Dimensions of control and their relation to disordered eating behaviours and obsessive-compulsive symptoms

Association between atopic dermatitis and eating disorders: a cross-sectional study in the All of Us Research Program

We investigated the association between atopic dermatitis (AD) and eating disorders through a cross-sectional study of US adults in the All of Us Research Program, a diverse cohort of over 250 000 participants with a focus on populations traditionally under-represented in biomedical research. Using multivariable analysis, we found that AD was significantly associated with all eating disorders tested, with binge eating disorder having the greatest multivariable odds ratio of 3.58 (95% confidence interval 2.48–5.02, P < 0.001) when adjusted for age, sex, ethnicity and race.

Deficiency in Self-Control: Unraveling Psychological and Behavioral Risk Factors for Obsessive-Compulsive Symptoms in College Students

Objective

Obsessive-compulsive disorder (OCD) is a complex mental disorder to treat. However, there are some deficiencies in research performed to date about the psychological and behavioral factors that may trigger obsessive-compulsive symptoms (OCS). Based on the Psychopathology of Self-Control Theory which states that deficits in self-control underpin psychiatric symptoms, this study investigated the factors influencing OCS among college students.

Methods

A total of 5599 non-clinical Chinese college students were recruited to complete the Chinese version of the Self-Control Scale, Aitken Procrastination Inventory, and Symptom Checklist-90. Pearson's correlation analyses and the bootstrap method were performed to test our hypothesis.

Results

The following results were obtained: (a) There were significant correlations among self-control, procrastination, anxiety, and OCS. (b) When controlling for the effects of age and sex, self-control remained a significant negative predictor of OCS. (c) The mediating roles of procrastination and anxiety, and the chain mediating role of procrastination and anxiety were the three predicted pathways linking self-control and OCS.

Conclusion

This study highlights the significance of self-control deficiencies in OCS. It provides new insights into the psychological and behavioral factors that increase the risk of OCS with important practical implications for early intervention in OCD.

On Orthorexia Nervosa: A Systematic Review of Reviews

INTRODUCTION

Orthorexia nervosa (ON), characterized by a pathological preoccupation with "extreme dietary purity," is increasingly observed as a mental health condition among young adults and the general population. However, its diagnosis is not formally recognized and has remained contentious.

OBJECTIVE

In this systematic review, we attempt to overview previous reviews on ON, focusing on the methodological and conceptual issues with ON. This would serve both as a summary and a way to highlight gaps in earlier research.

METHODS

This systematic review took reference from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines, and using combinations of the search terms ("orthorexia" OR "orthorexia nervosa" OR "ON") AND ("review" OR "systematic review" OR "meta-analysis"), a literature search was performed on EMBASE, Medline and PsycINFO databases from inception up to October 31, 2023. Articles were included if (1) they were written or translated into English and (2) contained information pertaining to the diagnostic stability or validity of ON, or instruments used to measure ON symptoms and behaviors. Only review articles with a systematic literature search approach were included.

RESULTS

A total of 22 reviews were qualitatively reviewed. Several studies have reported variable prevalence of ON and highlighted the lack of thoroughly evaluated measures of ON with clear psychometric properties, with no reliable estimates. ORTO-15 and its variations such as ORTO-11, ORTO-12 are popularly used, although their use is discouraged. Existing instruments lack specificity for pathology and several disagreements on the conceptualization and hence diagnostic criteria of ON exist.

DISCUSSION

Previous reviews have consistently highlighted the highly variable (and contradictory) prevalence rates with different instruments to measure ON, lack of stable factor structure and psychometrics across ON measures, paucity of data on ON in clinical samples, and a need for a modern re-conceptualization of ON. The diagnosis of ON is challenging as it likely spans a spectrum from "normal" to "abnormal," and "functional" to "dysfunctional." "Non-pathological" orthorexia is not related to psychopathological constructs in the same way that ON is.

Moving toward targeted eating disorder care for transgender, non-binary, and gender expansive patients in the United States

OBJECTIVE

Literature suggests that transgender, non-binary, and/or gender expansive (TNG) people are more likely than cisgender peers to experience eating disorders (EDs) and engage in dangerous weight control behaviors. TNG individuals with EDs are dramatically higher risk for self-harm behaviors, suicidal ideation, and suicidal behaviors than cisgender peers with EDs or TNG peers without EDs, and often engage in ED symptoms/behaviors to alleviate gender dysphoria. Yet, no treatment paradigms have yet been adapted for TNG-specific ED care. This qualitative study aims to identify stakeholder needs from such care to inform future clinical interventions.

METHODS

We elicited patient (n = 12) and mental health clinician (n = 9) stakeholder needs and preferences regarding TNG-specific ED care. Semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR) and a behavioral insights framework, EAST, were developed to ensure uniform inclusion and sequencing of topics and allow for valid comparison across interviews. Using a rapid analysis procedure, we produced a descriptive analysis for each group identifying challenges of and opportunities in providing ED care for TNG adults.

RESULTS

Stakeholders expressed needs and preferences for TNG-specific treatment including that it be: (1) TNG-affirming, weight-inclusive, trauma-informed, and anti-racist; (2) delivered by an interdisciplinary team, including gender-affirming care clinicians; (3) focused on parsing gender dysphoria from other body image concerns, building distress tolerance, and working toward gender euphoria (rather than body acceptance).

DISCUSSION

Future work is needed exploring ED care delivery models that integrate gender-affirming care services with mental health care. Such models may improve TNG access to ED treatment and recovery.

PUBLIC SIGNIFICANCE

Transgender, non-binary, and/or gender expansive (TNG) experience disproportionately high rates of eating disorders and have unique barriers to accessing care. In individual interviews, TNG adults with eating disorders and mental health clinicians who provide psychotherapy for eating disorders voiced desire for greater availability of TNG-affirming, weight-inclusive eating disorder care, integrated with other gender-affirming care services. This informs future research developing eating disorder care for TNG individuals.

Prevalence of Eating Disorders and Disordered Eating Behaviours amongst Adolescents and Young Adults in Saudi Arabia: A Systematic Review

Eating disorders (EDs) and disordered eating behaviours (DEBs) are significant health problems related to body image and weight dissatisfaction among adolescents and young adults worldwide. During this stage of sensitive development, these behaviours may hinder the optimal growth process and can consequently lead to wasting, stunting, and micronutrient deficiencies. However, there is a limited amount of literature on DEB among Arab populations, particularly in Saudi Arabia. This review aims to assess the prevalence of EDs/DEB and to develop a clear understanding of the epidemiology of such conditions among adolescents and youth in Saudi Arabia. Five databases were systematically searched and 14 papers met the inclusion criteria. The Eating Attitudes Test (EAT-26) was the predominant tool used for evaluating aberrant eating behaviours, indicating a high prevalence of EDs/DEB ranging from 10.2% to 48.1%. The highest prevalence of EDs/DEB was reported in the eastern region ranging from 29.4% to 65.5%. In terms of age and sex, the prevalence was higher among older students compared to younger school students and males reported more Eds/DEB compared to female students. These disorders are found to be prevalent in Saudi Arabia, and the risk of developing such conditions is high across the whole age range.

Diversity of Binge-Eating Disorder Symptoms Is Associated with Anxiety about Getting Fat Rather Than Body Image: A Clinical Study of Women in Poland

BACKGROUND

Anxiety about gaining weight is strongly related to body image. Evidence indicates that body dissatisfaction is a strong predictor of eating disorder development. Although not included in DSM-V diagnostic criteria, body image dissatisfaction, and concern are clearly relevant also for individuals with binge-eating disorder (BED). Weight gain anxiety is associated with psychopathological behaviors, but existing research in this area is primarily focused on bulimia nervosa and anorexia nervosa. The goal of this present study was to investigate body image and body mass anxiety in people with BED.

METHODS

Women diagnosed with BED (n = 105) aged 18 to 66 were surveyed using the questionnaire developed by the authors evaluating the presence of BED symptoms based on DSM-V criteria, and two other instruments: the Body Esteem Scale (BES), and the Body Mass Anxiety Scale (BMAS-20). Statistical analyses were conducted to examine the correlations of BED with body image and body mass anxiety (Pearson's r), to test differences between groups with greater and lesser BED symptom diversity (Student's t-test or the Mann-Whitney U test), and to assess differences among mild-, moderate- and severe-BED groups (ANOVA with a post-hoc test).

RESULTS

A medium positive relationship was found between anxiety about getting fat (AGF) and the diversity of BED, measured as the number of BED symptoms. A larger number of BED symptoms was shown to be associated with a higher level of AGF. However, no significant differences in AGF levels were observed among BED-severity groups, specified with the frequency of binge eating episodes. No correlations were found between BED and body image. There were also no significant differences in body image between groups with a larger and a smaller number of BED symptoms. The only significant difference in body image observed among BED-severity groups was the level of weight concern. People with mild BED displayed a higher level of weight concern than those with severe BED.

CONCLUSIONS

Women who binge eat experience high levels of AGF. In the present study, AGF was primarily associated with the number of BED symptoms and not the rate of recurrence of binge-eating episodes. The frequency of BED episodes, however, was linked with weight concern. On the other hand, the hypothesized relationship between disturbed body image and BED was not confirmed. The findings indicate that anxiety about getting fat should be viewed as one of the psychological costs incurred by women experiencing BED symptoms, and it should be mentioned in the next DSM version.

Psychedelics in the treatment of eating disorders: Rationale and potential mechanisms

Eating disorders are serious illnesses showing high rates of mortality and comorbidity with other mental health problems. Psychedelic-assisted therapy has recently shown potential in the treatment of several common comorbidities of eating disorders, including mood disorders, post-traumatic stress disorder, and substance use disorders. The theorized therapeutic mechanisms of psychedelic-assisted therapy suggest that it could be beneficial in the treatment of eating disorders as well. In this review, we summarize preliminary data on the efficacy of psychedelic-assisted therapy in people with anorexia nervosa, bulimia nervosa, and binge eating disorder, which include studies and case reports of psychedelic-assisted therapy with ketamine, MDMA, psilocybin, and ayahuasca. We then discuss the potential therapeutic mechanisms of psychedelic-assisted therapy in these three eating disorders, including both general therapeutic mechanisms and those which are relatively specific to eating disorders. We find preliminary evidence that psychedelic-assisted therapy may be effective in the treatment of anorexia nervosa and bulimia nervosa, with very little data available on binge eating disorder. Regarding mechanisms, psychedelic-assisted therapy may be able to improve beliefs about body image, normalize reward processing, promote cognitive flexibility, and facilitate trauma processing. Just as importantly, it appears to promote general therapeutic factors relevant to both eating disorders and many of their common comorbidities. Lastly, we discuss potential safety concerns which may be associated with these treatments and present recommendations for future research.

Abnormal sense of agency in eating disorders

The feeling of controlling one's own actions and, through them, impacting the external environment (i.e. Sense of Agency-SoA) can be relevant in the eating disorders (EDs) symptomatology. Yet, it has been poorly investigated. This study aims to implicitly assess SoA exploiting the Sensory Attenuation paradigm in two groups of EDs patients (Anorexia Nervosa Restrictive and Anorexia Nervosa Binge-Purging or Bulimia Nervosa) compared to a control group. We find that controls perceive self-generated stimuli as less intense than other-generated ones showing the classic pattern of sensory attenuation. By contrast, EDs patients show the opposite pattern, with self-generated perceived as more intense than other-generated stimuli. This result indicates an alteration of the implicit component of the feeling of control in EDs patients, thus suggesting a potential implication of these results for the clinical practice and the treatment of EDs symptomatology.

An examination of eating disorder fears in imaginal exposure scripts

OBJECTIVE

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

METHOD

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Psychometric properties of the BALCI Turkish version

The present study aimed to adapt and validate the Beliefs About Losing Control Inventory (BALCI) in the non-clinical Turkish emerging adults sample. The study group consisted of 549 participants from three study phases and aged between 18 and 28 years and mainly women. According to the results of the confirmatory factor analysis (CFA), the BALCI Turkish Version (BALCI-TV) confirmed 21 items in three factors. The network analysis findings showed that the items including the factors were together. The results indicated that configural, metric, scalar, and strict invariance across the gender. Cronbach's α and McDonald's ω of the total BALCI-TV were .90. Test-retest correlation result was .89. All results indicated that the BALCI-TV had good psychometric properties. The BALCI-TV can be provided to measure control and beliefs related to control within obsessive-compulsive disorder for Turkish academics and mental health practitioners.

"Like putting on an old pair of gloves" or "realising i am actually over it": a qualitative study exploring the impact of the COVID-19 pandemic lockdown restrictions on eating disorder recovery in the UK

The COVID-19 pandemic lockdown restrictions posed unique challenges for people living with eating disorders (EDs), particularly relating to social isolation and changes in treatment access. However, less is known about the experience of lockdown for people 'in recovery' from EDs or disordered eating (DE) (i.e., with an ED/DE history). This study explored: (i) how people with a self-reported ED/DE history responded to and managed the experience of lockdown, specifically in relation to their recovery, and (ii) coping strategies for the management of recovery. Semi-structured interviews were conducted between June and August 2020 with 20 adults with a self-reported ED/DE history living in the UK. Data were analysed using inductive thematic analysis within a critical realist framework. Three overarching themes were identified: (1) Seeking safety and stability during a pandemic, (2) Lockdown prompting realisations about recovery, and (3) Exploring self-compassion as a more adaptive approach. While most participants experienced a resurgence in ED symptoms during lockdown, many reflected on the successful management of these as reinforcing their recovery. These findings have important implications for understanding ED recovery, in addition to informing interventions to better promote recovery during the COVID-19 pandemic and beyond.

Supplementary information

The online version contains supplementary material available at 10.1007/s12144-023-04353-2.

It's not all about control: challenging mainstream framing of eating disorders

BACKGROUND

The concept of control has long been suggested as a central factor in eating disorder (ED) aetiology. The concept is now so mainstream that it risks being used in a potentially reductionist, stigmatising or otherwise harmful manner. In this paper, we explore and discuss our positions on the use of control-related terminology for EDs.

METHODS

The authors of this auto-ethnographic position paper include academic researchers, individuals with lived experience and clinicians (not mutually exclusive). In sharing our experiences and observations, we aim to raise awareness of the wider impacts that control framing can have on ED perceptions, treatment, recovery and individuals' lived experience.

RESULTS

We argue that although control can play a role in some ED experiences, an overemphasis upon this factor to the exclusion of other conceptualisations is not beneficial.

CONCLUSIONS

To mitigate against pathologisation of an individual, it is important to challenge a discourse that can lead to EDs being perceived as something 'wrong' with the individual, rather than a consequence of life events or other environmental influences. We identify priorities for the future for researchers, clinicians, policy makers and the wider public.

Learned industriousness as a translational mechanism in anorexia nervosa

It remains unexplained why some behaviours persist despite being non-hedonic and ostensibly aversive. This phenomenon is especially baffling when such behaviours are taken to excess in the form of psychopathology. Anorexia nervosa is one psychiatric disorder in which effortful behaviours that most people find unpleasant (suchas restrictive eating) are persistently performed. We propose thatthe social psychology theory of learned industriousness providesa novel mechanistic account for such phenomena. This theoryposits that high-effort behaviour can be conditioned to acquire secondary reinforcing properties through repeated pairing with reward. Accordingly, effort sensations become less aversive andmore appetitive, increasing willingness to engage in effortful behaviour. In this Perspective, we review pre-clinical behaviouraland biological data that support learned industriousness, contrast learned industriousness with other models of non-hedonic persistence (such as habit learning), highlight evidence that supports learned industriousness in individuals with anorexia nervosa and consider implications of the model, including translation to other psychiatric presentations.

The Effect of Exercise Motivation on Eating Disorders in Bodybuilders in Social Networks: The Mediating Role of State Anxiety

The aim of this study is to explore the relationship between exercise motivation and eating disorder and the mediating effect of anxiety in physical exercise. Athletes are in a social network, and the different human-machine relationships and situations generated in this may produce different sports motivations and anxiety states for athletes. The exercise motivation, status-trait anxiety, and eating disorder of 1076 fitness subjects were described and analyzed by questionnaire survey, and the survey data were statistically analyzed by means of correlation, regression, and structural equation model. The results showed that the overall detection rate of eating disorder was 56.3%. The overall detection rate of eating disorder was different between males and females. Exercise motivation has a significant positive correlation with state anxiety and eating disorder. Exercise motivation has a significant positive predictive effect on eating disorder, exercise motivation has a significant positive predictive effect on state anxiety, and state anxiety has a significant positive predictive effect on eating disorder. The mediating effect shows that state anxiety can partially mediate the relationship between exercise motivation and eating disorder, exercise motivation has a direct impact on eating disorder, and state anxiety has an indirect impact on eating disorder. In physical exercise, the exercisers’ bad exercise motivation will produce too much anxiety. Poor exercise motivation and anxiety can lead to symptoms of eating disorders. In physical exercise, we should adopt reasonable value orientation and positive psychological suggestion and encourage healthy and reasonable eating behavior, which will help to prevent and treat eating disorders.

Real-Life Self-Control Conflicts in Anorexia Nervosa: An Ecological Momentary Assessment Investigation

Background

Individuals with anorexia nervosa (AN) are often thought to show heightened self-control and increased ability to inhibit desires. In addition to inhibitory self-control, antecedent-focused strategies (e.g., cognitive reconstrual—the re-evaluation of tempting situations) might contribute to disorder maintenance and enable disorder-typical, maladaptive behaviors.

Methods

Over a period of 14 days, 40 acutely underweight young female patients with anorexia nervosa (AN) and 40 healthy control (HC) participants reported their affect and behavior in self-control situations via ecological momentary assessment during inpatient treatment (AN) and everyday life (HC). Data were analyzed via hierarchical analyses (linear and logistic modeling).

Results

Conflict strength had a significantly lower impact on self-control success in AN compared to HC. While AN and HC did not generally differ in the number or strength of self-control conflicts or in the percentage of self-control success, AN reported self-controlled behavior to be less dependent on conflict strength.

Conclusions

While patients with AN were not generally more successful at self-control, they appeared to resolve self-control conflicts more effectively. These findings suggest that the magnitude of self-control conflicts has comparatively little impact on individuals with AN, possibly due to the use of antecedent-focused strategies. If confirmed, cognitive-behavioral therapy might focus on and help patients to exploit these alternative self-control strategies in the battle against their illness.

Sense of agency during and following recovery from anorexia nervosa

The need to feel in control is central to anorexia nervosa (AN). The sense of control in AN has only been studied through self-report. This study investigated whether implicit sense of control (sense of agency; SoA) differs across AN patients, recovered AN (RAN) patients and healthy controls (HC). Furthermore, we assessed whether state anxiety is influenced by negative emotional states. SoA was measured with the intentional binding task (IB) and state-anxiety levels through a questionnaire. We did not find any evidence of differences in SoA between groups. Furthermore, state anxiety was not a significant predictor of SoA. Further research into SoA in AN should focus on other features of the SoA that are not targeted by the IB task.

Mastery Is Associated With Weight Status, Food Intake, Snacking, and Eating Disorder Symptoms in the NutriNet-Santé Cohort Study

Mastery is a psychological resource that is defined as the extent to which individuals perceive having control over important circumstances of their lives. Although mastery has been associated with various physical and psychological health outcomes, studies assessing its relationship with weight status and dietary behavior are lacking. The aim of this cross-sectional study was to assess the relationship between mastery and weight status, food intake, snacking, and eating disorder (ED) symptoms in the NutriNet-Santé cohort study. Mastery was measured with the Pearlin Mastery Scale (PMS) in 32,588 adults (77.45% female), the mean age was 50.04 (14.53) years. Height and weight were self-reported. Overall diet quality and food group consumption were evaluated with ≥3 self-reported 24-h dietary records (range: 3-27). Snacking was assessed with an ad-hoc question. ED symptoms were assessed with the Sick-Control-One-Fat-Food Questionnaire (SCOFF). Linear and logistic regression analyses were conducted to assess the relationship between mastery and weight status, food intake, snacking, and ED symptoms, controlling for sociodemographic and lifestyle characteristics. Females with a higher level of mastery were less likely to be underweight (OR: 0.88; 95%CI: 0.84, 0.93), overweight [OR: 0.94 (0.91, 0.97)], or obese [class I: OR: 0.86 (0.82, 0.90); class II: OR: 0.76 (0.71, 0.82); class III: OR: 0.77 (0.69, 0.86)]. Males with a higher level of mastery were less likely to be obese [class III: OR: 0.75 (0.57, 0.99)]. Mastery was associated with better diet quality overall, a higher consumption of fruit and vegetables, seafood, wholegrain foods, legumes, non-salted oleaginous fruits, and alcoholic beverages and with a lower consumption of meat and poultry, dairy products, sugary and fatty products, milk-based desserts, and sweetened beverages. Mastery was also associated with lower snacking frequency [OR: 0.89 (0.86, 0.91)] and less ED symptoms [OR: 0.73 (0.71, 0.75)]. As mastery was associated with favorable dietary behavior and weight status, targeting mastery might be a promising approach in promoting healthy behaviors.

Clinical Trial Registry Number

NCT03335644 at Clinicaltrials.gov.

Investigating Service Users' Perspectives of Eating Disorder Services: A Meta-Synthesis

Objective

Despite a number of qualitative studies published from the perspective of eating disorder (ED) service users, there has been no attempt to exclusively synthesize their views to gain a fuller understanding of their ED service experiences. It is important to understand this perspective, since previous research highlights the difficulties ED healthcare professionals report when working with this client group.

Method

A systematic search of the literature was conducted to identify qualitative studies focusing on experiences of ED services from the perspective of service users. Twenty‐two studies met the inclusion criteria and underwent a quality appraisal check using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. These were then synthesized using a meta‐synthesis approach.

Results

Four overarching themes were generated: “Treatment: Focus on physical vs. psychological symptoms”; “Service Environment: The role of control within services”; “Staff: Experiences with staff and the value of rapport”; and “Peer Influence: Camaraderie vs. comparison.” Service users expressed a desire for more psychological input to tackle underlying difficulties relating to their ED. A complex relationship with feelings of control was described, with some feeling over‐controlled by service providers, while others retrospectively recognized the need for control to be taken away. Staff values, knowledge and trust played a significant role in treatment and recovery. Peers with an ED were described to be a valuable source of understanding and empathy, but some found peer influence to perpetuate comparison and competitiveness.

Discussion

The results portray some of the conflicts and complexities that service users encounter in ED services. A running thread throughout is the perceived importance of adopting an individualized approach within these services.

Understanding the conversation around COVID-19 and eating disorders: A thematic analysis of Reddit

BACKGROUND

Current research has found dramatic changes in the lives of those with eating disorders (EDs) during the COVID-19 pandemic. We build on existing research to investigate the long-term effects and adaptations that people with EDs have faced due to COVID-19 related changes.

METHOD

We collected 234 posts from three separate time periods from the subreddit r/EatingDisorders and analyzed them using thematic analysis. The posts were examined for initial patterns, and then those concepts were grouped into themes to reveal the authentic experiences of people living with EDs during the COVID-19 pandemic.

RESULTS

Initially, we found "lack of control" and "familial influences (loved ones seeking support)" emerge as themes within our broader data set throughout all three timeframes. There were additional themes that were present in only one or two of the collection periods. These themes consisted of "symptom stress," "technical stresses and concerns," and "silver linings."

CONCLUSIONS

Our analysis shows that people with EDs have fought significantly during the pandemic. Initially, the (lack of) control and routine in their lives has caused symptoms to become more challenging, while being forced to move back home also caused significant stress. However, concerns transformed as the pandemic progressed, resulting in new pressures causing people to exhibit novel ED symptoms or relapse altogether. Also notable is the relatively few COVID-specific posts as the pandemic progressed, suggesting that people have accepted COVID as their "new normal" and begun to build resilience to the challenges associated. These are vital factors for clinicians to consider as they begin taking existing and new patients, particularly as face-to-face treatment options become a possibility again. Existing research shows that the COVID-19 pandemic has transformed the lives of people who live with eating disorders in various ways. First, the pandemic has placed barriers on the path to recovery by limiting coping mechanism (and sometimes removing them altogether) and changing their relationships with food and the people in their lives. Second, the pandemic has forced treatment options to change since ED patients can no longer seek treatment face-to-face. Finally, there have been unexpected benefits to the pandemic, such as allowing individuals time to slow down and focus on their mental health. Previous studies examined individuals in clinical contexts rather than in their natural environments. We explored an online forum for people with eating disorders for the various themes that were discussed at three points over the period of March 2020-December 2020 and found that many people with EDs report worsening symptoms or relapse. However, we also noted that, compared to the beginning of the pandemic, people seemed to be less frequently asking for support during the third data collection period, implying an adaptation to the "new normal" of life in a pandemic. We conclude with a discussion of the findings.

"It is the only constant in what feels like a completely upside down and scary world": Living with an eating disorder during COVID-19 and the importance of perceived control for recovery and relapse

The COVID-19 pandemic has had a profound, negative impact on the lives and wellbeing of much of the population, and it can raise additional challenges for individuals with eating disorders (EDs). During early stages of the UK lockdown, individuals reported disruptions to many aspects of their lives, including reduced feelings of control and serious concerns over the impact of the pandemic on ED symptoms and/or recovery. This study applied a mixed methods online survey to collect responses from 58 individuals (age 16-65yrs) with lived experience of EDs. Data was collected across two time points (April 2020 and June 2020) to explore the ongoing impacts of the pandemic on this population. The results suggest that higher perceptions of general, external control may be associated with ED recovery. Quantitative results show that individuals who reported recovering from their ED since the first time point, also reported significant increases in perceived control (compared to individuals who had relapsed or whose ED status was unchanged). Thematic analysis generated two themes: ED behaviours as an 'auxiliary control mechanism', and loss of auxiliary control after lockdown. Individuals who experienced less perceived control reported a tendency to rely upon eating disorder behaviours as an auxiliary coping mechanism, i.e., diminished external control was directed inwards and replaced with controlling their own behaviour. The preliminary results suggest that perceived control may be a significant factor in ED recovery. Individuals with EDs may be at significant risk of detrimental impacts on their recovery and wellbeing because of the pandemic reducing peoples' sense of control. These preliminary findings highlight the need for further research in this area, including investigation around potential interventions based upon strengthening perceptions of control to promote ED recovery.

Psychosocial health of adolescents in relation to underweight, overweight/obese status: the EU NET ADB survey

BACKGROUND

Both deviations from normal weight, namely, underweight and overweight/obese status, have been inversely associated with psychosocial health in adolescents. This study aimed to examine the relationship between psychosocial health and body mass index (BMI) among adolescents in five European countries, while assessing the effect of sociodemographic variables.

METHODS

A cross-sectional school-based study of adolescents aged 14-17.9 years was conducted in the framework of the European Network for Adolescent Addictive Behavior survey. Self-reported questionnaires from Greece, Iceland, the Netherlands, Romania and Spain were used for the current analysis. Associations between Youth Self-Report (YSR) scales and BMI status were investigated by multiple logistic regression analysis. The effect of sociodemographic variables was also measured.

RESULTS

Τhe sample consisted of 7005 adolescents aged 14-17.9 years. Borderline/clinical scores on some YSR scales were independently associated with overweight/obesity, specifically total problems (OR = 1.52, 95% CI: 1.18-1.96), internalizing ( OR = 1.48, 95% CI: 1.16-1.91), externalizing (OR = 1.36, 95% CI: 1.10-1.68), social (OR = 1.67, 95% CI: 1.19-2.35) and thought problems (OR = 1.62, 95% CI: 1.20-2.20). Among subscales, overweight/obesity specifically correlated with anxiety/depression (OR = 1.83, 95% CI: 1.33-2.51), withdrawal/depression (OR = 1.58, 95% CI: 1.02-2.48) and rule-breaking behavior (OR = 1.55, 95% CI: 1.15-2.08). Underweight was associated with problems on activities (OR = 1.31, 95% CI: 1.01-1.68) and withdrawal/depression (OR = 1.95, 95% CI: 1.27-3.01).

CONCLUSIONS

Lower levels of psychosocial health are associated with both deviations from normal weight. These findings suggest the need for health policies that target health habits and lifestyle, as well as positive attitudes towards the body image, with respect to the different psychosocial characteristics of each body weight status category.

Does ORTO-15 produce valid data for 'Orthorexia Nervosa'? A mixed-method examination of participants' interpretations of the fifteen test items

PURPOSE

Orthorexia Nervosa (ON) is defined as a pathological eating behaviour stemming from being "healthy" or "pure". Survey-based studies typically rely on the ORTO-15 questionnaire or its variations to detect orthorexia. However, frequent post-hoc adjustments to the ORTO-15 suggest psychometric problems. In this study, we explored people's cognitions about the ORTO-15 items to (1) identify problems specific to ORTO-15 items and (2) explore participants' understanding of ON symptoms.

METHODS

Fifty adult participants (40% male, mean age = 34.0 ± 14.4 years) completed the ORTO-15, the Eating Attitudes Test (EAT-26) and the Obsessive-Compulsive Inventory-Revised edition (OCI-R). Qualitative data were collected using the modified "think aloud" protocol, which asked participants to 'verbalise' their responses to the ORTO-15 items. These qualitative responses were first analysed conjunctively with the quantitative responses; then subjected to thematic analysis.

RESULTS

ORTO-15 identified 64% of the participants for orthorexic tendencies. In most cases (76%), participants reported no issues completing the ORTO-15. However, in some cases, qualitative responses differed from quantitative ones. When people encountered problems, it was because of poor psychometric construction: lack of clarity, ambiguous wording and multiple statements in a single item. Elaborations around the ORTO-15 items formed four major themes: "preoccupation with physical appearance", "control", "food is fuel" and "alone, not isolated".

CONCLUSION

Even though in the majority of cases there were no issues with completing ORTO-15, thematic analysis revealed several discrepancies between our participants' perceptions of the ORTO-15 items and the previously proposed diagnostic criteria for ON. The results suggest that ORTO-15 is, at best, a mediocre screening tool for ON, which is sensitive to diet but fails to have sufficient level of specificity to detect the pathological stage. More accurate instruments are needed to further research on ON.

LEVEL OF EVIDENCE

V (cross-sectional descriptive study with qualitative analysis).

A Reference-Dependent Computational Model of Anorexia Nervosa

Influential accounts interpret anorexia as arising from perfectionism, dichotomous thinking, and poor control expressed in a variety of life domains, resulting in low self-esteem. In this context, restraining eating would allow patients to re-establish some control and self-esteem. Although this view has offered important insight, one shortcoming is that constructs such as perfectionism, control, and dichotomous thinking, remain poorly specified. To clarify these constructs, we propose a computational model of anorexia. This relies on previous theories of evaluation, which highlight its reference-dependent nature: when attributing a value to an outcome, our brain automatically assesses the outcome relative to its context. Following these theories, the model proposes that a high reference point explains general characteristics such as perfectionism, dichotomous thinking, low self-esteem, and low sense of control. These characteristics would result specifically in anorexia when the sense of control regarding body shape, compared with other life domains, is relatively high. The model raises the possibility that reference effects also might explain why patients pursue extremely low weight; exposure to skinny body images-one product of obsessive dieting-might change the reference point for their own body, hence leading to extremely low body weight, staunch refusal to gain weight, and body misperceptions. The model contributes to clarify key concepts adopted in the literature and their relation. Such computational formulation might help to foster theoretical debate, formulating novel empirical predictions, and integrate psychological and neuroscientific perspectives on anorexia.

Eating disorders and the orthodontist: Diagnosis, considerations and referral

BACKGROUND

Eating disorders are relatively common mental health disorders in Western European and North American populations. The peak incidence occurs within the adolescent years, which correlates with the largest orthodontic patient population. The morbidity associated with these psychological conditions is significant, and has a direct impact upon patient well-being, orthodontic outcomes and the success of treatment. Therefore, it is of relevance to the orthodontist to be aware of potential presenting features of these conditions, when and where to seek advice, and how such disorders may impact upon orthodontic outcomes.

METHODS

Articles published on PUBMED and MEDLINE relevant to orthodontics and eating disorders were reviewed. Key information was extracted, and the relevant evidence for the orthodontist summarised.

RESULTS

Eating disorders may present to the orthodontist in specialist or hospital practice, either undiagnosed or as a co-morbidity. Orthodontists may benefit from an appreciation of these potential diagnoses, the orthodontic implications and to have the confidence to refer their patients to the necessary services.

LIMITATIONS

There is little existing research in this area.

CONCLUSIONS

These conditions have a significant impact on patient morbidity and mortality. This cohort of patients is not suitable for orthodontic treatment while their disease is active. The impact of a developing eating disorder can adversely affect orthodontic treatment.

Mediating role of depressive symptoms linking insecure attachment and disordered eating in adolescents: A multiwave longitudinal study

Research has supported a link between insecure attachment and disordered eating in adolescents; however, how this influence is exerted remains unclear. This study explored whether depressive symptoms constitute a pathway through which insecure attachment to parents predicts subsequent development of disordered eating in the transition from childhood to adolescence. The study also examines whether there are differential effects regarding the attachment figure, child's gender, or reciprocity between variables. A community-based sample of Spanish youth (n = 904; 49.4% girls) was followed biennially from age 10 to 16 years. Attachment, depressive symptoms, and disordered eating were measured using the Inventory of Parental and Peer Attachment, Children's Depression Inventory, and Children's Eating Attitudes Test, respectively. Prospective data were analyzed using a dynamic panel model, which accounts for unmeasured time-invariant factors. Whereas insecure attachment to the father did not predict later depression or disordered eating, higher insecure attachment to the mother at ages 10 and 12 years predicted more disordered eating at ages 14 and 16 years via increased depressive symptoms at ages 12 and 14 years. No child's gender-specific or reverse mediational effects were found. This study suggests that an increase in depressive symptoms might be one mechanism by which insecure attachment exerts its influence on the development of eating disorders symptomatology in adolescence. Intervention efforts aimed at strengthening particularly the mother-child attachment relationship may reduce the vulnerability to develop depressive symptoms and disordered eating.

What prevents young adults from seeking help? Barriers toward help-seeking for eating disorder symptomatology

OBJECTIVES

The aim of this study was to investigate help-seeking attitudes, intentions, and behaviors, and to systematically explore perceived barriers to help-seeking for eating, weight, or shape concerns among young adults. Differences in perceived barriers as a function of type of eating disorder symptomatology were also examined.

METHOD

Data were collected using an online survey among individuals (aged 18-25 years) in Australia. Overall, 291 young adults with varying levels of eating disorder symptoms completed measures of disordered eating, weight or shape concerns, help-seeking barriers, attitudes, intentions, and behaviors. According to their self-reported symptoms, participants were classified into four subgroups (i.e., anorexia nervosa [AN] symptoms, bulimia nervosa [BN] symptoms, binge-eating disorder [BED] symptoms, and other eating disorder symptoms).

RESULTS

Despite the belief that help-seeking is useful, only a minority of participants with elevated symptoms, namely those with AN, BN, and BED symptoms, believed they needed help. Across the sample, the most frequently cited barriers to seeking help for eating disorder symptoms were: concern for others, self-sufficiency, fear of losing control, denial and failure to perceive the severity of the illness, and stigma and shame.

DISCUSSION

The findings highlight the need to educate young adults about the severity of eating disorders and the importance of seeking help, and to increase the awareness of help-seeking barriers among those designing public health interventions as well as clinicians. Our findings suggest that help-seeking barriers may differ depending on the type of eating disorder symptomology.

A naturalistic investigation of cognitive-affective dysfunction in anorexia nervosa: The role of inefficiency

OBJECTIVE

Research has shown that rumination and negative affect are elevated in patients with anorexia nervosa (AN), but the underlying origins remain unclear. Drawing from the theoretical framework of the Goal Progress Theory of rumination, we propose that heightened feelings of "inefficiency" (i.e., low self-efficacy) in AN might play an important role in these dysfunctional cognitive-affective processes.

METHOD

Thirty-two weight-recovered participants with a history of AN and 32 healthy control participants filled out questionnaires regarding rumination and affect six times a day over a period of 2 weeks via ecological momentary assessment in real-life.

RESULTS

Analyses via hierarchical as well as conceptual process modeling suggest that while inefficiency is generally associated with more rumination and negative affect, additional amplifying mechanisms between these variables exist specifically in recovered participants with a history of AN.

DISCUSSION

Inefficiency as a core aspect of AN appears to trigger dysfunctional cognitive-affective processes which may contribute to vulnerability for AN.

Development and validation of the eating disorder fear questionnaire and interview: Preliminary investigation of eating disorder fears

Anxiety is highly characteristic of eating disorders (ED). Despite high levels of anxiety, little is known about ED specific fears. The current study developed and tested the psychometric properties of two measures of ED fears in two samples (N = 513 undergraduates; N = 129 clinical EDs): a self-report measure (Eating Disorder Fear Questionnaire; EFQ) and interview (Eating Disorder Fear Interview; EFI). We found strong support for a five-factor EFQ consisting of subscales assessing fear of weight gain, social consequences, personal consequences, physical sensations, and social eating. We found strong support for a six-factor EFI consisting of subscales assessing fear of food, weight gain, physical sensations, personal consequences, social consequences, and exercise-related fears. Both measures had adequate to strong internal consistency and convergent, divergent, incremental, and construct validity. These measures can be used to identify ED fears that can be targeted in personalized treatment. These data show that ED fears are multifaceted and heterogeneous.

Motivation for sport participation and eating disorder risk among female collegiate athletes

In light of conflicting research regarding eating disorder risk and sports participation, the current study examined the relationship between specific aspects of sports participation (i.e., level of competition, leanness requirements, and physical/cardiovascular intensity level), an individual's motivation for sports participation, and eating disorder symptomatology/risk. Participants included 319 female collegiate athletes (M age = 19.88; SD = 1.62) representing a variety of sports and competition levels. Multilevel modeling found that level of competition, receiving a scholarship, age, and years of collegiate sport played did not predict eating disorder risk. In the final model, there was a significant interaction between intrinsic motivation and sport intensity. For high intensity sports, higher levels of intrinsic motivation were associated with lower eating disorder risk. For low intensity sports, the level of intrinsic motivation did not impact eating disorder risk. For all sport intensities, extrinsic motivation was associated with a higher eating disorder risk. Results suggest that it is not the specific sport but athletes' motivation for those sports with high physical/cardiovascular intensity and leanness requirements that is associated with untoward consequences. The results clarify conflicting results previously reported in the literature that have primarily employed univariate analyses and have implications for athletic development programs.

Injury and Disordered Eating Behaviors: What is the Connection for Female Professional Dancers?

Dancers, like athletes, frequently endure injuries and disordered eating as a result of performance-specific demands. The purpose of this study was to explore the relationship between severe injuries and disordered eating from the perspectives of female professional dancers. In-depth, semi-structured interviews were conducted with 13 female professional dancers ages 18–38 (M = 23; SD = 6.2) whose dance participation was suspended for 4–36 weeks (M = 12.69; SD = 10.09) due to a dance-related injury. We adopted a social constructivist stance to view the experiences of dancers through the lens of a phenomenon highly influenced by environmental and cultural factors. A thematic analysis yielded five themes including negative emotions associated with injury, anxiety and uncertainty around future involvement, modifications in nutritional intake (e.g., reduction of calories), coping with injury, and the need for an effective and holistic injury rehabilitation program.

A network analysis of eating disorder symptoms and characteristics in an inpatient sample

Eating disorders (EDs) are characterized by symptoms that reflect disturbed eating habits. Available data on EDs largely reflects a traditional latent variable model, whereby symptoms reflect an underlying entity. The network model is an alternative approach where ED symptoms do not reflect an inferred, unobservable category or dimension, but rather are themselves constitutive of the disorder. In the present study, data from ED patients (n = 5193) that completed the Eating Disorders Inventory - 2 (EDI-2; Garner, 1991) before and after inpatient treatment were used to identify symptoms (i.e., body dissatisfaction) and characteristics (i.e., perfectionism) central to EDs. Results revealed that interoceptive awareness and ineffectiveness, but not body dissatisfaction and drive for thinness, were central to the ED network at admission and discharge. Although effect sizes were small, multiple regression analyses revealed that ineffectiveness at admission predicted discharge BMI (over and above interoceptive awareness and BMI at admission) and discharge depression (over and above interoceptive awareness and depression at admission), but not discharge anxiety. These findings suggest that interoceptive awareness and ineffectiveness are central symptoms of EDs that may have implications for treatment outcome. The implications of these findings for conceptualizing the nature and treatment of EDs are discussed.

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.

Psychological need satisfaction, control, and disordered eating

OBJECTIVES

Unfulfilled basic psychological needs have been associated with disordered eating behaviours, but the mechanisms underlying that associations are not well understood. This study examined a two-stage path model linking basic psychological need satisfaction to disordered eating behaviours via issues of control.

METHODS

Female university students (N = 323; M_age  = 19.61), community participants (N = 371; M_age  = 29.75), and women who self-reported having been diagnosed with an eating disorder (ED; N = 41; M_age  = 23.88) completed measures of psychological need satisfaction (i.e., autonomy and competence), issues of control (i.e., feelings of ineffectiveness and fear of losing self-control [FLC]), and ED pathology.

RESULTS

Path analysis revealed that unsatisfied needs of autonomy and competence were indirectly related to disordered eating behaviours through feelings of ineffectiveness and FLC.

CONCLUSIONS

The results indicate that issues of control might be one of the mechanisms through which lack of psychological need satisfaction is associated with disordered eating. Although the model was constructed using cross-sectional data, these findings suggest potential targets for prevention and treatment efforts aimed at reducing disordered eating in young females.

PRACTITIONER POINTS

Our results indicate that young women with chronically unfulfilled basic psychological needs might be vulnerable to developing disordered eating behaviours. The observed patterns suggest that persistent experience of need frustration may engender an internal sense of ineffectiveness and lack of control, which then compels individuals to engage in disordered eating behaviours in an attempt to regain autonomy and competence. Interventions for eating disorders may be most effective when emphasizing the promotion of people's needs for autonomy and competence. Limitations The model was constructed using cross-sectional data. Future experimental and longitudinal studies are needed to confirm the temporal sequence from basic psychological needs to issues of control. The sample only consisted of young women. Further research should explore how thwarting of psychological need satisfaction functions in men. Our clinical sample was small and diagnosis was not confirmed through clinical interview; therefore, those data should be interpreted with caution.