Facing Eating Disorder Fears: An Open Trial Adapting Prolonged Exposure to the Treatment of Eating Disorders

Eating disorders (EDs) are maintained by core fears, which lead to avoidance behaviors, such as food avoidance or compensatory behaviors. Previously tested exposure-based treatments for EDs have generally focused on proximal outcomes (e.g., food), rather than addressing core fears (e.g., fear of weight gain and its consequences). The current study tested the feasibility and initial clinical efficacy of 10 sessions of imaginal and in vivo exposure for core ED fears (termed "Facing Eating Disorder Fears"), mainly fear of weight gain and its associated consequences. Participants were 36 adults with anorexia nervosa (AN), bulimia nervosa, or other specified feeding and eating disorders determined by semistructured diagnostic interviews. ED symptoms, fears, and body mass index (BMI) were assessed at pretreatment, posttreatment, and 1-month follow-up. Treatment involved 10 sessions of imaginal and in vivo exposure to ED fears in combination with in vivo exposures to feared and avoided situations as homework. ED symptoms and fears decreased from pre- to posttreatment and at 1-month follow-up. BMI increased significantly from pre- to posttreatment, particularly for those with AN. Effect sizes ranged from small to very large. ED symptoms and fears decreased and BMI increased following exposure. Increases in BMI occurred without any direct intervention on eating, suggesting that weight gain can be achieved without a specific focus on food during ED treatment. Facing Eating Disorder Fears may be a feasible stand-alone intervention for EDs. Future research must test comparative efficacy through randomized controlled trials.

An Intensive time series investigation of the relationships across eating disorder-specific fear responses and behavior urges in partially remitted anorexia nervosa

Anorexia nervosa (AN) is a serious and persistent psychiatric illness. Many individuals with AN cycle between stages of remission (i.e., relapse), with research documenting that cognitive remission generally lags behind nutritional/weight restoration. Yet, little is known about which mechanisms promote movement from partial remission in AN (defined as nutritional, but not cognitive, recovery) to full remission. Fear-based processes, including avoidance and approach behaviors, likely contribute to the persistence of cognitive-behavioral AN symptoms after nutritional restoration. The current study used intensive longitudinal data to characterize these processes during partial remission (N = 41 participants with partially remitted AN; 4306 total observations). We aimed to a) characterize frequency of fear-based processes in real-time, b) investigate associations across fear-based processes and behavioral urges, and c) test if real-time associations among symptoms differed across commonly feared stimuli (e.g., food, social situations). On average, participants endorsed moderate fear and avoidance, with weight-gain fears rated higher than other feared stimuli. Momentary fear, avoidance, approach, and distress were all positively associated with AN behavior urges at one time-point and prospectively. Central symptoms and symptom connections differed across models with different feared stimuli. These findings provide empirical support for the theorized fear-avoidance-urge cycle in AN, which may contribute to the persistence of eating pathology during partial remission. Fear approach may be associated with temporary increases in urges, which should be considered during treatment. Future research should explore these associations in large, heterogeneous samples, and test the effectiveness of exposure-based interventions during partial remission.

A pilot randomized controlled trial of transdiagnostic network-informed personalized treatment for eating disorders versus enhanced cognitive behavioral therapy

OBJECTIVE

Eating disorders (EDs) are serious mental illnesses with high mortality and relapse rates and carry significant societal and personal costs. Nevertheless, there are few evidence-based treatments available. One aspect that makes treatment difficult is the high heterogeneity in symptom presentation. This heterogeneity makes it challenging for clinicians to identify pertinent treatment targets. Personalized treatment based on idiographic models may be well-suited to address this heterogeneity, and, in turn, presumably improve treatment outcomes.

METHODS

In the current randomized controlled trial, participants will be randomly assigned to either 20 sessions of enhanced cognitive behavioral therapy (CBT-E) or transdiagnostic network-informed personalized treatment for EDs (T-NIPT-ED). Assessment of ED symptoms, clinical impairment, and quality of life will occur at pre-, mid-, posttreatment, and 1-month follow-up.

RESULTS

We will examine the acceptability and feasibility of T-NIPT-ED compared to CBT-E. We also will test the initial clinical efficacy of T-NIPT-ED versus CBT-E on clinical outcomes (i.e., ED symptoms and quality of life). Finally, we will test if the network-identified precision targets are the mechanisms of change.

DISCUSSION

Ultimately, this research may inform the development and dissemination of evidence-based personalized treatments for EDs and serve as an exemplar for personalized treatment development across the broader field of psychiatry.

PUBLIC SIGNIFICANCE

Current evidence-based treatments for eating disorders result in low rates of recovery, especially for adults with AN. Our study aims to test the feasibility, acceptability, and clinical efficacy of a data-driven, individualized approach to ED treatment, network-informed personalized treatment, compared to the current evidence-based treatment for EDs, Enhanced CBT. Findings have the potential to improve treatment outcomes for EDs by identifying and targeting core symptoms maintaining EDs.

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.

Imaginal Exposure for Disordered Eating Related Fears: An Initial Randomized Controlled Trial

Exposure therapy has been investigated as a treatment for eating disorders, but prior research has largely neglected core fears underlying the disorder such as rejection, abandonment, disgust, and loss of control. We tested the feasibility and acceptability of using imaginal exposure to target disordered eating related fears by randomizing participants (N = 47) with disordered eating to: imaginal exposure (IE), imaginal exposure preceded by a brief food exposure (IE + Food), or an assessment control. Participants attended two in-person visits and completed pretreatment, posttreatment, and one-month follow-up questionnaires. IE was rated more acceptable than IE + Food. Retention was high across conditions. Habituation occurred for subjective distress and believability of feared outcomes, suggesting that imaginal exposure effectively activates core fears. Distress tolerance and confidence in ability to change improved. Disordered eating symptoms, fears, preoccupations, and rituals decreased in all conditions, indicating that IE was not specifically responsible for improvement.

Lived experiences of subjective binge eating: An inductive thematic analysis

OBJECTIVE

Growing evidence suggests that subjective binge eating (SBE; loss of control eating involving subjectively, but not objectively, large quantities of food) is clinically concerning even though it is not currently considered a diagnostic criterion for eating disorders. However, the lived experience of SBEs has not been examined in a systematic, and data-driven way.

METHOD

The current study used a qualitative, inductive interview approach to further define SBEs as described by individuals who experience them. Participants (N = 14; 11 cisgender women, M_age  = 35.29, 12 White/non-Latinx) reported SBEs that occurred at least twice per week over the prior 3 months. We completed semi-structured qualitative phone interviews with participants regarding their most recent SBE and objective binge-eating episode (OBE) if applicable, as well as broader experiences and attitudes regarding non-binge eating.

RESULTS

Inductive, reflexive, thematic coding yielded descriptive and interpretive codes regarding SBEs. Main themes regarding SBE experience included: (a) SBEs Occur Across Contexts and Food Types, (b) SBEs Are Contrasts to General Over-Control, (c) SBEs Are Distress- and Disconnection-Inducing, Not Relieving, (d) SBEs Are Responses to Hunger and Restriction, and (e) SBEs Can Be "Echoes" of OBEs.

DISCUSSION

The current study explored the lived experiences of those who report SBEs and provides an important foundation for hypothesis generation for future research on and clinical interventions for SBEs.

Social anxiety moderates the relationship between body mass index and motivation to avoid exercise

Higher weight individuals experience frequent weight-related discrimination, which is associated with exercise avoidance. Exercise is a health behavior with multiple physical and mental health benefits and should be accessible to all. The current study examined another factor that might influence exercise in addition to weight stigma: social anxiety (SA). Given the often public nature of exercise, individuals with SA may feel scrutinized when exercising, which may lead to avoidance. This study examined whether SA moderates the relationship between body mass index (BMI) and exercise and whether SA and its interaction with BMI predict exercise behavior after accounting for weight stigma. We administered an online survey to 603 undergraduates (72 % female, 60 % White). SA was not significantly associated with BMI, but it was positively associated with weight stigma and exercise-avoidance motivation and negatively associated with self-reported exercise. SA moderated the relationship between BMI and exercise-avoidance motivation; individuals with higher BMIs were motivated to avoid exercise, but only if they reported higher SA. This interaction predicted exercise-avoidance motivation after accounting for weight stigma and its interaction with BMI. However, SA did not moderate the relationship between BMI and self-reported exercise. SA may be associated with exercise avoidance among higher weight individuals.

Reductions in social anxiety during treatment predict lower levels of loneliness during follow-up among individuals with social anxiety disorder

INTRODUCTION

Individuals with social anxiety disorder (SAD) are at elevated risk of loneliness, yet little research has examined loneliness in this population. Cognitive-behavioral group therapy (CBGT) and mindfulness-based stress reduction (MBSR) have demonstrated efficacy in treating SAD, yet research has not examined whether they lead to reductions in loneliness.

METHODS

This sample comprised 108 individuals with SAD who were randomized to CBGT, MBSR, or a waitlist control (WL); WL participants were re-randomized to CBGT or MBSR following WL. Assessments were completed pre- and post-treatment, and 3-, 6-, 9-, and 12-month follow-up assessments.

RESULTS

Compared to WL, individuals in CBGT and MBSR were less lonely at post-treatment; there was no difference between treatments after treatment or during follow-up. Greater reductions in social anxiety from pre- to post-treatment predicted lower levels of loneliness during follow-up. Greater reductions in loneliness from pre- to post-treatment also predicted lower levels of social anxiety during follow-up.

DISCUSSION

Individuals who experience reductions in their social anxiety during treatment may also feel less lonely following treatment. Reductions in loneliness also lead to improvements in social anxiety. Future research should continue to examine the relationship between social anxiety and loneliness and how interventions for SAD may help reduce loneliness.

Cognitive Behavioral Therapy for Social Anxiety Disorder: Predictors of Treatment Outcome in a Quasi-Naturalistic Setting

We examined the outcomes of individual cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) in a sample of 93 adults seeking treatment in a university outpatient clinic specializing in CBT for SAD. Treatment followed the structure of a manual, but number of sessions varied according to client needs. After approximately 20 weeks of therapy, patients' social anxiety had decreased and their quality of life had increased. Patients with more severe SAD or comorbid major depressive disorder (MDD) at pretreatment demonstrated higher levels of social anxiety averaged across pre- and posttreatment. However, clinician-rated severity of SAD, comorbid MDD, or comorbid generalized anxiety disorder did not predict treatment outcome. Higher pretreatment scores on measures of safety behaviors and cognitive distortions were associated with higher social anxiety averaged across pre- and posttreatment and predicted greater decreases from pre- to posttreatment on multiple social anxiety outcome measures. We found no predictors of change in quality of life. Those with high levels of safety behaviors and distorted cognitions may benefit more from CBT, perhaps due to its emphasis on targeting avoidance through exposure and changing distorted thinking patterns through cognitive restructuring methods. Our study lends support to the body of research suggesting that manualized CBT interventions can be applied flexibly in clinical settings with promising outcomes for patients over a relatively short course of therapy.

The benefits of a longer course of cognitive behavioral therapy for some patients with social anxiety disorder

Historically, cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) has been evaluated in randomized-controlled trials as a 12-16 session treatment and has demonstrated response rates ranging from 58% to 75%. Despite these promising results, some patients do not improve substantially after this short course of CBT. It is unclear whether non-responding patients would make substantial improvements in social anxiety with further treatment. In a university outpatient clinic specializing in CBT for SAD, we compared outcomes for patients who ended treatment after approximately 20 sessions of CBT (n = 38) to those who continued treatment for a variable number of additional sessions (n = 34). We found no between-group differences in demographic characteristics, number of comorbid diagnoses, comorbid generalized anxiety disorder or major depressive disorder, or severity of depression at baseline. Patients who ended treatment after 20 sessions experienced greater improvements in SAD over those 20 sessions compared to those who continued treatment. Both groups experienced changes in depression and quality of life over the first 20 sessions. Those who continued treatment showed additional decreases in social anxiety beyond session 20. For those who initially appear to be non-responsive to CBT for SAD, a longer course of treatment may elicit significant improvements.

Rural living environment predicts social anxiety in transgender and gender nonconforming individuals across Canada and the United States

Transgender and gender nonconforming (TGNC) individuals frequently confront discrimination, rejection, and violence. Such experiences may put TGNC individuals at risk for minority stress and associated psychiatric symptoms. Protective factors like social support, pride in one's gender identity, or connectedness to similar others may make TGNC individuals less vulnerable to psychiatric symptoms, and the presence of risk and protective factors may vary depending on living environment. This study examined the relationship of living environment (urban vs. suburban vs. small-town/rural) to social anxiety (SA) in a sample of 902 TGNC individuals who participated in the Trans Health Survey. Analysis of variance revealed a significant difference in SA across living environments. Those living in small-town/rural environments reported significantly higher levels of SA compared to those living in urban environments. There was a trend-level difference in SA in suburban compared to urban environments. Linear regression analyses revealed that living environment significantly moderated the relationship between social support and SA. Higher social support was more protective against elevated SA in urban and suburban than in small-town/rural environments. This study is the first to demonstrate the experience of elevated SA among TGNC individuals living in rural environments. Implications and future directions for research are discussed.

Emotional clarity and attention to emotions in cognitive behavioral group therapy and mindfulness-based stress reduction for social anxiety disorder

We examined (1) differences between controls and patients with social anxiety disorder (SAD) in emotional clarity and attention to emotions; (2) changes in emotional clarity and attention to emotions associated with cognitive-behavioral group therapy (CBGT), mindfulness-based stress reduction (MBSR), or a waitlist (WL) condition; and (3) whether emotional clarity and attention to emotions moderated changes in social anxiety across treatment. Participants were healthy controls (n = 37) and patients with SAD (n = 108) who were assigned to CBGT, MBSR, or WL in a randomized controlled trial. At pretreatment, posttreatment, and 12-month follow-up, patients with SAD completed measures of social anxiety, emotional clarity, and attention to emotions. Controls completed measures at baseline only. At pretreatment, patients with SAD had lower levels of emotional clarity than controls. Emotional clarity increased significantly among patients receiving CBGT, and changes were maintained at 12-month follow-up. Emotional clarity at posttreatment did not differ between CBGT and MBSR or between MBSR and WL. Changes in emotional clarity predicted changes in social anxiety, but emotional clarity did not moderate treatment outcome. Analyses of attention to emotions were not significant. Implications for the role of emotional clarity in the treatment of SAD are discussed.

Perfectionism and Contingent Self-Worth in Relation to Disordered Eating and Anxiety

Perfectionism has been proposed as a transdiagnostic risk factor linked to eating disorders and anxiety. In the current study, we examine domains of contingent self-worth as potential moderators of the relationships between maladaptive perfectionism and disordered eating and anxiety using two waves of data collection. Undergraduate females (N = 237) completed online surveys of the study's core constructs at two points separated by about 14 months. At a bivariate level, maladaptive perfectionism was positively associated with disordered eating and anxiety. Maladaptive perfectionism and both appearance and relationship contingent self-worth interacted to predict increases in disordered eating. Neither of the interactive models predicted change in anxiety. Findings highlight maladaptive perfectionism as a transdiagnostic construct related to both disordered eating and anxiety. Interactive findings suggest that targeting maladaptive perfectionism and contingent self-worth (appearance, relationship) in prevention and treatment efforts could mitigate risk for the development or increase of disordered eating.

Dimensions of impulsivity in relation to eating disorder recovery

OBJECTIVE

Impulsivity is associated with eating pathology, but different dimensions of impulsivity have not been extensively studied in the eating disorders. The current study examined the relationship between four facets of impulsivity and eating disorder recovery status.

METHOD

Females formerly seen for an eating disorder were categorized as having an eating disorder (n = 53), partially recovered (n = 15), or fully recovered (n = 20) based on a diagnostic interview and physical, behavioral, and psychological indices. These groups and non-eating disorder controls were compared on impulsivity facets from the UPPS Impulsive Behavior Scale (UPPS): Urgency (negative urgency), Premeditation (lack of), Perseverance (lack of), and Sensation Seeking.

RESULTS

Negative urgency (the tendency to engage in impulsive behavior to alleviate negative affect) was related to recovery. The fully recovered group and controls experienced significantly less negative urgency than those with a current eating disorder; the partially recovered group did not differ from the eating disorder group.

DISCUSSION

Findings suggest that negative urgency may be a particularly important facet of impulsivity to target in therapeutic intervention for eating disorders, especially among those with a history of binge eating and/or purging. Future longitudinal work is needed to test a potential causal relationship between negative urgency and eating disorder recovery. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1027-1031).

What can you do to improve the environment?

Medicine has a dual obligation concerning the environment: (1) to supply laboratory and clinical research to document harmful effects on the environment, and (2) to encourage changes in the environment to reduce or eliminate adverse health effects. This article presents individual and group actions for the improvement of the environment. The American Academy of Otolaryngology-Head and Neck Surgery has developed a medical office pledge, "The Greening of Our Office for Improvement of Our Environment." Physicians are encouraged to agree to certain principles for environmental improvement.

Circuit weight training in early cardiac rehabilitation

A prospective, randomized study evaluated the feasibility, safety, and efficacy of upper body circuit weight training (CWT) in 25 stable male cardiac patients entering the initial out-of-hospital phase of cardiac rehabilitation. Both groups performed 30 minutes of aerobic exercise only for 6 weeks. The aerobic exercise group (N = 13) continued this regimen for 6 more weeks, during which time the CWT group (N = 12) performed 15 minutes of aerobic exercise followed by CWT (two loops, eight upper body exercises). The only adverse response was in one CWT patient in whom restenosis developed. Peak heart rate during aerobic exercise and CWT was similar, but peak systolic blood pressure during aerobic exercise was significantly greater than during CWT. Peak rate pressure product during aerobic exercise and CWT was similar. Treadmill time increased significantly in both groups. Upper body strength (cumulative pounds lifted) increased significantly only in the CWT group. A coordinated program of CWT and aerobic exercise can be performed safely in stable cardiac patients during phase 2 cardiac rehabilitation, resulting in improved upper body strength and aerobic capacity.

Exercise and prevention of coronary heart disease

Exercise programs can be used to improve functional capacity, lower the myocardial energy cost of performing work, and favorably alter one's cardiovascular risk profile. In addition, a large body of data support the role of exercise in the primary prevention of coronary heart disease. Standardized exercise programs are safe and effective for a large majority of patients.

Maternal sociomedical characteristics and birth weights of firstborns

Pregnancy outcome and sociomedical characteristics were examined in a sample of 1844 black and white primiparous females who received prenatal care. White females were more frequently married and more likely to live with their husbands than with their parents. Black females were better educated and more interested in obtaining further education. White women smoked significantly more cigarettes. There were no differences in contraceptive use in black and white females. Number of prenatal visits was least frequent among adolescent black females. With the exception of a higher incidence of vaginal infection among black females, there were no significant differences in general health status. There were no differences in birth weights between the firstborns of black and white adolescents, but adult white females had significantly heavier firstborns than blacks. Nonetheless, no differences were found in prevalence of low birth weight-for-gestational neonates between black and white females. Infrequent prenatal visits, maternal diabetes and smoking were the only significant multivariate factors associated with the occurrence of a low birth weight-for-gestational age neonate among the total sample.

Blunt laryngotracheal trauma

Images