Eating disorder psychopathology, psychiatric impairment, and symptom frequency of atypical anorexia nervosa versus anorexia nervosa: A systematic review and meta-analysis

OBJECTIVES

Restrictive eating disorders (EDs) occur across the weight spectrum, but historically more focus has been given to anorexia nervosa (AN) than atypical anorexia nervosa (atypAN). AtypAN's relegation to a diagnosis in the "other specified feeding and eating disorder" (OSFED) category and paucity of research surrounding atypAN invariably implies a less clinically severe ED. However, a growing body of research has begun to question the assumption that atypAN is less severe than AN. The current review and meta-analysis aimed to provide a comprehensive review to compare atypAN and AN on measures of eating disorder psychopathology, impairment, and symptom frequency to test whether atypAN is truly less clinically severe than AN.

METHODS

Twenty articles that reported on atypAN and AN for at least one of the variables of interest were retrieved from PsycInfo, PubMed, and ProQuest.

RESULTS

For eating-disorder psychopathology, results indicated that differences were nonsignificant for most indicators; however, atypAN was associated with significantly higher shape concern, weight concern, drive for thinness, body dissatisfaction, and overall eating-disorder psychopathology than AN. Results indicated that atypAN and AN did not significantly differ on clinical impairment or the frequency of inappropriate compensatory behaviors, whereas there was a significantly higher frequency of objective binge episodes in AN (vs. atypAN).

DISCUSSION

Overall, findings indicated that, in contrast to the current classification system, atypAN and AN were not clinically distinct. Results underscore the need for equal access to treatment and equal insurance coverage for restrictive EDs across the weight spectrum.

PUBLIC SIGNIFICANCE

The current meta-analysis found that atypAN was associated with higher drive for thinness, body dissatisfaction, shape concern, weight concern, and overall eating-disorder psychopathology than AN; whereas AN was associated with higher frequency of objective binge eating. Individuals with AN and atypAN did not differ on psychiatric impairment, quality-of-life, or frequency of compensatory behaviors, highlighting the need for equal access to care for restrictive EDs across the weight spectrum.

Understanding community provider practices in diagnosing and treating atypical anorexia nervosa: A mixed methods study

OBJECTIVE

There is a lack of consensus in defining "significant weight loss" when diagnosing atypical anorexia nervosa (atypical AN) and no guidelines exist for setting target weight (TW). The current study aimed to identify community providers' practices related to the diagnosis of atypical AN and the determination of TW. A secondary aim was to evaluate whether professional discipline impacted "significant weight loss" definitions.

METHOD

A variety of providers (N = 141; 96.4% female) completed an online survey pertaining to diagnostic and treatment practices with atypical AN. Descriptive statistics were computed to characterize provider-based practices and Fisher's exact tests were used to test for differences in diagnostic practices by professional discipline. Thematic analysis was used to examine open-ended questions.

RESULTS

Most (63.97%) providers diagnosed atypical AN in the absence of any weight loss if other AN criteria were met, but doctoral-level psychologists and medical professionals were less likely to do so compared to nutritional or other mental health professionals. Most providers found weight gain was only sometimes necessary for atypical AN recovery. Qualitative responses revealed providers found atypical AN to be a stigmatizing label that was not taken seriously. Providers preferred to use an individualized approach focused on behaviors, rather than weight when diagnosing and treating atypical AN.

DISCUSSION

Lack of diagnostic clarity and concrete treatment guidelines for atypical AN may result in substantial deviations from the DSM-5-TR criteria in real-world practice. Clinically useful diagnostic definitions for restrictive eating disorders and evidence-based treatment guidelines for TW and/or other relevant recovery metrics are needed.

PUBLIC SIGNIFICANCE

The current study found variability in how community providers diagnose and determine target recovery weight for atypical anorexia nervosa (atypical AN). Many providers viewed the diagnosis of atypical AN as stigmatizing and preferred to focus on behaviors, rather than weight. This study underscores the importance of creating a clinically useful diagnostic definition and guidelines for recovery for atypical AN backed by empirical evidence that providers may implement in practice.

Examining associations between disordered eating and harmful substance use in a nationally representative sample of US veterans

OBJECTIVE

The association between eating disorders (EDs) and harmful substance use (substance use that causes psychosocial impairment) is well recognized in the literature, and military veterans may be at heightened risk for both issues due to deployment-related stressors. However, little is known about which ED-related symptoms are associated with harmful substance use in veterans, and whether gender plays a differential role in this relationship. Our aims were to: (1) examine gender differences in ED-related symptoms; and (2) examine whether ED-related symptoms differentially predict harmful substance use in US veteran men and women who had recently separated from service.

METHOD

This study was based on a nationally representative four-wave longitudinal sample of post-9/11 veterans (N = 835; 61.2% female). Longitudinal mixed modeling was used to test whether specific ED-related behaviors at baseline predicted harmful substance use at follow-ups.

RESULTS

We replicated gendered patterns of ED-related symptoms observed in civilian populations, wherein men had higher weight-and-body-related concerns (including excessive exercise and muscle building) and negative attitude toward obesity, and women had higher bulimic and restricting symptoms. For women, alcohol, drug, and marijuana problems were predicted by higher bulimic symptoms, whereas for men, these problems were predicted by higher restricting symptoms.

CONCLUSION

Gender played a differential role in the relationship between EDs and harmful substance use. Bulimic symptoms were the most robust predictor for harmful substance use among veteran women, whereas restricting was the most robust predictor for harmful substance use among veteran men.

PUBLIC SIGNIFICANCE

The current study found that veteran women had higher bulimic symptoms (characterized by binge eating and purging) and restricting than veteran men. In women, bulimic symptoms predicted future harmful use of alcohol, marijuana, and other drugs. In contrast, veteran men had higher weight-and-body-related concerns (characterized by excessive exercise and muscle building) than veteran women. In men, restricting symptoms predicted future harmful use of alcohol, marijuana, and other drugs.

Weight bias internalization is positively associated with insomnia symptom severity in young women with disordered eating

OBJECTIVE

Social stigma has been associated with disparities in sleep heath; however, one type of stigma that has been less evaluated is weight bias internalization. Previous studies have shown inconsistent results linking weight bias internalization and sleep problems and few have examined associations with insomnia.

METHODS

Women with disordered eating (N = 173, Mage=20.22, SD=1.70, range=18-25) completed questionnaires measuring insomnia symptoms, weight bias internalization, alcohol use, and dysphoria. Linear regression tested associations between weight bias internalization and insomnia symptom severity, after adjusting for demographic variables, alcohol use, and dysphoria.

RESULTS

Weight bias internalization, alcohol use, and dysphoria were significantly positively associated with insomnia symptom severity above-and-beyond demographic variables.

CONCLUSIONS

Although effect sizes were small, weight bias internalization was associated with greater insomnia symptom severity. Results add to the growing literature examining the associations of stigma with sleep health.

The impact of trauma-related symptoms and neuroticism on compensatory behaviors in a sample of adults with eating disorders

INTRODUCTION

Inappropriate compensatory behaviors (ICBs), including purging, restricting, and excessive exercising, are key symptoms of several eating disorders (EDs). Studies have found positive associations between trauma and ICBs, although few studies have explored mechanisms that may explain these relationships. Emotion dysregulation has been posited as a mechanism that explains associations among ICBs and trauma. Given that individuals with high neuroticism may be particularly likely to use ICBs to regulate emotions following a trauma, the purpose of this study was to test whether neuroticism moderated the relationship between trauma-related symptoms and each type of ICB (purging, restricting, and excessive exercise).

METHOD

A community sample of adults with a DSM-5 ED (N = 263; 83.7 % female) completed measures of trauma-related symptoms, ED psychopathology, and personality.

RESULTS

Zero-inflated negative binomial models revealed that trauma-related symptoms alone predicted restricting and purging behavior. In addition, we found that neuroticism alone predicted the presence of excessive exercise. We found no significant interaction between trauma-symptoms and neuroticism.

CONCLUSION

Although past research has documented high rates of co-occurring ED and PTSD, the connections between trauma-related symptoms and ICBs are complex and may be unique to each type of ICB. Given that neuroticism may not influence the relationship between trauma-related symptoms and ICBs, more research should be done to establish an understanding of factors that could explain the relationship between ICBs and trauma-related symptoms. Novel interventions that simultaneously target restricting, purging, and trauma-related symptoms could be beneficial to explore.

Prospectively predicting naturalistic exposure to fitspiration and thinspiration in young women with disordered eating by leveraging an ecological momentary assessment design

OBJECTIVE

Although a growing body of research has examined the impacts of ED-salient content, such as fitspiration and thinspiration, on eating disorder (ED) symptoms, there is less known about the characteristics of who may be at risk for accessing this content on Instagram. Current research is limited by cross-sectional and retrospective designs. This prospective study used ecological momentary assessment (EMA) to predict naturalistic exposure to ED-salient content on Instagram.

METHODS

Female university students with disordered eating (N = 171, Mage = 20.23, SD = 1.71, range = 18-25) completed a baseline session, followed by a seven-day EMA protocol, in which they reported on Instagram use and exposure to fitspiration and thinspiration. Mixed-effects logistical regressions were used to predict exposure to ED-salient content on Instagram from four principal components (e.g., behavioral ED symptoms and trait social comparison) controlling for duration of Instagram use (i.e., dose) and day of study.

RESULTS

Duration of use was positively associated with all types of exposure. Purging/cognitive restraint and excessive exercise/muscle building prospectively predicted access to any ED-salient content and fitspiration only. Restricting positively predicted thinspiration only access. Purging/cognitive restraint positively predicted accessing fitspiration and thinspiration (dual exposure). Day of study was negatively associated with any exposure, fitspiration only, and dual exposure.

CONCLUSIONS

Baseline ED behaviors were differentially associated with exposure to ED-salient Instagram content; however, duration of use was also a significant predictor. Limiting use of Instagram may be important for young women with disordered eating to reduce probability of encountering ED-salient content.

A pilot multiple-baseline study of a mobile cognitive behavioral therapy for the treatment of eating disorders in university students

OBJECTIVE

Eating disorders (EDs) are serious psychiatric disorders associated with substantial morbidity and mortality that are prevalent among university students. Because many students do not receive treatment due to lack of access on university campuses, mobile-health (mHealth) adaptations of evidence-based treatments represent an opportunity to increase treatment accessibility and engagement. The purpose of this study was to test the initial efficacy of Building Healthy Eating and Self-Esteem Together for University Students (BEST-U), which is a 10-week mHealth self-guided cognitive-behavioral therapy (CBT-gsh) app that is paired with a brief 25-30-min weekly telehealth coaching, for reducing ED psychopathology in university students.

METHOD

A non-concurrent multiple-baseline design (N = 8) was used to test the efficacy of BEST-U for reducing total ED psychopathology (primary outcome), ED-related behaviors and cognitions (secondary outcomes), and ED-related clinical impairment (secondary outcome). Data were examined using visual analysis and Tau-BC effect-size calculations.

RESULTS

BEST-U significantly reduced total ED psychopathology and binge eating, excessive exercise, and restriction (effect sizes ranged from -0.39 to -0.92). Although body dissatisfaction decreased, it was not significant. There were insufficient numbers of participants engaging in purging to evaluate purging outcomes. Clinical impairment significantly reduced from pre-to-post-treatment.

DISCUSSION

The current study provided initial evidence that BEST-U is a potentially efficacious treatment for reducing ED symptoms and ED-related clinical impairment. Although larger-scale randomized controlled trials are needed, BEST-U may represent an innovative, scalable tool that could reach greater numbers of underserved university students than traditional intervention-delivery models.

PUBLIC SIGNIFICANCE

Using a single-case experimental design, we found evidence for the initial efficacy of a mobile guided-self-help cognitive-behavioral therapy program for university students with non-low weight binge-spectrum eating disorders. Participants reported significant reductions in ED symptoms and impairment after completion of the 10-week program. Guided self-help programs show promise for filling an important need for treatment among university students with an ED.

The Building Healthy Eating and Self-Esteem Together for University Students Mobile App to Treat Eating Disorders: User-Centered Research Design and Feasibility Study

BACKGROUND

University students are an at-risk group for the development of eating disorders (EDs); however, many college campuses lack sufficient resources to provide ED specialty care. Students report unique reasons for not seeking ED treatment, including the desire to solve the problem on their own (eg, seeking help from friends, self-medicating, or waiting to see if their problems improve), inability to afford treatment, lack of time to participate in the treatment, fear of seeing their primary care physician, and lack of recognition of their issues as an ED. Mobile health (mHealth) apps may be a cost-effective, helpful adjunctive tool to overcome personal and systemic barriers and encourage help seeking.

OBJECTIVE

This paper describes the development, usability, and acceptability of the Building Healthy Eating and Self-Esteem Together for University Students (BEST-U) mHealth smartphone app, which is designed to fill critical gaps in access to ED treatment on college campuses.

METHODS

We undertook a 4-phase iterative development process that focused on user-centered design. The 4 phases included needs assessment based on literature reviews, prototype development and initial evaluation in a pilot trial, redesign, and further pilot-testing to assess the usability and acceptability of the final version of the mHealth app. Acceptability and user satisfaction were assessed using an ad hoc survey that ranged from 1 (strongly disagree) to 7 (strongly agree).

RESULTS

Our needs assessment identified a lack of accessible and affordable treatments for university students. To help meet this need, the BEST-U prototype was designed as an 11-week program that provided interactive, weekly modules that focused on second- and third-wave cognitive behavioral skills. The modules focused on topics such as psychoeducation, reducing thought distortions and body checking, improving body image, interpersonal effectiveness, and behavior chain analysis. The content included interactive quizzes, short answer questions, daily and weekly logs, and surveys completed in the app. BEST-U was paired with brief 25-30 minutes of weekly telehealth coaching sessions provided by a licensed provider or supervised trainee. Pilot-testing revealed minor issues with one module of the app content, which some participants viewed as having low relevance to their experience and therapist concerns about the organization of the app content. These issues were addressed through the removal, addition, and reorganization of BEST-U modules, with the help of therapists-in-training across 2 workshops. The revised version of the BEST-U app had a grand mean acceptability rating of 5.73 out of 7. The participants completed 90.1% (694/770) of the BEST-U modules, indicating high compliance.

CONCLUSIONS

BEST-U is a new, acceptable, and user-friendly mHealth app to help therapists deliver brief, evidence-based cognitive behavioral interventions. Owing to its acceptability and user-friendly nature, BEST-U has high user compliance and holds promise for future implementation and dissemination in university mental health settings.

Eating Disorder Examination-Questionnaire and Clinical Impairment Assessment norms for intersectional identities using an MTurk sample

OBJECTIVE

There are limited data to guide the interpretation of scores on measures of eating-disorder psychopathology among underrepresented individuals. We aimed to provide norms for the Eating Disorder Examination-Questionnaire (EDE-Q) and Clinical Impairment Assessment (CIA) across racial/ethnic, gender, and sexual identities, and sexual orientations and their intersections by recruiting a diverse sample of Amazon MTurk workers (MTurkers; N = 1782).

METHOD

We created a comprehensive, quantitative assessment of racial/ethnic identification, gender identification, sex assigned at birth, current sexual identification, and sexual orientation called the Demographic Assessment of Racial, Sexual, and Gender Identities (DARSGI). We calculated normative data for each demographic category response option.

RESULTS

Our sample was comprised of 68% underrepresented racial/ethnic identities, 42% underrepresented gender identities, 13% underrepresented sexes, and 49% underrepresented sexual orientations. We reported means and standard deviations for each demographic category response option and, where possible, mean estimates by percentile across intersectional groups. EDE-Q Global Score for a subset of identities and intersections in the current study were higher than previously reported norms for those identities/intersections.

DISCUSSION

This is the most thorough reporting of norms for the EDE-Q and CIA among racial/ethnic, sexual, and gender identities, and sexual orientations and the first reporting on multiple intersections, filling some of the gaps for commonly used measures of eating-disorder psychopathology. These norms may be used to contextualize eating-disorder psychopathology reported by underrepresented individuals. The data from the current study may help inform research on the prevention and treatment of eating-disorder psychopathology in underrepresented groups.

PUBLIC SIGNIFICANCE

We provide the most thorough reporting on racial/ethnic, sexual, and gender identities, and sexual orientations for the Eating Disorder Examination - Questionnaire and Clinical Impairment Assessment, and the first reporting on intersections, which fills some of the gaps for commonly used measures of eating-disorder psychopathology. These norms help inform research on the prevention and treatment of eating-disorder psychopathology in underrepresented groups.

Screening for eating disorders across genders in college students: Initial validation of the brief assessment of stress and eating

Given that eating disorders (EDs) are relatively common in college populations, it is important to have reliable and valid tools to identify students so that they can be referred to evidence-based care. Although research supports the psychometric properties of existing ED screens for identifying cases of EDs, most studies have been conducted in samples of young white-majority women or have not reported the psychometric properties of the screening tool in men.

OBJECTIVE

The purpose of the current study was to validate a brief, 10-item screening tool for the identification of EDs-the brief assessment of stress and eating (BASE).

METHOD

Participants were college students (N = 596; 68.2% cisgender women) from a large Midwestern university who completed the BASE and SCOFF. The Eating Disorders Diagnostic Survey was used to generate DSM-5 ED diagnoses. We evaluated area under the curve (AUC) for both receiver operating curves (ROC) and precision-recall curves (PRC).

RESULTS

Both the BASE and SCOFF performed significantly better than chance at identifying probable EDs in cisgender women (BASE AUC: ROC = .787, PRC = .633, sensitivity = .733, specificity = .697; SCOFF AUC: ROC = .810, PRC = .684, sensitivity = .793, specificity = .701). However, the BASE (AUC: ROC = .821, PRC = .605, sensitivity = .966, specificity = .495) significantly outperformed the SCOFF (AUC: ROC = .710, PRC = .354, sensitivity = .828, specificity = .514) for identifying probable EDs in cisgender college men.

DISCUSSION

The BASE is appropriate for student healthcare and college research settings. Because the BASE outperforms the SCOFF in college men, results from the current study are expected to contribute to improved identification of EDs on college campuses.

PUBLIC SIGNIFICANCE

The BASE is a new screening tool to identify eating disorders. The BASE performed as well as, if not better than, the SCOFF (particularly in men). Given the need for brief, psychometrically strong, and unbiased ED screening tools in college students, the current study helps address an unmet student healthcare need that we expect will contribute to improved identification of EDs on college campuses.

Generalized network psychometrics of eating-disorder psychopathology

OBJECTIVE

As network models of eating disorder (ED) psychopathology become increasingly popular in modeling symptom interconnectedness and identifying potential treatment targets, it is necessary to contextualize their performance against other methods of modeling ED psychopathology and to evaluate potential ways to optimize and capitalize on their use. To accomplish these goals, we used generalized network psychometrics to estimate and compare latent variable models and network models, as well as hybrid models.

METHOD

We tested the structure of the Eating Pathology Symptoms Inventory (EPSI) and Eating Disorder Examination-Questionnaire (EDE-Q) in Recovery Record, Inc. mobile phone application users (N = 6856).

RESULTS

Although all models fit well, results favored a hybrid latent variable and network framework, which showed that ED symptoms fit best when modeled as higher-order constructs, rather than direct symptom-to-symptom connections, and when the relationships between those constructs are described as a network. Hybrid models in which latent factors were modeled as nodes within a network showed that EPSI Purging, Binge Eating, Cognitive Restraint, Body Dissatisfaction, and Excessive Exercise had high importance in the network. EDE-Q Eating Concern and Shape Concern were also important nodes. Results showed that the EPSI network was highly stable and replicable, whereas the EDE-Q network was not.

DISCUSSION

Integrating latent variable and network model frameworks enables tests of centrality to identify important latent variables, such as purging, that may promote the spread of ED psychopathology throughout a network, allowing for the identification of future treatment targets.

The Somatoform Spectrum Within the Hierarchical Taxonomy of Psychopathology System: A Taxometric Test of the Latent Structure

OBJECTIVE

The general understanding of disorders related to chronic somatic symptoms (e.g., somatic symptom disorder, functional somatic syndromes) is limited because of current categorical conceptualizations in traditional taxonomies. To improve clinical utility and validity, the Hierarchical Taxonomy of Psychopathology offers an empirically grounded dimensional approach. Therefore, the distribution of persistent somatic symptom distress observed in nature is highly relevant for informing decisions related to classification and treatment. This study analyzes the underlying structure of symptoms associated with the somatoform spectrum.

METHOD

Taxometric analyses were used to examine the latent status of the somatoform spectrum, which was measured via a dimensional questionnaire devised as part of the Hierarchical Taxonomy of Psychopathology scale development effort. We generated Comparison Curve Fit Index (CCFI) profile analyses across a clinical sample of psychotherapy outpatients ( n = 487), a community sample of German adults ( n = 451), and a student sample from New Zealand ( n = 549).

RESULTS

In the clinical sample (CCFI mean = 0.38) and in the student sample (CCFI mean = 0.36), a dimensional solution was clearly favored. Results in the community sample (CCFI mean = 0.51) were ambiguous.

CONCLUSIONS

Across the three independent samples, qualitatively distinct subgroups within the distribution of chronic somatic symptoms could not be identified. Therefore, continuous representations seemed to best represent the structure of somatic symptoms. Implications of these findings for etiology and treatment are discussed.

Design and methods of the Longitudinal Eating Disorders Assessment Project research consortium for veterans

INTRODUCTION

Military service members must maintain a certain body mass index and body fat percentage. Due to weight-loss pressures, some service members may resort to unhealthy behaviors that place them at risk for the development of an eating disorder (ED).

OBJECTIVES

To understand the scope and impact of EDs in military service members and veterans, we formed the Longitudinal Eating Disorders Assessment Project (LEAP) Consortium. LEAP aims to develop novel screening, assessment, classification, and treatment tools for veterans and military members with a focus on EDs and internalizing psychopathology.

METHODS

We recruited two independent nationally representative samples of post-9/11 veterans who were separated from service within the past year. Study 1 was a four-wave longitudinal survey and Study 2 was a mixed-methods study that included surveys, structured-clinical interviews, and qualitative interviews.

RESULTS

Recruitment samples were representative of the full population of recently separated veterans. Sample weights were created to adjust for sources of non-response bias to the baseline survey. Attrition was low relative to past studies of this population, with only (younger) age predicting attrition at 1-week follow-up.

CONCLUSIONS

We expect that the LEAP Consortium data will contribute to improved information about EDs in veterans, a serious and understudied problem.

Habitual adaptive emotion regulation moderates the association between maladaptive emotion regulation and eating disorder symptoms, but not clinical impairment

PURPOSE

Emotion regulation (ER) refers to the processes by which individuals influence the onset, intensity, and duration of emotions. Previous studies have examined the effects of adaptive ER and maladaptive ER in isolation, but growing evidence suggests that they should be studied in conjunction. This study examined the interactions between habitual adaptive and maladaptive ER strategies with eating disorder (ED) symptoms and ED-related clinical impairment.

METHODS

Students (N = 1377) from a Midwestern American university reported ED symptoms, ED-related impairment, habitual adaptive ER (i.e., cognitive reappraisal), and habitual maladaptive ER (i.e., distraction and suppression). Multiple linear regressions were conducted using the PROCESS v3 macro.

RESULTS

The study found that adaptive ER was negatively associated with ED symptoms and ED-related impairment, whereas maladaptive ER was positively associated with both outcome variables. Adaptive ER moderated the association between maladaptive ER and ED symptoms, but not clinical impairment. When habitual adaptive ER was low (< 33.4th percentile), there was no association between maladaptive ER and ED symptoms; however, when habitual adaptive ER was moderate to high (> 33.4th percentile), there was a positive association between frequency of maladaptive ER use and ED symptoms. There was no significant three-way interaction among adaptive ER, maladaptive ER, and probable ED diagnosis, for ED-related impairment or symptoms.

CONCLUSION

Results suggest that irrespective of frequency of maladaptive ER, people with low adaptive ER reported elevated psychopathology. Findings point to the utility of interventions to reduce maladaptive ER and increase adaptive ER in ED populations.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

The impact of discrimination on binge eating in a nationally representative sample of Latine individuals

OBJECTIVE

Latines have higher rates of eating disorders characterized by binge eating compared to their non-Latine white counterparts, yet culturally and socially relevant factors related to binge eating in Latines have been largely understudied. The purpose of the current study was to examine how discrimination and acculturative stress were associated with binge eating in a nationally representative sample of Latines. An additional aim was to test the extent to which family cohesion and social support could buffer against the effects of discrimination and acculturative stress on binge eating.

METHOD

Participants (56% female, N = 2550) were Latines enrolled in the National Latino and Asian American Study. Structural equation modeling using 1000 re-sampled data sets built from machine learning iterative sampling procedures was used to examine the effects of discrimination, acculturative stress, family cohesion, and social support on binge eating.

RESULTS

Results indicated that only discrimination was significantly associated with binge eating. Neither the direct effect of acculturative stress, interaction of family cohesion and acculturative stress, interaction of social cohesion and acculturative stress, nor the interaction of social support and discrimination were significantly associated with binge eating.

DISCUSSION

This study highlights the need for mental-health providers to understand and assess discrimination among Latines presenting with concerns of binge eating. Treatments that effectively provide coping strategies to manage discriminatory experiences and reduce binge eating could improve both effectiveness of treatment and retention rates for Latine individuals with binge eating.

PUBLIC SIGNIFICANCE

This study examined the association of discrimination, acculturative stress, family cohesion, and social support with binge eating in Latines. Only discrimination was significantly associated with binge eating, highlighting the importance for providers to assess discrimination among Latines with binge-eating concerns and to improve equity, inclusion, and belonging at a societal level. Modifying existing treatments to address coping with discrimination could improve the effectiveness for Latines with binge-eating concerns.

Eating-disorder psychopathology in female athletes and non-athletes: A meta-analysis

OBJECTIVE

There is ongoing discussion about whether sports participation is a risk or protective factor for eating disorders (EDs). Research is mixed, with some studies suggesting that athletes have higher mean levels of ED psychopathology compared to nonathletes, while other studies suggest the opposite effect or no differences. The purpose of the current meta-analysis was to identify whether female athletes reported higher mean levels of ED psychopathology compared to nonathletes.

METHOD

Following PRISMA guidelines, we identified 56 studies that reported ED psychopathology for female athletes and nonathletes. A three-level random-effects model of between- and within-study variance was completed for the following outcome variables: overall ED psychopathology, body dissatisfaction, drive for thinness, restricting, and loss-of-control eating.

RESULTS

Athletes reported lower levels of body dissatisfaction compared to nonathletes (g = -.21, p < .0001). Athletes and nonathletes reported similar levels of overall ED psychopathology, drive for thinness, restricting, and loss-of-control eating on average. Sport type significantly moderated standardized mean difference effect sizes of ED psychopathology in athletes versus nonathletes. Effect sizes comparing levels of drive for thinness, restricting, and loss-of-control eating in athletes versus nonathletes were larger for studies with athletes participating in aesthetic/lean sports compared to nonaesthetic/nonlean sports.

DISCUSSION

Findings from this meta-analysis could inform future ED prevention and treatment in female athletes by providing further evidence that athletes in aesthetic/lean sports may report higher levels of ED psychopathology. Participating in nonaesthetic/nonlean sports may be a protective factor for experiencing less body dissatisfaction.

PUBLIC SIGNIFICANCE STATEMENT

The current meta-analysis summarized findings from 56 studies that assessed levels of disordered eating, body dissatisfaction, dietary restricting, and loss-of-control eating in female athletes and nonathletes. Athletes reported lower levels of body dissatisfaction compared to nonathletes, highlighting that participation in sport could have some protective factors. Athletes participating in sports that require weight categories (e.g., judo) and sports that emphasize thinness/leanness (e.g., gymnastics and distance running) had higher levels of disordered eating relative to athletes participating in other types of sports that do not emphasize thinness/leanness (e.g., volleyball and basketball).

Hyper-palatable food consumption during binge-eating episodes: A comparison of intake during binge eating and restricting

OBJECTIVE

The study aim was to elucidate the degree to which hyper-palatable foods (HPF) are consumed during binge episodes compared to restricting episodes, and to test the association between HPF intake during each episode and respective episode frequency.

METHOD

This study was a secondary analysis of data from a larger study on eating disorders. The present sample included adults (N = 147, 83% women) diagnosed with sub-threshold (41%) or full-threshold (59%) bulimia nervosa (BN). Foods consumed during binge and restricting episodes were assessed using the Eating Pathology Symptoms Inventory-Clinician Rated Version. A standardized definition of HPF developed previously was applied to foods consumed during binge and restricting episodes. A Wilcoxon matched-pairs signed-rank test was used to test the difference between total caloric intake from HPF (KcalHPF) and percentage of caloric intake from HPF (PercHPF) during binge episodes relative to restricting episodes. Four linear regression models tested HPF intake (KcalHPF and PercHPF) during both episode types (binge and restricting) as predictors of respective episode frequency.

RESULTS

There was a significant difference between median KcalHPF (1846.6 vs. 279.6; Z = -13.38, p < .001) and PercHPF during binge compared to restricting episodes (95% vs. 61%; Z = -7.35, p < .001). Regression analyses demonstrated that KcalHPF during binge episodes was significantly associated with binge episode frequency (B = 0.002; p < .001), but not PercHPF (p = .287).

DISCUSSION

Results suggest that HPF may be primarily consumed during binge episodes among individuals with BN, and may be associated with greater binge-eating frequency.

PUBLIC SIGNIFICANCE

Findings from the current study support an underlying assumption of theoretical models of binge eating, suggesting that highly rewarding, hyper-palatable foods (HPF), may constitute the vast majority of energy intake during binge-eating episodes. Additionally, a substantial amount of energy intake from HPF may occur during restricting episodes among people with bulimia nervosa. Greater HPF intake during binge eating may also be associated with binge-eating severity.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): III. Emotional dysfunction superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a quantitative nosological system that addresses shortcomings of traditional mental disorder diagnoses, including arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, substantial heterogeneity within disorders, and diagnostic unreliability over time and across clinicians. This paper reviews evidence on the validity and utility of the internalizing and somatoform spectra of HiTOP, which together provide support for an emotional dysfunction superspectrum. These spectra are composed of homogeneous symptom and maladaptive trait dimensions currently subsumed within multiple diagnostic classes, including depressive, anxiety, trauma-related, eating, bipolar, and somatic symptom disorders, as well as sexual dysfunction and aspects of personality disorders. Dimensions falling within the emotional dysfunction superspectrum are broadly linked to individual differences in negative affect/neuroticism. Extensive evidence establishes that dimensions falling within the superspectrum share genetic diatheses, environmental risk factors, cognitive and affective difficulties, neural substrates and biomarkers, childhood temperamental antecedents, and treatment response. The structure of these validators mirrors the quantitative structure of the superspectrum, with some correlates more specific to internalizing or somatoform conditions, and others common to both, thereby underlining the hierarchical structure of the domain. Compared to traditional diagnoses, the internalizing and somatoform spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and greater clinical applicability. Validated measures are currently available to implement the HiTOP system in practice, which can make diagnostic classification more useful, both in research and in the clinic.

Clinical science can address rising eating disorder psychopathology during the COVID-19 pandemic: Comment on Gruber et al. (2020)

Eating disorders (EDs) are serious psychiatric disorders that affect 13%-18% of young men and women. EDs are associated with substantial psychiatric and medical morbidity and mortality, indicating a critical need for improved identification and treatment. Despite the relatively high prevalence and severity of EDs, they are often omitted from discussions of mental health. This comment is in response to Gruber et al. (2020), who wrote an important article on the challenges and opportunities facing clinical scientists in the time of COVID-19. Our response extends Gruber et al.'s article by noting additional challenges facing people with an ED during COVID-19 and recognizing opportunities for improved evidence-based assessment and treatment of this important population. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Measurement invariance of the Eating Pathology Symptoms Inventory (EPSI) in adolescents and adults

Adolescence is a common period for eating disorder (ED) onset. The availability of psychometrically sound measures of ED psychopathology enables clinicians to accurately assess symptoms and monitor treatment outcomes continuously from adolescence and adulthood. The purpose of this study was to assess if the Eating Pathology Symptoms Inventory (EPSI) is invariant across adolescents and adults. Participants (N = 29,821) were adolescent (n = 5250) and adult (n = 24,571) users of the Recovery Record (RR) mobile phone application who provided EPSI responses through the application. Measurement invariance testing was conducted to assess invariance of the EPSI Body Dissatisfaction, Restricting, Excessive Exercise, Purging, Cognitive Restraint, and Binge Eating scales across adolescents (age 13 through 17) and adults (age 18 and older). Findings indicated that all EPSI factors administered in the RR app replicated in both adolescent and adult users. The EPSI factor structure was largely equivalent in adolescents and adults, demonstrating evidence for configural and metric invariance, as well as some evidence for scalar invariance. Our results indicated that EPSI scales measured the same constructs across development. Clinicians and researchers may benefit from utilizing the EPSI to measure ED psychopathology in adolescents and for continued progress monitoring into adulthood.

Predicting probable eating disorder case-status in men using the Clinical Impairment Assessment: Evidence for a gender-specific threshold

The Clinical Impairment Assessment (CIA) is a widely used self-report measure of the psychosocial impairment associated with eating-disorder symptoms. Past studies recommended a global CIA score of 16 to identify clinically significant impairment associated with a probable eating disorder (ED). However, to date, research on the properties of the CIA has been conducted in majority-women samples. Preliminary research on gender differences in CIA scores suggested men with EDs report less impairment on the CIA relative to women with EDs. Thus, the purpose of this study was to test if a different impairment threshold is needed to identify cases of men with EDs. We hypothesized that a lower CIA threshold, relative to that identified in majority-women samples, would most accurately identify men with EDs. Participants (N = 162) were men from our university-based and general community-based ED participant registry who completed the CIA and Eating Disorder Diagnostic Scale. Both precision-recall and receiver operating characteristic curves assessed what CIA global score threshold most accurately identified men with EDs. Both analytic approaches indicated that a CIA global score of 13 best predicted ED case-status in men. Consistent with past research, men with a clinically significant ED appear to report lower impairment on the CIA. Results have implications for screening and assessing for substantial ED-related impairment in men. Additionally, past research using the CIA to identify men with EDs may have under-identified men with clinically significant symptoms.

An empirical evaluation of the diagnostic threshold between full-threshold and sub-threshold bulimia nervosa

Previous research has failed to find differences in eating disorder and general psychopathology and impairment between people with sub- and full-threshold bulimia nervosa (BN). The purpose of the current study was to test the validity of the distinction between sub- and full-threshold BN and to determine the frequency of objective binge episodes and inappropriate compensatory behaviors that would best distinguish between sub- and full-BN. Community-recruited adults (83.5% female) with current sub-threshold (n = 105) or full-threshold BN (n = 99) completed assessments of eating-disorder psychopathology, clinical impairment, internalizing problems, and drug and alcohol misuse. Receiver operating characteristic curve analysis was used to evaluate whether eating-disorder psychopathology, clinical impairment, internalizing problems, and drug and alcohol misuse could empirically discriminate between sub- and full-threshold BN. The frequency of binge episodes and inappropriate compensatory behaviors (AUC = 0.94) was "highly accurate" in discriminating between sub- and full-threshold BN; however, only objective binge episodes was a significant predictor of BN status. Internalizing symptoms (AUC = 0.71) were "moderately accurate" at distinguishing between sub- and full-BN. Neither clinical impairment (AUC = 0.60) nor drug (AUC = 0.56) or alcohol misuse (AUC = 0.52) discriminated between groups. Results suggested that 11 episodes of binge eating and 17 episodes of inappropriate compensatory behaviors optimally distinguished between sub- and full-BN. Overall, results provided mixed support for the distinction between sub- and full-threshold BN. Future research to clarify the most meaningful way to discriminate between sub- and full-threshold is warranted to improve the criterion-related validity of the diagnostic system.

Validation of the factor structure of the Eating Pathology Symptoms Inventory in an international sample of sexual minority men

Sexual minority individuals are at greater risk for the development of eating-disorder (ED) psychopathology. Despite the importance of understanding ED symptoms in sexual minority men, most ED measures were developed and validated in heterosexual, young adult, white women. The psychometric properties of ED measures in diverse populations remain largely unknown. The purpose of this study was to test: 1) whether the eight-factor structure of the Eating Pathology Symptoms Inventory (EPSI) replicated in sexual minority men and 2) group-level mean differences between gay and bisexual men on the eight EPSI scales. International participants (N = 722 sexual minority men from 20 countries) were recruited via the Grindr smartphone application. Confirmatory factor analysis (CFA) was completed using a weighted least square mean and variance adjusted estimator. Group differences in eating pathology between gay and bisexual men were tested using independent samples t-tests. The CFA model fit was good on all fit indices (CFI/TLI > 0.90, RMSEA < 0.06). Gay and bisexual men only differed on the EPSI Binge Eating scale. The results of this investigation suggest that the EPSI may be a useful tool for understanding eating pathology in this population. Using psychometrically sound assessment tools for sexual minority men is a vital piece of treatment planning and clinical decision making. The current study fills an important gap in the clinical and research literature by testing the validity and psychometric properties of a commonly used ED measure in sexual minority men.

Evaluating associations between fitspiration and thinspiration content on Instagram and disordered-eating behaviors using ecological momentary assessment: A registered report

INTRODUCTION

Greater use of appearance-focused social media, such as Instagram, is associated with increased body dissatisfaction and eating disorder (ED) symptoms; however, questions remain about the mechanism connecting social media use to disordered-eating behaviors (DEBs). The proposed study evaluates how and for whom exposure to fitspiration or thinspiration on Instagram is associated with DEBs.

METHODS

We will evaluate a hypothesized pathway from Instagram use to disordered-eating mediated by negative affect. We will test how individual differences in internalized weight stigma, trait self-esteem, and trait self-comparison moderate the pathway from social media use to negative affect. We will recruit 175 undergraduate women who report engaging in DEBs on average at least once per week over the past 3 months. Participants will complete a 7-day ecological momentary assessment protocol, during which they will report their Instagram use, affect, and engagement in DEBs.

RESULTS

Multi-level modeling will be used to assess moderated mediation. Results from this study will provide increased specificity about how Instagram usage is linked to eating pathology and who may be most vulnerable to experiencing distress.

DISCUSSION

Information about negative affect from Instagram and engagement in DEBs could contribute to the development of Just-In-Time Interventions for problematic social media use.

Food insecurity associated with elevated eating disorder symptoms, impairment, and eating disorder diagnoses in an American University student sample before and during the beginning of the COVID-19 pandemic

OBJECTIVE

This study tested the association between food insecurity and eating disorder (ED) pathology, including probable ED diagnosis, among two cohorts of university students before and during the beginning of the COVID-19 pandemic.

METHOD

Students (n = 579) from a large Midwestern American university completed self-report questionnaires assessing frequency of ED behaviors, ED-related impairment, and individual food insecurity as measured by the Eating Disorder Diagnostic Scale 5, Clinical Impairment Assessment, and Radimer/Cornell, respectively. Chi-square tests and MANOVA with post-hoc corrections were conducted to compare demographic characteristics, ED pathology, and probable ED diagnosis prevalence between students with and without individual food insecurity.

RESULTS

Partially supporting hypotheses, MANOVA indicated significantly greater frequency of objective binge eating, compensatory fasting, and ED-related impairment for students with food insecurity compared with individuals without food insecurity. Chi-squared tests showed higher prevalence of ED diagnoses among individuals with food insecurity compared with those without food security (47.6 vs. 31.1%, respectively, p < .01, NNT = 6.06), specifically bulimia nervosa and other specified feeding and eating disorder. There were no differences in food insecurity before or during the beginning of the COVID-19 pandemic.

DISCUSSION

Consistent with prior literature, food insecurity was associated with elevated ED psychopathology in this sample. Findings emphasize the importance of proper ED screening for college students vulnerable to food insecurity and EDs.

HiTOP Assessment of the Somatoform Spectrum and Eating Disorders

We report on Phase 1 efforts of the Hierarchical Taxonomy of Psychopathology (HiTOP) measurement subgroup tasked with developing provisional scales for the somatoform spectrum and eating disorders. In Study 1, items were written to assess five somatoform spectrum constructs (bodily distress symptoms, conversion symptoms, health anxiety, disease conviction, and somatic preoccupation). Scale development analyses were conducted on 550 university students. The conversion symptom items were too infrequently endorsed and were set aside for Phase 2. Analyses of the other items yielded four scales corresponding closely to their hypothesized structure. In Study 2, we delineated 15 specific feeding and eating disorder constructs. A sample of 400 university students were administered candidate items and several eating disorder questionnaires for criterion validity. Analyses yielded six scales capturing previously described constructs, tapping content related to body image and weight concerns, restricting and purging, cognitive restraint, binging, excessive exercise, and muscle building. Two scales representing additional constructs deemed to be of high clinical import-negative attitude towards obesity and avoidant/restrictive food intake disorder-were retained for Phase 2, for a total of eight scales. Overall, we concluded that Phase 1 had been successful at generating a comprehensive set of provisional scales for inclusion in Phase 2.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): II. Externalizing superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is an empirical effort to address limitations of traditional mental disorder diagnoses. These include arbitrary boundaries between disorder and normality, disorder co-occurrence in the modal case, heterogeneity of presentation within dis-orders, and instability of diagnosis within patients. This paper reviews the evidence on the validity and utility of the disinhibited externalizing and antagonistic externalizing spectra of HiTOP, which together constitute a broad externalizing superspectrum. These spectra are composed of elements subsumed within a variety of mental disorders described in recent DSM nosologies, including most notably substance use disorders and "Cluster B" personality disorders. The externalizing superspectrum ranges from normative levels of impulse control and self-assertion, to maladaptive disinhibition and antagonism, to extensive polysubstance involvement and personality psychopathology. A rich literature supports the validity of the externalizing superspectrum, and the disinhibited and antagonistic spectra. This evidence encompasses common genetic influences, environmental risk factors, childhood antecedents, cognitive abnormalities, neural alterations, and treatment response. The structure of these validators mirrors the structure of the phenotypic externalizing superspectrum, with some correlates more specific to disinhibited or antagonistic spectra, and others relevant to the entire externalizing superspectrum, underlining the hierarchical structure of the domain. Compared with traditional diagnostic categories, the externalizing superspectrum conceptualization shows improved utility, reliability, explanatory capacity, and clinical applicability. The externalizing superspectrum is one aspect of the general approach to psychopathology offered by HiTOP and can make diagnostic classification more useful in both research and the clinic.

Reward learning in unmedicated women with bulimia nervosa: A pilot investigation

Bulimia nervosa (BN) is characterized by recurrent engagement in eating disorder behaviors despite negative consequences, potentially reflecting aberrant stimulus-response or reward-learning processes. Indeed, frontostriatal circuitry involved in reward learning is altered in persons with BN and preliminary research suggests reward learning is impaired in persons with BN. Additional research on reward learning in BN and its association with eating disorder symptom expression is warranted to further the field's understanding of potential pathophysiological mechanisms of BN. To this end, the probabilistic reward learning task (PRLT) was administered to unmedicated women with BN (n = 15) and demographically matched psychiatrically healthy women (n = 18). Contrary to our hypotheses, results demonstrated that women with BN showed greater reward learning during the PRLT relative to healthy comparison women when covarying for symptoms of depression, social anxiety, and mania. Exploratory analyses showed that binge-eating frequency was inversely associated with reward learning in women with BN; however, results should be interpreted with caution due to the small sample size. Together, results suggest that women with BN do not have deficits in implicit reward learning. Given the preliminary nature of this investigation, larger-scale studies are needed to further examine reward learning in current BN and could compare reward learning using general (e.g., monetary) and disorder-specific (e.g., food) reinforcers. Further work is needed to confirm the inverse association between reward learning and binge eating.

A network investigation of core symptoms and pathways across duration of illness using a comprehensive cognitive-behavioral model of eating-disorder symptoms

BACKGROUND

In the past decade, network analysis (NA) has been applied to psychopathology to quantify complex symptom relationships. This statistical technique has demonstrated much promise, as it provides researchers the ability to identify relationships across many symptoms in one model and can identify central symptoms that may predict important clinical outcomes. However, network models are highly influenced by node selection, which could limit the generalizability of findings. The current study (N = 6850) tests a comprehensive, cognitive-behavioral model of eating-disorder symptoms using items from two, widely used measures (Eating Disorder Examination Questionnaire and Eating Pathology Symptoms Inventory).

METHODS

We used NA to identify central symptoms and compared networks across the duration of illness (DOI), as chronicity is one of the only known predictors of poor outcome in eating disorders (EDs).

RESULTS

Our results suggest that eating when not hungry and feeling fat were the most central symptoms across groups. There were no significant differences in network structure across DOI, meaning the connections between symptoms remained relatively consistent. However, differences emerged in central symptoms, such that cognitive symptoms related to overvaluation of weight/shape were central in individuals with shorter DOI, and behavioral central symptoms emerged more in medium and long DOI.

CONCLUSIONS

Our results have important implications for the treatment of individuals with enduring EDs, as they may have a different core, maintaining symptoms. Additionally, our findings highlight the importance of using comprehensive, theoretically- or empirically-derived models for NA.

Reconsidering delay discounting in bulimia nervosa

Delay discounting measures one's preference for smaller-sooner versus larger-later reward and is a facet of impulsivity. Studying delay discounting in bulimia nervosa (BN) may enhance clinical understanding of BN, as BN is characterized by engagement in behaviors that provide immediate reward (i.e., binge eating, purging) at the expense of future well-being. Prior research suggests that individuals with BN prefer smaller amounts of money available sooner compared to psychiatrically healthy (HC) persons. Here, we aimed to replicate and extend previous work by studying delay discounting of both monetary and food reward in women with BN relative to HC women. We also compared delay discounting of monetary and food reward, and examined associations among delay discounting, trait impulsivity, and eating disorder symptom expression in women with BN. Participants were 20 women with sub- or full-threshold DSM-5 BN and 20 HC women who completed a diagnostic interview, paper-and-pencil measures of delay discounting of monetary and food commodities, and a measure of trait impulsivity. Contrary to previous work, we found that women with BN showed decreased delay discounting of monetary and food reward relative to HC women. Within-group analyses demonstrated that women with BN showed elevated delay discounting of food reward relative to monetary reward. Within women with BN, elevated delay discounting of food, but not money, was associated with elevated negative and positive urgency, two facets of trait impulsivity that relate to acting rashly when experiencing strong emotion. Results suggest that delay discounting may be more variable in BN than previously assumed.

A single-case multiple baseline design for treating insomnia in eating disorders: The TIRED study

OBJECTIVE

The purpose of this trial is to evaluate the novel use of an empirically supported treatment for sleep problems for people with residual insomnia disorder following ED treatment.

METHOD

Participants (N = 6) will complete a single-case multiple baseline study using Brief Behavioral Treatment for Insomnia (Buysse et al., Archives of Internal Medicine, 171, 2011, 887-895; Troxel et al., Behavioral Sleep Medicine, 10, 2012, 266-279). Participants will complete pre- and post-treatment evaluations of insomnia severity, sleep efficiency, daytime fatigue, ED symptoms, depressive symptoms, and anxiety symptoms. Throughout treatment, participants will complete daily diaries of sleep indices (sleep latency, wake after sleep onset, total sleep time, and sleep efficiency).

RESULTS

The primary outcome will be treatment effects on insomnia severity, measured by the Insomnia Severity Index. Secondary outcomes include sleep efficiency and daytime fatigue. Exploratory outcomes include ED-related impairment and symptoms, anxiety symptoms, and depression symptoms. We will provide subject-level graphs of sleep indices and ED symptoms throughout treatment. Additionally, treatment effects will be examined at one- and three-month follow-up.

DISCUSSION

Although insomnia treatments have been evaluated in other psychiatric disorders, there has yet to be a study examining behavioral interventions for insomnia in EDs. Results of this study will inform the development and application of interventions for residual insomnia symptoms in this population.

Les progrès dans la réalisation de la classification quantitative de la psychopathologie☆

Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad "spectrum level" dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the "problem of comorbidity" by explicitly modeling patterns of co-occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.

Are the Criterion B binge-eating symptoms interchangeable in understanding binge-eating severity? An item response theory analysis

OBJECTIVE

The Criterion B binge-eating symptoms represent five symptoms associated with binge eating. Any three out of five symptoms can be used to meet Criterion B. However, Criterion B symptoms may not be interchangeable in terms of how binge-eating severity is associated with each symptom. Item response theory (IRT) can test how endorsing each symptom relates to the overall level (i.e., severity) of binge-eating measured by Criterion B. We used IRT to identify (a) how each Criterion B symptom corresponded with binge-eating severity in a transdiagnostic binge-eating sample and (b) how well each symptom differentiated individuals with differing levels of severity.

METHOD

Participants (N = 219) were adults (80.8% female) with a current ED that included objective binge-eating episodes assessed via semi-structured interview. A two-parameter logistic IRT model evaluated how endorsement of each Criterion B symptom corresponded with the level of latent binge-eating severity.

RESULTS

"Eating large amounts when not hungry" and "eating alone" reflected the highest binge-eating severity. "Eating alone" was the best discriminator across different binge-eating severity levels, whereas "uncomfortably full" was the poorest discriminator across binge-eating severity levels.

DISCUSSION

Criterion B symptoms were not interchangeable in terms of what level of binge-eating severity corresponded with symptom endorsement. "Eating large amounts when not hungry" or "eating alone" may signify elevated binge-eating severity, whereas "uncomfortably full" and "feeling disgusted/depressed/guilty" were not necessarily indicative of elevated severity. Results suggested that Criterion B may need to be revised to eliminate symptoms that are redundant with other binge-eating diagnostic criteria.

Eating-disorder psychopathology and driven exercise change models: A latent change score analysis

OBJECTIVE

Approximately 50% of people with eating disorders (EDs) engage in driven exercise to influence their weight or shape and/or to compensate for loss-of-control eating. When present, driven exercise is associated with a lower quality-of-life, longer hospital stays, and faster rates-of-relapse. Despite the seriousness of driven exercise, most treatments for EDs do not target maladaptive exercise behaviors directly. Given the large proportion of patients with an ED who engage in driven exercise and its effect on treatment outcomes, it is critical to understand what predicts change in driven exercise. The purpose of this study was to test whether ED symptoms prospectively predicted change in driven exercise and vice versa.

METHOD

Participants were Recovery Record (RR) users (N = 4,568; 86.8% female) seeking treatment for an ED. Participants completed the Eating Pathology Symptoms Inventory (EPSI) monthly for 3 months.

RESULTS

In the full sample, dynamic bivariate latent change score analyses indicated that high levels of dietary restraint and restricting prospectively predicted reductions in driven exercise. Among persons with anorexia nervosa (AN), high levels of binge eating predicted increased driven exercise. Among persons with bulimia nervosa (BN), high levels of body dissatisfaction predicted increased driven exercise. Among persons with binge-eating disorder (BED), high levels of binge eating, purging, and restricting predicted reductions in driven exercise.

DISCUSSION

Results highlight changes that may predict increased or decreased driven exercise relative to other ED symptoms for AN, BN, and BED groups. These preliminary findings could inform future research on ED treatment efforts to manage driven exercise.

Impact of trauma in childhood and adulthood on eating-disorder symptoms

Exposure to a traumatic event is concurrently and prospectively associated with disordered-eating behaviors such as binge eating, restricting, and purging. Specifically, purging has been found to be elevated in individuals with trauma histories, suggesting that purging may be a method for coping with trauma-related distress. However, there has been limited research investigating whether the time at which trauma occurs during development is differentially associated with disordered-eating behaviors and internalizing psychopathology. The purpose of this study was to examine the effect of trauma that occurred in childhood, adulthood, or childhood and adulthood on eating disorder (ED) and internalizing psychopathology. Participants were community-recruited adults with a current DSM-5 ED (N = 225) and were subsequently grouped into categories based on the time at which trauma occurred. Groups included: no trauma exposure ED controls (n = 54), child trauma group (n = 53), adult trauma group (n = 53), and child+adult trauma group (n = 65). We compared groups on their level of disordered-eating symptoms. Participants were administered the Structured Clinical Interview for DSM-IV, the Eating Pathology Symptoms Inventory (EPSI), and the Inventory of Depression and Anxiety Symptoms-II (IDAS-II). Univariate analyses revealed significantly higher levels of purging symptomatology in the child+adult trauma group compared to the no trauma, child trauma, and adult trauma groups. The current study highlights the importance of assessing the timing of trauma among individuals with EDs. In particular, our study indicates a need for further investigation to explain why individuals with ED and trauma histories engage in greater purging.

Development and initial validation of the Eating Pathology Symptoms Inventory-Clinician-Rated Version (EPSI-CRV)

Proper assessment and diagnosis of eating disorders (EDs) are critical to determine to whom prevention and treatment efforts should be targeted, the extent to which treatment is working, and when an individual has recovered. Although existing ED diagnostic interviews have numerous strengths, they also have certain limitations, including poor internal consistency, low discriminant validity, and poor factor-structure replicability. The purpose of the current study was to address problems of past ED diagnostic interviews through the creation of a new clinician-rated interview-the Eating Pathology Symptoms Inventory-Clinician-Rated Version (EPSI-CRV). The EPSI-CRV was designed to measure dimensional constructs assessed in the self-report version of the EPSI and generate current Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) diagnoses. Participants were community-recruited adults with a DSM-5 ED (N = 257). Participants completed self-report and interview-based measures of eating, mood, and anxiety disorders and self-report measures of psychiatric impairment. The EPSI-CRV demonstrated evidence for interrater reliability, convergent and discriminant validity, and a good-fitting factor structure. EPSI-CRV dimensions showed concurrent validity for distinguishing among ED diagnoses. Baseline EPSI-CRV dimensions significantly predicted psychiatric impairment at baseline but not at 1-year follow-up. Although some scales had lower internal consistency than ideal, internal consistency values were similar to those of other established diagnostic measures. The EPSI-CRV appears to represent a promising new interview that can be used across a variety of clinical and research settings. Interested readers can access the EPSI-CRV and relevant training materials here: https://kuscholarworks.ku.edu/handle/1808/29616. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): I. Psychosis superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a scientific effort to address shortcomings of traditional mental disorder diagnoses, which suffer from arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, heterogeneity within disorders, and diagnostic instability. This paper synthesizes evidence on the validity and utility of the thought disorder and detachment spectra of HiTOP. These spectra are composed of symptoms and maladaptive traits currently subsumed within schizophrenia, other psychotic disorders, and schizotypal, paranoid and schizoid personality disorders. Thought disorder ranges from normal reality testing, to maladaptive trait psychoticism, to hallucinations and delusions. Detachment ranges from introversion, to maladaptive detachment, to blunted affect and avolition. Extensive evidence supports the validity of thought disorder and detachment spectra, as each spectrum reflects common genetics, environmental risk factors, childhood antecedents, cognitive abnormalities, neural alterations, biomarkers, and treatment response. Some of these characteristics are specific to one spectrum and others are shared, suggesting the existence of an overarching psychosis superspectrum. Further research is needed to extend this model, such as clarifying whether mania and dissociation belong to thought disorder, and explicating processes that drive development of the spectra and their subdimensions. Compared to traditional diagnoses, the thought disorder and detachment spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and higher acceptability to clinicians. Validated measures are available to implement the system in practice. The more informative, reliable and valid characterization of psychosis-related psychopathology offered by HiTOP can make diagnosis more useful for research and clinical care.

Longitudinal trajectories of behavior change in a national sample of patients seeking eating-disorder treatment

OBJECTIVE

Rapid response to treatment, indicated by substantial decreases in eating-disorder (ED) symptoms within the first 4-6 weeks of treatment, is the most reliable predictor of treatment outcomes for EDs. However, there is limited research evaluating short-term longitudinal trajectories of ED symptoms during treatment. Thus, it is difficult to know which aspects of ED psychopathology are slow or fast to change. The purpose of this study was to elucidate three-month trajectories of ED psychopathology during treatment and test whether ED diagnosis influenced the direction and rate of change.

METHOD

Participants were Recovery Record users seeking treatment for an ED (N = 4,568; 86.8% female). Participants completed the Eating Pathology Symptoms Inventory once per month for 3 months.

RESULTS

Latent growth curve models indicated that ED diagnosis influenced the rate of ED behavior change. Anorexia nervosa was associated with faster reductions in cognitive restraint, excessive exercise, restricting, yet slower reductions in body dissatisfaction, and binge eating. Bulimia nervosa was associated with faster reductions in binge eating, cognitive restraint, excessive exercise, and purging. Binge-eating disorder was associated with faster reductions in body dissatisfaction and binge eating, yet slower reductions in restricting.

CONCLUSIONS

Our results have implications for future research by providing initial information about the direction and rate of ED change over the course of treatment. If clinicians and researchers know which ED symptoms are slow to change, on average, across diagnostic groups, treatment protocols could be adjusted to target slow changing symptoms more quickly, and therefore improve ED treatment outcomes.

Do differences between individuals who are healthy weight or overweight on self-report measures of disinhibited eating and restrained eating reflect reality or item "bias"?

In light of increasing rates of overweight and obesity worldwide, there is a critical need for accurate self-report measures of disinhibited and restrained eating behaviors across the weight spectrum. Item response theory was used to determine whether differences in disinhibited and restrained eating between healthy weight and overweight or obese individuals were due to item bias (i.e., differential item functioning). Study 1 participants were healthy weight (n = 510) or overweight or obese (n = 304) adults recruited from the community. Study 2 participants were healthy weight (n = 778) or overweight or obese (n = 320) college students. Study 1 participants completed the Eating Disorder Examination-Questionnaire (EDE-Q), Eating Disorder Inventory-3, Dutch Eating Behaviors Questionnaire, Restraint Scale, and Three-Factor Eating Questionnaire. Study 2 participants completed the Eating Pathology Symptoms Inventory (EPSI). Items on the Restraint Scale demonstrated the most evidence for bias (60% of items), whereas the majority of other scales demonstrated low to moderate levels of item bias (17-38% of items). However, EDE-Q Restraint and EPSI Binge Eating, Cognitive Restraint, Excessive Exercise, Muscle Building, and Negative Attitudes Toward Obesity scales did not show any evidence of differential item functioning among weight groups. Participants with the same level of disordered eating responded differently to certain eating disorder self-report items due to weight-bias, rather than true between-groups differences. Nevertheless, EDE-Q Restraint, EPSI Cognitive Restraint, and EPSI Binge Eating did not exhibit any evidence of bias and are ideal for assessing restrained and disinhibited eating across the weight spectrum in both research and clinical settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Integrating the Hierarchical Taxonomy of Psychopathology (HiTOP) into clinical practice

OBJECTIVE

Diagnosis is a cornerstone of clinical practice for mental health care providers, yet traditional diagnostic systems have well-known shortcomings, including inadequate reliability, high comorbidity, and marked within-diagnosis heterogeneity. The Hierarchical Taxonomy of Psychopathology (HiTOP) is a data-driven, hierarchically based alternative to traditional classifications that conceptualizes psychopathology as a set of dimensions organized into increasingly broad, transdiagnostic spectra. Prior work has shown that using a dimensional approach improves reliability and validity, but translating a model like HiTOP into a workable system that is useful for health care providers remains a major challenge.

METHOD

The present work outlines the HiTOP model and describes the core principles to guide its integration into clinical practice.

RESULTS

Potential advantages and limitations of the HiTOP model for clinical utility are reviewed, including with respect to case conceptualization and treatment planning. A HiTOP approach to practice is illustrated and contrasted with an approach based on traditional nosology. Common barriers to using HiTOP in real-world health care settings and solutions to these barriers are discussed.

CONCLUSIONS

HiTOP represents a viable alternative to classifying mental illness that can be integrated into practice today, although research is needed to further establish its utility. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Redefining phenotypes to advance psychiatric genetics: Implications from hierarchical taxonomy of psychopathology

Genetic discovery in psychiatry and clinical psychology is hindered by suboptimal phenotypic definitions. We argue that the hierarchical, dimensional, and data-driven classification system proposed by the Hierarchical Taxonomy of Psychopathology (HiTOP) consortium provides a more effective approach to identifying genes that underlie mental disorders, and to studying psychiatric etiology, than current diagnostic categories. Specifically, genes are expected to operate at different levels of the HiTOP hierarchy, with some highly pleiotropic genes influencing higher order psychopathology (e.g., the general factor), whereas other genes conferring more specific risk for individual spectra (e.g., internalizing), subfactors (e.g., fear disorders), or narrow symptoms (e.g., mood instability). We propose that the HiTOP model aligns well with the current understanding of the higher order genetic structure of psychopathology that has emerged from a large body of family and twin studies. We also discuss the convergence between the HiTOP model and findings from recent molecular studies of psychopathology indicating broad genetic pleiotropy, such as cross-disorder SNP-based shared genetic covariance and polygenic risk scores, and we highlight molecular genetic studies that have successfully redefined phenotypes to enhance precision and statistical power. Finally, we suggest how to integrate a HiTOP approach into future molecular genetic research, including quantitative and hierarchical assessment tools for future data-collection and recommendations concerning phenotypic analyses. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Application of network analysis to investigate sex differences in interactive systems of eating-disorder psychopathology

OBJECTIVE

Although men comprise 25% of persons with eating disorders (EDs), most research has focused on understanding EDs in women. The theoretical framework underlying common ED treatment has not been rigorously tested in men. The purpose of this study was to compare the interconnectivity among ED symptoms in men versus women.

METHOD

Participants (N = 1,348; 50% men) were individuals with anorexia nervosa, bulimia nervosa, binge-eating disorder, or other specified feeding or eating disorder who were users of Recovery Record, a smartphone app for monitoring ED symptoms. Participants were matched on age and duration of illness. Network analysis was used to create networks of symptoms for both sexes. Strength centrality, network stability, and bootstrapped centrality differences were tested. The network comparison test (NCT) was used to identify sex differences between networks. Key players analysis was used to compare fragmentation of each network.

RESULTS

For both sexes, items related to binge eating and restricting emerged as highest in strength centrality. The NCT identified significant differences global strength (p = .03) but not network invariance (p = .06) suggesting that although the structure of the networks was not statistically different, the strength of the connections within the network was greater for women. Key players analysis indicated that both networks were similarly disrupted when important nodes within the network were removed.

DISCUSSION

Findings suggested that there are more similarities than differences in networks of EDs in men and women. Results have important clinical implications by supporting theoretical underpinnings of cognitive-behavioral models of EDs in both men and women.

Eating disorder core symptoms and symptom pathways across developmental stages: A network analysis

Eating disorders (EDs) often develop during adolescence and early adulthood but may persist, arise, or reemerge across the life span. Research and treatment efforts primarily focus on adolescent and young adult populations, leaving large knowledge gaps regarding ED symptoms across the entire developmental spectrum. The current study uses network analysis to compare central symptoms (i.e., symptoms that are highly connected to other symptoms) and symptom pathways (i.e., relations among symptoms) across five developmental stages (early adolescence, late adolescence, young adulthood, early-middle adulthood, middle-late adulthood) in a large sample of individuals with EDs (N = 29,902; N = 32,219) in two network models. Several symptoms related to overeating, food avoidance, feeling full, and overvaluation of weight and shape emerged as central in most or all developmental stages, suggesting that some core symptoms remain central across development. Despite similarities in central symptoms, significant differences in network structure (i.e., how symptom pathways are connected) emerged across age groups. These differences suggest that symptom interconnectivity (but not symptom severity) might increase across development. Future research should continue to investigate developmental symptom differences in order to inform treatment for individuals with EDs of all ages. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Education, dissemination, and the science of eating disorders: Reflections on the 2019 International Conference on Eating Disorders: Editorial to accompany IJED Virtual Issue in honor of the 2019 International Conference on Eating Disorders

OBJECTIVE

This virtual issue of the International Journal of Eating Disorders highlights recently published research that aligns with the broad themes of the 2019 International Conference on Eating Disorders (ICED), held in New York, NY, USA.

METHODS AND RESULTS

We selected articles that were published between 2017 and 2019 that complement the content of the keynote and plenary sessions. We also curated additional articles from early career scholars, given that an important component of the annual ICED is to foster the development and training of the next generation of eating-disorder clinicians and researchers.

DISCUSSION

We hope that this virtual issue will spark more in-depth discussion and reflection on the topics, questions, and critical advances in the field of eating disorders that were presented at the 2019 ICED.

A Hierarchical Taxonomy of Psychopathology Can Transform Mental Health Research

For more than a century, research on psychopathology has focused on categorical diagnoses. Although this work has produced major discoveries, growing evidence points to the superiority of a dimensional approach to the science of mental illness. Here we outline one such dimensional system-the Hierarchical Taxonomy of Psychopathology (HiTOP)-that is based on empirical patterns of co-occurrence among psychological symptoms. We highlight key ways in which this framework can advance mental-health research, and we provide some heuristics for using HiTOP to test theories of psychopathology. We then review emerging evidence that supports the value of a hierarchical, dimensional model of mental illness across diverse research areas in psychological science. These new data suggest that the HiTOP system has the potential to accelerate and improve research on mental-health problems as well as efforts to more effectively assess, prevent, and treat mental illness.

Network analysis of pediatric eating disorder symptoms in a treatment-seeking, transdiagnostic sample

Classifying eating disorders in youth is challenging in light of developmental considerations and high rates of diagnostic migration. Understanding the transactional relationships among eating disorder symptoms, both across the transdiagnostic spectrum and within specific diagnostic categories, may clarify which core eating disorder symptoms contribute to, and maintain, eating-related psychopathology in youth. We utilized network analysis to investigate interrelationships among eating disorder symptoms in 636 treatment-seeking children and adolescents (90.3% female) ages 6-18 years (M age = 15.4 ± 2.2). An undirected, weighted network of eating disorder symptoms was created using behavioral and attitudinal items from the Eating Disorder Examination. Across diagnostic groups, symptoms reflecting appearance-related concerns (e.g., dissatisfaction with shape and weight) and dietary restraint (e.g., a desire to have an empty stomach) were most strongly associated with other eating disorder symptoms in the network. Binge eating and compensatory behaviors (e.g., self-induced vomiting) were strongly connected to one another but not to other symptoms in the network. Network connectivity was similar across anorexia nervosa, bulimia nervosa, and otherwise specified feeding or eating disorder subgroups. Among treatment-seeking children and adolescents, dietary restraint and shape- and weight-related concerns appear to play key roles in the psychopathology of eating disorders, supporting cognitive-behavioral theories of onset and maintenance. Similarities across diagnostic categories provide support for a transdiagnostic classification scheme. Clinical interventions should seek to disrupt these symptoms early in treatment to achieve maximal outcomes. (PsycINFO Database Record

Progress in achieving quantitative classification of psychopathology

Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad "spectrum level" dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the "problem of comorbidity" by explicitly modeling patterns of co-occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.

The Athletes' Relationships with Training scale (ART): A self-report measure of unhealthy training behaviors associated with eating disorders

OBJECTIVE

Several studies indicate that eating-disorder (ED) psychopathology is elevated in athletes compared to non-athletes. The assessment of excessive exercise among athletes is a challenge because, compared to non-athletes, athletes are required to train at higher intensities and for longer periods of time. However, individuals participating in competitive sports are still susceptible to unhealthy physical-activity patterns. Most ED assessments were developed and normed in non-athlete samples and, therefore, do not capture the nuances of athletes' training experiences. The purpose of the current study was to develop and validate a clinically useful, self-report measure of unhealthy training behaviors and beliefs in athletes, the Athletes' Relationships with Training Scale (ART).

METHOD

The initial item pool was administered to N = 267 women collegiate athletes who were participating in an ED prevention program study and N = 65 women athletes who were in ED treatment.

RESULTS

Factor analyses indicated the ART had a four-factor structure. Factorial and construct validity of the ART were demonstrated. ART scores significantly predicted health care utilization and differed between athletes with an ED versus athletes without an ED. For athletes in ED treatment, ART scores significantly decreased from treatment admission to discharge.

DISCUSSION

The ART showed evidence of strong psychometric properties and clinical utility. The ART could be helpful for clinicians and athletic trainers to help gauge whether athletes are engaging in unhealthy training practices that may warrant clinical attention and for tracking clinical outcomes in athletes with EDs who are receiving treatment.

A new approach to eating-disorder classification: Using empirical methods to delineate diagnostic dimensions and inform care

OBJECTIVE

Despite changes to the diagnostic criteria for eating disorders (EDs) in the DSM-5, the current diagnostic system for EDs has limited ability to inform treatment planning and predict outcomes. Our objective was to test the clinical utility of a novel dimensional approach to understanding the structure of ED psychopathology.

METHOD

Participants (N = 243; 82.2% women) were community-recruited adults with a DSM-5 ED assessed at baseline, 6-month, and 1-year follow-up. Hierarchical factor analysis was used to identify a joint hierarchical-dimensional structure of eating, mood, and anxiety symptoms. Exploratory structural equation modeling was used to test the ability of the dimensional model to predict outcomes.

RESULTS

At the top of the hierarchy, we identified a broad Internalizing factor that reflected diffuse symptoms of eating, mood, and anxiety disorders. Internalizing branched into three subfactors: distress, fear-avoidance (fears of certain stimuli and behaviors to neutralize fears, including ED behaviors designed to reduce fear of weight gain), and body dissatisfaction, which was nested within distress. The lowest level of the hierarchy was characterized by 15 factors. The hierarchical model predicted 60.1% of the variance in outcomes at 6-month follow-up, whereas all DSM eating, mood, and anxiety disorders combined predicted 35.8% of the variance in outcomes.

DISCUSSION

A dimensional approach to understanding and diagnosing EDs improved the ability to prospectively predict clinical course above-and-beyond the traditional categorical (DSM-based) approach. Our findings have implications for endeavors to improve the prediction of ED prognosis and course, and to develop more effective trans-diagnostic treatments.