Eating disorder fear networks: Identification of central eating disorder fears

Muscularity Concerns and Disordered Eating Symptoms in Adult Women: A Network Analysis

This study examined the role of muscularity concerns in eating disorder (ED) symptoms among a sample of women. We expanded on previous research by exploring a broader range of ED symptoms, including orthorexia (ON) and avoidant/restrictive food intake disorder (ARFID). Using network analysis, we analysed data from 308 adult women (18 years or older) who completed muscularity, disordered eating, and sociodemographic assessments. Our findings revealed five interconnected symptom communities reflecting traditional ED symptoms, such as eating concerns and shape and weight overvaluation. Notably, muscularity concerns emerged as a distinct community, emphasising their relevance to ED symptoms in women. Additionally, we identified selective eating tendencies and compulsive healthy eating. Highly central symptoms were rumination about healthy eating, fear and guilt over unhealthy eating, body-related embarrassment, and muscularity concerns (wishing to be heavier, wishing for heavier arms). These results suggest that muscularity concerns could constitute a uniquely identifiable and central diagnostic target for body image concerns and disordered eating in women.

Negative emotion differentiation, but not gastric interoception, is linked to "feeling fat" among women with elevated eating pathology

"Feeling fat" is the subjective sensation of being overweight, which is not fully explained by one's body weight. Disruptions in emotion differentiation and gastric interoception may contribute to feeling fat. We hypothesized that poor negative emotion differentiation and poor gastric interoceptive accuracy would each be associated with higher levels of feeling fat after adjusting for negative affect intensity and body fat percentage. Cisgender female university students (N = 69; M(SD) age = 20.3(3.7), 60.9 % heterosexual, 91.3 % white) completed questionnaires and the two-step water load test. Regression analyses, which adjusted for negative affect intensity and body fat percentage, found that neither negative emotion differentiation (B < 0.001, p = .52) nor gastric interoceptive accuracy (B = 0.01, p = .97) were related to feeling fat. Post hoc, eating pathology severity moderated the relationship between negative emotion differentiation and feeling fat (B = -6.97, p = .03); poorer negative emotion differentiation was associated with greater feeling fat for those with Eating Disorder Examination Questionnaire Global Scores above 1.47 (B = -5.79, p = .050). The relationship between gastric interoception and feeling fat did not vary by eating pathology severity (B = -0.04, p = .79). Self-reported feeling full also contributed to feeling fat after consuming water to perceived maximum fullness (p < .001); however, changes in feeling full were not associated with changes in feeling fat across the task (p = .09). Poorer negative emotion differentiation is associated with feeling fat for those with elevated eating pathology. Individuals with elevated eating pathology may benefit from improving their ability to label and understand emotions to reduce feeling fat. Future research should test whether changes in feeling full cause feeling fat.

Low Overlap and High Heterogeneity Across Common Measures of Eating Disorder Pathology: A Content Analysis

This study evaluated symptoms assessed in common measures of eating disorder pathology and tested overlap to evaluate the extent to which measures may be interchangeable. Six measures were included: Bulimia Test-Revised, Eating Attitudes Test-26, Eating Disorder Diagnostic Scale, Eating Disorder Examination Questionnaire, Eating Pathology Symptoms Inventory, and Questionnaire for Eating Disorder Diagnoses. Content overlap was quantitatively estimated using the Jaccard Index. Mean overlap was low (.195), likely due to the wide range of symptoms (87) assessed. The mean overlap of each measure with all others was .117 - .267, and the overlap among individual measures was .083 - .382. Implications of low overlap among measures include variable characterization of eating disorder phenotypes and the risk for lower generalizability of findings due to measurement variability.

Exercise moderates longitudinal group psychopathology networks in individuals with eating disorders

Individuals with eating disorders (EDs) often engage in exercise no matter potential negative long-term outcomes (e.g., weight loss, injury). Yet exercising may temporarily attenuate ED symptoms, but whether exercise also affects network structure and pairwise associations of ED symptoms remained unclear. We used a novel approach called Moderated Multilevel Graphical Vector Autoregression to estimate changes in psychopathology networks from before to after exercising in ecological momentary assessment data from 102 individuals with EDs across multiple days (M = 22.14, SD = 5.40; range: 6-22 days) at 4 times daily. Between-person and within-person temporal networks were computed, obtaining stable centrality coefficients for temporal networks only. In those, autoregressive effects of several symptoms, including binge-eating, overeating, or weighing oneself, were attenuated when participants previously exercised. Exercise mostly downregulated temporal effects of ED symptoms on other symptoms, including effects of binge eating and other compensatory behaviors on feeling guilty after the most recent meal, vomiting on weighing oneself, and overeating on fear of weight gain. Our study highlights the complex dynamic effects of exercise on ED symptoms in daily life and calls for novel studies investigating mechanisms of exercise to inform treatments targeting detrimental long-term effects of exercise in EDs.

The future of the eating disorder field: Inclusive, aware of systems, and personalized

Eating disorders are serious psychiatric illnesses associated with large amounts of suffering, high morbidity, and high mortality rates, signifying a clear need for rapid advancements in the underlying science. Relative to other fields of clinical psychological science, the eating disorder field is new. However, despite the fields' late beginnings, there is growing science in several important areas. The current paper discusses the current literature in three primary areas of importance: (a) diversity and inclusion, (b) systemic and social factors, and (c) treatment personalization. We discuss how these areas have huge potential to push both eating disorder and clinical psychological science in general forward, to improve our underlying understanding of psychological illness, and to enhance treatment access and effectiveness. We call for more research in these areas and end with our vision for the field for the next decade, including areas in need of significant future research.

A pilot randomized trial of the body advocacy movement: a novel, dissonance-based intervention designed to target fear of weight gain and anti-fat bias in young adults

The Body Advocacy Movement (BAM) is a novel, cognitive-dissonance-based intervention designed to target fatphobia and anti-fat bias as mechanisms to drive reductions in eating disorder (ED) risk. Previous dissonance-based programs (i.e. the Body Project; BP) have successfully targeted thin-ideal internalization as an intervention mechanism. As burgeoning research indicates that fatphobia and anti-fat bias may play a central role in the maintenance of ED pathology, a focused intervention designed to target these constructs could bolster prevention efforts. The aims of this pilot study include confirming acceptability and feasibility of BAM and developing preliminary estimates of its effects on intervention targets, along with benchmarking these effects against the BP intervention. BAM was found to be accepted by participants and feasible to facilitate in a peer-led model. Preliminary results from 50 participants (BAM: N = 26; BP: N = 24) reveal small-to-moderate pre-to-post intervention effects on fatphobia, anti-fat bias, thin-ideal internalization, and eating pathology, which dissipated at 8-week follow-up. The BAM intervention has the potential to supplement the existing suite of ED prevention programs by specifically targeting anti-fat bias, though additional testing in larger and more diverse samples is necessary to clarify its impact on both hypothesized risk mechanisms and ED outcomes.

Anxiety matters: a pilot lab study into food, weight, and virtual body exposure in anorexia nervosa

BACKGROUND

Anxiety is a core characteristic of anorexia nervosa and a potential target of exposure therapy, which requires a profound understanding of the patients' fears in order to be successful. The knowledge about fears in anorexia nervosa that should be targeted during exposure therapy can be enriched by laboratory research to the precise emotional and behavioral responses of anorexia nervosa patients when they are exposed to disorder relevant fear stimuli.

METHODS

In the laboratory, patients with anorexia nervosa (n = 15) and healthy controls (n = 51) were exposed to 1. their own body weight and a 10% higher body weight on the scale, 2. a standardized lab breakfast, and 3. five virtual bodies with different BMIs ranging from extreme underweight to lower healthy weight. The participants emotional (anxiety, disgust, satisfaction, acceptance) and behavioral responses (calorie consumption) were assessed. Patients with anorexia nervosa but not the healthy controls then received an intensive exposure treatment (~ 30 individual exposure sessions) targeting their individual fears, next to standard care. After the exposure treatment, it was investigated whether the patients' responses to the laboratory tasks changed.

RESULTS

Across all tasks, the patients reported more anxiety than healthy controls. The patients also consumed less calories during the breakfast and accepted the different body weights on the scale less than healthy controls. During the virtual body exposure, the patients' emotional responses did not differ per avatar but they reacted more negatively towards avatars with healthier weights than did healthy controls. After the exposure treatment, the patients reported less fears and they consumed more calories while their BMIs had increased. They were also more accepting of healthier weights.

CONCLUSIONS

Exposure to food-, body- and weight-related stimuli in the laboratory induces emotional reactions in patients with anorexia nervosa that are informative for the identification of exposure therapy treatment targets. In addition, exposure therapy targeting individual fears in patients with anorexia nervosa led to symptom reduction and is a promising intervention for the treatment of anorectic fears, though more research is needed to optimize its efficacy.

Reciprocal relations between body dissatisfaction and excessive exercise in college women

Objective: Body dissatisfaction elevates the risk for disordered eating behaviors. Excessive exercise is prevalent among college women and associated with harm. Risk theory posits a bidirectional relationship between risk factors for disordered eating behaviors and the behaviors themselves. This study investigated the longitudinal, reciprocal relationship between body dissatisfaction and excessive exercise.

Participants and methods: College women (n = 302) assessed in August (baseline) and November (follow-up).

Results: Baseline body dissatisfaction significantly predicted increases in excessive exercise endorsement at follow-up, controlling for baseline excessive exercise endorsement and body mass index (BMI). Baseline excessive exercise endorsement predicted increases in body dissatisfaction at follow-up, controlling for baseline body dissatisfaction and BMI.

Conclusions: Findings support the presence of a positive feedback loop between body dissatisfaction and excessive exercise; both predict increases in risk for the other, regardless of weight status. Future research should test whether this process is ongoing and predicts further distress.

Visceral sensitivity, hunger responsiveness, and satiety responsiveness: Associations between facets of gastrointestinal interoception and disordered eating profiles in an undergraduate sample

This preregistered study examined associations between empirically derived profiles of disordered eating in a diverse nonclinical sample and three facets of gastrointestinal (GI) interoception (visceral sensitivity, hunger responsiveness, satiety responsiveness). University students (n = 591; 53.3% women; 23.0% Hispanic) completed the Visceral Sensitivity Index, Adult Eating Behavior Questionnaire, and Eating Pathology Symptom Inventory. Latent profile analysis was conducted in Mplus v8.3 with four behavioral indicators (restricting, binge eating, excessive exercise, purging [binary]). Facets of GI interoception predicting odds of disordered eating profile membership compared to an asymptomatic group were evaluated. Five profiles were identified. Facets of GI interoception differentially predicted odds of membership in disordered eating profiles. However, higher scores on all three facets of GI interoception were associated with increased odds of membership in a high disordered eating profile. The relationship between distinct facets of GI interoception and specific disordered eating patterns appears nuanced, though individuals displaying a range of disordered eating behaviors may exhibit broad GI interoceptive dysfunction. Findings are consistent with the recent emphasis on idiographic treatment approaches for disordered eating and may have implications for screening among university students. Prospective longitudinal work and extension to clinical samples is needed.

State mechanisms of change in eating disorder symptoms and fears during an online imaginal exposure treatment for eating disorders

Anxiety and fear are key characteristics of eating disorders (EDs). Exposure therapy is a specific type of intervention aimed at reducing fear and anxiety and is efficacious in treating a variety of anxiety and related disorders. A growing body of research suggests that exposure therapy is also efficacious for the treatment of EDs. However, there is currently little research investigating mechanisms of change during exposure therapy for EDs. The current study (N = 143) expanded on an open series trial of imaginal exposure for EDs that found significant reductions in ED symptoms and core ED fears. In the current study we investigated change in state drive for thinness, body dissatisfaction, and anxiety as mechanisms underpinning change in ED symptoms and core ED fears during four sessions of online imaginal exposure treatment for EDs. We found that state body dissatisfaction, but not state drive for thinness or anxiety, was a mechanism of change for ED symptoms and some core ED fears. Our findings suggest that body dissatisfaction may be a mechanism driving change during exposure therapy for EDs. Optimizing exposure treatments to focus on body dissatisfaction may improve treatment outcomes for EDs.

Development and Validation of a Broad and Fear-Adaptable Measure of Fear Approach and Application to Common Eating Disorder Fears

Fear approach is a theorized mechanism of exposure treatment for anxiety-based disorders. However, there are no empirically established self-report instruments measuring the tendency to approach feared stimuli. Because clinical fears are heterogeneous, it is important to create a measure that is adaptable to person- or disorder-specific fears. The current study (N = 455) tests the development, factor structure, and psychometric properties of a self-report instrument of fear approach broadly and the adaptability of this measure to specific eating disorder fears (i.e., food, weight gain). Factor analyses identified a unidimensional, nine-item factor structure as the best fitting model. This measure had good convergent, divergent, and incremental validity and good internal consistency. The eating disorder adaptations retained good fit and strong psychometric properties. These results suggest that this measure is a valid, reliable, and adaptable measure of fear approach, which can be used in research and exposure therapy treatment for anxiety-based disorders.

Persistent avoidance of virtual food in anorexia nervosa-restrictive type: Results from motion tracking in a virtual stopping task

OBJECTIVE

Food avoidance is central to patients with anorexia nervosa-restrictive type (AN-R). Competing accounts in experimental psychopathology research suggest that food avoidance may result from automatic, habitual responses or from elevated inhibitory control abilities. This study investigated behavioral trajectories of food avoidance in a novel virtual reality stopping task.

METHOD

Sixty patients with AN-R and 29 healthy controls with normal weight were investigated using a novel, kinematic task in virtual reality. We recorded spatial displacement in stop- and go-trials to virtual food and control objects. Inhibitory control abilities were operationalized by the VR task in stopping performance (i.e., interrupted movement in stop-trials), whereas we also measured habitual avoidance of virtual food across both go- and stop-trials (i.e., delayed movement relative to nonfood objects).

RESULTS

In patients with AN-R, hand displacements were shorter to food versus nonfood across stop- and go-trials, reflected in a Stimulus × Group interaction. Healthy controls showed no differences. Importantly, the food-specific effect in AN-R was identical across stop- and go-trials, indicating habitual food avoidance. Moreover, stop error rates (i.e., stop-trials with response) were lower in patients with AN-R.

DISCUSSION

The findings suggest food-specific habitual avoidance and heightened generalized inhibitory control in AN-R. The continuously delayed displacements during active hand movements across stop- and go-trials indicated the persistence of patients' avoidance of food.

PUBLIC SIGNIFICANCE

Experimental research investigates the mechanisms underlying mental disorders such as anorexia nervosa. In this study, we measured interrupted hand movements in response to food pictures or neutral pictures (shoes) in patients with anorexia nervosa and healthy controls. A virtual reality scenario was used. Findings indicated that patients were slower at approaching food, interrupted or not. Key mechanisms of food avoidance can be translated into habit-based treatment options in future research.

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.

Adaptive and Maladaptive Exercise in Eating Disorders

While exercise is generally associated with positive health outcomes, in the context of eating disorders, exercise has high potential to become maladaptive. Maladaptive exercise is compelled or compulsive in nature for the purposes of weight and shape control or to obtain/avoid other eating disorder-relevant consequences. A transdiagnostic eating disorder feature with moderate-to-high prevalence across restrictive- and bulimic-spectrum eating disorders, maladaptive exercise is often associated with negative mental and physical health sequalae. Several proposed threat- and reward-related biobehavioral mechanisms may initiate or perpetuate maladaptive exercise. While exercise is generally contraindicated during periods of acute medical concern, adaptive forms of exercise are also present among those with eating disorders, and facilitation of adaptive exercise has potential to promote physical and mental health benefits during eating disorder recovery. Detailed assessment and targeted interventions are needed to address the clinical conundrum of how and when to integrate exercise into eating disorder treatment.

Facial EMG startle response and self-report reactions after exposure to severely underweight and severely obese body images in individuals with disordered eating: An examination of motivational responses

Examining appetitive and aversive responses toward body image stimuli of those with disordered eating may illuminate motivational systems unique to eating pathology. The current study extended previous literature by examining self-report and startle responses to a range of body sizes. In this cross-sectional design, female, adult participants (n = 45) were sorted into disordered eating (DE; n = 22) and healthy control (HC; n = 23) groups based on Eating Disorder Examination Questionnaire global scores that were one standard deviation above or below normative values. Participants viewed eight computer-generated female body pictures from each group: severely underweight (BMI < 16.0), average (BMI 18.5-24.99), and severely obese (BMI > 40.0). Startle responses and self-reported valence and anxiety scores were collected to assess implicit and explicit reactions. 2 × 3 ANCOVA/ANOVAs were used to examine startle responses and self-report differences between groups, in response to image types. Results indicated startle responses did not differ between groups. There was a significant main effect for body picture type (p < .001), after controlling for psychotropic medication. Startle responses were higher for severely underweight body images compared to severely obese body images, although non-significant at post-hoc. The DE group reported higher levels of anxiety and sadness when viewing body images compared to the HC group. Average bodies were rated as less anxiety provoking and more positive than severely underweight and obese bodies. Group differences in anxiety and valence scores could be due to more maladaptive cognitions related to fear of weight gain among people with disordered eating.

Affective profiles of exercise episodes are associated with maladaptive and adaptive motivations for exercise

OBJECTIVE

Maladaptive exercise (i.e., driven and/or compensatory exercise) is common in binge-spectrum eating disorders (EDs; e.g., bulimia nervosa, binge ED) and associated with adverse treatment outcomes. Alternatively, individuals with EDs are often also engaging in adaptive exercise (e.g., for enjoyment or health improvement), and increasing adaptive exercise may decrease ED symptoms. The current study aimed to understand which exercise episodes are likely to be maladaptive/adaptive so that interventions can appropriately decrease/increase maladaptive and adaptive exercise.

METHOD

We used latent profile analysis (LPA) to identify pre-exercise affective profiles of 661 exercise episodes among 84 individuals with binge-spectrum EDs and examined associations between LPA-identified profiles and subsequent exercise motivations using ecological momentary assessment.

RESULTS

A two-profile solution best fit our data: Profile 1 (n = 174), 'positive affectivity,' and Profile 2 (n = 487), 'negative affectivity.' Episodes in the 'negative affectivity' profile were more likely to be endorsed as both driven and intended to influence body shape/weight. Episodes in the 'positive affectivity' profile were more likely to be endorsed as exercising for enjoyment.

CONCLUSIONS

Results support two phenotypes of exercise episodes, and differential associations of these phenotypes with adaptive and maladaptive motivations for exercise.

Patterns of maladaptive exercise behavior from ages 14-24 in a longitudinal cohort

BACKGROUND

Exercise for weight loss and maladaptive exercise (exercise that results in negative consequences or interference with daily life) are common behaviors among youth and are associated with increased risk of disordered eating symptoms. The current study clarifies processes that influence exercise-related risk in adolescence and young adulthood, including the frequency with which young people transition between engaging in exercise for weight loss and experiencing negative consequences of this behavior.

METHOD

Participants from the Avon Longitudinal Study of Parents and Children (ALSPAC) reported on eating disorder cognitions at age 14, and exercise behavior at ages 14, 16, 18, and 24 years old. Analyses examined rates of transition between the categories of 'No Exercise for Weight Loss', 'Exercise for Weight Loss', and 'Maladaptive Exercise' over time, identified overall trends in endorsement of exercise for weight loss and maladaptive exercise, and clarified predictors of these behaviors.

RESULTS

Endorsement of exercise for weight loss and maladaptive exercise increased over time in both males and females. Those in the 'Exercise for Weight Loss' category were more likely than those in the 'No Exercise for Weight Loss Category' to transition to 'Maladaptive Exercise' over time. Body mass index (Age 13) and fear of weight gain (Age 14) were consistent predictors of maladaptive exercise across sex.

CONCLUSIONS

Results support re-framing motivations for exercise in youth away from weight loss at a population level and targeting reductions in fear of weight gain for high-risk individuals.

Challenges and priorities for researching the gut microbiota in individuals living with anorexia nervosa

OBJECTIVE

The gut microbiota is implicated in several symptoms and biological pathways relevant to anorexia nervosa (AN). Investigations into the role of the gut microbiota in AN are growing, with a specific interest in the changes that occur in response to treatment. Findings suggest that microbial species may be associated with some of the symptoms common in AN, such as depression and gastrointestinal disturbances (GID). Therefore, researchers believe the gut microbiota may have therapeutic relevance. Whilst research in this field is rapidly expanding, the unique considerations relevant to conducting gut microbiota research in individuals with AN must be addressed.

METHOD

We provide an overview of the published literature investigating the relationship between the gut microbiota and symptoms and behaviors present in AN, discuss important challenges in gut microbiota research, and offer recommendations for addressing these. We conclude by summarizing research design priorities for the field to move forward.

RESULTS

Several ways exist to reduce participant burden and accommodate challenges when researching the gut microbiota in individuals with AN.

DISCUSSION

Recommendations from this article are foreseen to encourage scientific rigor and thoughtful protocol planning for microbiota research in AN, including ways to reduce participant burden. Employing such methods will contribute to a better understanding of the role of the gut microbiota in AN pathophysiology and treatment.

PUBLIC SIGNIFICANCE

The field of gut microbiota research is rapidly expanding, including the role of the gut microbiota in anorexia nervosa. Thoughtful planning of future research will ensure appropriate data collection for meaningful interpretation while providing a positive experience for the participant. We present current challenges, recommendations for research design and priorities to facilitate the advancement of research in this field.

Imagery, emotion, and bioinformational theory: From body to brain

The bioinformational theory of emotional imagery is a model of the hypothetical mental representations activated when people imagine emotionally engaging events, and was initially proposed to guide research and practice in the use of imaginal exposure as a treatment for fear and anxiety (Lang, 1979). In this 50 year overview, we discuss the development of bioinformational theory and its impact on the study of psychophysiology and psychopathology, most importantly assessing its viability and predictions in light of more recent brain-based studies of neural functional activation. Bioinformational theory proposes that narrative imagery, typically cued by language scripts, activates an associative memory network in the brain that includes stimulus (e.g., agents, contexts), semantic (e.g., facts and beliefs) and, most critically for emotion, response information (e.g., autonomic and somatic) that represents relevant real-world coping actions and reactions. Psychophysiological studies in healthy and clinical samples reliably find measurable response output during aversive and appetitive narrative imagery. Neuroimaging studies confirm that emotional imagery is associated with significant activation in motor regions of the brain, as well as in regions implicated in episodic and semantic memory retrieval, supporting the bioinformational view that narrative imagery prompts mental simulation of events that critically includes the actions and reactions engaged in emotional contexts.

From Bad to Worse: Safety Behaviors Exacerbate Eating Disorder Fears

When evaluating ambiguous situations, humans sometimes use their behavior as a source of information (behavior-as-information effect) and interpret safety behaviors as evidence for danger. Accordingly, we hypothesized that eating disorder safety behaviors (restrictive eating, body checking, etc.) might aggravate fear and anxiety in individuals with an eating disorder. The present study tested to what extent eating disorder safety behaviors increase threat perception in individuals with and without an eating disorder. For this, 108 individuals with a self-reported eating disorder diagnosis and 82 healthy controls rated the dangerousness of several short situations. The situations systematically varied in the presence of eating disorder safety behaviors and danger information. As expected, all participants perceived situations in which the protagonist executed an eating disorder safety behavior as more threatening than situations without a safety behavior. This 'behavior-as-information' effect was equally strong in individuals with and without an eating disorder. Additionally, safety behaviors strengthened threat perception more in safe situations than in dangerous situations. To conclude, the presence of eating disorder safety behavior can increase threat perception regardless of whether individuals have an eating disorder or not. This makes eating disorder safety behaviors a potential risk factor for the development and maintenance of eating disorder fears.

Can you learn to starve yourself? Inducing food avoidance in the laboratory

The restriction of energy intake is a central and persistent symptom of anorexia nervosa. Recent models of the disorder suggest that food restrictions are learned avoidance behaviours, which are acquired and maintained by classical and operant conditioning. The present study aims to test this learning model of food restriction. It investigates whether introducing negative consequences for the intake of tasty high-calorie food and introducing positive consequences for its avoidance can create food avoidance, increase fear of food, and decrease eating desires in healthy individuals. 104 women were randomly assigned to an experimental or control condition and completed an appetitive conditioning and avoidance learning task. While the experimental condition received money after avoiding the tasty high-calorie food item and heard an aversive sound after not avoiding food intake, the control condition never received these consequences. In the extinction phase, reward and punishment discontinued for both conditions. We measured avoidance frequency, mouse movements, fear, eating desires and stimulus liking. Participants in the experimental condition avoided the food more often than controls and showed increased fear, reduced eating desires and less liking for cues associated with food intake. These results support the notion that food avoidance behaviours, reduced eating desires and fear of food can be learned via classical and operant conditioning. Conditioning paradigms might be a useful tool to study the development and maintenance of food restriction in anorexia nervosa.

Loss of control in binge-eating disorder: Fear and resignation

OBJECTIVE

Binge-eating disorder involves overeating while feeling a loss of control (LOC). Emotions around LOC appear to vary; some patients fear LOC whereas others feel powerless or "resigned" to LOC. This study examined differences in psychopathology among treatment-seeking patients with binge-eating disorder categorized with fear of LOC, resignation to LOC, and no fear/resignation of LOC.

METHOD

Doctoral research clinicians administered diagnostic and semistructured interviews to characterize psychopathology and establish a diagnosis of binge-eating disorder in participants (N = 382). The interview assessed fear of LOC in the past month. Further queries assessed whether, in the absence of fear of LOC, patients were resigned to LOC or had no fear/resignation.

RESULTS

Patients with fear of LOC and resigned to LOC endorsed significantly greater global eating-disorder psychopathology than patients with no fear/resignation. Patients with fear of LOC reported greater distress about binge eating and greater depression than those with no fear/resignation. Patients resigned to LOC reported significantly more frequent binge-eating episodes than those with fear of LOC and no fear/resignation. Black individuals and men were more likely to report no fear/resignation than other demographic groups.

DISCUSSION

This study describes a novel clinical aspect of binge-eating disorder: resignation to LOC. Findings highlight the importance of including anticipatory cognitive-affective experiences in treatment formulations and planning. Future research should examine co-occurrence of these experiences and their association with impairment. Future research should also examine how fear of LOC and resignation to LOC change during treatment and whether they predict or moderate treatment outcomes.

PUBLIC SIGNIFICANCE

Adults with binge-eating disorder have anticipatory cognitive-affective experiences about loss of control (LOC) over eating (i.e., fear of LOC, resigned to LOC, no fear nor resignation of LOC). Individuals who experience fear of LOC and those who are resigned to LOC had more severe psychopathology than those without fear/resignation. Binge-eating disorder has the highest prevalence of the eating disorders; thus, findings have high public significance in guiding clinicians' treatment planning.

Inhibitory Learning during Exposure Treatment in Anorexia Nervosa: A Practical Guide

Exposure therapy is known to be an effective intervention in the treatment of anxiety-related disorders. In eating disorders, such as anorexia nervosa, anxiety and avoidance are identified as maintenance factors. Therefore, they may constitute an important treatment target, suitable for the use of exposure therapy. Remarkably, exposure techniques to target fears and avoidance behaviors are not commonly used in the treatment of anorexia nervosa. We present a practical guide for the implementation of exposure therapy in the treatment of anorexia nervosa. We outline how exposure therapy is supposed to work according to the inhibitory learning model and how the exposure intervention can be designed for individuals with anorexia nervosa. Practical examples are provided through the case presentation of a patient with anorexia nervosa who completed 31 exposure sessions that focused on her fears of food, eating, weight, weight gain, their feared social consequences and the associated safety behaviors.

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.

Fear of weight gain during cognitive behavioral therapy for binge-spectrum eating disorders

PURPOSE

Fear of weight gain may play a central role in maintaining eating disorders (EDs), but research on the role of fear of weight gain during cognitive behavioral therapy (CBT-E) for binge-spectrum EDs is sparse. We examined changes in fear of weight gain during CBT-E for binge-spectrum EDs. We investigated whether fear of weight gain predicted loss of control (LOC) eating or weight change.

METHODS

Participants (N = 63) were adults of any gender recruited as part of a larger trial. Participants received 12 sessions of CBT-E, completed diagnostic assessments at pre-, mid-, and post-treatment, and completed brief surveys before sessions.

RESULTS

Fear of weight gain decreased across treatment, moderated by diagnosis. Those with bulimia nervosa spectrum EDs (BN-spectrum), compared to binge eating disorder, reported higher fear of weight gain at baseline and experienced a larger decrease in fear across treatment. Those reporting higher fear of weight gain at a given session experienced more frequent LOC episodes the following week. Fear of weight gain was not associated with session-by-session changes in BMI.

CONCLUSION

CBT-E results in decreases in fear of weight gain, but levels remain high at post-treatment, especially for those with BN-spectrum EDs. Future interventions should consider targeting fear of weight gain as a maintaining factor for LOC episodes TRIAL REGISTRATION: NCT04076553.

LEVEL OF EVIDENCE

Level II controlled trial without randomization.

Eating Disorder Symptom and Fear Change Trajectories During Imaginal Exposure Therapy: A Slope Network Analysis

Eating disorders (EDs) are characterized by fears related to food, body image, and social evaluation. Exposure-based interventions hold promise for targeting a range of ED fears and reducing ED psychopathology. We investigated change mechanisms and optimal fear targets in imaginal exposure therapy for EDs using a novel approach to network analysis. Individuals with an ED (N = 143) completed up to four online imaginal exposure sessions. Participants reported ED symptoms and fears at pretreatment, posttreatment, and 6-month follow-up. We constructed networks of symptoms (Model 1), fears (Model 2), and combined symptoms and fears (Model 3). Change trajectory networks from the slopes of symptoms/fears across timepoints were estimated to identify how change in specific ED symptoms/fears related to change in other ED symptoms/fears. The most central changing symptoms and fears were feeling fat, fear of weight gain, guilt about one's weight/shape, and feared concerns about consequences of eating. In Model 3, change in ED fears bridged to change in desire to lose weight, desiring a flat stomach, following food rules, concern about eating with others, and guilt. As slope networks present averages of symptom/fear change slopes over the course of imaginal exposure therapy, further studies are needed to examine causal relationships between symptom changes and heterogeneity of change trajectories. Fears of weight gain and consequences of eating may be optimal targets for ED exposure therapy, as changes in these fears were associated with maximal change in ED pathology. Slope networks may elucidate change mechanisms for EDs and other psychiatric illnesses.

Transdiagnostic fears and avoidance behaviors in self-reported eating disorders

BACKGROUND

Fears and avoidance behaviors are common symptoms of eating disorders. It was investigated whether different eating disorder diagnoses are equally characterized by similar fears and avoidance behaviors.

METHODS

Individuals with self-reported eating disorders (n = 250) and healthy controls (n = 95) completed online questionnaires assessing general fears, eating related fears, and avoidance behaviors.

RESULTS

All self-reported eating disorder diagnoses showed more eating related fears, general fears, and avoidance behaviors than healthy controls. Individuals with binge eating disorder showed less specific and general fears on some but by no means all scales, yet they showed less food avoidance behaviors than all other eating disorders and less eating restraint than anorexia nervosa and bulimia nervosa.

CONCLUSIONS

Eating related fears, general fears, and food avoidance behaviors were found to be transdiagnostic symptoms in self-reported eating disorders. Individuals with binge eating disorder also exhibit more fears and avoidance behaviors than healthy controls, but to a lesser extent than the other eating disorders. Specialized interventions targeting fears and avoidance may be promising add-on interventions not only in the treatment of anorexia nervosa, but in the treatment of all eating disorders.

Association of emotion recognition ability and interpersonal emotional competence in anorexia nervosa: A study with a multimodal dynamic task

OBJECTIVE

Interpersonal difficulties are evidenced in Anorexia Nervosa (AN) and are thought to contribute to disease onset and maintenance, however, research in the framework of emotional competence is currently limited. Previous studies have often only used static images for emotion recognition tasks, and evidence is lacking on the relationships between performance-based emotional abilities and self-reported intra- and interpersonal emotional traits. This study aimed to test multimodal dynamic emotion recognition ability in AN and analyze its correlation with the psychometric scores of self- and other-related emotional competence.

METHOD

A total of 268 participants (128 individuals with AN and 140 healthy controls) completed the Geneva Emotion Recognition Test, the Profile of Emotional Competence, the Reading the Mind in the Eyes Test, and measures of general and eating psychopathology. Scores were compared between the two groups. Linear mixed effects models were utilized to examine the relationship between emotion recognition ability and self-reported measures and clinical variables.

RESULTS

Individuals with AN showed significantly poorer recognition of emotions of both negative and positive valence and significantly lower scores in all emotional competence dimensions. Beside emotion type and group, linear mixed models evidenced significant effects of interpersonal comprehension on emotion recognition ability.

DISCUSSION

Individuals with AN show impairment in multimodal emotion recognition and report their difficulties accordingly. Notably, among all emotional competence dimensions, interpersonal comprehension emerges as a significant correlate to emotion recognition in others, and could represent a specific area of intervention in the treatment of individuals with AN.

PUBLIC SIGNIFICANCE

In this study, we evidence that the ability to recognize the emotions displayed by others is related to the level of interpersonal emotional competence reported by individuals with anorexia nervosa. This result helps in understanding the social impairments in people with anorexia nervosa and could contribute to advancements in the application of the training of emotional competence in the treatment of this disorder.

Understanding outcomes in family-based treatment for adolescent anorexia nervosa: a network approach

BACKGROUND

Family-based treatment (FBT) is the first-line treatment for adolescent anorexia nervosa (AN). Yet, remission is not achieved for about half of adolescents with AN receiving FBT. Understanding patient- and parent-level factors that predict FBT response may inform treatment development and improve outcomes.

METHODS

Network analysis was used to identify the most central symptoms of AN in adolescents who completed the Eating Disorder Examination (EDE) prior to FBT (N = 409). Bridge pathways between adolescent AN and parental self-efficacy in facilitating their child's recovery from AN were identified in a subset of participants (n = 184). Central and bridge symptoms were tested as predictors of early response (⩾2.4 kg weight gain by the fourth session of FBT) and end-of-treatment weight restoration [⩾95% expected body weight (EBW)] and full remission (⩾95% EBW and EDE score within 1 standard deviation of norms).

RESULTS

The most central symptoms of adolescent AN included desiring weight loss, dietary restraint, and feeling fat. These symptoms predicted early response, but not end-of-treatment outcomes. Bridge symptoms were parental beliefs about their responsibility to renourish their child, adolescent discomfort eating in front of others, and adolescent dietary restraint. Bridge symptoms predicted end-of-treatment weight restoration, but not early response nor full remission.

CONCLUSIONS

Findings highlight the prognostic utility of core symptoms of adolescent AN. Parent beliefs about their responsibility to renourish their child may maintain associations between parental self-efficacy and AN psychopathology. These findings could inform strategies to adapt FBT and improve outcomes.

Psychopathology predicts mental but not physical bariatric surgery outcome at 3-year follow-up: a network analysis study

PURPOSE

This study aimed to explore the psychopathological variables that may predict bariatric surgery outcomes after 3 years.

METHODS

One hundred ninety-six candidates for bariatric surgery completed self-report questionnaires to assess eating attitudes, eating disorder (ED)-related psychopathology, affective symptoms, interpersonal and psycho-social functioning. One-hundred patients repeated this assessment 3 years after bariatric surgery. A network analysis was run including the pre-surgical measurements in the network. A composite score derived from the combination of the most central network nodes, as well as clinical and socio-demographical variables, was included in a multivariate regression analysis with weight loss, ED psychopathology and psycho-social functioning as outcomes.

RESULTS

Depression, stress, and shape concerns were the most central network nodes. The composite network score predicted higher ED psychopathology and worse psycho-social functioning at 3-year follow-up, but not weight loss. Higher age, restricting type of bariatric surgery and higher pre-operative BMI were further predictors of reduced weight loss and greater ED psychopathology.

CONCLUSIONS

Affective symptoms and shape concern play a central role in the psychopathology of candidates to bariatric surgery and predict post-surgery ED psychopathology and psycho-social functioning. These variables may allow to identify patients with higher pre-operative risk and in need of further psycho-social interventions.

LEVEL OF EVIDENCE

III, evidence obtained from well-designed cohort study.

Integrating clinician and patient case conceptualization with momentary assessment data to construct idiographic networks: Moving toward personalized treatment for eating disorders

Eating disorders are serious psychiatric illnesses with treatments ineffective for about 50% of individuals due to high heterogeneity of symptom presentation even within the same diagnoses, a lack of personalized treatments to address this heterogeneity, and the fact that clinicians are left to rely upon their own judgment to decide how to personalize treatment. Idiographic (personalized) networks can be estimated from ecological momentary assessment data, and have been used to investigate central symptoms, which are theorized to be fruitful treatment targets. However, both efficacy of treatment target selection and implementation with 'real world' clinicians could be maximized if clinician input is integrated into such networks. An emerging line of research is therefore proposing to integrate case conceptualizations and statistical routines, tying together the benefits from clinical expertise as well as patient experience and idiographic networks. The current pilot compares personalized treatment implications from different approaches to constructing idiographic networks. For two patients with a diagnosis of anorexia nervosa, we compared idiographic networks 1) based on the case conceptualization from clinician and patient, 2) estimated from patient EMA data (the current default in the literature), and 3) based on a combination of case conceptualization and patient EMA data networks, drawing on informative priors in Bayesian inference. Centrality-based treatment recommendations differed to varying extent between these approaches for patients. We discuss implications from these findings, as well as how these models may inform clinical practice by pairing evidence-based treatments with identified treatment targets.

Associations between fear of weight gain and exercise in binge-spectrum eating disorders

PURPOSE

Maladaptive exercise (i.e., exercise that is either driven or compensatory) is thought to momentarily down-regulate elevated fear of weight gain (FOWG). However, little research has examined associations between FOWG and exercise, and no research has measured FOWG at a momentary level or considered exercise type (i.e., maladaptive vs. adaptive). Thus, we examined both within- and between-subject associations between FOWG and exercise among individuals with trans-diagnostic binge eating.

METHODS

We recruited treatment-seeking adults (N = 58, 82.9% female) to complete a 7-14-day ecological momentary assessment protocol which assessed levels of FOWG and exercise engagement and type. Mixed models and generalized estimating equations assessed within-subject associations, and linear regression assessed between-subject associations.

RESULTS

There was no main effect of FOWG on exercise engagement at the next survey. However, unexpectedly, exercise type moderated this relationship such that the relationship between FOWG and exercise was strongest for episodes of adaptive exercise. Overall exercise frequency accounted for 10.4% of the variance in FOWG and exercise type explained an additional 1.7% of the variance in FOWG.

CONCLUSION

The findings of the current study indicate that momentary levels of FOWG are associated with subsequent adaptive exercise episodes, while higher overall levels of maladaptive exercise were associated with higher levels of FOWG. Future treatments should place a greater emphasis on reducing the frequency of maladaptive exercise by providing strategies for reducing FOWG.

LEVEL OF EVIDENCE

Level IV: Evidence obtained from multiple time series analysis such as case studies.

Core eating disorder fears: Prevalence and differences in eating disorder fears across eating disorder diagnoses

OBJECTIVE

Fear and anxiety are key maintaining factors for eating disorder (ED) pathology. Maladaptive fears lead to ED behaviors and avoidance, which provide temporary relief, but ultimately reinforce the fear and contribute to a cycle that maintains the ED. To date, fears of food and weight gain are the most explored fears underlying ED pathology. However, recently other important ED fears have been identified, including fears of social consequences and personal consequences.

METHOD

The current study (N = 229 individuals with an ED) aimed to better characterize ED fears. Specifically, this study examined which ED fears were most endorsed across and within ED diagnoses, and if there were differences in ED fears by diagnosis and by weight status.

RESULTS

Overall, fear of gaining weight was the most frequently endorsed fear, followed by fear of food, and fear of judgment. Individuals with anorexia nervosa (AN) most frequently endorsed fear of food, individuals with atypical AN and bulimia nervosa: fear of gaining weight, and those with other specified feeding and eating disorder: fear of judgment. Limited differences were found between diagnoses. When examining by weight category, participants with underweight most frequently endorsed fear of food, participants with normal weight: fear of gaining weight, and participants with overweight and obesity: fear of judgment.

DISCUSSION

These findings suggest ED fears are heterogenous. Given such high heterogeneity, this work highlights the importance of assessing for specific ED fears at the beginning of treatment, which could be used to deliver personalized exposure treatment.

PUBLIC SIGNIFICANCE STATEMENT

Eating disorders (EDs) are serious mental illnesses with high rates of medical and psychiatric comorbidities. Fear plays an important role in the development and maintenance of EDs. The present study found fear of food, weight gain, and judgment are the most frequently endorsed fears for individuals with EDs and found few differences in fears based on ED diagnosis. These findings highlight the importance of assessing individuals' specific ED fears for treatment.

Eating disorder and social anxiety symptoms in Iranian preadolescents: a network analysis

PURPOSE

Network studies of eating disorder (ED) symptoms have identified central and bridge symptoms in Western samples, yet few network models of ED symptoms have been tested in non-Western samples, especially among preadolescents. The current study tested a network model of ED symptoms in Iranian preadolescents (ages 9 to 13), as well as a model of co-occurring social anxiety disorder (SAD) and ED symptoms.

METHOD

Preadolescent boys (n = 405) and girls (n = 325) completed the Children Eating Attitudes Test-20 and Social Anxiety Scale for Children. We estimated two network models (ED and ED/SAD networks) and identified central and bridge symptoms, as well as tested if these models differed by sex.

RESULTS

We found that discomfort eating sweets were the most central symptoms in ED networks. Concern over being judged was central in networks including both ED and SAD symptoms. Additionally, concern over being judged was the strongest bridge symptoms. Networks did not differ by sex.

CONCLUSION

Future research is needed to test if interventions focused on bridge symptoms (i.e., concern over being judged) as primary intervention points target comorbid ED-SAD pathology in preadolescents at risk for ED and SAD.

LEVEL OF EVIDENCE

Level III; Evidence obtained from well-designed observational study, including case-control design for relevant aspects of the study.

Disgust and Self-Disgust in Eating Disorders: A Systematic Review and Meta-Analysis

Disgust and self-disgust are aversive emotions which are often encountered in people with eating disorders. We conducted a systematic review and meta-analysis of disgust and self-disgust in people with eating disorders using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The systematic review of the literature revealed 52 original research papers. There was substantial heterogeneity regarding the research question and outcomes. However, we found 5 articles on disgust elicited by food images, 10 studies on generic disgust sensitivity, and 4 studies on self-disgust, and we proceeded to a meta-analytic approach on these studies. We found that women with eating disorders have significantly higher momentary disgust feelings in response to food images (1.32; 95% CI 1.05, 1.59), higher generic disgust sensitivity (0.49; 95% CI 0.24, 0.71), and higher self-disgust (1.90; 95% CI 1.51, 2.29) compared with healthy controls. These findings indicate the potential clinical relevance of disgust and self-disgust in the treatment of eating disorders.

Momentary associations between fear of weight gain and dietary restriction among individuals with binge-spectrum eating disorders

OBJECTIVE

Fear of weight gain (FOWG) is increasingly implicated in the maintenance of binge-spectrum eating disorders (EDs; e.g., bulimia nervosa [BN], binge-eating disorder [BED]) through the pathway of increased dietary restriction. However, particularly in binge-spectrum EDs, research is nascent and based on retrospective self-report. To improve treatment outcomes, it is critical to better understand the momentary relations between FOWG and dietary restriction.

METHOD

Sixty-seven adults with binge spectrum EDs completed a 7-14-day ecological momentary assessment protocol that included items regarding FOWG, ED behaviors, and types of dietary restriction (e.g., attempted restraint vs. actual restriction) several times per day. Multilevel models were used to evaluate reciprocal associations between FOWG and dietary restriction, and to evaluate the indirect of effects of dietary restriction on the relation between FOWG and binge eating.

RESULTS

While main effects were not statistically significant, ED presentation significantly moderated the association between increases in FOWG at time1 and both attempted and actual avoidance of enjoyable foods at time2 such that those with BN-spectrum EDs were more likely to avoid enjoyable foods following increased FOWG compared to those with BED-spectrum EDs. Engagement in restriction at time1 was not associated with decreased FOWG at time2.

DISCUSSION

Prospective associations between FOWG and restriction suggest that individuals with BN may be more likely to restrict their eating following increased FOWG. These findings suggest FOWG may be an important target for future treatments.

Mindfulness and Eating Disorders: A Network Analysis

Higher trait mindfulness may be protective against eating disorder (ED) pathology. However, little is understood about which specific mindfulness processes connect to specific ED symptoms. This study (N = 1,056 undergraduates) used network analysis at the symptom/process level to identify: (1) central nodes, or symptoms/processes with the greatest collective connection with all other symptoms/processes; and (2) bridge nodes, or symptoms/processes driving interconnection between mindfulness processes and ED symptoms. We conducted analyses both with and without food- and body-related mindfulness items. Central nodes included: describing how one feels in detail, expressing how one feels in words, and feeling guilty about eating due to shape/weight. Bridge nodes connecting higher mindfulness processes with lower ED symptoms included: the eating disorder symptom, being uncomfortable about others seeing one eat, and the mindfulness process, not criticizing oneself for having irrational/inappropriate emotions. Bridge nodes connecting higher mindfulness processes with higher ED symptoms included: noticing sensations of the body moving when walking and noticing how food/drinks affect thoughts, bodily sensations, and emotions. Findings suggest that future research should explore whether mindfulness-based interventions for EDs may be more effective by targeting mindfulness processes related to describing, expressing, and accepting emotions, accepting discomfort when eating with others, and reducing hyper-focus on and reactivity to food-and-body related sensations.

Emotion regulation in adolescents with anorexia and bulimia nervosa: Differential use of adaptive and maladaptive strategies compared to healthy adolescents

OBJECTIVE

Adolescents with anorexia (AN) and bulimia nervosa (BN) often struggle with emotion regulation (ER). These difficulties have predominantly been assessed across emotions, without considering adaptive and maladaptive ER separately. We compared adolescents with AN or BN to healthy adolescents (HCs) regarding the adaptive and maladaptive ER of three emotions.

METHOD

A treatment-seeking sample of 197 adolescents (atypical/full-threshold AN: N = 118, atypical/full-threshold BN: N = 32; HC: N = 47) reported emotion-specific ER with the FEEL-KJ questionnaire. Mixed models were calculated for adaptive and maladaptive ER to assess differences between emotions (anxiety, anger, and sadness) and groups (AN, BN, and HC).

RESULTS

Main effects of emotion (p < .001) and group (p < .001) were found, but no interaction effects were found (p > .05). Post hoc tests showed lower maladaptive and higher adaptive ER for anxiety than anger or sadness (p < .001). AN and BN reported lower adaptive (p < .001) and higher maladaptive ER than HCs (p < .001). BN showed the highest levels of maladaptive ER (p = .009).

DISCUSSION

The differences between AN and BN in adaptive and maladaptive ER should be considered. Furthermore, investigating differences in ER of other emotions in eating disorders might be promising.

Pinpointing core and pathway symptoms among sleep disturbance, anxiety, worry, and eating disorder symptoms in anorexia nervosa and atypical anorexia nervosa

BACKGROUND

Sleep, anxiety, and worry are strongly related to psychiatric illness and in particular to eating disorder (ED) symptoms. However, it is unclear how these specific sleep and anxiety symptoms are interrelated with anorexia nervosa (AN) pathology.

METHODS

We utilized network analysis to test our theoretically-based conceptual model, by identifying core features and illness (i.e., bridge) pathways among sleep disturbance, anxiety, worry, and ED symptoms in 267 participants with a diagnosis of AN or atypical AN.

RESULTS

The following core symptoms were identified: shape judgement, restriction, and feeling tired. The strongest bridge symptoms included worry, feeling tired, loss of energy, and physical anxiety. Worry was connected positively to fasting, fear of gaining weight or becoming fat, loss of energy, and feeling tired, and negatively to changes in sleeping patterns. Feeling tired was connected to restriction, fasting, binge eating, and worry. Loss of energy was connected to loss of control over eating and worry. Physical anxiety was negatively connected to restriction.

CONCLUSIONS

We identified specific core symptoms and illness pathways supporting our theoretical conceptual model of how ED symptoms, anxiety, worry, and sleep disturbances inter-relate in AN and atypical AN. In particular we found that symptoms associated with sleep and anxiety were central and had strong connections with AN symptoms. In addition to targeting AN symptoms, these data suggest that targeting sleep disturbance, anxiety, and worry could improve treatment for AN.

Network Analysis of PTSD Symptoms in a Sample of Polyvictimized Youth

Polyvictimization (i.e., the experience of multiple types of victimization) increases the risk for post-traumatic stress disorder (PTSD) relative to single-type victimization. Network analysis has been used to conceptualize PTSD among children and adolescents exposed to specific types of victimization (e.g., maltreatment, natural disasters), but not among those theorized to be at highest risk of poor outcomes (i.e., polyvictimized youth). The current study used network analysis to enhance our understanding of PTSD symptoms in a diverse sample of adolescents exposed to polyvictimization. Data were drawn from the Longitudinal Studies on Child Abuse and Neglect, a multi-site study of children and adolescents living in the United States (ages 0-18). Using indicators of seven different types of age-16 victimization, k-means cluster analysis identified a subgroup of polyvictimized youth. A PTSD symptom network was estimated for polyvictimized youth, with depersonalization, self-blame, and sadness emerging as central symptoms. Regression analyses indicated that depersonalization prospectively predicted age-18 anxiety symptoms, p = .033. Central symptoms did not predict age-18 PTSD or depression symptoms. To date, this is the first network study on a polyvictimized sample. While preliminary, our findings suggest that dissociation and self-blame may be central to polyvictimized youth and that dissociation may represent an important prevention target for anxiety.

Feeling imperfect and imperfectly feeling: A network analysis on perfectionism, interoceptive sensibility, and eating symptomatology in anorexia nervosa

OBJECTIVE

In recent years, the network analysis (NA) methodology has been applied to identify the central features of the psychopathology of anorexia nervosa (AN) and specific connections to previously recognized vulnerabilities. However, an NA investigating both multidimensional perfectionism and interoceptive sensibility in connection to eating symptomatology is currently missing.

METHOD

A total of 260 individuals (139 patients with AN, 121 healthy control individuals) completed the Frost Multidimensional Perfectionism Scale, the Multidimensional Assessment of Interoceptive Awareness and the Eating Disorders Inventory-2. Using state-of-the-art techniques, we estimated a main network with data from all participants and then compared the two separated networks. We checked the variables for empirical overlap through goldbricker, combined as suggested and implemented the empirical measure of the bridge nodes.

RESULTS

Ineffectiveness and need for control over self and body (resulting from combining Asceticism and Drive for Thinness) were the most central nodes, whereas perfectionistic evaluative concerns (resulting from combining Doubts about Actions and Concern over Mistakes) and mistrust in body sensations were the bridge nodes. No significant differences between the patient and control networks emerged.

CONCLUSIONS

Perfectionistic evaluative concerns and mistrust in body sensations could be key components in the relationships among perfectionism, interoceptive sensibility and eating symptomatology.

Network investigation of eating disorder symptoms and positive and negative affect in a clinical eating disorder sample

OBJECTIVE

Growing literature suggests that emotions influence the maintenance of eating disorder (ED) symptoms. However, most research has studied the relationship between ED symptoms and affect broadly (i.e., negative affect [NA], positive affect [PA]), rather than examining models comprised of multiple specific affective states (e.g., upset, proud).

METHOD

The current study (N = 196 individuals with EDs) used network analysis to examine the most interconnected (i.e., central) NA and PA states in EDs and test the complex associations between specific NA, PA, and ED symptoms. We estimated two networks: one with affective states only and another with affective states and ED symptoms.

RESULTS

Feeling distressed, afraid, attentive, and determined were the most central symptoms in the affect-only network. ED symptoms related to overvaluation of weight and shape, including affect-based ED symptoms (i.e., guilt about eating), were central in the network of affect and ED symptoms. Guilt about eating and shame were central bridge symptoms across affect and ED symptom clusters, meaning that they were each strongly connected across clusters, and may represent important pathways among affect and ED symptoms.

DISCUSSION

Limitations include the cross-sectional and between-person nature of these analyses, from which we cannot derive causal or within-persons processes. Clinical interventions that target central and bridge symptoms (e.g., fear, shame) may disrupt the reinforcing cycle of NA in EDs that may contribute to ED behaviors. Future research should examine relationships among affective states and ED symptoms in longitudinal and intraindividual network models to develop more effective treatments for EDs.

An examination of social group memberships in patients with eating disorders, carers, and healthy controls

This study compared the quantity and quality of social group memberships in patients with anorexia nervosa (n = 30), carers of patients with anorexia nervosa, unrelated to those patients (n = 30), and two cohorts of healthy controls (n = 60) age-matched to these focal groups. A secondary aim was to examine the associations between the quality of group relationships and severity of eating disorder and depression symptoms in patients; and depression symptoms in carers. Participants completed the online Social Identity Mapping Tool, which was used to measure the quantity and quality of social group memberships (e.g., number of social groups, number of groups rated 'highly positive'). Participants also completed self-report measures of clinical symptoms. Compared to controls, patients reported fewer social groups when eating disorder-related groups were included, and significantly fewer social groups, and community groups in particular, when eating disorder-related groups were excluded. Number of positive groups was negatively associated with severity of eating disorder and depression symptoms in patients when eating disorder-related groups were excluded. Carers reported fewer groups overall, fewer family groups, and fewer positive and supportive groups compared to healthy controls. There was a weak association between the number of positive groups and the severity of depression symptoms in carers. Positive group memberships might play a protective role towards developing more severe eating disorder and depression symptoms.

Avoidance in Anorexia Nervosa: Towards a research agenda

Anorexia Nervosa is a severe and disabling mental disorder and a huge challenge to treat. Intense fears of e.g., food, eating, weight gain and social evaluation are core features of anorexia nervosa and obstacles during treatment. The perceived threats trigger avoidance and safety behaviors like highly restrictive eating, strict eating rules, vomiting and body checking, to minimize feared outcomes. The role of avoidance in anorexia nervosa is however hardly studied experimentally. In the present article, the focus is on a new transdiagnostic research agenda featuring both basic and clinical experimental research into avoidance as a most important mechanism maintaining the eating disorder. Avoidance learning and the generalization of learned avoidance behaviors are discussed, as well as safety behaviors and the need for inhibitory learning as a treatment target during exposure therapy.

A systematic review of network analysis studies in eating disorders: Is time to broaden the core psychopathology to non specific symptoms

Objective

Network theory considers mental disorders as the product of symptom interaction. A growing number of studies employing this methodology has been conducted in eating disorders (EDs). We aimed to review those studies to provide evidence and limitations for a novel conceptualisation of EDs.

Methods

According to PRISMA guidelines and PICOS criteria, studies eligible for inclusion were those employing network analysis in people with a clinically defined diagnosis of ED. Twenty‐five studies were included and were analysed in relation to diagnosis, comorbidity, and treatment outcome.

Results

Despite the central role of overvaluation of body shape and weight and cognitive restraint across ED diagnoses, ineffectiveness, interoceptive awareness and affective problems appear central symptoms. Ineffectiveness and interoceptive awareness emerge as bridge symptoms promoting comorbidity in people with anorexia nervosa and in mixed ED samples. Although few studies assessed treatment outcome, there is evidence supporting the predictive role of central network nodes.

Conclusions

Ineffectiveness, interoceptive ability and affective problems may be included in the core ED psychopathology, in addition to ED‐specific symptoms. Network analysis is a promising method to reconceptualize comorbidity. Future studies are recommended to include general psychopathology in ED networks, to assess connections with the external field and clinical meaning of network connectivity.

Overvaluation of body shape and weight and cognitive restraint appear as central nodes across eating disorder diagnoses and ages.

In addition to specific symptoms, ineffectiveness, low interoceptive ability and affective problems also emerge as central nodes in eating disorders.

There is some evidence to point to ineffectiveness and low interoceptive ability as bridge nodes promoting psychiatric comorbidity.

Only few studies assessed treatment outcome through the network analysis approach

AN-VR-BE. A Randomized Controlled Trial for Reducing Fear of Gaining Weight and Other Eating Disorder Symptoms in Anorexia Nervosa through Virtual Reality-Based Body Exposure

In vivo body exposure therapy is considered an effective and suitable intervention to help patients with anorexia nervosa (AN) reduce their body image disturbances (BIDs). However, these interventions have notable limitations and cannot effectively reproduce certain fears usually found in AN, such as the fear of gaining weight (FGW). The latest developments in virtual reality (VR) technology and embodiment-based procedures could overcome these limitations and allow AN patients to confront their FGW and BIDs. This study aimed to provide further evidence of the efficacy of an enhanced (by means of embodiment) VR-based body exposure therapy for the treatment of AN. Thirty-five AN patients (16 in the experimental group, 19 in the control group) participated in the study. FGW, BIDs, and other body-related and ED measures were assessed before and after the intervention and three months later. The experimental group received treatment as usual (TAU) and five additional sessions of VR-based body exposure therapy, while the control group received only TAU. After the intervention, ED symptoms were clearly reduced in both groups, with most of the changes being more noticeable in the experimental group. Specifically, after the intervention and at follow-up, significant group differences were found in the FGW and BIDs, with the experimental group showing significantly lower values than the control group. The current study provides new insights and encouraging findings in the field of exposure-based therapies in AN. VR technology might improve research and clinical practice in AN by providing new tools to help patients confront their core fears (i.e., food- or weight-related cues) and improve their emotional, cognitive, and behavioral responses to their body image.

Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research

Eating disorders (EDs) and anxiety disorders (ADs) evidence shared risk and significant comorbidity. Recent advances in understanding of anxiety-based disorders may have direct application to research and treatment efforts for EDs. The current review presents an up-to-date, behavioral conceptualization of the overlap between anxiety-based disorders and EDs. We identify ways in which anxiety presents in EDs, consider differences between EDs and ADs relevant to treatment adaptions, discuss how exposure-based strategies may be adapted for use in ED treatment, and outline directions for future mechanistic, translational, and clinical ED research from this perspective. Important research directions include: simultaneous examination of the extent to which EDs are characterized by aberrant avoidance-, reward-, and/or habit-based neurobiological and behavioral processes; improvement in understanding of how nutritional status interacts with neurobiological characteristics of EDs; incorporation of a growing knowledge of biobehavioral signatures in ED treatment planning; development of more comprehensive exposure-based treatment approaches for EDs; testing whether certain exposure interventions for AD are appropriate for EDs; and improvement in clinician self-efficacy and ability to use exposure therapy for EDs.