Perfectionism in anorexia nervosa: novel performance based evidence

Exaggerated frontoparietal control over cognitive effort-based decision-making in young women with anorexia nervosa

Effortful tasks are generally experienced as costly, but the value of work varies greatly across individuals and populations. While most mental health conditions are characterized by amotivation and effort avoidance, individuals with anorexia nervosa (AN) persistently engage in effortful behaviors that most people find unrewarding (food restriction, excessive exercise). Current models of AN differentially attribute such extreme weight-control behavior to altered reward responding and exaggerated cognitive control. In a novel test of these theoretical accounts, we employed an established cognitive effort discounting paradigm in combination with fMRI in young acutely underweight female patients with AN (n = 48) and age-matched healthy controls (HC; n = 48). Contrary to the hypothesis that individuals with AN would experience cognitive effort (operationalized as N-back task performance) as less costly than HC participants, groups did not differ in the subjective value (SV) of discounted rewards or in SV-related activation of brain regions involved in reward valuation. Rather, all group differences in both behavior (superior N-back performance in AN and associated effort ratings) and fMRI activation (increased SV-related frontoparietal activation during decision-making in AN even for easier choices) were more indicative of increased control. These findings suggest that while effort discounting may be relatively intact in AN, effort investment is high both when performing demanding tasks and during effort-based decision-making; highlighting cognitive overcontrol as an important therapeutic target. Future research should establish whether exaggerated control during effort-based decision-making persists after weight-recovery and explore learning the value of effort in AN with tasks involving disorder-relevant effort demands and rewards.

Autistic traits and perspective taking in youths with anorexia nervosa: an exploratory clinical and eye tracking study

BACKGROUND

Despite their apparent dissimilarity, Anorexia Nervosa (AN) and Autism Spectrum Disorder (ASD) share many features, especially in terms of social and emotional difficulties. In recent years, empathic abilities in AN have been frequently assessed using self-report measures. Otherwise, the director task (DT) has been used to investigate the ability to take the visual perspective of another individual in a communicative context, using eye-tracking technology. The aim of the current study was to test the presence of autism-relevant features in AN, through: (i) comparing self-reported autistic traits and empathic abilities in a group of young inpatients with AN and age/gender matched healthy controls (HC); (ii) comparing performance on the director paradigm.

METHODS

The participants were females in the age-range between 11 and 18 years: 24 with AN and 23 HC. Autistic traits, empathic abilities, and severity of the eating disorder were respectively measured using: the Autism Quotient (AQ), the Interpersonal Reactivity Index (IRI), and the Eating Disorder Inventory-3 (EDI-3). Both groups performed a computerized task in which a director instructed them to move objects placed on a set of shelves using a mouse, while their eye gaze was tracked. A total of 36 shelf configurations, divided into three categories (with dimensional distractor - with spatial distractor - control), were created.

RESULTS

Subjects with AN showed higher autistic traits than HC. Eye-tracking data revealed that subjects with AN took longer to decide which object to select and where to move it, both in distractor-trials and in control-trials. In the AN group, we found a significant negative correlation between the total score of the AQ and the number of fixations to the irrelevant object in the dimensional control condition -in which the subjects were asked to focus on dimensional aspects of the object (large-small)-.

CONCLUSIONS

Autistic traits were over-represented in a group of young inpatients with AN. Through the use of eye-tracking technology, this exploratory study documented some differences between AN inpatients and HC in their online processes during the perspective taking tasks, which could be considered a target of tailored intervention. A larger sample of patients is needed to confirm these preliminary findings.

Genetic polymorphisms and their association with neurobiological and psychological factors in anorexia nervosa: a systematic review

Background and aims

Anorexia nervosa (AN) is a complex neuropsychiatric disorder. This systematic review synthesizes evidence from diverse studies to assess and investigate the association between gene polymorphisms and psychological and neurobiological factors in patients with AN.

Methods

A systematic search across PubMed, PsycINFO, Scopus, and Web of Science databases, along with manual searching, was conducted. The review protocol was approved by PROSPERO (CRD42023452548). Out of 1,250 articles, 11 met the inclusion criteria. The quality of eligible articles was assessed using the Newcastle-Ottawa Scale (NOS) tool. The systematic review followed the PRISMA guidelines.

Results

The serotoninergic system, particularly the 5-HTTLPR polymorphism, is consistently linked to altered connectivity in the ventral attention network, impaired inhibitory control, and increased susceptibility to AN. The 5-HTTLPR polymorphism affects reward processing, motivation, reasoning, working memory, inhibition, and outcome prediction in patients with AN. The dopaminergic system, involving genes like COMT, DRD2, DRD3, and DAT1, regulates reward, motivation, and decision-making. Genetic variations in these dopaminergic genes are associated with psychological manifestations and clinical severity in patients with AN. Across populations, the Val66Met polymorphism in the BDNF gene influences personality traits, eating behaviors, and emotional responses. Genes like OXTR, TFAP2B, and KCTD15 are linked to social cognition, emotional processing, body image concerns, and personality dimensions in patients with AN.

Conclusion

There was an association linking multiple genes to the susceptibly and/or severity of AN. This genetic factor contributes to the complexity of AN and leads to higher diversity of its clinical presentation. Therefore, conducting more extensive research to elucidate the underlying mechanisms of anorexia nervosa pathology is imperative for advancing our understanding and potentially developing targeted therapeutic interventions for the disorder.Systematic review registration: [https://clinicaltrials.gov/], identifier [CRD42023452548].

Performing well but not appreciating it - A trait feature of anorexia nervosa

Background

Despite advances in the etiology of anorexia nervosa (AN), a large subgroup of individuals does not profit optimally from treatment. Perfectionism has been found to be a risk factor predicting the onset, severity, and duration of AN episodes. To date, perfectionism has been studied predominantly by the use of self-report questionnaires, a useful approach that may, however, be impacted by demand characteristics, or other distortions of introspective or metacognitive access.

Methods

Here we circumvent these problems via a behavioral paradigm in which participants perform a modified Go/NoGo task, whilst self-evaluating their performance. We compared a group of 33 adolescent females during their first episode of AN (age = 16.0) with 29 female controls (age = 16.2), and 23 adolescent girls recovered from AN (age = 18.3) with 23 female controls (age = 18.5). The controls were closely matched by intelligence quotient and age to the two clinical groups.

Results

First-episode AN and control participants performed equally well on the task (reaction time and errors of commission), whereas the recovered group displayed significantly faster reaction times but incurred the same error rate. Despite performing at least as good as and predominantly better than control groups, both clinical groups evaluated their performances more negatively than controls.

Conclusion

We offer a novel behavioral method for measuring perfectionism independent of self-report, and we provide tentative evidence that this behavioral manifestation of perfectionism is evident during first-episode AN and persists even after recovery.

A randomized clinical trial of a gamified app for the treatment of perfectionism

OBJECTIVES

Perfectionism is a common transdiagnostic problem that may lead to substantial distress and functional impairments. Cognitive behavioural therapy (CBT) is an effective treatment for perfectionism. However, the existing significant barriers to access and utilization of mental health services, including among college students, demand the development of low-intensity accessible interventions. The aim of the present study was to evaluate the effectiveness of a low-intensity CBT-based self-help gamified app developed specifically for perfectionism in a sample of college students.

METHODS

Participants completed assessments of perfectionism, related symptoms, emotional burden and functional impairments at pretreatment, posttreatment and at one-month follow-up.

RESULTS

Compared with the waitlist condition (n = 35), the app condition (n = 35) demonstrated a significant and greater reduction in perfectionism, obsessive-compulsive symptoms, functional impairments and subjective ratings of emotional burden.

CONCLUSIONS

Results suggest that a brief, daily app-based game-like intervention targeting maladaptive perfectionistic beliefs may be a viable, low-cost alternative to traditional CBT treatments for vulnerable populations on college campuses.

Did Kant suffer from misophonia?

Misophonia is a disorder of decreased tolerance to specific sounds, often produced by humans but not always, which can trigger intense emotional reactions (anger, disgust etc.). This relatively prevalent disorder can cause a reduction in the quality of life. The causes of misophonia are still unclear. In this article, we develop a hypothesis suggesting that misophonia can be caused by a failure in the organization of the perceived world. The perceived world is the result of both the structure of human thought and the many conditioning factors that punctuate human life, particularly social conditioning. It is made up of abstract symbols that map the world and help humans to orient himself in a potentially dangerous environment. In this context, the role of social rules acquired throughout life is considerable. Table manners, for example, are a set of deeply regulated and controlled behaviors (it's considered impolite to eat with the mouth open and to make noise while eating), which contribute to shape the way the perceived world is organized. So it's not surprising to find sounds from the mouth (chewing etc.) among the most common misophonic sound triggers. Politeness can be seen as an act of obedience to moral rules or courtesy, which is a prerequisite for peaceful social relations. Beyond this example, we also argue that any sound can become a misophonic trigger as long as it is not integrated into the perceived ordered and harmonious world, because it is considered an "anomaly," i.e., a disorder, an immorality or a vulgarity.

Acoustics Features of Voice in Adolescent Females With Anorexia Nervosa

INTRODUCTION

The process of human voice production is a complex physiological and acoustic phenomenon that depends on many structural, physical, and hormonal factors, systemic diseases as well as emotional states. All these factors can be present in eating disorders. However, studies on eating disorders and voice problems have usually been evaluated in terms of bulimia. Chronic starvation and emotional problems in the course of anorexia nervosa (AN) appear to be under-researched, despite various biochemical, metabolic, and hormonal changes.

OBJECTIVE

The purpose of this study was to evaluate voice quality, specifically acoustic analysis, in adolescent female with AN from the point of view of the possible influence on the function and structure of the larynx, low body mass accompanying AN, as well as energy deficiency, hormonal and emotional disturbances.

MATERIALS AND METHODS

A total of 84 girls diagnosed with AN (Gr.A) (15.32 years, SD = 2.12; range 12-19, BMI = 14.11 ± 1.72) were assessed for the condition of the voice such as perceptual voice evaluation on the GRBAS scale, maximal phonation time (MPT), laryngoscopy, with special attention to voice acoustic analysis - Multi-Dimensional Voice Program (MDVP). The control group (Gr.C) included 62 girls without eating disturbances (aged 12-19, mean age 15.41 ± 2.40, BMI = 21.60 ± 1.92). Perceptual voice assessment, aerodynamic test MPT, and acoustic parameters were analyzed according to girls' age.

RESULTS

Total GRBAS scale was higher in girls with AN compared to the control group mainly for two parameters: breathiness (B) (P = 0.00015) and asthenia (A) (P < 0.05). The MPT for Gr.A was significantly shorter compared to Gr.C (15.40 ± 3.51 seconds vs. 23.19 ± 5.17 seconds) (P < 0.001), and a correlation of MPT values with the age of the adolescent female was observed: Spearman's coefficient for Gr.A = (-)0.5378, for Gr.C = 0.5516 (P = 0.0012). Acoustic analysis revealed the decrease in the basic frequency F0 in Gr.A compared to Gr.C (231.08 Hz vs. 242.30 Hz), and narrowing of the voice scale was observed, resulting mainly from a reduction in the upper limit. Significant differences were found for measures of frequency perturbations (Jita, Jitter, RPA, PPQ, sPPR), with Gr.A scoring significantly higher than Gr.C (P < 0.05 for all). Significant changes in voice acoustic analysis parameters were found with age. Negative correlations were found for measures of F0 for Gr.A to a much greater extent compared to Gr.C. Positive correlations were found with measures of tremor assessment (SPI, FTRI, ATRI) for Gr.A.

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.

Associations between Schizotypal Facets and Symptoms of Disordered Eating in Women

Research has suggested that schizotypy-a personality organisation representing latent vulnerability for schizophrenia-spectrum disorders-may be elevated in women with symptoms of disordered eating. However, studies have not fully considered associations between symptoms of disordered eating and multidimensional schizotypy. To overcome this limitation, we asked an online sample of 235 women from the United States to complete measures of symptoms of disordered eating (drive for thinness, body dissatisfaction, and bulimic symptoms) and multidimensional schizotypy. Correlational analyses indicated significant associations between drive for thinness and bulimic symptoms, respectively, and most schizotypal facets. Body dissatisfaction was significantly associated with only two schizotypal facets. Overall, the strength of correlations was weak-to-moderate. Regression results indicated that only the schizotypal feature of excessive social anxiety was significantly associated with all risk for disordered eating factors. These results are consistent with aetiological models of disordered eating that highlight socio-affective difficulties as risk factors for symptoms of disordered eating.

Emotional Eating and Perfectionism as Predictors of Symptoms of Binge Eating Disorder: The Role of Perfectionism as a Mediator between Emotional Eating and Body Mass Index

(1) Background: Perfectionism has been linked to eating disorders and might be a risk factor for the appearance of eating pathologies. The aims of this study are (a) to verify the relationship between perfectionism, emotional eating (EE), binge eating (BE), and body mass index (BMI); (b) to identify the variables that predict BE symptoms and BMI; (c) to study the role of perfectionism as a mediator between EE and BMI. (2) Methods: 312 adult participants answered a cross-sectional survey that included the Multidimensional Perfectionism Scale, the Emotional Eater Questionnaire (EEQ), the Binge Eating Scale (BES), and a sociodemographic questionnaire including BMI. (3) Results: The results suggest a direct correlation between EE, BE, and BMI, showing that EE is a powerful predictor of BE symptoms and BMI. Furthermore, two dimensions of perfectionism have a mediator role between EE and BMI, specifically doubts and actions and concern over mistakes: the presence of these two components of perfectionism reverses the relationship between EE and BMI. (4) Conclusions: These results have significant implications for the understanding of the two different (pathological) eating patterns: intake restriction and overeating and should be considered in intervention programs.

Adolescent, parent, and provider perspectives on school-related influences of mental health in adolescents with suicide-related thoughts and behaviors

Previous research supports a link between school-related factors, such as bullying and school connectedness, and suicidal thoughts and behaviors. To deepen understanding of how school experiences may function as both protective and risk factors for youth struggling with suicidal thoughts and behaviors, this qualitative study explored multiple perspectives. Specifically, in-depth interviews were conducted with adolescents previously hospitalized for a suicidal crisis (n = 19), their parents (n = 19), and the professionals they may interact with in schools and hospitals (i.e., school professionals [n = 19] and hospital providers [n = 7]). Data were analyzed using applied thematic analysis revealing three main themes related to perceptions of how school experiences can positively or negatively impact mental health, including (a) school activities, (b) school social experiences, and (c) school interventions. An emergent theme related to the complexity of suicide-related risk identified the ways in which school experiences may intersect with other environmental, biological, and psychological factors. Findings underscore the need for school-based approaches to address the unique academic, social, and emotional needs of students with suicide-related risk that complement the supports and services provided in their home and community.

Beyond Description and Deficits: How Computational Psychiatry Can Enhance an Understanding of Decision-Making in Anorexia Nervosa

PURPOSE OF REVIEW

Despite decades of research, knowledge of the mechanisms maintaining anorexia nervosa (AN) remains incomplete and clearly effective treatments elusive. Novel theoretical frameworks are needed to advance mechanistic and treatment research for this disorder. Here, we argue the utility of engaging a novel lens that differs from existing perspectives in psychiatry. Specifically, we argue the necessity of expanding beyond two historically common perspectives: (1) the descriptive perspective: the tendency to define mechanisms on the basis of surface characteristics and (2) the deficit perspective: the tendency to search for mechanisms associated with under-functioning of decision-making abilities and related circuity, rather than problems of over-functioning, in psychiatric disorders.

RECENT FINDINGS

Computational psychiatry can provide a novel framework for understanding AN because this approach emphasizes the role of computational misalignments (rather than absolute deficits or excesses) between decision-making strategies and environmental demands as the key factors promoting psychiatric illnesses. Informed by this approach, we argue that AN can be understood as a disorder of excess goal pursuit, maintained by over-engagement, rather than disengagement, of executive functioning strategies and circuits. Emerging evidence suggests that this same computational imbalance may constitute an under-investigated phenotype presenting transdiagnostically across psychiatric disorders. A variety of computational models can be used to further elucidate excess goal pursuit in AN. Most traditional psychiatric treatments do not target excess goal pursuit or associated neurocognitive mechanisms. Thus, targeting at the level of computational dysfunction may provide a new avenue for enhancing treatment for AN and related disorders.

Understanding implicit and explicit learning in adolescents with and without anorexia nervosa

BACKGROUND

Cognitive disturbances such as impairments in learning are thought to play a role in adult Anorexia Nervosa (AN). It is remains unclear to what extent these disturbances result from starvation of the brain, or relate to an abnormal premorbid cognitive profile. This study investigates learning processes in adolescents with AN, hypothesizing that implicit learning is intact, as found previously in explicit learning tasks. Secondly, we hypothesized that anxiety and depression symptoms, inherent to AN, are associated to learning processes in AN.

METHODS

In total 46 adolescents diagnosed with AN and 44 control participants were administered an implicit category learning task in which they were asked to categorize simple perceptual stimuli (Gabor patches) based on a linear integration (i.e., an implicit task) of orientation and spatial frequency of the stimulus. A subgroup of adolescents (n = 38) also completed a task assessing explicit learning.

RESULTS

Model-based analyses indicated that adolescents with AN performed significantly more accurately compared to their healthy peers regardless of whether they used the optimal strategy or not. Depression and anxiety did not relate to learning performance in the AN group.

CONCLUSIONS

Overall, our findings of augmented implicit and explicit learning in adolescents with AN corroborate recent studies that suggested higher stimulus-response learning during prediction error paradigms. Learning disturbances in adult AN may then be at least partly due to long-term malnourishment, highlighting the importance of early recognition and refeeding in treatments for AN.

Deficient Goal-Directed Control in a Population Characterized by Extreme Goal Pursuit

Research in computational psychiatry has sought to understand the basis of compulsive behavior by relating it to basic psychological and neural mechanisms: specifically, goal-directed versus habitual control. These psychological categories have been further identified with formal computational algorithms, model-based and model-free learning, which helps to provide quantitative tools to distinguish them. Computational psychiatry may be particularly useful for examining phenomena in individuals with anorexia nervosa (AN), whose self-starvation appears both excessively goal directed and habitual. However, these laboratory-based studies have not aimed to examine complex behavior, as seen outside the laboratory, in contexts that extend beyond monetary rewards. We therefore assessed (1) whether behavior in AN was characterized by enhanced or diminished model-based behavior, (2) the domain specificity of any abnormalities by comparing learning in a food-specific (i.e., illness-relevant) context as well as in a monetary context, and (3) whether impairments were secondary to starvation by comparing learning before and after initial treatment. Across all conditions, individuals with AN, relative to healthy controls, showed an impairment in model-based, but not model-free, learning, suggesting a general and persistent contribution of habitual over goal-directed control, across domains and time points. Thus, eating behavior in individuals with AN that appears very goal-directed may be under more habitual than goal-directed control, and this is not remediated by achieving weight restoration.

Moving towards specificity: A systematic review of cue features associated with reward and punishment in anorexia nervosa

Models of anorexia nervosa (AN) posit that symptoms are maintained through deficient reward and enhanced punishment processing. However, theoretical and empirical inconsistencies highlight the need for a more nuanced conceptualization of this literature. Our goal was to comprehensively review the research on reward and punishment responding in AN from a cue-specific lens to determine which stimuli evoke or discourage reward and punishment responses in this population, and, ultimately, what properties these rewarding and punishing cues might share. A systematic review interrogating reward and punishment responses to specific cues yielded articles (n = 92) that examined responses to disorder relevant (e.g., food) and irrelevant (e.g., money) stimuli across self-report, behavioral, and biological indices. Overall, in most studies individuals with AN exhibited aversive responses to cues signaling higher body weights, social contexts, and monetary losses, and appetitive responses to cues for weight loss behaviors and thinness. Findings were more mixed on responses to palatable food and monetary gains. Results highlight that reward and punishment responding in AN are context specific and may be affected by varied stimulus qualities (e.g., predictability, controllability, delay, effort). Increasing specificity in future research on reward and punishment mechanisms in AN will better inform development of precisely-targeted interventions.

Goal-directed vs. habitual instrumental behavior during reward processing in anorexia nervosa: an fMRI study

Previous studies have proposed that altered reward processing and elevated cognitive control underlie the etiology of anorexia nervosa (AN). A newly debated notion suggests altered habit learning and an overreliance on habits may contribute to the persistence of AN. In weight-recovered AN patients, we previously found neuroimaging-based evidence for unaltered reward processing, but elevated cognitive control. In order to differentiate between state versus trait factors, we here contrast the aforementioned hypotheses in a sample of acutely underweight AN (acAN) patients. 37 acAN patients and 37 closely matched healthy controls (HC) underwent a functional MRI while performing an established instrumental motivation task. We found no group differences with respect to neural responses during the anticipation or receipt of reward. However, the behavioral response data showed a bimodal distribution, indicative for a goal-directed (gAN) and a habit-driven (hAN) patient subgroup. Additional analyses revealed decreased mOFC activation during reward anticipation in hAN, which would be in line with a habit-driven response. These findings provide a new perspective on the debate regarding the notion of increased goal-directed versus habitual behavior in AN. If replicable, the observed dissociation between gAN and hAN might help to tailor therapeutic approaches to individual patient characteristics.

Similarities and Differences in Theory of Mind Responses of Patients With Anorexia Nervosa With and Without Autistic Features

Theory of Mind (ToM) is the ability to understand and represent mental states of others, a skill that plays a key role in how we interact with people around us. Difficulties with ToM have been posited as an underlying mechanism for autism and implicated in difficulties faced by those with anorexia nervosa (AN). This study examined, both quantitatively and qualitatively, the responses of women between the ages of 14 and 25 years on the Frith-Happé Triangle Animations, a well-validated test of ToM. Participants were split into healthy controls (HCs), AN patients (AN), and AN patients with high levels of autistic features (AN+ASF). We found no significant quantitative differences between groups in performance on the task. Qualitatively, there were differences between groups such that AN patients, especially those in the AN+ASF group, were more focused on describing the videos than creating narratives, were more negative in their interpretations, and were much more anxious about their performance. These qualitative differences have clinical implications, including that not all AN patients with autistic features should be assumed to have difficulties with ToM.

Social anxiety in the eating disorders: a systematic review and meta-analysis

Social anxiety disorder is one of the most common comorbid conditions in eating disorders (EDs). The aim of the current review and meta-analysis is to provide a qualitative summary of what is known about social anxiety (SA) in EDs, as well as to compare levels of SA in those with EDs and healthy controls. Electronic databases were systematically searched for studies using self-report measures of SA in ED populations. In total, 38 studies were identified, 12 of which were included in the meta-analyses. For both anorexia nervosa (AN) and bulimia nervosa, there were significant differences between ED groups and HCs, with medium to large effect sizes. Findings from the qualitative review indicate that levels of SA are similar across the ED diagnoses, and SA improves with treatment in AN. In addition, high levels of SA are associated with more severe ED psychopathology, but not body mass index. These findings add to the wider literature on socio-emotional functioning in EDs, and may have implications for treatment strategies.

Increased delayed reward during intertemporal decision-making in schizophrenic patients and their unaffected siblings

Intertemporal choices are decisions with consequences in multiple time periods and constitute a significant part of social cognition. The shared neuropathological characteristics of patients with schizophrenia and their siblings might express intermediate phenotypes in behavior that could be used to further characterize the illness. Schizophrenic patients, unaffected siblings, and healthy controls underwent a computerized version of the "Intertemporal Choice Task". All participants could choose between sooner-smaller (SS) and later-larger (LL) options in now-trials and in not-now-trials. Subjects also underwent a battery of cognitive neuropsychological assessment. Our results indicated that schizophrenic patients and unaffected siblings both had a tendency to choose LL options in now-trials or not-now-trials compared to healthy controls. Schizophrenic patients had significantly lower scores in several cognitive tasks, including MoCA, attention, executive functions, and information processing when compared with the other two groups. Moreover, within the schizophrenic patient group, significant correlations were found between intertemporal decision-making performance and executive function. The present study showed that both schizophrenic patients and unaffected siblings preferred to choose larger-delayed rewards during intertemporal decision-making, which may result from frontal-striatal and frontal-parietal network dysfunction. Their intertemporal decision-making performance was associated with executive function performance.

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

INTRODUCTION

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

OBJECTIVE

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

METHOD

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

DISCUSSION

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

Smartphone-Enhanced Low-Threshold Intervention for adolescents with Anorexia Nervosa (SELTIAN) waiting for outpatient psychotherapy: study protocol of a randomised controlled trial

INTRODUCTION

As smartphones are widely distributed nowadays, mental health apps seem to be a promising treatment tool. First self-help apps for eating disorders have been developed recently. However, studies assessing the efficacy of such apps are scarce. A smartphone app could prevent further weight reduction and increase commitment during waiting time for outpatient treatment, especially for adolescents with anorexia nervosa (AN). In this study protocol, a randomised controlled trial to assess the efficacy of a smartphone-enhanced low-threshold intervention for AN during waiting time is described.

METHODS AND ANALYSIS

30 adolescents with AN aged 12-19 years will be recruited at three child and adolescent psychiatry centres in Germany. All participants will be randomised to consultations only or consultations and the use of the Jourvie Research app. The app will be installed either on their own smartphone or on a research device. The participants will receive biweekly to monthly consultations for 3 months to review meal plans and weight management with a clinician. In addition, the Jourvie Research app for meal, behaviour and emotion protocolling will be provided to the intervention group. The protocols will be discussed with a clinician during the consultations. Dialectical behaviour therapy-informed skills for tension regulation to increase compliance with the meal plan will be taught in the intervention group and the app will remind the participant of a skill in a moment of need. The primary outcome is the age-adjusted and height-adjusted weight gain in standard deviation score after 3 months.

ETHICS AND DISSEMINATION

Results will be disseminated at conferences and through peer-reviewed publications. The trial was approved by the ethics review board of the local medical association, Mainz, Germany, under the reference number 837.338.15.

TRIAL REGISTRATION NUMBER

German clinical trials register, reference number DRKS00008946.

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.

Control over interfering memories in eating disorders

INTRODUCTION

Recent studies have suggested that patients suffering from either anorexia nervosa (AN) or bulimia nervosa (BN) exhibit abnormal performance in the ability to control cognitive interference in response selection.

METHOD

We assessed the status of cognitive control in episodic memory by addressing the ability to inhibit interfering memories. To this end, we used the retrieval-practice paradigm, which allows for measuring both the beneficial and the detrimental effects of memory practice. The latter phenomenon, known as retrieval-induced forgetting (RIF), is thought to reflect an adaptive inhibitory mechanism aimed at reducing competition in memory retrieval. Twenty-seven healthy controls and 27 patients suffering from eating disorders (either AN or BN) performed a retrieval-practice paradigm and a control task addressing general reactivity and filled a self-report questionnaire on impulsivity.

RESULTS

No differences between patients and healthy controls were observed for the beneficial effects of practice. The same pattern also emerged for RIF. However, when patients with AN and BN were analyzed separately, a clear dissociation emerged: patients with AN displayed no hint of RIF, whereas patients with BN showed an intact memory suppression performance. No group differences emerged in the control task.

CONCLUSIONS

Our findings suggest a specific impairment in the ability to suppress interfering memories in patients with AN, thus extending current evidence of cognitive control deficits in AN to episodic memory.

Group Qigong for Adolescent Inpatients with Anorexia Nervosa: Incentives and Barriers

Background

Qigong is a mind-body intervention focusing on interoceptive awareness that appears to be a promising approach in anorexia nervosa (AN). In 2008, as part of our multidimensional treatment program for adolescent inpatients with AN, we began a weekly qigong workshop that turned out to be popular among our adolescent patients. Moreover psychiatrists perceived clinical benefits that deserved further exploration.

Methods and findings

A qualitative study therefore sought to obtain a deeper understanding of how young patients with severe AN experience qigong and to determine the incentives and barriers to adherence to qigong, to understanding its meaning, and to applying it in other contexts. Data were collected through 16 individual semi-structured face-to-face interviews and analyzed with the interpretative phenomenological analysis method. Eleven themes emerged from the analysis, categorized in 3 superordinate themes describing the incentives and barriers related to the patients themselves (individual dimension), to others (relational dimension), and to the setting (organizational dimension). Individual dimensions associated with AN (such as excessive exercise and mind-body cleavage) may curb adherence, whereas relational and organizational dimensions appear to provide incentives to join the activity in the first place but may also limit its post-discharge continuation. Once barriers are overcome, patients reported positive effects: satisfaction associated with relaxation and with the experience of mind-body integration.

Conclusions

Qigong appears to be an interesting therapeutic tool that may potentiate psychotherapy and contribute to the recovery process of patients with AN. Further analysis of the best time window for initiating qigong and of its place in overall management might help to overcome some of the barriers, limit the risks, and maximize its benefits.

Altered Neural Efficiency of Decision Making During Temporal Reward Discounting in Anorexia Nervosa

OBJECTIVE

The ability of individuals with anorexia nervosa (AN) to resist hunger and restrict caloric intake is often believed to reflect an unusual amount of self-control. However, the underlying neural substrate is poorly understood, especially in adolescent patients.

METHOD

Functional magnetic resonance imaging was used during an intertemporal choice task to probe the hemodynamic correlates of a common measurement of self-control-delayed (monetary) reward discounting-in a sample of acutely ill, predominately adolescent female patients with AN (n = 31) and age-matched healthy controls (n = 31).

RESULTS

Delayed discounting rates did not differ between the groups, but decision making was consistently faster in the AN group. Although no group differences in the neural correlates of reward valuation were evident, activation associated with decision making was decreased in the AN group, most notably in the lateral prefrontal and posterior parietal regions implicated in executive control. Follow-up analysis of difficult decisions showed decreased activation in the AN group in a region of the dorsal anterior cingulate cortex.

CONCLUSION

Decreased activation in frontoparietal regions involved in decision making, but faster and more consistent choice behavior, suggests that the altered efficiency of neural resource allocation might underlie an increased level of self-control in AN. This pattern of neural activation and behavior might reflect an ingrained "habit" to sustain high-level proactive (anticipatory) cognitive control in AN, which in turn might compromise reactive control mechanisms needed to adapt to changing cognitive demands, such as when difficult decisions must be made.

Exploration of Friendship Experiences, before and after Illness Onset in Females with Anorexia Nervosa: A Qualitative Study

Background

Difficulties with social relationships have been implicated in both the development and maintenance of Anorexia Nervosa (AN) but the friendship experiences of individuals with AN have not been explored in depth.

Method

Ten adults with AN took part in a semi-structured interview about their friendship experiences both before and since the onset of their illness.

Results

Five principle themes were identified through thematic analysis: Social Concern; Impact of AN; Social Connectedness; Inflexibility and Preferred Social Activity. Difficulties with friendship were present prior to the onset of AN in all cases, with participants experiencing anxiety in relation to various aspects of their friendships. Participants described mixed experiences of how their AN has affected their friendships but most participants described having less contact with their friends since becoming unwell.

Conclusion

This research highlights the role that social difficulties may play in the development of AN, whilst also emphasising the importance of addressing problems with friendship in the course of inpatient treatment.

Temperament and personality in eating disorders

PURPOSE OF REVIEW

In the last decades, three main different personality domains have been investigated in the field of eating disorders: personality traits, temperament, and personality disorders. The use of a wide range of instruments and the presence of many different approaches in the definition of personality dimensions make it difficult to summarize the emerging results from different studies. The aim of this narrative review is to critically highlight and discuss all interesting developments in this field, as reflected in the recent literature.

RECENT FINDINGS

The study of personality and temperament in eating disorders seems to be in line with the recently suggested dimensional approach, which highlights the importance of symptoms aggregation, rather than the categorical diagnoses. Recent literature seems to confirm that specific personality and temperamental profiles can be drawn for patients with eating disorders, which can discriminate different eating disorders' diagnoses/symptoms.

SUMMARY

These observations have relevant clinical implications as treatment of eating disorders is largely based on psychotherapeutic interventions. However, large longitudinal studies are needed to better clarify the suggested relationships and to identify more defined therapeutic strategies.

Self-reported and performance based perfectionism in mothers of individuals with Anorexia Nervosa: a pilot study

BACKGROUND

Perfectionism is implicated in the development and maintenance of Anorexia Nervosa and there is some evidence that perfectionism may be elevated in family members. However to date there are no studies investigating behavioural aspects of perfectionism in unaffected mothers.

METHODS

Forty-one participants took part in this pilot study: 21 unaffected mothers of individuals with Anorexia Nervosa and 20 healthy control mothers. Participants completed two performance based tasks assessing perfectionism-a text replication task and a bead sorting task-along with self-report measures of perfectionism.

RESULTS

No group differences were found between unaffected AN mothers and HC mothers on performance measures of perfectionism.

DISCUSSION

The findings are discussed in relation to existing studies and clinical implications explored.