Review of Attentional Bias Modification: A Brain-directed Treatment for Eating Disorders

Attentional Processing Biases in Young People With Binging and Purging Behavior

OBJECTIVE

Binging and purging are transdiagnostic features of eating disorders (EDs). Attentional biases (ABs) toward food and body shape cues and negative affect (NA) are associated with ED psychopathology. These ABs might also be present in people with subthreshold ED not meeting full diagnostic criteria. We investigated ABs to food and body shape cues and the interaction between ABs and NA in young people with binge/purge behavior (B/P group) and healthy controls (HC group). Our B/P sample consisted of individuals with threshold and subthreshold ED, including participants with BN, AN-R, and AN-B/P.

METHOD

We conducted two studies. Study 1 recruited n = 54 HC and n = 53 B/P participants aged 16-25, and Study 2 recruited n = 73 HC and n = 72 B/P participants. In Study 1, ABs toward food and body shape cues were compared between B/P versus HC participants using a pictorial dot-probe task. In Study 2, ABs were compared between B/P versus HC participants after NA induction using the Cyberball social exclusion task. Indexes of attentional engagement and disengagement were computed.

RESULTS

There was a main effect of cue type on attentional engagement at 0.2 s (p = 0.006,η p 2 $\eta _p^2$  = 0.075) and 2 s (p = 0.040,η p 2 $\eta _p^2$  = 0.043), and attentional disengagement at 2 s (p = 0.006,η p 2 $\eta _p^2$  = 0.077) in Study 1. Findings were not replicated following NA induction in Study 2. No main effect of group or group × cue type interaction was found.

DISCUSSION

Our results disagree with previous research supporting the importance of ABs toward food and body shape cues in young people with threshold and subthreshold EDs and suggest these might not constitute a relevant target in the treatment of ED behavior. However, due to a heterogeneous approach to measuring ABs and multiple types of AB being described in EDs, further research is needed to clarify whether ABs map onto transdiagnostic models of behavioral dysregulation.

Improving emotion regulation ability after brain injury: A systematic review of targeted interventions

Emotion dysregulation is a common sequela after a brain injury, and it can have serious negative consequences for individuals, families, and the community. A systematic review of the literature was conducted to identify and evaluate interventions designed to improve emotion regulation ability in adults with acquired brain injury. Studies were identified on ProQuest, PsycInfo, ScienceDirect, Scopus, and Web of Science; last searched on 3 August 2023. A review protocol was prospectively registered on PROSPERO (CRD42020218175). Risk of bias was assessed using the Cochrane Risk-of-Bias tool (version 2). Sixteen studies were included in the review comprising one case series, five pilot studies, four pre-post studies, and six RCTs. There was a total of 652 participants across studies. Fourteen of the sixteen studies reported statistically significant improvements in at least one emotional functioning variable. Ten studies reported medium-large effect sizes. Limitations included inconsistency in the measurement, reporting of intervention outcomes and processes. Future directions are discussed.

The effect of an odd-one-out visual search task on attentional bias, body size adaptation, and body dissatisfaction

Body image disturbance is a both a risk factor for, and a symptom of, many eating disorders and refers to the misperception of and dissatisfaction with one's own body. Women with high body dissatisfaction have been shown to direct more attention to low body mass index (BMI) bodies, which results in the overestimation of body size via body size adaptation. Therefore, attention may have a causal role in body image disturbance. We conducted a novel training visual search task with 142 young adult women who we trained to attend to either high or low BMI bodies. We assessed the effects of this training on attention to bodies of different sizes, body size adaptation, and body dissatisfaction. Women trained to attend to low BMI bodies decreased their perceptions of a 'normal' body size via adaptation from pre- to post-training (p < 0.001); however, women trained to attend to high BMI bodies showed no change in their perception of a 'normal' body size. We found no lasting effects of the training on attention to body size or body dissatisfaction; however, our visual search task showed poor internal consistency as a measure of attention. These findings indicate that attention to low BMI bodies may exacerbate body image disturbance in women. However, more reliable measures of attentional are required to confirm this finding.

Modification of Body-Related Attentional Bias through Virtual Reality and Eye-Tracking in Healthy Participants: Implications for Anorexia Nervosa Treatments

Cognitive biases have a significant impact on the etiology and treatment of eating disorders (EDs). These biases, including selective attentional bias (AB) to disliked body parts, may reinforce concerns about body shape, fear of gaining weight and body image disturbances and may contribute to dietary restriction and restraint. Decreasing AB could reduce core symptoms in anorexia nervosa (AN). This study represents a preliminary exploration aiming to assess whether AB towards weight-related (WR) and non-weight-related (NW) body parts could be reduced through an AB modification task in a virtual reality (VR) environment in healthy participants. A total of 54 female participants, aged 22.98 ± 1.89, were recruited. The task consisted of directing the participants' attention towards all body parts equally in a VR setting. Eye-tracking (ET) measurements (complete fixation time [CFT] and number of fixations [NF]) were made before and after the task. The results showed a significant reduction of the AB in the two groups with an initial AB towards WR body parts or towards NW body parts. Participants showed a tendency to more balanced (non-biased) attention after the intervention. This study provides evidence of the usefulness of AB modification tasks in a non-clinical sample.

A randomised controlled feasibility study of food-related computerised attention training versus mindfulness training and waiting-list control for adults with overweight or obesity: the FOCUS study

BACKGROUND

In a feasibility randomised controlled trial in people with overweight/obesity with and without binge eating disorder (BED) symptoms, we assessed eight weekly sessions of attention bias modification training (ABMT) and mindfulness training (MT) versus waiting list (WL) and explored potential mechanisms.

METHODS

45 participants were randomly allocated to one of three trial arms. Primary outcomes were recruitment, retention and treatment adherence rates. Secondary outcomes included measures of eating behaviour, mood, attention and treatment acceptability. Assessments were conducted at baseline, post-intervention (week 8), and follow-up (week 12).

RESULTS

Participant retention at follow-up was 84.5% across groups. Session completion rates in the laboratory were 87% for ABMT and 94% for MT, but home practice was much poorer for ABMT. Changes in BMI and body composition were small between groups and there was a medium size BMI reduction in the MT group at follow-up. Effect sizes of eating disorder symptom changes were not greater for either intervention group compared to WL, but favoured ABMT compared to MT. Hedonic hunger and mindful eating scores favoured MT compared to ABMT and WL. ABMT reduced attention biases towards high-calorie food cues, which correlated with lower objective binge eating days at post-intervention. No significant changes were observed in the MT, or WL conditions.

CONCLUSIONS

Both ABMT and MT have potential value as adjuncts in the treatment of obesity and BED, and a larger clinical trial appears feasible and indicated.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN15745838. Registered on 22 May 2018.

The Role of Habit Formation and Automaticity in Diabetes Self-Management: Current Evidence and Future Applications

PURPOSE OF REVIEW

Diabetes is a chronic condition that requires consistent self-management for optimal health outcomes. People with diabetes are prone to burnout, cognitive burden, and sub-optimal performance of self-management tasks. Interventions that focus on habit formation have the potential to increase engagement by facilitating automaticity of self-management task performance. The purpose of this review is to (1) clarify the conceptualizations of habit formation and behavioral automaticity in the context of health behavior interventions, (2) review the evidence of habit in relation to behaviors relevant to diabetes self-management, and (3) discuss opportunities for incorporating habit formation and automaticity into diabetes self-management interventions.

RECENT FINDINGS

Modern habit research describes a habit as a behavior that results over time from an automatic mental process. Automatic behaviors are experienced as cue-dependent, goal-independent, unconscious, and efficient. Habit formation requires context-dependent repetition to form cue-behavior associations. Results of diabetes habit studies are mixed. Observational studies have shown positive associations between habit strength and target self-management behaviors such as taking medication and monitoring blood glucose, as well as glycemic outcomes such as HbA1c. However, intervention studies conducted in similar populations have not demonstrated a significant benefit of habit-forming interventions compared to controls, possibly due to varying techniques used to promote habit formation. Automaticity of self-management behaviors has the potential to minimize the burden associated with performance of self-management tasks and ultimately improve outcomes for people with diabetes. Future studies should focus on refining interventions focused on context-dependent repetition to promote habit formation and better measurement of habit automaticity in diabetes self-management.

Evidence of attentional bias toward body stimuli in men

Over the past 30 years, attentional bias for body shape and weight content has been implicated in the precipitation and maintenance of body dissatisfaction and eating disorders. Although the existence of this bias toward body stimuli is well-established in female populations, it is comparatively understudied in men. This review aimed to examine the nature of this visual attentional bias toward male bodies in male samples across a range of different attentional paradigms, including eye-tracking, dot-probe, and the visual search task. Results were heterogenous, finding some evidence that men with higher body dissatisfaction and eating disorder symptoms demonstrated an attentional bias toward desirable bodies of other men, and undesirable features of their own bodies. These results suggest that schematic cognitive models of body dissatisfaction and eating disorders body may also be applicable to men, however more research is needed.

Visualizing Emotional Arousal within the Context of Body Size Evaluation: A Pilot Study of Steady-State Visual Evoked Potentials in Women with Anorexia Nervosa and Healthy Controls

Maladaptive body size evaluation processes and body dissatisfaction are known as central risk factors for the development and maintenance of anorexia nervosa (AN). This study aimed to experimentally test potential key facets, such as (psycho)physiological, cognitive-verbal and behavioral mechanisms, within the context of these evaluation processes. Twenty-two females with AN (AN-G) and 22 healthy controls (HC-G) looked at pictures of their body gradually increasing in weight using a morphing technique. Implicit emotional arousal was assessed using steady-state visual evoked potentials (SSVEP) in electroencephalography. Additionally, in a forced-choice body size evaluation task, participants were asked to classify pictures of their own body as not big or big while reaction times were captured. A significantly earlier increase in SSVEPs emerged in AN-G compared to HC-G (p <.05), with AN-G evaluating their bodies in the morphing process as big at a significantly thinner body size (p <.05). The AN-G showed faster reaction times in the categorical evaluation of body stimuli (p <.05). Findings from this multimodal paradigm underline the importance of body size evaluation mechanisms and underlying emotional arousal for AN. A differentiated understanding of these processes is essential, since the effectiveness of therapeutic interventions for AN is limited and relapses are frequent.

Computer Based Body Exposure in Adolescents With Anorexia Nervosa: A Study Protocol

Body dissatisfaction is a core feature of eating disorders (EDs) and plays an essential role in the development and maintenance of anorexia nervosa (AN). In the current study, a computer based body exposure intervention is conducted and evaluated regarding short-term effects on body dissatisfaction, psychopathology, viewing patterns, and stress reactivity. Within a randomized controlled trial (RCT) female adolescents and young women with AN are either receiving the intervention or treatment as usual (TAU). Furthermore, in a transdiagnostic approach, a highly body-dissatisfied group of clinical control participants obtaining the intervention will be surveyed to identify AN-specific processes. The standardized four-session body exposure intervention using photographs of the own body is adapted from a manualized body image treatment program for computer use. Psychopathology (body dissatisfaction, body image avoidance, body checking, depression, anxiety) is assessed via standardized questionnaires before and after the intervention. During each session, attentional biases regarding one's own body are measured via eye tracking, stress levels are measured via subjective ratings, heart rate variability, as well as salivary cortisol and alpha amylase. Between- and within-subject effects will be assessed. The pilot study aims to identify short-term effects of the intervention on body dissatisfaction and attentional bias, as well as to investigate the potential underlying mechanism of physiological habituation.

Does concurrent self-administered transcranial direct current stimulation and attention bias modification training improve symptoms of binge eating disorder? Protocol for the TANDEM feasibility randomized controlled trial

BACKGROUND

Binge eating disorder (BED) is a common and disabling problem associated with impaired cognitive control. Preliminary studies show that brain-directed treatments, including transcranial direct current stimulation (tDCS) and attention bias modification training (ABMT), improve cognitive control and alleviate symptoms of BED. When combined, tDCS may enhance the effects of ABMT, and vice versa, thereby improving treatment outcomes.

METHODS

This protocol describes a feasibility single-blind randomized sham-controlled trial of concurrent self-administered tDCS and ABMT in adults with BED (The TANDEM Trial). Eighty adults with BED will be randomly assigned to one of four groups: ABMT with real or sham self-administered tDCS, ABMT only, or waiting list control. In the treatment arms, participants will complete 10-sessions of their allocated intervention over 2-3 weeks. Outcomes will be assessed at baseline (T0), immediately post treatment (T1), and 6 weeks after end of treatment (T2), and at comparable timepoints for participants in the waitlist control group. Feasibility will be evaluated by assessing recruitment/retention rates and blinding success. Acceptability will be assessed quantitatively via participant ratings and qualitatively via semi-structured interviews. Episodes of binge eating at follow-up will be the primary clinical outcome and rate ratios from Poisson regression will be reported. Secondary outcomes will assess changes in ED and general psychopathology, attention bias toward high calorie foods, and executive function.

DISCUSSION

It is hoped that data from the trial will contribute to the development of neurobiologically informed treatments for BED, provide insights into the potential use of at-home variants of tDCS, and inform the design of future large scale trials.

Attentional bias in eating disorders: A meta-review

OBJECTIVE

This meta-review summarizes and synthesizes the most reliable findings regarding attentional bias in eating disorders across paradigms and stimulus types and considers implications for theory and future research.

METHOD

Four databases were systematically searched, along with reference lists of included reviews, yielding 15 systematic reviews (four of which were also meta-analyses). The quality of each review was appraised using the AMSTAR-2.

RESULTS

Key findings from systematic reviews are summarized, organized by paradigm and stimulus type.

DISCUSSION

The authors synthesize evidence from the highest-quality studies. There is evidence for attentional avoidance and vigilance in eating disorders depending on stimulus properties (low vs. high-calorie food; high-body mass vs. low-body mass index photos of others) and attentional avoidance of food stimuli in those with anorexia nervosa. Sad mood induction may generate attentional bias for food in those with binge-eating disorder. There may also be attentional bias to general threat in eating disorder samples. This meta-review concludes that most systematic reviews in this field are low in quality and summarizes the main areas that could be improved upon in future reviews. Implications of this study's findings for theory and intervention research are also discussed.

Incentive sensitization in binge behaviors: A mini review on electrophysiological evidence

Introduction

Binge behavior not only refers to the consumption of substances such as alcohol or food, but is also used in relation to gaming, watching and gambling. Dependent on context it makes for a widespread, benign recreational activity or can pose a serious mental health problem with deleterious consequences. Incentive sensitization theory describes the attribution of salience towards stimuli strongly associated with dopamine-mediated reward as a result of repeated consumption. The sensitized neural networks cause cue-triggered craving and excessive desire, but thus, this mechanism may also be applicable to stimulus-induced behaviors not associated with classical withdrawal symptoms. Event-related potentials (ERP) are a useful method of examining motivated attention towards incentive stimuli. This mini review aims to synthesize ERP findings from different types of binge behaviors in order to compare cue-reactivity to incentive stimuli.

Methods

Studies investigating binge drinking, binge eating as well as binge watching, gaming and gambling were screened. To limit the influence of concurrent task demands, ERP studies applying picture viewing paradigms with incentive stimuli were selected.

Results

Across binge behaviors, evidence on altered mid-latency ERPs has been mixed. However, studies investigating later stages of attentional processes more consistently find enlarged P300 and late positive potentials (LPP) amplitudes to relevant cues.

Conclusion

An altered attentional processing of incentive stimuli reflecting motivated attention is in line with incentive sensitization theory. Considering the limited number of studies, especially regarding binge behaviors not involving substances, more research is needed to attain a more thorough understanding of incentive sensitization across binge behaviors.

People who overvalue appearance selectively attend to descriptors of the attractiveness ideal: Findings from an emotional Stroop task

OBJECTIVE

Attentional biases to stimuli related to stigmatized appearance are theorized to stem from appearance overvaluation, but little research has examined this link. As well, little research has examined whether appearance overvaluation is associated with biases toward stimuli that describe the attractiveness ideal. We addressed these gaps in the literature using the emotional Stroop task and tested whether appearance overvaluation is associated with an attentional bias for words that describe stigmatized appearance (e.g., fat, ugly, shabby), the attractiveness ideal (e.g., thin, beautiful, fashionable), or both.

METHOD AND RESULTS

In Study 1, a community sample of people (N = 86) completed measures of appearance overvaluation, body dissatisfaction, and body mass index (BMI) followed by an emotional Stroop task. Appearance overvaluation was associated with an attentional bias for attractiveness ideal words-not stigmatized appearance words. Results remained significant when controlling for participants' body dissatisfaction, BMI, and gender. Study 2 (N = 316) replicated these findings. Finally, an integrative data analysis that pooled the data of Studies 1 and 2 (N = 402) provided additional support for our general hypothesis that people who overvalue appearance display an attentional bias to stimuli related to the attractiveness ideal.

DISCUSSION

The results show a robust association between appearance overvaluation and selective attention for attractiveness ideal stimuli. Results are discussed in reference to theory and research on information processing in eating disorders. We also call for research to examine information processing of stimuli related to the attractiveness ideal among people with eating disorders and who place high importance on appearance for self-definition.

Is It Possible to Train the Focus on Positive and Negative Parts of One's Own Body? A Pilot Randomized Controlled Study on Attentional Bias Modification Training

Dysfunctional body- and shape-related attentional biases are involved in the etiology and maintenance of eating disorders (ED). Various studies suggest that women, particularly those with ED diagnoses, focus on negatively evaluated parts of their own body, which leads to an increase in body dissatisfaction. The present study aims to empirically test the hypothesis that non-ED women show an attentional bias toward negative body parts and that the focus on positive and negative parts of one’s own body can be modified by attentional bias modification training based on a dot-probe task. Although several studies have measured body-related attentional biases by using pictures of participants’ own bodies, the approach of investigating attentional bias via a dot-probe task while presenting pictures of the participants’ own body parts and modifying the biased attention using such pictures is novel. Women (n = 60) rank-ordered 10 parts of their own body regarding their attractiveness. To examine and modify the attentional focus, pictures of the self-defined positive and negative parts of one’s own body were presented by means of a dot-probe task. A paired-sample t-test revealed no difference between reaction times to negative compared to positive body parts, indicating no attentional bias toward negative parts of one’s own body. A two-way ANOVA revealed a main effect of time for pictures of positive and negative parts of one’s own body, with a decrease in reaction times from pre- to post-training. However, there was no significant interaction between time and training condition concerning reaction times to positive and negative body parts. Our findings replicate previous evidence of a balanced attentional pattern regarding one’s own body in women without ED diagnoses. However, the dot-probe task failed to modify the attentional focus. As the modifiability of state body image increases with more pronounced body dissatisfaction, the next step would be to test this approach in clinical samples of women with ED diagnoses.

Study protocol of a randomised controlled feasibility study of food-related computerised attention training versus mindfulness training and waiting-list control for adults with overweight or obesity

Background

Obesity is a highly prevalent condition with multiple adverse health consequences. Widely available first-line treatments for obesity, such as dietary and other lifestyle interventions, typically have only short-term effects. Thus, new treatment approaches are needed. Novel interventions such as Attention Bias Modification Training (ABMT) and mindfulness-based interventions focus on modifying different maladaptive cognitive patterns typically present in people with obesity (e.g. attention bias to food cues); however, their mechanisms of action remain largely unknown. We describe the theoretical basis and the rationale for a study protocol of a feasibility randomised controlled trial (RCT) comparing two attention trainings (ABMT vs Mindfulness Training [MT]) in people with overweight or obesity. The aim of this study is to inform the development of a large-scale RCT in relation to acceptability and attendance rates and to identify preliminary evidence for the interventions’ clinical efficacy and potential underlying mechanisms.

Design

Forty-five adults who are either overweight or obese (minimum body mass index of 25 kg/m²) will be randomly allocated to receive eight sessions over eight weeks of either computerised ABMT or MT or be on a waiting list. Clinical and cognitive outcomes will be assessed at baseline, post-treatment (8 weeks) and follow-up (12 weeks post-randomisation). These include mood, body composition and attention biases. Credibility and acceptability of the trainings will be assessed using questionnaires, and recruitment and retention rates will be recorded.

Discussion

Findings will inform the feasibility of developing a large-scale RCT that takes into consideration effect sizes for primary outcome measures and the acceptability of the design. The study will also provide preliminary evidence on the clinical efficacy of two different attention trainings for people with obesity and associated underlying mechanisms.

Trial registration

ISRCTN Registry, ISRCTN15745838. Registered on 22 May 2018. 

Food related attention bias modification training for anorexia nervosa and its potential underpinning mechanisms

Treatment outcomes in anorexia nervosa (AN) remain suboptimal, evidencing the need for better and more targeted treatments. Whilst the aetiology of AN is complex, cognitive processes such as attention bias (AB) have been proposed to contribute to maintaining food restriction behaviour. Attention bias modification raining (ABMT) has been investigated in other eating disorders (EDs) such as binge eating disorder (BED) as a means of modifying AB for food and of changing eating behaviour. Promising findings have been reported, but the mechanisms underlying ABMT are poorly understood. We hypothesise that in AN, ABMT has the potential to modify maladaptive eating behaviours related to anxiety around food and eating and propose two mechanistic models; (1) ABMT increases general attentional control (which will improve control over disorder-relevant thoughts) or (2) ABMT promotes stimulus re-evaluation. In this second case, the effects of ABMT might arise via changes in the subjective value of food stimuli (i.e. reward processing) or via habituation, with both resulting in a reduced threat response. Investigating the clinical potential of ABMT in AN holds the promise of a novel, evidence-based adjunctive treatment approach. Importantly, understanding ABMT's underlying mechanisms will help tailor treatment protocols and improve understanding of the cognitive characteristics of AN and other EDs.

Sustained hypervigilance for one's own body in women with weight and shape concerns: Competition effects in early visual processing investigated by steady-state visual evoked potentials (SSVEP)

This study aimed to analyze the covert attentional time course in early body processing areas in women with high body concerns. Therefore, we assessed the effect of pictures of one's own body and other bodies as distractions from a demanding dot detection task in 24 women with low and 20 women with high body concerns. Participants were instructed to attend to flickering dots eliciting steady-state visual evoked potentials (SSVEP) measured by EEG. Both groups showed a sustained SSVEP amplitude reduction, which was more pronounced for average-weight or thin bodies than for overweight bodies. For women with high body concerns, SSVEP amplitudes decreased more in the case of pictures of their own body. The results indicate covert vigilance and maintenance patterns for body stimuli, especially for bodies representing the thin ideal. Moreover, women with high body concerns attend more to information about their own body, which might maintain body dissatisfaction.

Eye-tracking research in eating disorders: A systematic review

OBJECTIVE

Those with eating disorders (EDs) show attentional biases to disorder-relevant stimuli, such as food and body shape information. However, attentional bias research in EDs largely relies on reaction time based measures, which are limited in their ability to assess different components and the time course of attention. Eye-tracking paradigms have therefore been utilized to provide greater ecological validity, and directly capture the detailed sequence of processes in perception and attention. While numerous studies have examined eye movements in the mood, anxiety, and psychotic disorders, there has been a lack of studies in EDs. The purpose of this qualitative review is to provide a summary of eye-tracking studies in clinical ED populations.

METHOD

The review was conducted using the PRISMA guidelines. Electronic databases were systematically searched to identify studies examining gaze parameters in ED compared to healthy controls (HCs). Thirty-one studies met inclusion criteria.

RESULTS

Across ED diagnoses, there was evidence of attentional biases towards food and body stimuli. In addition, differential patterns of attention to social information, and differences in smooth pursuit and saccadic eye movements were found in anorexia nervosa (AN).

DISCUSSION

Findings are discussed in relation to research in other psychiatric disorders, and recommendations for future studies using eye-tracking in EDs are given. The findings add to the wider literature on attentional biases in EDs, and provide potential avenues for treatment. IJED-18-0331.R1. Investigación de seguimiento ocular en trastornos de la conducta alimentaria: una revisión sistemática.

Effects of Bias Modification Training in Binge Eating Disorder

Food-related attentional biases have been identified as maintaining factors in binge eating disorder (BED) as they can trigger a binge episode. Bias modification training may reduce symptoms, as it has been shown to be successful in other appetitive disorders. The aim of this study was to assess and modify food-related biases in BED. It was tested whether biases could be increased and decreased by means of a modified dot-probe paradigm, how long such bias modification persisted, and whether this affected subjective food craving. Participants were randomly assigned to a bias enhancement (attend to food stimulus) group or to a bias reduction (avoid food stimulus) group. Food-related attentional bias was found to be successfully reduced in the bias-reduction group, and effects persisted briefly. Additionally, subjective craving for food was influenced by the intervention, and possible mechanisms are discussed. Given these promising initial results, future research should investigate boundary conditions of the experimental intervention to understand how it could complement treatment of BED.

Neurocognitive Treatments for Eating Disorders and Obesity

PURPOSE OF REVIEW

Recent research has highlighted executive function and neurocognitive deficits among individuals with eating and weight disorders, identifying a potential target for treatment. Treatments targeting executive function for eating and weight disorders are emerging. This review aims to summarize the recent literature evaluating neurocognitive/executive function-oriented treatments for eating and weight disorders and highlights additional work needed in this area.

RECENT FINDINGS

Cognitive remediation therapy (CRT) for anorexia nervosa has been the most extensively studied neurocognitive treatment for eating disorders. Results demonstrate that CRT improves executive function and may aid in the reduction of eating disorder symptomatology. Computer training programs targeting modifying attention and increasing inhibition are targeting reduction of binge eating and weight loss with modest success. Neurocognitive treatments are emerging and show initial promise for eating and weight disorders. Further research is necessary to determine whether these treatments can be used as stand-alone treatments or whether they need to be used as an adjunct to or in conjunction with other evidence-based treatments to improve outcomes.

The risk of eating disorders comorbid with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis

OBJECTIVE

There has been interest in whether people with Attention-Deficit/Hyperactivity Disorder (ADHD) are at higher risk of developing an Eating Disorder (ED). The aim of this study was estimate the size of this association with a meta-analysis of studies.

METHODS

We retrieved studies following PRISMA guidelines from a broad range of databases.

RESULTS

Twelve studies fitted our primary aim in investigating ED in ADHD populations (ADHD = 4,013/Controls = 29,404), and five exploring ADHD in ED populations (ED = 1,044/Controls = 11,292). The pooled odds ratio of diagnosing any ED in ADHD was increased significantly, 3.82 (95% CI:2.34-6.24). A similar level of risk was found across all ED syndromes [Anorexia Nervosa = 4.28 (95% CI:2.24-8.16); Bulimia Nervosa = 5.71 (95% CI: 3.56-9.16) and Binge Eating Disorder = 4.13 (95% CI:3-5.67)]. The risk was significantly higher if ADHD was diagnosed using a clinical interview [5.89 (95% CI:4.32-8.04)] rather than a self-report instrument [2.23 (95% CI:1.23-4.03)]. The pooled odds ratio of diagnosing ADHD in participants with ED was significantly increased, 2.57 (95% CI:1.30-5.11). Subgroup analysis of cohorts with binge eating only yielded a risk of 5.77 (95% CI:2.35-14.18). None of the variables examined in meta-regression procedures explained the variance in effect size between studies.

DISCUSSION

People with ADHD have a higher risk of comorbidity with an ED and people with an ED also have higher levels of comorbidity with ADHD. Future studies should address if patients with this comorbidity have a different prognosis, course and treatment response when compared to patients with either disorder alone.

RESUMEN OBJETIVO

Ha habido interés en saber si la gente con Trastorno por Déficit de Atención e Hiperactividad (TDAH) están en mayor riesgo de desarrollar un Trastorno de la Conducta Alimentaria (TCA). El objetivo de este estudio fue estimar el tamaño de esta asociación con un meta-análisis de los estudios. Métodos: Recuperamos estudios de una amplia gama base de datos,  que siguen los lineamientos PRISMA. Resultados: Doce estudios encajaron con nuestro objetivo primario de investigar los TCA en poblaciones con TDAH (TDAH = 4,013/Controles = 29,404), y 5 exploraron TDAH en poblaciones con TCA (TCA = 1,044/Controles = 11,292). El odds ratio (OR) agrupado de diagnosticar cualquier TCA en el TDAH se incrementó significativamente, 3.82 (95% CI:2.34-6.24). Un nivel de riesgo similar fue encontrado en todos los síndromes de TCA [Anorexia Nervosa = 4.28 (95% CI:2.24-8.16); Bulimia Nervosa = 5.71 (95% CI:3.56-9.16) y Trastorno por Atracón = 4.13 (95% CI: 3-5.67)]. El riesgo fue significativamente mayor si el TDAH fue diagnosticado utilizando una entrevista clínica [5.89 (95% CI:4.32-8.04)] en lugar de un instrumento de auto-reporte [2.23 (95% CI:1.23-4.03)]. El odds ratio (OR) agrupado de diagnosticar TDAH en participantes con TCA fue significativamente incrementado, 2.57 (95% CI:1.30-5.11). El análisis de los subgrupos de cohort con atracones solamente produjo un riesgo de 5.77 (95% CI:2.35-14.18). Ninguna de las variables examinadas en los procedimientos de meta-regresión explicaron la varianza en el tamaño del efecto entre los estudios. Discusión: La gente con TDAH tiene un mayor riesgo de comorbilidad con un TCA y la gente con un TCA también tiene niveles altos de comorbilidad con TDAH. Los estudios futuros deberán abordar si los pacientes con esta comorbilidad tienen diferente pronóstico, curso y respuesta a tratamiento cuando son comparados con pacientes que solamente tienen uno de los trastornos.  © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016) © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1045-1057).

The ABBA study - approach bias modification in bulimia nervosa and binge eating disorder: study protocol for a randomised controlled trial

BACKGROUND

The core symptoms of bulimia nervosa (BN) and binge eating disorder (BED) are recurrent episodes of binge eating. Despite negative psychological and physical consequences, BN/BED patients show uncontrollable approach tendencies towards food. This cognitive bias occurs at an early stage of information processing. Cognitive bias modification (CBM) directly targets such biases and has been shown to be effective in treating several mental disorders. In alcohol addiction, automatic action tendencies towards alcohol cues and relapse rates were successfully reduced by a specific form of CBM, termed approach bias modification. Based on these findings and data from a proof-of-concept study in people with high levels of food craving, CBM is considered a promising new treatment approach for BN/BED. Given the similarities between BN/BED and addictive disorders, the rationale for using approach bias modification appears to be particularly strong. The aim of the present study is to examine whether, compared to a sham training, computerised approach bias modification (10 sessions) can reduce binge-eating episodes in BN/BED patients from pre-treatment to follow-up. Additionally, we will investigate whether this CBM programme also reduces global eating disorder psychopathology, trait and cue-elicited food craving, food intake as well as approach and attentional bias towards visual food cues. Treatment acceptance will be determined by attrition rates and responses on a feedback form.

METHODS

This is a double-blind, randomised, placebo-controlled, parallel-group superiority trial with two parallel arms. A total of 54 BN/BED patients will be recruited. Approach bias towards food will be retrained by a computer task adopting an implicit learning paradigm. Patients in the control condition (sham) will conduct a similar task but will not be trained to avoid food cues. Methods against bias include public registration, randomisation by a central study office, standardisation of the treatments and blinding of assessors. Furthermore, the session number and duration will be equivalent in the two conditions.

DISCUSSION

This is the first registered randomised controlled trial of approach bias modification in a clinical BN/BED sample. Results from this study will provide an indication of the efficacy of approach bias modification training for BN/BED and the potential mechanisms of action underlying this treatment.

TRIAL REGISTRATION

DRKS00010231 (retrospectively registered on 24 March 2016; first version).

Altered social attention in anorexia nervosa during real social interaction

The capacity to devote attentional resources in response to body-related signals provided by others is still largely unexplored in individuals with Anorexia Nervosa (AN). Here, we tested this capacity through a novel paradigm that mimics a social interaction with a real partner. Healthy individuals (Experiment 1) and individuals with AN (Experiment 2) completed a task with another person which consisted in performing, alternatively, rapid aiming movements to lateralised targets. Generally, this task leads to a form of Inhibition of Return (IOR), which consists of longer reaction times when an individual has to respond to a location previously searched by either himself (individual IOR) or by the partner (social IOR) as compared to previously unexplored locations. IOR is considered as an important attentional mechanism that promotes an effective exploration of the environment during social interaction. Here, healthy individuals displayed both individual and social IOR that were both reliable and of the same magnitude. Individuals with AN displayed a non-significant individual IOR but a reliable social IOR that was also significantly stronger than individual IOR. These results suggest the presence of a reduced sensitivity in processing body-related stimuli conveyed by oneself in individuals with AN which is reflected in action-based attentional processes.

Anorexia nervosa: aetiology, assessment, and treatment

Anorexia nervosa is an important cause of physical and psychosocial morbidity. Recent years have brought advances in understanding of the underlying psychobiology that contributes to illness onset and maintenance. Genetic factors influence risk, psychosocial and interpersonal factors can trigger onset, and changes in neural networks can sustain the illness. Substantial advances in treatment, particularly for adolescent patients with anorexia nervosa, point to the benefits of specialised family-based interventions. Adults with anorexia nervosa too have a realistic chance of achieving recovery or at least substantial improvement, but no specific approach has shown clear superiority, suggesting a combination of re-nourishment and anorexia nervosa-specific psychotherapy is most effective. To successfully fight this enigmatic illness, we have to enhance understanding of the underlying biological and psychosocial mechanisms, improve strategies for prevention and early intervention, and better target our treatments through improved understanding of specific disease mechanisms.

Anorexia nervosa

Anorexia nervosa (AN) is a psychiatric condition characterized by severe weight loss and secondary problems associated with malnutrition. AN predominantly develops in adolescence in the peripubertal period. Without early effective treatment, the course is protracted with physical, psychological and social morbidity and high mortality. Despite these effects, patients are noted to value the beliefs and behaviours that contribute to their illness rather than regarding them as problematic, which interferes with screening, prevention and early intervention. Involving the family to support interventions early in the course of the illness can produce sustained changes; however, those with a severe and/or protracted illness might require inpatient nursing support and/or outpatient psychotherapy. Prevention programmes aim to moderate the overvaluation of 'thinness' and body dissatisfaction as one of the proximal risk factors. The low prevalence of AN limits the ability to identify risk factors and to study the timing and sex distribution of the condition. However, genetic profiles, premorbid features, and brain structures and functions of patients with AN show similarities with other psychiatric disorders and contrast with obesity and metabolic disorders. Such studies are informing approaches to address the neuroadaptation to starvation and the other various physical and psychosocial deficits associated with AN. This Primer describes the epidemiology, diagnosis, screening and prevention, aetiology, treatment and quality of life of patients with AN.

Behavioral Bias for Food Reflected in Hand Movements: A Preliminary Study with Healthy Subjects

Palatable food induces general approach tendencies when compared to nonfood stimuli. For eating disorders, the modification of an attention bias toward food was proposed as a treatment option. Similar approaches have been efficient for other psychiatric conditions and, recently, successfully incorporated approach motivation. The direct impact of attentional biases on spontaneous natural behavior has hardly been investigated so far, although actions may serve as an intervention target, especially seeing the recent advances in the field of embodied cognition. In this study, we addressed the interplay of motor action execution and cognition when interacting with food objects. In a Virtual Reality (VR) setting, healthy participants repeatedly grasped or warded high-calorie food or hand-affordant ball objects using their own dominant hand. This novel experimental paradigm revealed an attention-like bias in hand-based actions: 3D objects of food were collected faster than ball objects, and this difference correlated positively with both individual body mass index and diet-related attitudes. The behavioral bias for food in hand movements complements several recent experimental and neurophysiological findings. Implications for the use of VR in the treatment of eating-related health problems are discussed.

Cognitive and emotional functioning in binge-eating disorder: A systematic review

OBJECTIVE

Binge-eating disorder (BED) is characterized by recurrent episodes of binge eating and is associated with eating disorder and general psychopathology and overweight/obesity. Deficits in cognitive and emotional functioning for eating disorders or obesity have been reported. However, a systematic review on cognitive and emotional functioning for individuals with BED is lacking.

METHOD

A systematic literature search was conducted across three databases (Medline, PubMed, and PsycINFO). Overall, n = 57 studies were included in the present review.

RESULTS

Regarding cognitive functioning (CoF), individuals with BED consistently demonstrated higher information processing biases compared to obese and normal-weight controls in the context of disorder-related stimuli (i.e., food and body cues), whereas CoF in the context of neutral stimuli appeared to be less affected. Thus, results suggest disorder-related rather than general difficulties in CoF in BED. With respect to emotional functioning (EmF), individuals with BED reported difficulties similar to individuals with other eating disorders, with a tendency to show less severe difficulties in some domains. In addition, individuals with BED reported greater emotional deficits when compared to obese and normal-weight controls. Findings suggest general difficulties in EmF in BED. Thus far, however, investigations of EmF in disorder-relevant situations are lacking.

DISCUSSION

Overall, the cross-sectional findings indicate BED to be associated with difficulties in CoF and EmF. Future research should determine the nature of these difficulties, in regards to general and disorder-related stimuli, and consider interactions of both domains to foster the development and improvement of appropriate interventions in BED.

Abnormal Social Reward Responses in Anorexia Nervosa: An fMRI Study

Patients with anorexia nervosa (AN) display impaired social interactions, implicated in the development and prognosis of the disorder. Importantly, social behavior is modulated by reward-based processes, and dysfunctional at-brain-level reward responses have been involved in AN neurobiological models. However, no prior evidence exists of whether these neural alterations would be equally present in social contexts. In this study, we conducted a cross-sectional social-judgment functional magnetic resonance imaging (fMRI) study of 20 restrictive-subtype AN patients and 20 matched healthy controls. Brain activity during acceptance and rejection was investigated and correlated with severity measures (Eating Disorder Inventory -EDI-2) and with personality traits of interest known to modulate social behavior (The Sensitivity to Punishment and Sensitivity to Reward Questionnaire). Patients showed hypoactivation of the dorsomedial prefrontal cortex (DMPFC) during social acceptance and hyperactivation of visual areas during social rejection. Ventral striatum activation during rejection was positively correlated in patients with clinical severity scores. During acceptance, activation of the frontal opercula-anterior insula and dorsomedial/dorsolateral prefrontal cortices was differentially associated with reward sensitivity between groups. These results suggest an abnormal motivational drive for social stimuli, and involve overlapping social cognition and reward systems leading to a disruption of adaptive responses in the processing of social reward. The specific association of reward-related regions with clinical and psychometric measures suggests the putative involvement of reward structures in the maintenance of pathological behaviors in AN.

The processing of food stimuli in abnormal eating: a systematic review of electrophysiology

To update the knowledge about attentional processing of food stimuli, a systematic review of electrophysiological studies was conducted using PubMed, PsychInfo and Web of Knowledge (2000-2014). Twenty-one studies were included into a qualitative synthesis. Presentation of food and control pictures was used to analyze event-related potentials related to sensory processing and motivated attention. Results show consistent attentional bias towards food pictures compared with neutral pictures for patient and control groups. Group comparisons between individuals with abnormal-eating and healthy-eating participants were more inconsistent. Results suggest that temporal differences in the millisecond range are essential for the understanding of visual food processing. In obesity, early attention engagement to food is followed by relatice disengagement. Loss of control eating, as well as external and emotional eating, are associated with a sustained maintenance of attention towards high-caloric food. There is a lack of studies in anorexia nervosa, bulimia nervosa and binge eating disorder.

Application of the Research Domain Criteria (RDoC) framework to eating disorders: emerging concepts and research

The Research Domain Criteria (RDoC) project was initiated by the National Institute of Mental Health as a heuristic for addressing the limitations of categorical, symptom-based psychiatric diagnoses. RDoC is conceptualized as a matrix, with the rows representing dimensional constructs or domains implicated in the expression of psychiatric symptoms and the columns representing units of analysis that can be used to assess dimensional constructs (i.e., genes, molecules, cells, circuits, physiology, behavior, and self-reports). Few studies in eating disorders have adopted an RDoC framework, but accumulating data provide support for the relevance of RDoC dimensions to eating disorder symptoms. Herein, we review findings from RDoC-informed studies across the five domains of functioning included in the RDoC matrix-negative valence systems, positive valence systems, cognitive systems, systems for social processes, and arousal and regulatory systems-and describe directions for future research utilizing RDoC to enhance study design and treatment development in eating disorders.