Implicit and explicit memory for shape, body weight, and food-related words in patients with anorexia nervosa and nondieting controls

Repeated exposure to body-related memories in women with high body-related self-disgust: Impact on disgust, avoidance, and acceptance

Disgust-based body image concerns can bias autobiographical memory towards the recall and avoidant processing of disgust-related memories of the own body. Repeated exposure to such memories may help breaking avoidance and promote the habituation of disgust, thereby lowering body concerns. Using a pre-post within-participant experimental design, we tested if repeatedly exposing women with high self-disgust (N = 61) to disgust-focused body memories vs. neutral memories led to changes in disgust, body acceptance, and reactive avoidance. Contrary to expectations, state disgust towards the body itself only decreased following exposure to neutral memories. Yet, disgust elicited by body-related memories decreased following both repeated exposure to neutral and body memories. Although acceptance was not found to significantly change in either exposure session, pre-post decreases in state disgust were associated with increases in acceptance following the disgust-focused exposure. In contrast to expectations, reactive avoidance increased from pre to post in the disgust-focused exposure. Overall, the results indicate that repeated exposure to disgust-focused body memories may help reduce disgust elicited by these memories and promote body acceptance. Yet, the effect of this repeated exposure to body memories did not extend to changing state disgust towards the body, possibly due to reactive avoidance.

Can eating behaviour traits be explained by underlying, latent factors? An exploratory and confirmatory factor analysis

Eating Behaviour Traits (EBTs) are psychological constructs developed to explain patterns of eating behaviour, including factors that motivate people to (over or under) eat. There is a need to align and clarify their unique contributions and harmonise the understanding they offer for human eating behaviour. Therefore, the current study examined whether 18 commonly cited EBTs could be explained by underlying, latent factors (domains of eating behaviour). An exploratory factor analysis (EFA) was used to identify latent factors, and these factors were validated using a confirmatory factor analysis (CFA). 1279 participants including the general public and members of a weight management programme were included in the analysis (957 females, 317 males, 3 others, 2 prefer not to say), with a mean age of 54 years (median = 57 years, SD = 12.03) and a mean BMI of 31.93 kg/m2 (median = 30.86, SD = 6.00). The participants completed 8 questionnaires which included 18 commonly cited EBTs and the dataset was split at random with a 70/30 ratio to conduct the EFA (n = 893) and CFA (n = 383). The results supported a four-factor model which indicated that EBTs can be organised into four domains: reactive, restricted, emotional, and homeostatic eating. The four-factor model also significantly predicted self-reported BMI and weight change. Future research should test whether this factor structure is replicated in more diverse populations, and including other EBTs, to advance these domains of eating as a unifying framework for studying individual differences in human eating behaviour.

Disgust-induced avoidant processing of autobiographical memories as a transdiagnostic mechanism in the persistence of psychopathology

We present a model of disgust-induced avoidant processing of autobiographical memories contributing to the persistence of psychopathology. Following the model, autobiographical memory retrieval is biased toward disgust-related experiences. Critically, disgust promotes the avoidance of specific autobiographical memories by reactively aborting the processing of those memories or by strategically preventing access to them, making disgust appraisals immune to corrective information. In the context of eating disorders/body image, studies provided consistent evidence for a bias toward disgust-related memories of their own body in women with a more negative body image. Although the current research casts doubt on disgust-induced strategic avoidant retrieval of body-related memories, it provided initial evidence for reactive avoidance of such memories. Insight into the role of disgust-induced avoidant memory processing as a transdiagnostic mechanism may help in understanding the refractoriness of disgust-relevant psychopathologies (including depressive and trauma-related disorders) and point to the necessity of therapeutic strategies to address disgust-induced avoidance.

Orthorexia nervosa, mindful eating, and perfectionism: an exploratory investigation

PURPOSE

Research has drawn associations between Mindful Eating (ME) and perfectionism in the aetiology and treatment of eating disorders (ED), but understanding into the relationship between these factors and Orthorexia nervosa (ON) is limited. The purpose of this research is to explore the relationship between perfectionism, ME, and ON.

METHOD

Participants (n = 670) completed the Düsseldorf Orthorexia scale, the Mindful Eating Behavior scale, and the Big-Three Perfectionism scale Short-form, to reveal the relationship between ON, ME, and perfectionism. The relationship was assessed using correlational and regression analyses.

RESULTS

A positive association was observed between perfectionism and ON. Moreover, perfectionism demonstrated a significant negative correlation with three out of four ME facets, with "eating without distraction" displaying the highest correlation. The "eating with awareness" facet of ME demonstrated a significant relationship with ON, in a negative direction. An unexpected relationship was observed between the focused eating facet of ME and ON, with a positive association being found. A further regression analysis revealed both perfectionism and ME to predict orthorexic tendencies.

CONCLUSION

These findings identify a relationship between ON, ME, and perfectionism. It offers suggestion for the complexity of ME, and how it should be recognised by its different components, estimating a differential predictability and estimation of ON. Further research is required to clarify the direction of causality in the relationships observed, to inform the clinical diagnoses and intervention of ON.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Escaping from revulsion - disgust and escape in response to body-relevant autobiographical memories

The term Repulsive Body Image (RBI) refers to a schematic construct combining body-directed self-disgust and other negative body image features, that is assumed to bias information processing, including autobiographical memory retrieval. When specific memories about the own body are retrieved, intense self-disgust may arise and trigger urges to escape from those memories. We asked 133 women with high (H_RBI; n = 63) and low (L_RBI; n = 70) levels of habitual body-directed self-disgust to recall autobiographical memories in response to 11 concrete body-related cue words in a minimal instructions Autobiographical Memory Test (AMT). Despite an overall low level of memory specificity, we found that RBI levels were associated with stronger disgust reactions and stronger motivations to escape from body-related memories. In addition, disgust reactions to body-related memories accounted for the association between habitual levels of self-disgust and urges to escape from these memories. Thus, the findings indicated that women with body image concerns showed disgust-based urges to escape from body-related memories. This disgust-based urge to avert from body-related autobiographical memories might counteract the correction of an RBI, thereby contributing to the persistence of body image concerns and associated psychopathology.

The KOALA-study: study protocol for a comprehensive study of cognitive biases in adolescent anorexia nervosa patients compared to healthy and clinical controls

BACKGROUND

Anorexia nervosa (AN) is characterized by dysfunctional cognitions including cognitive biases at various levels of information processing. However, less is known about the specificity of these biases, i.e., if they occur for eating-disorder-related information alone or also for non-eating-disorder-related emotional information in AN patients (content-specificity) and if they are unique to individuals with AN or are also shown by individuals with other mental disorders (disorder-specificity).

METHODS

The present study systematically assesses cognitive biases in 12-18-year-old female adolescents with AN on three levels of information processing (attention, interpretation, and memory) and with regard to two types of information content (eating-disorder-related, i.e., stimuli related to body weight and shape, and non-eating-disorder-related). To address not only content- but also disorder-specificity, adolescents with AN will be compared not only to a healthy control group but also to a clinical control group (adolescents with major depression or particular anxiety disorders). Cognitive biases are assessed within a single experimental paradigm based on the Scrambled Sentences Task. During the task eye movements are recorded in order to assess attention biases while interpretation biases are derived from the behavioural outcome. An incidental free recall test afterwards assesses memory biases. We expect adolescents with AN to show more pronounced negative cognitive biases on all three levels of information processing and for both types of content compared to healthy adolescents. In addition, we expect the specificity of biases to translate into differential results for the two types of content: AN patients are expected to show stronger biases for disorder-related stimuli but similar or less pronounced biases for non-disorder-related stimuli compared to the clinical control group.

DISCUSSION

This is the first study to comprehensively assess cognitive biases in adolescents with AN. It will have essential implications not only for cognitive-behavioural models of AN but also for subsequent studies aiming to modify cognitive biases in this population, thereby addressing important maintaining factors already at an early stage of the disorder.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Implicit bias to food and body cues in eating disorders: a systematic review

BACKGROUND

Rigid, restrictive eating patterns, fear of gaining weight, body image concerns, but also binge eating episodes with loss of control leading to overweight, at times followed by compensatory measures to control weight, are typical symptoms in eating disorders (EDs). The regulation of food intake in EDs may underlie explicit processes that require cognitive insight and conscious control or be steered by implicit mechanisms that are mostly automatic, rapid, and associated with affective-rather than cognitive-processing. While introspection is not capable of assessing implicit responses, so-called indirect experimental tasks can assess implicit responses underlying a specific behavior by-passing the participant's consciousness. Here, we aimed to present the current evidence regarding studies on implicit biases to food and body cues in patients with EDs.

METHODS

We performed a systematic review (PRISMA guidelines). We included controlled studies performed in clinical ED cohorts (vs. healthy control subjects or another control condition, e.g., restrictive vs. binge/purge AN) and using at least one indirect assessment method of interest.

RESULTS

Out of 115 screened publications, we identified 29 studies fulfilling the eligibility criteria, and present a synthesis of the essential findings and future directions.

CONCLUSION

In this emerging field of research, the present work provides cornerstones of evidence highlighting aspects of implicit regulation in eating disorders. Applying both direct (e.g., self-reports) and indirect measures for the assessment of both explicit and implicit responses is necessary for a comprehensive investigation of the interplay between these different regulatory mechanisms and eating behavior. Targeted training of implicit reactions is already in use and represents a useful future tool as an add-on to standard psychotherapeutic treatments in the battle against eating disorders.

EVIDENCE LEVEL

1 (systematic review).

Biases in attention and memory for body shape images in eating disorders

PURPOSE

To investigate attentional and memorial biases towards body shape pictures among female patients with clinical eating disorders and healthy female controls.

METHODS

A visual dot-probe task was used to assess attention towards pictures reflecting either a thin, normal, or obese female body shape. Pictures were presented in pairs; each pair depicted two different body shapes and were presented twice. Participant responses were compared across time and population.

RESULTS

Overall, the eating disorder patients responded more slowly than controls, F(1,63) = 20.32, p < .001. Both groups showed an attentional bias towards the larger of two body shapes, F(1,63) = 4.30, p = .04, and responded more quickly the second time they viewed the picture pairs, F(1,63) = 33.80, p < .001. Upon second viewing of picture pairs, the eating disorder patients had a larger decrease in reaction time (86 ms) than the control sample (33 ms) only when both pictures included extreme body shapes (thin and obese); the decrease in reaction time when one of the pictures included a normal body shape was the same across groups upon second viewing (eating disorder: 37 ms; control: 32 ms), F(1,63) = 9.32, p = .003.

CONCLUSIONS

These findings suggest that individuals with eating disorders may be biased towards recall of dichotomous and/or extreme body shape images. While it remains unclear whether attentional and/or memorial bias is a risk, maintenance, or causal factor in eating disorders, future studies should employ longitudinal, prospective research designs to address these questions.

LEVEL OF EVIDENCE

Level II, comparative study.

A systematic and methodological review of attentional biases in eating disorders: Food, body, and perfectionism

OBJECTIVE

The current systematic and methodological review aimed to critically review existing literature utilizing implicit processing, or automatic approach- and/or avoidance-related attentional biases between eating disorder (ED) and nonclinical samples, which (a) highlights how psychophysiological methods advance knowledge of ED implicit bias; (b) explains how findings fit into transdiagnostic versus disorder-specific ED frameworks; and (c) suggests how research can address perfectionism-related ED biases.

METHOD

Three databases were systematically searched to identify studies: PubMed, Scopus, and PsychInfo electronic databases. Peer-reviewed studies of 18- to 39-year-olds with both clinical ED and healthy samples assessing visual attentional biases using pictorial and/or linguistic stimuli related to food, body, and/or perfectionism were included.

RESULTS

Forty-six studies were included. While behavioral results were often similar across ED diagnoses, studies incorporating psychophysiological measures often revealed disease-specific attentional biases. Specifically, women with bulimia nervosa (BN) tend to approach food and other body types, whereas women with anorexia nervosa (AN) tend to avoid food as well as overweight bodies.

CONCLUSIONS

Further integration of psychophysiological and behavioral methods may identify subtle processing variations in ED, which may guide prevention strategies and interventions, and provide important clinical implications. Few implicit bias studies include male participants, investigate binge-eating disorder, or evaluate perfectionism-relevant stimuli, despite the fact that perfectionism is implicated in models of ED.

Food-related salience processing in healthy subjects during word recognition: Fronto-parietal network activation as revealed by independent component analysis

BACKGROUND

The study aimed to isolate and localize mutually independent cognitive processes evoked during a word recognition task involving food-related and food-neutral words using independent component analysis (ICA) for continuously recorded EEG data. Recognition memory (old/new effect) involves cognitive subcomponents-familiarity and recollection-which may be temporally and spatially dissociated in the brain. Food words may evoke additional attentional salience which may interact with the old/new effect.

METHODS

Sixteen satiated female participants undertook a word recognition task consisting of an encoding phase (learning of presented words, 40 food-related and 40 food neutral) and a test phase (recognition of previously learned words and new words). Simultaneously recorded 64-channel EEG data were decomposed into mutually independent components using the Infomax algorithm in EEGLAB. The components were localized using single dipole fitting using a four-shell BESA head model. The resulting (nonartefactual) components with <15% residual variance were clustered across subjects using the kmeans algorithm resulting in five meaningful clusters localized to fronto-parietal regions. Repeated-measures anova was employed to test main effects (old/new and food relevance) and their interaction on cluster time courses.

RESULTS

Early task-relevant old/new effects were localized to the medial frontal gyrus (MFG) and later old/new effects to the right parietal regions (precuneus). Food-related (nontask-relevant) salience effects were localized to bilateral parietal regions (left precuneus and right postcentral gyrus). Food-related salience interacted with task relevance, the old/new effect in MFG being significant only for food-neutral words highlighting central the role of MFG as the converging site of endogenous and exogenous salience inputs.

CONCLUSION

Our results indicate ICA to be a valid technique to decompose complex neurophysiological signals involving multiple cognitive processes and implicate the fronto-parietal network as an important attentional network for processing salience and task demands.

Childhood Obesity and Academic Performance: The Role of Working Memory

The present study examined the role of working memory in the association between childhood obesity and academic performance, and further determined whether memory deficits in obese children are domain-specific to certain tasks or domain-general. A total of 227 primary school students aged 10-13 years were analyzed for weight and height, of which 159 children (44 "obese," 23 "overweight," and 92 "normal weight") filled out questionnaires on school performance and socioeconomic status. And then, all subjects finished three kinds of working memory tasks based on the digit memory task in 30 trials, which were image-generated with a series of numbers recall trial sets. After each trial set, subjects were given 5 s to recall and write down the numbers which hand appeared in the trial, in the inverse order in which they had appeared. The results showed there were significant academic performance differences among the three groups, with normal-weight children scoring higher than overweight and obese children after Bonferroni correction. A mediation model revealed a partial indirect effect of working memory in the relationship between obesity and academic performance. Although the performance of obese children in basic working memory tests was poorer than that of normal-weight children, they recalled more items than normal-weight children in working memory tasks involving with food/drink. Working memory deficits partially explain the poor academic performance of obese children. Those results indicated the obese children show domain-specific working memory deficits, whereas they recall more items than normal-weight children in working memory tasks associated with food/drink.

Meaningful Memory in Acute Anorexia Nervosa Patients-Comparing Recall, Learning, and Recognition of Semantically Related and Semantically Unrelated Word Stimuli

OBJECTIVE

It is unclear whether observed memory impairment in anorexia nervosa (AN) depends on the semantic structure (categorized words) of material to be encoded. We aimed to investigate the processing of semantically related information in AN.

METHOD

Memory performance was assessed in a recall, learning, and recognition test in 27 adult women with AN (19 restricting, 8 binge-eating/purging subtype; average disease duration: 9.32 years) and 30 healthy controls using an extended version of the Rey Auditory Verbal Learning Test, applying semantically related and unrelated word stimuli.

RESULTS

Short-term memory (immediate recall, learning), regardless of semantics of the words, was significantly worse in AN patients, whereas long-term memory (delayed recall, recognition) did not differ between AN patients and controls.

DISCUSSION

Semantics of stimuli do not have a better effect on memory recall in AN compared to CO. Impaired short-term versus long-term memory is discussed in relation to dysfunctional working memory in AN. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Do Females with Bulimia Nervosa and Eating Disorder Not Otherwise Specified Have Selective Memory Biases?

Background: The cognitive model suggests memory biases for weight/shape and food related information could be important in the maintenance of eating disorders. Aims: The current study aims to evaluate this and extend previous research by (a) including females with eating disorder not otherwise specified (EDNOS) as a discreet group; (b) considering whether levels of hunger and the pleasantness of the stimulus words are important in word recall. Method: The study includes three groups of females, 16 with bulimia nervosa, 18 with EDNOS and 17 non-dieting general population controls. All participants completed a self-referential encoding and memory recall task. Results: A main effect of word type (p < .01) with no group by word type interaction or between group difference was found. A priori contrasts indicated that both eating disorder groups recalled significantly more weight/shape and food words compared to all other word categories (p < .01) compared to the control group; with no significant difference found between the eating disorder groups. In relation to the recall of food words, no significant differences were found between groups for levels of hunger. Both eating disorder groups rated the negative weight/shape (p < .01), negative food (p < .01) and neutral body words (p < .01) as more unpleasant than the control group. Conclusions: The implications for cognitive theory and future research are discussed.

The relationship between anorexia nervosa and body dysmorphic disorder

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are severe body image disorders that highly impair individuals in their daily functioning. They are discrete but overlapping nosological entities. In this review, we examine similarities between AN and BDD with regard to clinical, personality and demographic aspects, such as comorbidity, phenomenology, and treatment outcome. The review suggests that the two disorders are highly comorbid, and show similar ages of onset, illness trajectories, and comparable clinical and personality characteristics. However, important differences emerge in their responsiveness to psychosocial and psychopharmacological treatment, which are discussed. Clinical implications of these findings are summarized and directions for future research are delineated, with a focus on how current treatment components from each disorder may inform new interventions for both disorders.

Neuropsychology of eating disorders: 1995-2012

Eating disorders are considered psychiatric pathologies that are characterized by pathological worry related to body shape and weight. The lack of progress in treatment development, at least in part, reflects the fact that little is known about the pathophysiologic mechanisms that account for the development and persistence of eating disorders. The possibility that patients with eating disorders have a dysfunction of the central nervous system has been previously explored; several studies assessing the relationship between cognitive processing and certain eating behaviors have been conducted. These studies aim to achieve a better understanding of the pathophysiology of such diseases. The aim of this study was to review the current state of neuropsychological studies focused on eating disorders. This was done by means of a search process covering three relevant electronic databases, as well as an additional search on references included in the analyzed papers; we also mention other published reviews obtained by handsearching.

Attention and memory biases toward body-related images among restrained eaters

This study examined biases in attention and memory toward body-related images among restrained (n=31) and unrestrained (n=29) eaters. Attentional allocation to images of thin and overweight bodies during a visual search task was measured by tracking participants' eyegaze. This task was followed by a recognition test assessing participants' memory for those images. Restrained and unrestrained eaters allocated more attention to body-related images than to control images, but there was no difference in attentional allocation between the two groups. Restrained eaters showed better recognition of body-related images that they had previously seen during the visual search task. Finally, increased attention was associated with better recognition of body-related images for both restrained and unrestrained eaters, but restrained eaters had better overall recognition regardless of the level of attention. These findings suggest that restrained eaters may have more organized strategies for processing body-related information than do unrestrained eaters.

Event-related potentials during recognition of semantic and pictorial food stimuli in patients with anorexia nervosa and healthy controls with varying internal states of hunger

OBJECTIVE

To elucidate maladaptive central processing of food cues during recognition tasks in anorexia nervosa (AN), while considering influences of nutritional preload and presentation modality (word versus picture).

METHODS

Event-related potentials to food-related word and pictorial stimuli were assessed during recognition tasks in 16 patients with AN, 16 control participants with food intake before the study, and 16 control participants with a fasting period before the study.

RESULTS

Patients with AN showed a P3b amplitude reduction especially at the midline parietal site compared with satiated controls (5.7 [standard deviation = 3.3] versus 8.7 [3.1] μV, p < .03). Subtle recognition deficits in patients with AN were indicated by smaller "old/new" effects compared with satiated (p = .049) and fasting controls (p < .003) for pictorial stimuli. Hunger-modulated enhanced old/new effects for food pictures compared with neutral pictorial stimuli could be observed in fasting controls only (2.7 [2.6] versus 0.8 [2.2] μV, p < .01).

CONCLUSIONS

The presented data provide evidence for a midline parietal P3b amplitude reduction in patients with AN, which might point to reduced network activation in AN even during satiety. Observed subtle recognition deficits either represent a stable trait characteristic or a "scar" effect of chronic starvation that may play a role in the development and/or persistence of the disorder.

Selective processing of body image words in women at-risk for developing an eating disorder: a preliminary study

We evaluated the utility of the Modified Stroop task as a measure of body image concerns in women at-risk for an eating disorder. Data were collected among 31 participants from an eating disorder prevention program. The Modified Stroop was significantly associated with overeating episodes and an explicit measure of shape concern. The traditional Stroop effect was found while the Modified Stroop effect was non-significant. The results raise questions about the Modified Stroop task's utility in identifying at-risk women. Methodological and clinical implications are discussed.

Memory performance in acute and weight-restored anorexia nervosa patients

BACKGROUND

Anorexia nervosa (AN), at the stage of starvation and emaciation, is characterized by abnormalities in cognitive function, including memory performance. It is unclear whether memory impairment persists or is reversible following weight restoration, and whether memory function differs between AN subtypes. The aim of the present study was to investigate general memory performance in currently ill and fully weight-restored patients of different AN subtypes.

METHOD

Memory performance was assessed using the Wechsler Memory Scale-Revised (WMS-R) in a total of 99 participants, including 34 restricting-type AN patients (AN-RESTR), 19 binge-eating/purging-type AN patients (AN-PURGE), 16 weight-restored AN patients (AN-W-R) and 30 healthy controls (CONTROL). Cognitive evaluation included a battery of standardized neuropsychological tasks for validating the findings on memory function.

RESULTS

Deficits were found with respect to immediate and delayed story recall in currently ill AN patients irrespective of AN subtype. These deficits persisted in weight-restored AN patients. Currently ill and weight-restored AN patients did not differ significantly from healthy controls with respect to working memory or other measures of neuropsychological functioning.

CONCLUSIONS

The findings suggest that impaired memory performance is either a stable trait characteristic or a scar effect of chronic starvation that may play a role in the development and/or persistence of the disorder.

Cognitions and emotions in eating disorders

The cognitive model of eating disorders (EDs) states that the processing of external and internal stimuli might be biased in mental disorders. These biases, or cognitive errors, systematically distort the individual's experiences and, in that way, maintains the eating disorder. This chapter presents an updated literature review of experimental studies investigating these cognitive biases. Results indicate that ED patients show biases in attention, interpretation, and memory when it comes to the processing of food-, weight-, and body shape-related cues. Some recent studies show that they also demonstrate errors in general cognitive abilities such as set shifting, central coherence, and decision making. A future challenge is whether cognitive biases and processes can be manipulated. Few preliminary studies suggest that an attention retraining and training in the cognitive modulation of food reward processing might be effective strategies to change body satisfaction, food cravings, and eating behavior.

Information processing of food cues in overweight and normal weight adolescents

OBJECTIVES

Based on cognitive theory (CT), the aim of this study is to investigate the cognitive processing of food cues in clinically overweight adolescents.

DESIGN

An experimental design with performance-based measures.

METHODS

Eighty-seven (45 overweight, 42 normal weight) adolescents between the ages of 12 and 18 years were examined. All completed an imbedded word task (IWT), containing high caloric food words and matched control words, as a measure of attention interference. A free-recall task was used to detect explicit memory biases. To study the effects of cognitive avoidance, participants were instructed to suppress thoughts about food or merely to monitor them, prior to completing the IWT and memory task.

RESULTS

No evidence was found for interference in the attention processing of food cues. Also, no effects of thought suppression were found. However, consistent with hypotheses, the overweight adolescents did show an explicit memory bias for food stimuli, not due to a more general negative evaluation of food words.

CONCLUSIONS

The results provide at least partial support for the applicability of CT to adolescent obesity. The study was the first to reveal a memory bias for high caloric food cues in overweight youngsters, which may well reflect a later-stage activation of food-related schemata. These may play a role in food-related preoccupations and overeating. The existence of an early-stage attention bias is less clear and requires further investigation.

Explicit memory bias for positively valenced body-related cues in women with binge eating disorder

Overweight women with and without binge eating disorder (BED) are characterized by a marked body dissatisfaction, which may in part be due to the negative comments about their weight. Weight-related teasing and discrimination is reported both by healthy overweight women and women with BED, whereas body dissatisfaction is markedly increased among women with BED. Therefore, a memory bias for negatively valenced body-related cues is suspected to occur as a mediating factor in women with BED. In an experimental study, 18 women with BED were compared to 18 overweight healthy female controls (HC) on a free recall task containing four word categories: positively valenced with and without body-related content and negatively valenced with and without body-related content. While both groups showed a bias towards negatively valenced shape-/weight-related words, women with BED retrieved positively valenced shape-/weight-related words significantly less often compared to overweight HC. Findings suggest that it may be the reduced ability to attend to positively valenced shape-/weight-related information, rather than the activation of negative body schemata that differentiates overweight women with BED from overweight women without BED. Results are discussed in the context of cognitive biases in the maintenance of body dissatisfaction.

Memory bias for schema-related stimuli in individuals with bulimia nervosa

This study investigates whether individuals with bulimia nervosa (BN) have a memory bias in relation to explicit memory (cued and free recall vs. verbal and pictorial recognition tasks). Twenty-five participants diagnosed with BN and 27 normal controls (NC) were exposed to body-related, food-related, and neutral TV commercials, and then recall and recognition rates were assessed. Poorer recognition and recall of body-related stimuli was found for BN in comparison to NC, suggesting a memory bias. Results are discussed in relation to previous studies, along with suggestions as to how future studies can gain more insight into dysfunctions in information processing that can lead to the maintenance of eating disorders.

Development and validation of a Food Preoccupation Questionnaire

OBJECTIVE

Existing Food Preoccupation Questionnaires do not take account of food-related thoughts that have a positive emotional valence. We report on the development and validation of a questionnaire that provides independent assessments of thought frequency and emotional valence (positive, negative or neutral).

METHOD

In Study 1 questionnaire items were validated against a three-day diary measure with 40 males and females. In Study 2 the questionnaire was administered to 130 males and females alongside a range of other measures.

RESULTS

The questionnaire showed good construct validity, internal reliability, and test-retest reliability. Dieters and females scored higher on frequency and negativity subscales. There was also a significant interaction between sex and diet status on thought frequency, with females showing a stronger relationship between the two.

DISCUSSION

The questionnaire should be useful for exploring the cognitive impact of dieting and relationships between food preoccupation, food processing biases and overeating.

Cognitive processing of body and appearance words as a function of thin-ideal internalization and schematic activation

To better understand how women at risk of body image disturbance respond when their body concerns are activated, we examined attentional and memory biases in undergraduate women with high thin-ideal internalization, an identified risk factor for eating disorders, following priming of body and appearance concerns. Female undergraduates (N=186) viewed photos of either sports cars or attractive swimsuit models, then completed the Lexical Decision Test, a word recall test, and questionnaires assessing thin-ideal internalization and eating disorder symptomatology. High thin-ideal internalizers did not exhibit cognitive biases predicted by cognitive models of eating disorders, even when their body and appearance concerns were primed by exposure to attractive models. Converging evidence suggests that high-risk non-clinical samples rarely exhibit cognitive biases characteristic of individuals with eating disorders, and, in fact, may actually incorporate ideal appearance into their schemas and preferentially attend to attractive stimuli.

Memory bias in anorexia nervosa: evidence from directed forgetting

The aim of this study was to examine memory bias for disorder-relevant information in anorexia nervosa by using the directed forgetting paradigm. Normal controls and patients with anorexia nervosa were given a list consisting of neutral and disorder-relevant words, which they were either asked to remember (R) or forget (F). Memory performance was measured by a free recall and a Yes/No recognition task for all items. There was a directed forgetting effect for both groups; however, the magnitude of the effect (difference between R and F words) was smaller for the patient group due to higher recall of F items. Further analyses showed that this was true only for disorder-relevant but not for neutral items. Our findings support the existence of a strong memory bias for disorder-relevant information in patients with anorexia nervosa, who had difficulty in avoiding the processing of information that they were asked to forget.

Anorexia nervosa: selective processing of food-related word and pictorial stimuli in recognition and free recall tests

OBJECTIVE

Maladaptive processing of food cues is considered pivotal in the psychopathology of anorexia nervosa. However, the influence of hunger and differences in processing because of the type of stimuli remain largely unclear.

METHOD

Memory bias for food-related pictorial and semantic stimuli was assessed in a recognition and a free recall test in 16 anorexia nervosa (AN) patients, 16 control participants with food intake prior to the study (CG-FI) and 16 control participants with a fasting period prior to the study (CG-NF).

RESULTS

Compared with CG-FI participants, both AN and CG-NF participants responded faster to food-related as compared with neutral words (p < .001) in the recognition test. Differences were found for word but not for pictorial stimuli. No group differences were observed with respect to the number of correct retrievals in either the recognition or the free recall test.

CONCLUSION

The present study found behavioral indications of abnormal processing of food-related and neutral stimuli in anorectic patients similar to those found in fasted healthy controls. Results are discussed in terms of self-schemata in eating disorders, competitive interference, and levels of processing.

Selective memory biases for words reflecting sex-specific body image concerns

Women show "fear of fatness" and men a "drive for muscularity." Moreover, women perceive themselves as larger and men more muscular than they actually are. We tested potential memory biases congruent with these sex-specific body image concerns. Free recall performance for weight-related and muscle-related positive and negative words was assessed in 40 healthy undergraduate students (20 men). Men revealed a recall advantage for positive muscle words, while women showed a general advantage for positive and negative weight-related words. Thus, men revealed a memory bias congruent with their personal preference (more muscular), while women showed a general memory bias for weight information independent of their personal preference of being thinner. The absence of a positive memory bias in women might explain the higher incidence of body dissatisfaction and eating disorders in this population.

Psychophysics reveals a right hemispheric contribution to body image distortions in women but not men

We tested the hypothesis that the right cerebral hemisphere contributes to the enhanced body image distortions seen in women when compared to men. Using classical psychophysics, 60 right-handed healthy participants (30 women) were briefly presented with size-distorted pictures of themselves, another person (an experimenter), and a non-corporal, familiar object (a coke bottle) to the central, right, and left visual field. Participants had to decide whether the presented stimulus was fatter or thinner than the real body/object, and thus compare the presented picture with the stored representation of the stimulus from memory. From these data we extracted the amount of image distortion at which participants judged the various stimuli to be veridical. We found that right visual field presentations (initial left hemisphere processing) revealed a general "fatter" bias, which was more evident for bodies than for objects. Crucially, a "fatter" bias with own body presentations in the left visual field (initial right hemisphere processing) was only found for women. Our findings suggest that right visual field presentation results in a general size overestimation, and that this overestimation is more pronounced for bodies than for objects. Moreover, the particular "fatter" bias after own body presentations to the left visual field in women supports the notion of a specific role of the right hemisphere in sex-specific body image distortion.

Neuropsychologische Beeinträchtigungen und kognitive Verarbeitung von Essensreizen bei Anorexia nervosa

Zusammenfassung. Essstörungen stellen eine wichtige psychiatrische Behandlungsindikation dar. Es ist bekannt, dass bei diesen Erkrankungen auch klinisch relevante kognitive Defizite und Auffälligkeiten in der Informationsverarbeitung bestehen, die im Alltag der PatientInnen zu Beeinträchtigungen führen. Insbesondere im Hinblick auf die schwierige und langwierige Behandlung und hohen Rückfallquoten dieser Patientengruppe ist die Berücksichtigung dieser kognitiven Besonderheiten in der Therapie von Essstörungen wichtig. Der vorliegende Artikel beschreibt neurokognitive Auffälligkeiten bei Anorexia nervosa (AN) in verschiedenen relevanten Funktionsbereichen. Im zweiten Teil der Arbeit werden aktuelle Verhaltens- und Bildgebungsstudien zur Verarbeitung von nahrungsrelevanten Stimuli dargestellt.

Cognitive theory in anorexia nervosa and bulimia nervosa: Progress, development and future directions

Important developments have taken place in cognitive theory of eating disorders (EDs) (and also in other disorders) since the review paper published by M.J. Cooper in 1997. The relevant empirical database has also expanded. Nevertheless, cognitive therapy for anorexia nervosa and bulimia nervosa, although helpful to many patients, leaves much to be desired. The current paper reviews the relevant empirical evidence collected, and the theoretical revisions that have been made to cognitive models of eating disorders, since 1997. The status and limitations of these developments are considered, including whether or not they meet the criteria for "good" theory. New theoretical developments relevant to cognitive explanations of eating disorders (second generation theories) are then presented, and the preliminary evidence that supports these is briefly reviewed. The lack of integration between cognitive theories of EDs and risk (vulnerability) factor research is noted, and a potential model that unites the two is noted. The implications of the review for future research and the development of cognitive theory in eating disorders are then discussed. These include the need for study of cognitive constructs not yet fully integrated (or indeed not yet applied clinically) into current theories and the need for cognitive theories of eating disorders to continue to evolve (as they have indeed done since 1997) in order to fully integrate such constructs. Treatment studies incorporating these new developments also urgently need to be undertaken.

Stroop interference for food- and body-related words: a meta-analysis

According to cognitive theories of eating disorders, biased information processing in favour of dysfunctional attitudes about food and body appearance plays a vital role in the development and maintenance of such disorders. Data from 27 studies evaluating Stroop interference for food- and body-related words with negative overtones were included in a meta-analysis in order to investigate whether such processing biases are specific to eating disordered samples. Participants were females characterised as eating disordered, non-eating disordered but nevertheless over-concerned with body appearance and eating, and normal controls. Mean Stroop interference for eating disordered females was of medium effect size (Cohen's d=0.48) and significantly larger than for both non-eating disordered females concerned with body appearance and eating, and normal control females (both d=0.21). Stroop interference for eating disordered females was thus of fairly modest magnitude where it was unclear whether such interference is specific to this sample.

Smoking expectancy associates among college smokers

Although it has been suggested that implicit expectancies influence smoking and other addictive behaviors, there is little direct evidence to support this notion. This study offers the first step in exploring implicit expectancy operation in cigarette smoking. Ninety-nine college smokers completed the sentence, "Smoking makes one_____." with as many words as possible within 30 s, developing a list of expectancy associates. The results of the sentence completion task were positively correlated with an explicit measure of smoking-related expectancies. Future studies will be able to use the expectancy associates developed by this study to employ implicit memory tasks and further the understanding of the role of smoking-related expectancies.

Incidental learning of food and emotional words in women with anorexia nervosa

Prior research suggests that anorexic patients show a memory bias for fattening foods when they are processed in depth or with reference to the self. The present study examined whether anorexic subjects exhibit a bias for fattening foods when these are presented as task-irrelevant distractor stimuli. It also investigated whether anorexic patients pay less attention to emotion stimuli. A sequential word-word evaluation task was administered to 11 inpatients with anorexia nervosa and 11 non-dieting normal subjects. There were four types of distractor words: high caloric foods, positive, negative, and neutral. Anorexic patients recalled no more food words but fewer neutral and positive words than normal subjects. The present data suggest that, compared to healthy young women, anorexic patients show no memory bias for fattening foods when these data are presented as peripheral environmental information. Anorexic patients are perceptually no less sensitive to negative emotional information than normal subjects.

Cognitive-behavioral theories of eating disorders

This article presents an integrated cognitive-behavioral theory of eating disorders that is based on hypotheses developed over the past 30 years. The theory is evaluated using a selected review of the eating disorder literature pertaining to cognitive biases, negative emotional reactions, binge eating, compensatory behaviors, and risk factors for eating disorders. In general, hypotheses derived from cognitive-behavioral theories have been supported by a variety of research studies. The implications of these findings for treatment and prevention of eating disorders are discussed. This review of the literature serves as a conceptual base for some of the other articles that are included in this special issue of Behavior Modification. The article concludes with an introduction to six articles that discuss issues related to psychiatric classification, assessment, treatment, and prevention of eating disorders.

Neuropsicologia dos transtornos alimentares: revisão sistemática da literatura

ANTECEDENTES: A etiologia dos transtornos alimentares (TA) ainda não se encontra estabelecida. Dentre os diversos fatores envolvidos, a hipótese de uma disfunção do sistema nervoso central tem sido explorada de diversas maneiras. Assim, a avaliação neuropsicológica de pacientes com TA tem por finalidade investigar a ocorrência de déficits cognitivos associados a estas patologias. OBJETIVOS: O objetivo deste artigo é avaliar o estado atual das investigações sobre a avaliação neuropsicológica em pacientes com TA. MÉTODOS: Foi realizada uma pesquisa bibliográfica - utilizando as seguintes bases de dados como estratégias de procura: MedLINE, PsychoINFO, LILACS e Cochrane Data Bank -, procurando artigos relacionados ao tema e publicados até o ano de 2004. RESULTADOS: A anorexia nervosa é o transtorno alimentar que conta com mais estudos neuropsicológicos e, de uma forma geral, os resultados apontam para déficits de atenção, déficits viso-espaciais e de viso-construção. Na bulimia nervosa, as alterações mais encontradas são déficits de atenção seletiva e das funções executivas. O transtorno da compulsão alimentar periódica ainda não conta com estudos neuropsicológicos até o momento. Após um tratamento bem-sucedido do transtorno alimentar, embora haja uma diminuição dos déficits cognitivos, algumas alterações cognitivas parecem persistir. CONCLUSÕES: Os transtornos alimentares parecem estar associados a algum grau de disfunção neuropsicológica, muito embora as funções específicas que se apresentam deficitárias variem entre os estudos encontrados, talvez em decorrência de variações metodológicas. O fato de que, após o tratamento, alguns pacientes apresentem uma melhora no funcionamento cognitivo poderia indicar que, em alguns casos, os déficits seriam funcionais. A ausência de melhora no funcionamento cognitivo de alguns pacientes, após diversas formas de intervenção, pode sugerir que estes déficits antecederiam o desenvolvimento dos transtornos alimentares, podendo, assim, contribuir para seu desenvolvimento ou para um pior prognóstico. O melhor delineamento do perfil cognitivo dos pacientes com transtorno alimentar torna-se importante para orientar abordagens terapêuticas mais seletivas.

The specificity of restrained versus unrestrained eaters' responses to food cues: general desire to eat, or craving for the cued food?

Previous research has shown that exposure to food cues increases eating, especially in restrained eaters. The present study attempted to determine whether this elevated consumption reflects a general desire to eat in response to food cues, or specific desire/craving for the cued food. Restrained and unrestrained eaters were exposed to the smell of either pizza, cookies, or no smell for 10 minutes, were asked to write their thoughts (corresponding to the smell cue) about pizza, cookies or in general, and were then presented with either pizza or cookies to 'taste and rate'. Results indicated that restrained eaters are more responsive than are unrestrained eaters to pre-eating exposure to smell and thought cues, eating significantly more after such cues. An interaction with food type, however, indicated that restrained eaters ate more only when the food presented to eat was the same as the prior food cues. Self-reported desire to eat, liking, and craving for a particular food increased somewhat for restrained eaters after exposure to the smell and thought of that food. Restrained eaters' intake of a food that differed from the pre-eating food cues did not differ from their intake following no prior exposure to food cues. Restrained eaters thus showed a highly specific response to exposure to food cues.

Actual and possible body-image self-schemas in young women with bulimic tendencies

To examine whether information about body image is processed and cognitively organized around a self-concept, two experiments analyzed reaction time and memory for 48 young women with bulimic tendencies. Information was self-referencing to body shape vs trait words and information processing of adjectives referenced to "I dream of" and "I am afraid of" facets of self. Bulimic subjects encoded "fat" adjectives faster when these words were referenced to the present self. Reaction times were also faster to both "thin" and "fat" adjectives when these words were self-referenced to an "I dream of" and to an "I am afraid of" self, respectively. Processing of body-image information depended on which facet of self was activated rather than on the denotative meaning of the stimulus words. Memory for thin and fat adjectives was not related to preoccupation with body image or to which facet of the self was invoked. Findings suggest that an actual body-image schema and a possible body-image schema could coexist for bulimic persons. Such coexistence is necessary for a theory which posits knowledge structures might be dynamically related.

Causes of eating disorders

Anorexia nervosa and bulimia nervosa have emerged as the predominant eating disorders. We review the recent research evidence pertaining to the development of these disorders, including sociocultural factors (e.g., media and peer influences), family factors (e.g., enmeshment and criticism), negative affect, low self-esteem, and body dissatisfaction. Also reviewed are cognitive and biological aspects of eating disorders. Some contributory factors appear to be necessary for the appearance of eating disorders, but none is sufficient. Eating disorders may represent a way of coping with problems of identity and personal control.