italian Clinical Sample

Eating disorders are multifaceted psychopathologies and the transdiagnostic approach is currently considered a useful framework to understand their complexity. This preliminary study aimed to investigate both broad (i.e., intolerance of uncertainty and emotion dysregulation) and narrow (i.e., extreme body dissatisfaction) transdiagnostic risk factors underlying eating disorders. 50 Italian female patients seeking treatment for an eating disorder were involved (M_age = 31.6 years ± 12.8, 18–65). They completed self-report measures assessing emotion regulation difficulties, intolerance of uncertainty, extreme body dissatisfaction, general psychological distress, and eating disorder symptomatology. To explore whether the abovementioned transdiagnostic factors predicted patients’ psychological distress and eating disorder symptoms, two linear regressions were performed. Emotion dysregulation emerged as the only significant predictor of distress, while extreme body dissatisfaction was the only significant predictor of overall eating disorder symptomatology. Then, to analyze the differences between patients with anorexia nervosa and bulimia nervosa in intolerance of uncertainty and emotion regulation problems, t-tests were conducted. The two groups differed significantly in intolerance of uncertainty levels only, with higher scores obtained by patients with anorexia nervosa. Overall, our findings suggest that emotion dysregulation and extreme body dissatisfaction may be relevant constructs in eating disorders in general, while intolerance of uncertainty may be more involved in restrictive eating disorders. The clinical implications of such results are discussed.

How deep is your thought? The relations between intolerance of uncertainty, worry and weight and shape concerns in adolescent girls with anorexia nervosa

BACKGROUND

Inherent to anorexia nervosa are repetitive thoughts about weight and shape. Growing research suggests the relevance of intolerance of uncertainty and worry in maintaining these types of repetitive thoughts. The relation between these cognitive processes and weight and shape concerns in adolescent girls with anorexia nervosa is understudied. This study investigated associations between prospective (desire for predictability) and inhibitory (uncertainty paralysis) intolerance of uncertainty, and weight and shape concerns and the mediating role of worry in these associations.

METHODS

In a cross-sectional study, 93 adolescent girls with anorexia nervosa completed questionnaires measuring the variables of interest. A mediation model with worry as a mediator between inhibitory and prospective intolerance of uncertainty and weight and shape concerns was tested.

RESULTS

A total and direct effect of inhibitory intolerance of uncertainty on weight and shape concerns was found. Worry did not mediate this relation.

CONCLUSIONS

These results confirm the importance of inhibitory intolerance of uncertainty in adolescent girls with anorexia nervosa, more specifically to weight and shape concerns. This group may benefit from intervention strategies targeting intolerance of uncertainty. General worry seems less relevant to weight and shape concerns in adolescent girls with anorexia nervosa. Adolescent girls with anorexia nervosa often experience repetitive thoughts about weight and shape. Growing research suggests the relevance of intolerance of uncertainty and worry in maintaining these types of repetitive thoughts. Intolerance of uncertainty is defined as the incapacity to tolerate uncertainty and is often divided into two components; prospective intolerance of uncertainty (desire for predictability) and inhibitory intolerance of uncertainty (uncertainty paralysis). The relation between intolerance of uncertainty, worry and weight and shape concerns in adolescent girls with anorexia nervosa is understudied. This study aims to investigate study relations between prospective and inhibitory intolerance of uncertainty, worry, and weight and shape concerns. A total of 93 adolescent girls with anorexia nervosa completed three questionnaires, measuring prospective and inhibitory intolerance of uncertainty worry, and weight and shape concerns, respectively. The results of this study confirmed the importance of inhibitory intolerance of uncertainty in adolescent girls with anorexia nervosa, more specifically to weight and shape concerns. This group may benefit from intervention strategies targeting intolerance of uncertainty. General worry seems less relevant to weight and shape concerns in adolescent girls.

A cross-lagged panel model for testing the bidirectional relationship between depression and smartphone addiction and the influences of maladaptive metacognition on them in Chinese adolescents

AIMS

Despite the high prevalence of both depression and smartphone addiction among Chinese adolescents, research examining their bidirectional relationship has been limited. Moreover, longitudinal research regarding the influence of maladaptive metacognitive beliefs on smartphone addiction is scarce. This 6-month longitudinal study aimed to address these research gaps by testing a cross-lagged panel model of maladaptive metacognition, depression, and smartphone addiction.

METHODS

Four hundred and fifty-nine Chinese high school students voluntarily completed an anonymous questionnaire at baseline, and 313 of them (36.1% male; age = 14 to 18; M = 16.88, SD = 0.62) completed the same questionnaire at follow-up.

RESULTS

Positive correlations were shown among depression, smartphone addiction, and maladaptive metacognition at both waves (r = 0.16 to 0.57, p < .01). The results of the cross-lagged analysis demonstrated only the prospective effect of depression on smartphone addiction (β = 0.18, p < .001) but not vice versa. Moreover, maladaptive metacognition assessed at baseline significantly predicted subsequent depression (β = 0.14, p < .01) but not smartphone addiction (p>.05). Additional path analysis showed a significant indirect effect of baseline maladaptive metacognition (0.099 [95% CI = 0.042, 0.183]) on subsequent smartphone addiction, via depression.

CONCLUSIONS

Findings of this study showed that the relationship between depression and smartphone addiction was unidirectional rather than bidirectional among Chinese adolescents. Specifically, depression predicted smartphone addiction, while maladaptive metacognition predicted depression. Depression also mediated the relationship between maladaptive metacognition and smartphone addiction. The findings suggest that incorporating metacognition and depression interventions into smartphone addiction prevention designs for adolescents may be beneficial.

Changes in meal-related anxiety predict treatment outcomes in an intensive family-based treatment program for adolescents with anorexia nervosa

Meal-related anxiety in individuals with eating disorders is associated with reduced caloric intake and persisting eating-disordered behaviors, which may reduce the likelihood of attaining or sustaining remission. The current study is the first to examine changes in meal-related anxiety as a predictor of outcomes in the context of a family-based partial hospitalization program. A sample of 51 adolescents with anorexia nervosa or atypical anorexia rated anxiety before and after all treatment meals using the Subjective Units of Distress Scale (SUDS). Regression analyses suggested that participants experiencing a greater reduction in meal anxiety endorsed fewer eating disordered symptoms on the EDE at the end of treatment. Reductions in meal anxiety did not predict EBW at end of treatment, which could be because family-based treatment (FBT) supports adequate food intake regardless of meal anxiety (i.e., parents ensure food intake). Findings suggest that reductions in meal-related anxiety may be an important predictor of outcomes in family-based interventions, and future research is needed to examine if directly targeting meal anxiety may enhance outcomes.

Metacognitive beliefs across eating disorders and eating behaviours: A systematic review

BACKGROUND

Literature has pointed out a probable association between metacognitive beliefs and eating disorders. To date, no study has synthetized all research exploring the differences or similarities in metacognitive beliefs across different eating disorders diagnoses and eating problems.

AIMS

To review the evidence on metacognitive beliefs across the spectrum of eating disorders and eating behaviours.

METHOD

A comprehensive search was conducted on PubMed and PsycInfo. The search terms used were: 'eating disorders/anorexia/bulimia/binge eating disorder/binge eating' AND 'metacognitions/metacognitive beliefs'. A manual search of reference lists was also run.

RESULTS

Eleven studies were identified. Anorexia Nervosa was broadly characterized by higher levels of metacognitive beliefs compared to the general population, particularly negative beliefs about worry and beliefs about the need to control thoughts. Positive beliefs about worry were higher in Anorexia Nervosa compared to Bulimia Nervosa and Eating Disorder Not Otherwise Specified, and in Bulimia Nervosa compared to Eating Disorder Not Otherwise Specified. Negative beliefs about worry were higher in Anorexia Nervosa compared to Bulimia Nervosa. Cognitive self-consciousness was higher in Anorexia Nervosa compared to Bulimia Nervosa and Eating Disorder Not Otherwise Specified.

CONCLUSIONS

Metacognitive beliefs appear to be implicated in eating disorders and eating behaviours.

Understanding the nature of association between anxiety phenotypes and anorexia nervosa: a triangulation approach

BACKGROUND

Evidence from observational studies suggests an association between anxiety disorders and anorexia nervosa (AN), but causal inference is complicated by the potential for confounding in these studies. We triangulate evidence across a longitudinal study and a Mendelian randomization (MR) study, to evaluate whether there is support for anxiety disorder phenotypes exerting a causal effect on AN risk.

METHODS

Study One assessed longitudinal associations of childhood worry and anxiety disorders with lifetime AN in the Avon Longitudinal Study of Parents and Children cohort. Study Two used two-sample MR to evaluate: causal effects of worry, and genetic liability to anxiety disorders, on AN risk; causal effects of genetic liability to AN on anxiety outcomes; and the causal influence of worry on anxiety disorder development. The independence of effects of worry, relative to depressed affect, on AN and anxiety disorder outcomes, was explored using multivariable MR. Analyses were completed using summary statistics from recent genome-wide association studies.

RESULTS

Study One did not support an association between worry and subsequent AN, but there was strong evidence for anxiety disorders predicting increased risk of AN. Study Two outcomes supported worry causally increasing AN risk, but did not support a causal effect of anxiety disorders on AN development, or of AN on anxiety disorders/worry. Findings also indicated that worry causally influences anxiety disorder development. Multivariable analysis estimates suggested the influence of worry on both AN and anxiety disorders was independent of depressed affect.

CONCLUSIONS

Overall our results provide mixed evidence regarding the causal role of anxiety exposures in AN aetiology. The inconsistency between outcomes of Studies One and Two may be explained by limitations surrounding worry assessment in Study One, confounding of the anxiety disorder and AN association in observational research, and low power in MR analyses probing causal effects of genetic liability to anxiety disorders. The evidence for worry acting as a causal risk factor for anxiety disorders and AN supports targeting worry for prevention of both outcomes. Further research should clarify how a tendency to worry translates into AN risk, and whether anxiety disorder pathology exerts any causal effect on AN.

Predicting the restrictive eating, exercise, and weight monitoring compulsions of anorexia nervosa

PURPOSE

Compulsions surrounding restrictive eating, exercise, and weight monitoring are thought to maintain abnormal eating behaviour in individuals with anorexia nervosa (AN). This study aimed to determine if AN psychopathology and trait anxiety explain the presence of restrictive eating, exercise, and weight monitoring compulsions in a mixed sample.

METHODS

Participants were 31 females with AN and 31 age and gender-matched healthy individuals (HC). Restrictive eating, exercise and weight monitoring compulsion presence was compared between AN and HC groups. Multivariable poisson regression analyses, adjusted for diagnostic status, were conducted to assess the association of both AN psychopathology and trait anxiety with compulsions across the mixed group.

RESULTS

Individuals with AN endorsed a greater number of restrictive eating, exercise and weight monitoring compulsions compared to HC. In adjusted poisson regression analyses neither AN psychopathology nor trait anxiety predicted compulsion presence: incidence rate ratio (IRR) for AN psychopathology = 1.15 [95% CI 0.84, 1.57], p = 0.39; IRR for trait anxiety = 1.01 [95% CI 0.97, 1.06], p = 0.50.

CONCLUSIONS

Greater presence of restrictive eating, exercise and weight monitoring compulsions was reported by individuals with AN, supporting the conceptualisation of disorder behaviours as compulsive. The study was underpowered to robustly evaluate the association between predictors of interest and the compulsions outcome, largely owing to the small sample size. Further investigation is required, ideally using methods able to identify causal and mediation effects.

LEVEL OF EVIDENCE

Level V, cross-sectional study.

Intolerance of uncertainty moderates the relationship between high personal standards but not evaluative concerns perfectionism and eating disorder symptoms cross-sectionally and prospectively

Two dimensions of perfectionism related to eating disorder (ED) symptoms are evaluative concerns and high standards. Evaluative concerns are consistently linked with ED symptoms, whereas there are conflicting results regarding high standards and ED symptoms. High standards are unrelated to ED symptoms in some studies and are linked to higher ED symptoms in others. Intolerance of uncertainty (IU) may influence the relation between high standards and ED symptoms; individuals elevated in both IU and high standards may find it distressing to be uncertain about future situations for fear of not living up to high expectations and use ED behaviors to cope with such uncertainty. In the current study (N = 216), we explored whether IU moderates the relationships between high standards and evaluative concerns and ED symptoms, both cross-sectionally and prospectively across two weeks. IU significantly moderated high standards and ED symptoms both cross-sectionally and across time while accounting for baseline ED symptoms, but did not moderate the relationship between evaluative concerns and ED symptoms. Higher standards were associated with greater ED symptoms in individuals higher, but not lower in IU. These findings suggest high standards may only contribute to ED symptoms when individuals are also high in IU.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

LIMITATIONS

The study employed a non-clinical sample.

CONCLUSIONS

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

Neural correlates of taste reward value across eating disorders

Individuals with eating disorders (ED) make extreme food choices, raising the possibility of altered food-value computation. We utilized an associative taste reward learning paradigm to test whether value signaling differs between participants with EDs vs. healthy controls (HC). We followed up on previous work examining prediction error (PE) signaling, which is a brain response to violation of a learned reward contingency. Expected value (EV) signal is a trial-by-trial assessment of reward significance accounting for error signaling, reward-likelihood, and learning rate. Adult female participants (N = 111) performed a temporal difference (TD) fMRI taste task, which is a specific type of associative reward learning paradigm, to determine EV signal: Anorexia Nervosa-ill (N = 28), Anorexia Nervosa-recovered (N = 20), Bulimia Nervosa (BN) (N = 20), and HC (N= 43). Anatomical region-of-interest (ROI) analyses were performed utilizing EV regressors derived via algorithm, with ROIs based on prior EV analyses: orbitofrontal cortex, anterior cingulate (ACC), amygdala, and striatum. EV signal was elevated in the bilateral ACC in AN-ill vs. HC and BN. Intolerance of uncertainty negatively correlated with EV in AN-ill. BMI and EV were negatively-correlated across groups. Altered ACC EV computation in response to food stimuli could contribute to food restriction in AN-ill.

A systematic review of studies probing longitudinal associations between anxiety and anorexia nervosa

The current study aimed to establish whether anxiety predicts subsequent anorexia nervosa onset and maintenance. A systematic review of longitudinal studies assessing the association between stable anxiety exposures (e.g. trait anxiety/anxiety disorder pathology) and anorexia nervosa development or maintenance was undertaken. Eight studies met inclusion criteria. Seven probed the association between anxiety and anorexia nervosa onset, and one assessed the association between anxiety and anorexia nervosa maintenance. Individuals with anorexia nervosa were more likely to report childhood anxiety compared to healthy individuals, but whether childhood anxiety explains unique variance in anorexia nervosa development is unclear. Current evidence does not support longitudinal associations between specific anxiety disorders (independently of other anxiety disorders) and subsequent anorexia nervosa onset, however anxiety disorder diagnosis in general may predict increased anorexia nervosa risk. The single study probing the association between anxiety and anorexia nervosa maintenance did not find evidence supporting a relationship. The quality of individual studies was fair to high, however the body of evidence was of low quality. Further research that minimises bias, allowing for strong conclusions concerning longitudinal associations between anxiety and subsequent anorexia nervosa outcomes, is required to inform anorexia nervosa aetiology. This in turn may promote improved prevention and treatment.

The experience of intolerance of uncertainty for young people with a restrictive eating disorder: a pilot study

PURPOSE

Research is consistently reporting elevated levels of intolerance of uncertainty (IU) in individuals with an eating disorder (ED). Less is known about the phenomenology of uncertainty for this clinical group. The present study aims to advance our understanding of the relationship between IU and restrictive EDs by providing insight into young people's subjective experiences of uncertainty.

METHODS

Thirteen young people with a restrictive ED were recruited from multi-family therapy groups run within the Maudsley Centre for Child and Adolescent Eating Disorders at the South London and Maudsley NHS Foundation Trust. Three focus groups were conducted asking young people to discuss their views, experiences and coping strategies when faced with uncertainty.

RESULTS

Data were analysed using interpretative phenomenological analysis which yielded five superordinate themes: (1) young people perceived uncertainty as something negative; (2) high levels of anxiety and stress were identified as primary responses to uncertainty; (3) ED behaviours were given a functional role in reducing uncertainty; (4) need to control various aspects of young peoples' lives was of high importance; (5) young people discussed how they struggled to find ways to cope with uncertainty and often used behaviours associated with the eating disorder psychopathology as coping strategies.

CONCLUSION

Young people's experiences of what uncertainty is like for them revealed a dynamic interplay between ED symptoms and fear of uncertainty. Findings support IU as a relevant concept for young people suffering from a restrictive ED and indicate that further exploration of IU from both theoretical and clinical perspectives could be fruitful.

LEVEL OF EVIDENCE

V.

A dark past, a restrained present, and an apocalyptic future: time perspective, personality, and life satisfaction among anorexia nervosa patients

BACKGROUND

Despite reporting low levels of well-being, anorexia nervosa patients express temperament traits (e.g., extraversion and persistence) necessary for high levels of life satisfaction. Nevertheless, among individuals without eating disorders, a balanced organization of the flow of time, influences life satisfaction beyond temperamental dispositions. A balanced time perspective is defined as: high past positive, low past negative, high present hedonistic, low present fatalistic, and high future. We investigated differences in time perspective dimensions, personality traits, and life satisfaction between anorexia nervosa patients and matched controls. We also investigated if the personality traits and the outlook on time associated to positive levels of life satisfaction among controls also predicted anorexia patients' life satisfaction. Additionally, we investigated if time perspective dimensions predicted life satisfaction beyond personality traits among both patients and controls.

METHOD

A total of 88 anorexia nervosa patients from a clinic in the West of Sweden and 111 gender-age matched controls from a university in the West of Sweden participated in the Study. All participants responded to the Zimbardo Time Perspective Inventory, the Ten Item Personality Inventory, and the Temporal Satisfaction with Life Scale.

RESULTS

A t-test showed that patients scored higher in the past negative, the present fatalistic, and the future dimensions, lower in the past positive and the present hedonistic dimensions, higher in conscientiousness, extraversion, and agreeableness, and lower in life satisfaction. Regression analyses showed that life satisfaction was predicted by openness to experience and emotional stability for controls and by emotional stability among patients. When time dimensions were entered in the regression, emotional stability and the past negative and past positive time dimensions predicted life satisfaction among controls, but only the past positive and present hedonistic time dimensions predicted life satisfaction among patients.

CONCLUSION

Anorexia patients were less satisfied with life despite being more conscientious, social, and agreeable than controls. Moreover, compared to controls, patients had an unbalanced time perspective: a dark view of the past (i.e., high past negative), a restrained present (i.e., low present hedonistic) and an apocalyptic view of the future (i.e., high present fatalistic). It is plausible to suggest that, therapeutic interventions should focus on empowering patients to cultivate a sentimental and positive view of the past (i.e., high past positive) and the desire to experience pleasure without concern for future consequences (i.e., high present hedonistic) so that they can make self-directed and flexible choices for their own well-being. Such interventions might have effects on life satisfaction beyond the patients' temperamental disposition.

How extreme dieting becomes compulsive: A novel hypothesis for the role of anxiety in the development and maintenance of anorexia nervosa

The US National Institute of Mental Health's Research Domain Criteria (NIMH RDoC) advocates the study of features common to psychiatric conditions. This transdiagnostic approach has recently been adopted into the study of anorexia nervosa (AN), an illness that can be considered compulsive in nature. This has led to the development of an account of AN that identifies key roles for the heightened reinforcement of starvation, leading to its excessive repetition, and goal-directed system dysfunction. Considering models of illness in other compulsive disorders, we extend the existing account to explain the emergence of reinforcement and goal-directed system abnormalities in AN, proposing that anxiety is central to both processes. As such we emphasise the particular importance of the anxiolytic effects of starvation, over other reinforcing outcomes, in encouraging the continuation of starvation within a model that proposes a number of mechanisms by which anxiety operates in the development and maintenance of AN. We suggest the psychopathology of AN mediates the relationship between the anxiolytic effects of starvation and excessive repetition of starvation, and that compulsive starvation has reciprocal effects on its determinants. We thus account for the emergence of symptoms of AN other than compulsive starvation, and for the relationship between different features of the disorder. By extending and adapting an existing explanation of AN, we provide a richer aetiological model that invites new research questions and could inform novel approaches to prevention and treatment.

Proactive and reactive inhibitory control in eating disorders

Altered inhibitory control has been implicated in the development and maintenance of eating disorders (ED), however it is unclear how different types of inhibitory control are affected across the EDs. We explored whether individuals with bulimia nervosa (BN), binge eating disorder (BED) and anorexia nervosa (AN) differed from healthy individuals (HC) on two types of motor inhibitory control: proactive inhibition (related to the preparation/initiation of a response) and reactive inhibition (withholding a response in reaction to a signal). Ninety-four women (28 AN, 27 BN, 11 BED, 28 HC) completed two neuropsychological tasks (a cued reaction time task and a stop signal task), and questionnaires assessing clinical variables, mood, anxiety, and inhibitory control. Self-reported inhibitory control was poorer in women with BN compared to the HC and AN groups, but greater in women with AN compared to all other groups. However, no group differences in reactive inhibition were observed. Proactive inhibition was augmented in women with AN compared to HC, and this was related to self-reported intolerance of uncertainty. The findings suggest that proactive inhibition may be a relevant target for behavioural interventions for AN, and call for further research into the relationship between intolerance of uncertainty and proactive inhibition.

Predicting intolerance of uncertainty in individuals with eating disorder symptoms

BACKGROUND

Intolerance of Uncertainty (IU) is recognized for its contribution to various psychopathologies, in particular anxiety and depression. Studies highlight the relevance of IU for Eating Disorders (EDs) however, potential factors contributing to IU in EDs remain unstudied.

METHODS

Three hundred and forty-nine women with ED symptoms and 214 individuals without ED symptoms were recruited and compared on levels of IU, insecure (anxious and avoidant) attachment styles, extraversion and openness. Secondly, the contribution of these factors to IU were tested.

RESULTS

Compared to the non-ED group, the ED group scored higher on IU, insecure attachment, and lower on extraversion and openness. Regression analyses confirmed that higher insecure attachment, and lower extraversion predicted higher IU scores in the ED group, and that insecure attachment predicted higher IU scores in the non-ED group.

CONCLUSIONS

Results confirm the relevance of IU to ED, and demonstrate that personality traits and insecure attachment styles contribute to IU in ED. Findings add to the growing literature on IU in ED and suggest that people with EDs may benefit from clinical interventions targeting IU.

Intolerance of Uncertainty in eating disorders: An update on the field

Pathological fear and anxiety regarding food, eating, weight and body shape are at the core of eating disorder (ED) psychopathology. To manage anxiety, patients develop complicated repertoires of ritualistic and repetitive behaviours, which can lead to total functional impairment. Yet the cognitive processes underlying anxiety, fear, and anxiety-driven behaviours in EDs remain poorly understood. Intolerance of Uncertainty (IU) is defined as a tendency to react negatively on an emotional, cognitive, and behavioural level to uncertain situations and events. There is substantial evidence that IU is a transdiagnostic process that contributes to the maintenance of anxiety disorders; however, IU may also be relevant to the understanding and treatment of EDs. The current review summarises the growing literature examining IU in relation to ED symptoms, including restriction, bingeing, purging, ritualised behaviours, reassurance-seeking and body checking. Extending from the obsessive-compulsive disorder (OCD) and anxiety disorder literature, we propose that IU provides a novel theoretical and clinical framework from which to understand the anxiety, fixation with rules and rituals, and the cognitively rigid profile that is characteristic of ED presentations. We conclude with suggestions for future research, and discuss IU as a potential treatment target for core features of EDs and comorbid symptoms.

Extinction theory & anorexia nervosa: Deepening therapeutic mechanisms

By virtue of adopting the core symptomatic fear (i.e., a fear of weight gain) as a primary treatment target, the treatment of AN centrally involves exposure-driven processes. However, exposure trials targeting the fear of weight gain in AN have been sparse, yielding mixed results to date. In translating extinction theory to the treatment of AN, it is likely that the absence of a clear distinction between what constitutes the core feared cue and the core feared outcome has stymied the application of exposure treatments in AN. This review considers several configurations of the core fear association in AN, noting distinct therapeutic strategies which may allow for more precise efforts in violating fear-based expectancies. Specific guidance is offered in the clinical decision making process as to which strategies might best promote inhibitory learning, and a clinical case is discussed, in which treatment was adjusted to specifically violate the core underlying fear association.