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

Perfectionism, self-esteem, and affective symptoms in anorexia nervosa subtypes: A network analysis of French inpatients

OBJECTIVE

Previous studies have highlighted the relevance of perfectionism, self-esteem, and anxio-depressive symptoms in anorexia nervosa (AN). However, the relationships between these factors and cardinal eating disorders (ED) symptoms remain unclear, particularly in AN subtypes. This study aimed to examine their interconnections using network analysis.

METHOD

The sample included n = 338 inpatients with AN who completed the Eating Disorder Examination Questionnaire, Frost Multidimensional Perfectionism Scale, Rosenberg Self-Esteem Scale, and Hospital Anxiety and Depression Scale. Using network analysis, we estimated three networks: full sample, AN-restrictive (AN-R) and AN-binge/purging (AN-BP) subtypes. We estimated central and bridge symptoms using expected influence and conducted an exploratory network comparison test to compare AN subtypes.

RESULTS

Overvaluation of Weight and Shape, Concern over Mistakes, and Personal Standards were consistently central in all networks. The most central bridge symptoms across all networks were Concern over Mistakes and Self-Esteem. Concern over Mistakes bridged perfectionism and ED symptoms, while Self-Esteem was highly connected to all symptom clusters. Anxiety was significantly more central in the AN-R network compared to the AN-BP network.

CONCLUSIONS

The present study contributes to a growing body of network studies suggesting that nodes related to perfectionism are just as central as cardinal ED symptoms, indicating the relevance of perfectionism in ED pathology. The high bridge centrality of self-esteem suggests that it may be an important link between perfectionism, mood, and ED symptoms. Future research should investigate the efficacy of targeting multiple psychological factors in the treatment of AN, as well as their potential transdiagnostic relevance.

Mindfulness and Interoceptive Awareness: A Network Analysis

ABSTRACT

Higher trait mindfulness is correlated with higher interoceptive awareness. However, there is a gap in understanding which mindfulness dimensions connect to which interoceptive awareness dimensions. This study (N = 1005) used network analysis to identify central and bridge nodes driving the linkage between mindfulness and interoceptive awareness. Central nodes included trusting body sensations, feeling a sense of calm when bringing awareness to the body, the ability to refocus one's attention from thinking to sensing the body, and the ability to accept all emotions. Bridge nodes included noticing how food and drink affect thoughts, bodily sensations, and emotions; staying alert to the sensations of the body when taking a shower; and noticing and letting go of distressing thoughts and feelings. Future research studies should explore whether mindfulness-based interventions may be more effective by targeting observations of sensations related to eating and the body as well as noticing and letting go of distressing thoughts and feelings.

Sensory processing across eating disorders: A systematic review and meta-analysis of self-report inventories

OBJECTIVE

This review investigated the extant literature regarding the relationship between eating disorder diagnoses and sensory processing as measured by validated and reliable self-report inventories. Increasing evidence highlights the role of sensory processing in cognitive functions. Sensory processing is implicated in mental-ill health, including eating disorders (ED) and body image disturbances. However, the pathophysiological underpinnings of sensory processing, encompassing exteroception and interoception, in relation to ED remain underexplored.

METHOD

We included studies involving participants aged 15 years or older with an eating disorder diagnosis confirmed by semi-structured or structured interviews. We further limited inclusion to articles using validated and reliable self-report instruments to measure sensory processing. Our meta-analysis focused on studies using the interoceptive awareness subscale from the second version of the Eating Disorder Inventory. We used the Critical Appraisal checklist for quasi-experimental studies to assess the quality of included articles.

RESULTS

There were 19 studies that met our inclusion criteria. Most studies showed moderate-to-high quality. Anorexia nervosa (AN) and bulimia nervosa (BN) were associated with heightened exteroception. Moreover, people with AN reported a heightened sense of taste compared to those with BN. Our meta-analysis comprising 10 studies, 19 samples, and 6382 participants revealed that AN (binge-purge subtype) and BN were associated with increased interoceptive difficulties compared to AN (restrictive subtype) or binge-eating disorder.

DISCUSSION

Overall, this review emphasizes the need for a deeper investigation into sensory processing, spanning both exteroception and interoception, in relation to ED. This may prove important for individualizing person-centered care.

PUBLIC SIGNIFICANCE

How people process internal, for example, hunger, and external, for example, taste and sensations is known to influence cognition and mental-ill health, including ED and body image disturbances. However, the ways in which sensory processing may contribute to ED are incompletely understood. We found that individuals with AN or BN experienced heightened exteroception, while people with an eating disorder characterized by purging reported increased interoceptive difficulties. These patterns could inform the development of more personalized treatments.

A meta-analysis of disordered eating and its association with self-criticism and self-compassion

OBJECTIVE

Future treatments for eating disorders (ED) need to be enhanced by targeting maintaining mechanisms. Literature suggests self-criticism and self-critical perfectionism act as key mechanisms exacerbating ED, and self-compassion protects against self-criticism. This meta-analysis examines associations between self-criticism and self-critical perfectionism on disordered eating (DE), and reviews how self-compassion and self-criticism relate to each other with respect to DE.

METHOD

Searches across three databases yielded 135 studies across 42,952 participants. Heterogeneity, publication bias, and quality assessments were analyzed. Moderation analyses between self-criticism measures, self-compassion measures, between clinical and nonclinical samples, and between cross-sectional and experimental studies were also conducted.

RESULTS

Random-effects models showed a medium positive link between self-criticism and DE (r = .37), and 10 subgroups pertaining to various measures of self-criticism utilized in literature showed small to large positive links with DE (r = .20-.52). Preliminary evidence also suggests negative relationships between self-compassion and DE (r = -.40 to -.43) and negative relationships between self-compassion and self-criticism (r = -.04 to -.88).

DISCUSSION

Greater levels of self-criticism is linked with greater levels of DE and reduced levels of self-compassion, suggesting a need to tackle self-criticism and nurture self-compassion in standard treatments for ED. Understanding these interactions better in conjunction with dismantling intervention studies can help develop more effective and efficient interventions targeting self-criticism and self-compassion for people with DE.

PUBLIC SIGNIFICANCE STATEMENT

Higher levels of self-criticism are linked with higher levels of DE and lower self-compassion. Self-compassion interventions could be more effective and efficient in reducing ED symptoms if self-criticism is tackled early in such treatments.

Psychometric evaluation of the Chinese version of the Scale of Effects of Social Media on Eating Behaviour and research of its influencing factors

BACKGROUND

Social media has become an indispensable part of contemporary young people's lives, and the influence of social media on college students' eating and other health-related behaviors has become increasingly prominent. However, there is no assessment tool to determine the effects of social media on Chinese college students' eating behavior. This study aims to translate the Scale of Effects of Social Media on Eating Behaviour (SESMEB) into Chinese. Its applicability to Chinese college students was examined through reliability and validity indexes, and the influencing factors of SESMEB were explored.

METHODS

The questionnaire survey included 2374 Chinese college students. The Brislin translation model was used to translate the original scale into Chinese. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to test the construct validity of the scale, and the content validity of the scale was assessed through the content validity index. The internal consistency of the scale was assessed by calculating Cronbach's alpha coefficient, McDonald's Omega coefficient, split-half reliability, and test-retest reliability. Multiple stepwise linear regression analysis was performed to identify potential influences on the effects of social media on eating behavior.

RESULTS

EFA supported the one-factor structure, and the factor loadings of each item on this dimension were higher than 0.40. CFA showed good model fitness indexes. The content validity index of the scale was 0.94. The Cronbach's alpha coefficient and McDonald's Omega coefficient for the scale were 0.964, the split-half reliability coefficient was 0.953, and the test-retest reliability was 0.849. Gender, education, major, frequency of social media use, online sexual objectification experiences, fear of negative evaluations, and physical appearance perfectionism explained 73.8% of the variance in the effects of social media on eating behavior.

CONCLUSIONS

The Chinese version of the SESMEB has good psychometric properties and is a valid measurement tool for assessing the effects of social media on college students' eating behavior. Subjects who were female, highly educated, non-medical, had frequent social media use, online sexual objectification experiences, fear of negative evaluations, and physical appearance perfectionism used social media to have a higher impact on eating behavior.

Investigating the Theory of Clinical Perfectionism in a Transdiagnostic Eating Disorder Sample Using Network Analysis

Eating disorders are deadly psychiatric illnesses, with treatments working for less than half of individuals who seek treatment. The transdiagnostic theory of eating disorders proposes that eating disorders share similar maintaining symptoms, such as what this theory calls clinical perfectionism (i.e., high levels of concern over mistakes and personal standards). However, it has been difficult to examine the interrelationship of specific aspects of perfectionism, beyond assessing moderation effects, which have generally not found support for the theory of clinical perfectionism in eating disorders. Thus, we used network analysis to test the theory of perfectionism by testing the interrelationships between maladaptive perfectionism facets (concern over mistakes, personal standards, parental criticism, parental expectations, and personal standards) and eating disorder symptoms in 397 individuals diagnosed with an eating disorder. Concern over mistakes was a central symptom and demonstrated the strongest interrelationships with eating disorder symptoms compared to the other aspects of perfectionism, connecting to eating concerns and cognitive restraint. Objective binge eating had a strong negative connection to personal standards. We identified specific central symptoms and illness pathways of perfectionism, which partially supports the theory of clinical perfectionism. Results, if replicated, may suggest that concern over mistakes might be best reconceptualized as part of eating disorder pathology and be targeted to improve treatment outcomes for eating disorders.

Life meaning and feelings of ineffectiveness as transdiagnostic factors in eating disorder and comorbid internalizing symptomatology - A combined undirected and causal network approach

The field of eating disorders is facing problems ranging from a suboptimal classification system to low long-term success rates of treatments. There is evidence supporting a transdiagnostic approach to explain the development and maintenance of eating disorders. Meaning in life has been proposed as a promising key transdiagnostic factor that could potentially not only bridge between the different eating disorder subtypes but also explain frequent co-occurrence with symptoms of comorbid psychopathology, such as anxiety and depression. The present study used self-report data from 501 participants to construct networks of eating disorder and comorbid internalizing symptomatology, including factors related to meaning in life, i.e., presence of life meaning, perceived ineffectiveness, and satisfaction with basic psychological needs. In an undirected network model, it was found that ineffectiveness is a central node, also bridging between eating disorder and other psychological symptoms. A directed network model displayed evidence for a causal effect of presence of life meaning both on the core symptomatology of eating disorders and depressive symptoms via ineffectiveness. These results support the notion of meaning in life and feelings of ineffectiveness as transdiagnostic factors within eating disorder symptomatology in the general population.

Perfectionism in anorexia nervosa: Associations with clinical picture and personality traits

Although many researchers addressed the topics, no consistent data are currently available regarding the relationship between perfectionism and personality traits in anorexia nervosa (AN). The present study aimed to assess differences between high- and low-perfectionism groups of patients with AN and to identify which variables show the strongest association with perfectionism. A group of inpatients with AN (n = 193) was recruited and completed a battery of self-report questionnaires regarding eating-related and general psychopathology, perfectionism, and personality. On the basis of perfectionism scores, patients were divided into high- and low-perfectionism groups. High-perfectionist patients displayed higher eating-related and general psychopathology; higher depressive, cyclothymic, irritable and anxious temperament, and lower self-directedness, cooperativeness and self-esteem. Perfectionism was associated with the drive for thinness, cooperativeness, self-esteem and anxious temperament. On the basis of the two personality traits most strongly correlated with perfectionism (i.e., cooperativeness and anxious temperament), patients could be correctly assigned to the high- or low-perfectionism group by an algorithm. The study suggests that perfectionism in AN is related to eating psychopathology, especially of restrictive type, and personality features such as cooperativeness and anxious temperament. These findings confirm the important role of perfectionism in AN, not only concerning eating behaviour but personality as well.

Interoceptive accuracy mediates the longitudinal relationship between attention deficit hyperactivity disorder (ADHD) inattentive symptoms and disordered eating in a community sample

Attention deficit hyperactivity disorder (ADHD) symptoms are associated with disordered eating and interoceptive deficits (as assessed by reliance on hunger/satiety cues) have been suggested as a potential mediating influence. The aim of this longitudinal study was to examine whether the association between ADHD symptoms and disordered eating is explained by deficits in specific facets of interoception. We also aimed to provide further evidence on the previously reported association between ADHD symptoms, negative mood and disordered eating. A community-based sample of 345 adult men and women (M age = 33.9, 72.5% women) completed questionnaires assessing disordered eating (restrictive and binge-type), ADHD symptoms, reliance on hunger/ satiety cues, specific facets of interoception (interoceptive accuracy and interoceptive sensibility) and negative mood at two timepoints over a 6-month period. We tested the mediating influence of reliance on hunger/satiety cues, facets of interoception and negative mood on the relationship between ADHD symptoms and disordered eating. Reliance on hunger/satiety cues mediated the relationship between inattentive symptoms of ADHD and both restrictive and binge-type eating. Interoceptive accuracy, but not sensibility mediated the relationship between inattentive ADHD symptoms and binge-type eating. Negative mood mediated the relationship between both ADHD symptom types and restrictive and binge-type eating. The results from this longitudinal study confirm that deficits in interoception and negative mood contribute to the relationship between ADHD symptoms and disordered eating and extend knowledge by highlighting interoceptive accuracy specifically as the most important facet of interoception in the relationship between inattentive symptoms and binge-type eating.

Abnormal sense of agency in eating disorders

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

Exploring Caloric Restriction in Inpatients with Eating Disorders: Cross-Sectional and Longitudinal Associations with Body Dissatisfaction, Body Avoidance, Clinical Factors, and Psychopathology

Reduction in food intake is an important feature of eating disorders (EDs). However, whereas self-reported cognitive control over food (i.e., dietary restraint) is commonly assessed, we are not aware of any study evaluating the actual reduction in caloric intake (i.e., caloric restriction, CR) and its relationships with psychopathological, clinical, and anamnestic factors in individuals with EDs. In this study, we quantified caloric intake, CR, and weight suppression in 225 ED inpatients and explored significant relationships with self-reported eating symptoms, body dissatisfaction, body avoidance, personality, and affective symptoms. For underweight inpatients (n = 192), baseline predictors of caloric intake and restriction at discharge were assessed through a data-driven approach. CR at admission was significantly related to eating symptomatology, state anxiety, and body image. In regression models, CR, higher BMI, binge-purging symptoms, and the interaction between weight suppression and CR were significantly related to body dissatisfaction. The best psychopathological predictors of caloric intake and restriction at discharge for underweight inpatients were perfectionistic concern over mistakes and state anxiety. These results suggest that caloric restriction is associated to relevant ED features and warrant for a multidimensional assessment of ED psychopathology.

A network perspective on cognitive function and obsessive-compulsive related symptoms

BACKGROUND

The relationship between cognitive function and psychopathological symptoms has been an important research field in recent years. Previous studies have typically applied case-control designs to explore differences in certain cognitive variables. Multivariate analyses are needed to deepen our understanding of the intercorrelations among cognitive and symptom phenotypes in OCD.

METHODS

The present study used network analysis to construct networks of cognitive variables and OCD-related symptoms in patients with OCD and healthy controls (N = 226), aiming to explore the relationship among numerous cognitive function variables and OCD-related symptoms in detail and compare the network features between the two groups.

RESULTS

In the network of cognitive function and OCD-related symptoms, nodes representing IQ, letter/number span test, accuracy of task switching test and obsession were much important in the network in terms of their larger strengths and edges. By constructing the networks of these two groups respectively, there was a strong similarity except that the symptom's network in healthy group had a higher degree of overall connectivity.

LIMITATIONS

Due to the small sample size, the stability of the network cannot be guaranteed. Due to the cross-sectional nature of the data, we were unable to determine how the cognitive-symptom network would change with disease deterioration or treatment.

CONCLUSIONS

The present study highlights the important role of variables such as obsession and IQ from a network perspective. These results deepen our understanding of the multivariate relationship between cognitive dysfunction and OCD symptoms, and may promote the prediction and diagnosis of OCD.

Cognitive and Interpersonal Factors in Adolescent Inpatients with Anorexia Nervosa: A Network Analysis

The cognitive-interpersonal model of anorexia nervosa (AN) posits that cognitive and interpersonal traits contribute to the development and maintenance of AN. We investigated cognitive and interpersonal factors put forward by the model in a sample of 145 adolescent inpatients with AN using network analysis. Our main outcomes included core eating disorder symptoms, cognitive style, socio-affective factors, and mood symptoms. We estimated a cross-sectional network using graphical LASSO. Core and bridge symptoms were identified using strength centrality. Goldbricker was used to reduce topological overlap. The node with the highest strength centrality was Concern over Mistakes, followed by Eating Preoccupation, Social Fear, and Overvaluation of Weight and Shape. The nodes with the highest bridge strength were Concern over Mistakes, Doubt about Actions, Overvaluation of Weight and Shape, and Depression. Notably, both performance on a cognitive flexibility task and BMI were not connected to any other nodes and were subsequently removed from the final network. We provide partial support for the cognitive-interpersonal model while also supporting certain premises put forward by the transdiagnostic cognitive-behavioral model. The high centrality of Concern over Mistakes and Social Fear supports the theory that both cognitive and interpersonal difficulties contribute to AN, particularly in adolescence.

Network-based methods for psychometric data of eating disorders: A systematic review

BACKGROUND

Network science represents a powerful and increasingly promising method for studying complex real-world problems. In the last decade, it has been applied to psychometric data in the attempt to explain psychopathologies as complex systems of causally interconnected symptoms. One category of mental disorders, relevant for their severity, incidence and multifaceted structure, is that of eating disorders (EDs), serious disturbances that negatively affect a person's eating behavior.

AIMS

We aimed to review the corpus of psychometric network analysis methods by scrutinizing a large sample of network-based studies that exploit psychometric data related to EDs. A particular focus is given to the description of the methodologies for network estimation, network description and network stability analysis providing also a review of the statistical software packages currently used to carry out each phase of the network estimation and analysis workflow. Moreover, we try to highlight aspects with potential clinical impact such as core symptoms, influences of external factors, comorbidities, and related changes in network structure and connectivity across both time and subpopulations.

METHODS

A systematic search was conducted (February 2022) on three different literature databases to identify 57 relevant research articles. The exclusion criteria comprehended studies not based on psychometric data, studies not using network analysis, studies with different aims or not focused on ED, and review articles.

RESULTS

Almost all the selected 57 papers employed the same analytical procedures implemented in a collection of R packages specifically designed for psychometric network analysis and are mostly based on cross-sectional data retrieved from structured psychometric questionnaires, with just few exemptions of panel data. Most of them used the same techniques for all phases of their analysis. In particular, a pervasive use of the Gaussian Graphical Model with LASSO regularization was registered for in network estimation step. Among the clinically relevant results, we can include the fact that all papers found strong symptom interconnections between specific and nonspecific ED symptoms, suggesting that both types should therefore be addressed by clinical treatment.

CONCLUSIONS

We here presented the largest and most comprehensive review to date about psychometric network analysis methods. Although these methods still need solid validation in the clinical setting, they have already been able to show many strengths and important results, as well as great potentials and perspectives, which have been analyzed here to provide suggestions on their use and their possible improvement.

Construct Validity of the Sensory Profile Interoception Scale: Measuring Sensory Processing in Everyday Life

Scholars and providers are coming to realize that one’s ability to notice and respond to internal body sensations (i.e., interoception) contributes to an overall sense of wellbeing. Research has demonstrated a relationship between interoceptive awareness and anxiety, for example. Currently, however, tools for evaluating one’s interoception lack the conceptual foundation and clarity necessary to identify everyday behaviors that specifically reflect interoceptive awareness. Unlike existing interoceptive measures, the Sensory Profile Interoception (SPI) scale is participation-based and grounded in Dunn’s Sensory Processing framework. In this study we investigated concurrent validity by correlating the SPI with the Adolescent/Adult Sensory Profile (A/ASP); we investigated construct validity by correlating the SPI with the Perth Alexithymia Scale (PAS), the Body Awareness Scale (BAS), and the State-Trait Anxiety Inventory (STAI). Using the REDCAP online platform, 74 college-aged participants completed the measures. Using Spearman rank order correlations there were statistically significant relationships between the corresponding sensory pattern subscales on SPI and A/ASP (r = 0.277 to r = 0.582). The PAS was only weakly related to the registration subscale of the SPI (r = 0.260). The BAS had significant relationships with seeking and avoiding on the SPI (r = 0.496 and r = 0.385). The STAI had significant relationships with sensitivity and registrations of the SPI (r = 0.266 and r = 0.361 for state; r = 0.403 and r = 0.321 for trait). Taken together, these findings provide evidence of construct validity of the SPI to identify participation patterns associated with both high and low interoception. With the more precise information the SPI provides, professionals can design tailored interventions to support everyday life goals and researchers can study interoception within authentic activities.