Language style matching and treatment outcome in anorexia nervosa.

OBJECTIVE: Psychotherapy is the treatment of choice for anorexia nervosa (AN) but mechanisms of action are still largely unknown. Growing research suggests that synchrony between patient and therapist contributes to treatment success. Adding to this literature, this study examined the association between language style matching (LSM) among patient and therapist as an indicator of interpersonal (verbal) synchrony and treatment outcome in AN. METHOD: Audio recordings of mid-treatment therapy sessions (n = 25) in a multi-centre randomized controlled trial on the Maudsley Model of Anorexia Nervosa Treatment for Adults were transcribed and used to calculate LSM for each patient-therapist dyad. These scores were used to predict treatment outcome at 12-month follow-up. RESULTS: LSM did not predict body mass index (primary outcome) at follow-up. However, higher LSM (M = 0.87, SD = 0.04) was associated with lower eating disorder psychopathology (accounting for 11% of the variance) and higher recovery rates (accounting for 28% of variance) at follow-up. CONCLUSIONS: These preliminary findings suggest that verbal synchrony between patients with AN and their therapists contributes to favourable treatment outcomes. High levels of LSM may reflect therapeutic empathy, cooperation, or mutual positive perception. Further research should explore the mechanisms of linguistic synchrony with larger samples to allow for stronger conclusions.

Patient and mentor language style matching as a predictor of working alliance, engagement with treatment as usual, and eating disorders symptoms over the course of an online guided self-help intervention for anorexia nervosa.

OBJECTIVE: The aim of this study was to examine the processes involved in a guided self-help (GSH) pre-treatment intervention (RecoveryMANTRA) for patients with anorexia nervosa (AN), by measuring the levels of patient/mentor Language Style Matching (LSM). RecoveryMANTRA was supported by student mentors or peer mentors (recovered individuals) over six weekly chat-based sessions. We examined whether LSM during RecoveryMANTRA predicted patients'working alliance with the clinic therapist, motivation, eating disorder (ED) and general psychopathology. A further aim was to examine differences in LSM between student mentors and peer mentors. METHOD: 87 AN adults received RecoveryMANTRA plus treatment as usual. The LSM algorithm was used to calculate verbal attunement between patient and mentor. Participants were assessed at baseline and at the end of the intervention. RESULTS: Both early (1st session) and late (6th session) LSM predicted higher working alliance with the clinic therapist. Moreover, late LSM predicted lower EDs symptoms at the end of the RecoveryMANTRA intervention. Patient/peer mentor dyads showed higher late verbal attunement than patient/student mentor dyads. CONCLUSIONS: These findings suggests that in the early phase of treatment relational aspects can impact on engagement with treatment. Verbal attunement in a GSH for AN is associated with working alliance and better clinical outcome.

Approach avoidance training to curb consumption of sugar-sweetened beverages - A pilot randomized controlled trial in healthy volunteers.

Elevated consumption of sugar-sweetened beverages (SSBs) contributes to overweight and obesity. Automatic action tendencies like an approach bias might promote the consumption of SSBs. We investigated whether an Approach-Avoidance Training (AAT) reduces this approach bias and related behaviors like craving for and consumption of SSBs. Fifty-six healthy participants, with a self-reported SSB consumption of at least 330 ml per day, were randomized to 6 sessions of real or sham AAT. In the real AAT condition, participants were trained to react with avoidance movements to pictures of SSBs in an implicit learning paradigm (i.e. participants were instructed to respond to a task-irrelevant feature), whereas in the sham AAT condition the same pictures were used but no systematic (avoidance) reaction was trained. Approach bias, craving for SSB and SSB intake in a bogus taste test were assessed. Real AAT was not superior to sham AAT in any outcome measure. AAT in its current form and as a stand-alone intervention does not appear to be effective in reducing SSB consumption.

Participants' experience of approach bias modification training with transcranial Direct Current Stimulation as a combination treatment for binge eating disorder.

OBJECTIVE: This study explored participants' experience of approach bias modification training (ABM) with transcranial Direct Current Stimulation (tDCS) for binge eating disorder (BED) within a randomised controlled trial (RCT). A subset of participants who completed the RCT were interviewed to attain feedback on treatment experience and outcomes. METHOD: 15 participants with BED who completed the RCT were recruited, using purposive sampling. Participants received six sessions of concurrent ABM training with either real or sham tDCS. Semi-structured interviews relating to study experience and treatment outcomes were conducted and data were analysed thematically. RESULTS: The combined ABM and tDCS intervention was deemed acceptable and worthwhile by participants interviewed across both intervention groups. Negative preconceptions of tDCS were an initial deterrent to study participation for some, yet the brain stimulation experience was found to be tolerable. Minor and transient sensations and side effects attributed to tDCS were reported by most participants during and after stimulation, in addition to less pleasant aspects of ABM training, with no significant adverse effects reported by interviewees. Positive outcomes were described by participants across both intervention groups, relating to changes in BED symptoms and to broader beneficial effects on associated cognitive and emotional factors. Two participants experienced a shift in autonomy, attributed to tDCS and the combined intervention respectively. CONCLUSIONS: Adults with symptoms of BED found concurrent ABM and tDCS sessions to be acceptable, despite initial apprehension about the safety of tDCS. Findings are relevant to the neuroethics literature and may inform science communication strategies on neuromodulation treatments.

No effect of very brief exposure to masked food pictures on fear of food in anorexia nervosa.

OBJECTIVE: Very brief exposure to masked images of spider stimuli can facilitate approach behaviour towards spiders in fearful subjects. We hypothesized that a similar effect might occur for fear of food in patients with anorexia nervosa (AN), possibly offering a new treatment approach, with advantages over other methods of food exposure. METHODS: Patients with AN (n = 60) were randomly assigned to one of three experimental conditions and received a single session of exposure to either masked and very briefly presented food images, clearly visible food images, or masked non-food images (i.e. household items). Effects of the three exposure conditions on fear of food and food avoidance were examined. RESULTS: Contrary to our expectations, very brief food cue exposure was not superior to the control conditions regarding fear of food and approach behaviour towards food immediately after the intervention and body mass index four weeks later. CONCLUSION: This finding suggests important differences between fear of food in AN and specific phobias such as fear of spiders. The absence of an effect reveals limitations of the very brief exposure method, which might be better suited for evolutionarily relevant threat stimuli.

Reduced emotion recognition from nonverbal cues in anorexia nervosa.

OBJECTIVE: Recent models of anorexia nervosa (AN) emphasise the role of reduced emotion recognition ability (ERA) in the development and maintenance of the disorder. However, methodological limitations impede conclusions from prior research. The current study tries to overcome these limitations by examining ERA with an audio-visual measure that focuses strictly on multimodal nonverbal cues and allows to differentiate between ERA for different emotion categories. METHOD: Forty women with AN and 40 healthy women completed the Geneva Emotion Recognition Test. This test includes 83 video clips in which 10 actors express 14 different emotions while saying a pseudo-linguistic sentence without semantic meaning. All clips contain multimodal nonverbal cues (i.e., prosody, facial expression, gestures, and posture). RESULTS: Patients with AN showed poorer ERA than the healthy control group (d = 0.71), particularly regarding emotions of negative valence (d = 0.26). Furthermore, a lower body weight (r = 0.41) and longer illness duration (ρ = -0.32) were associated with poorer ERA in the AN group. CONCLUSIONS: Using an ecologically valid instrument, the findings of the study support illness models emphasising poor ERA in AN. Directly addressing ERA in the treatment of AN with targeted interventions may be promising.

Improving emotion recognition in anorexia nervosa: An experimental proof-of-concept study.

OBJECTIVE: Previous research has found increasing evidence for difficulties in emotion recognition ability (ERA) and social cognition in anorexia nervosa (AN), and recent models consider these factors to contribute to the development and maintenance of the disorder. However, there is a lack of experimental studies testing this hypothesis. Therefore, the present proof-of-concept study examined whether ERA can be improved by a single session of a computerized training in AN, and whether this has short-term effects on eating disorder symptoms. METHOD: Forty inpatients (22.20 ± 7.15 years) with AN were randomly assigned to receive a single session of computerized training of ERA (TERA) or a sham training (training the recognition of different types of clouds). ERA, self-reported eating disorder symptoms, and body mass index (BMI) were assessed within 3 days before and after training. RESULTS: After training, both groups showed improved ERA, reduced self-reported eating disorder symptoms, and an increased BMI. As compared to patients in the control group, patients who received TERA showed greater improvements in ERA and self-reported eating disorder symptoms. DISCUSSION: ERA can be effectively trained in patients with AN. Moreover, short-term improvements in self-reported eating disorder symptoms provide tentative support for the hypothesis that difficulties in ERA contribute to the maintenance of AN, and that specific trainings of ERA hold promise as an additional component in AN treatment. Future studies are needed to replicate these findings in larger samples, and to investigate long-term effects and transfer into real-world settings.

Measuring approach-avoidance tendencies towards food with touchscreen-based arm movements.

Most tasks for measuring automatic approach-avoidance tendencies do not resemble naturalistic approach-avoidance behaviors. Therefore, we developed a paradigm for the assessment of approach-avoidance tendencies towards palatable food, which is based on arm and hand movements on a touchscreen, thereby mimicking real-life grasping or warding movements. In Study 1 (n = 85), an approach bias towards chocolate-containing foods was found when participants reached towards the stimuli, but not when these stimuli had to be moved on the touchscreen. This approach bias towards food observed in grab movements was replicated in Study 2 (n = 60) and Study 3 (n = 94). Adding task features to disambiguate distance change through either corresponding image zooming (Study 2) or emphasized self-reference (Study 3) did not moderate this effect. Associations between approach bias scores and trait and state chocolate craving were inconsistent across studies. Future studies need to examine whether touchscreen-based approach-avoidance tasks reveal biases towards other stimuli in the appetitive or aversive valence domain and relate to relevant interindividual difference variables.

Risk for psychotherapy drop-out in survival analysis: The influence of general change mechanisms and symptom severity.

Dropping out of psychotherapeutic treatment (i.e., the patient ending treatment unilaterally) poses a problem for patients, therapists, and the health care sector. Previous research showed that changes in symptom severity and general change mechanisms (GCMs), such as interpersonal experiences, intrapersonal experiences, and problem actuation, might be related to drop-out. We investigated the relationship of these predictors and drop-out in a sample of 724 patients (21.1% drop-out) receiving cognitive-behavioral therapy in routine care from a German outpatient clinic. Survival analysis was used to account for the longitudinal nature of the data created by routine outcome monitoring and to deal with the time varying predictors, GCMs, and changes in symptom severity. As outcome, we predicted the risk of dropping out. Results showed that patient- and therapist-rated interpersonal experiences, which include alliance, significantly predicted the risk for drop-out. Contrary to previous research, intrapersonal experiences and symptom severity change did not predict drop-out. Overall, GCMs and symptom severity change accounted for 3.8% of explained variance in the outcome. These results entail that it is important to monitor interpersonal experiences over the course of treatment to identify patients at risk for drop-out. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Approach and avoidance bias for thin-ideal and normal-weight body shapes in anorexia nervosa.

OBJECTIVE: The two studies aimed to examine implicit affective evaluations of thin-ideal and normal-weight body shapes in women with anorexia nervosa (AN), taking identification with body shapes into account. METHOD: In study 1, approach-avoidance bias for thin-ideal and normal-weight bodies was assessed in 40 women with AN and 40 healthy women by using an Approach-Avoidance Task and female avatar bodies with a standard face as stimuli. In study 2, 39 women with AN and 38 healthy women underwent a similar task but identification with bodies was manipulated by presenting bodies once with the participant's own face and once with another woman's face. RESULTS: In study 1, patients with AN did not differ from healthy participants in their automatic approach-avoidance tendencies towards thin-ideal and normal-weight bodies. In study 2, no definite approach bias for a thin self and no avoidance bias for thin other women or for a normal-weight self were found. However, as compared to healthy women, those with AN showed a less positive implicit evaluation of thin other women, and an implicit preference for thin bodies depicted as themselves over thin bodies depicted as another woman. CONCLUSIONS: The findings suggest that intra-sexual competition for being slim is increased in AN.

Approach bias modification training in bulimia nervosa and binge-eating disorder: A pilot randomized controlled trial.

OBJECTIVE: Bulimia nervosa (BN) and binge-eating disorder (BED) are associated with poorly controlled approach behavior toward food resulting in binge eating. Approach bias modification (ABM) may reduce these automatic action tendencies (i.e., approach bias) toward food and may thus decrease binge eating and related symptoms. METHOD: A total of 56 patients with BN/BED participated in this double-blind, randomized controlled trial (RCT) comparing real and sham ABM. The real ABM condition adopted an implicit learning paradigm in which participants were trained to show avoidance behavior in response to food cues. Participants in the sham condition used a similar task but were not trained to avoid food cues. Both conditions comprised 10 training sessions within 4 weeks. RESULTS: Participants in both groups experienced significant reductions in binge eating, eating disorder symptoms, trait food craving, and food cue reactivity. Real ABM tended to result in greater reductions in eating disorder symptoms than sham ABM. Food intake, approach bias, and attention bias toward food did not change. DISCUSSION: This is the first RCT on ABM in eating disorders. The findings provide limited support for the efficacy of ABM in BN/BED and pose questions regarding its active ingredients and its usefulness as a stand-alone treatment for eating disorders.

Blunted emotion-modulated startle reflex in anorexia nervosa.

OBJECTIVE: Patients with anorexia nervosa (AN) often show difficulties in the perception, expression, and regulation of emotions and a strong avoidance of aversive feelings. According to psychobiological models, dietary restraint and accompanying weight loss may serve as a maladaptive mechanism of emotion regulation by attenuating aversive emotional states in AN, thereby contributing to the maintenance of the disorder. METHOD: Twenty-seven women with AN and 26 age-matched healthy women were shown short film-clips to elicit fear, sadness, amusement, and neutral emotional states. Eyeblink startle response was measured by electromyography in reaction to startle-eliciting acoustic stimuli presented 12 times binaurally during each film-clip. RESULTS: As compared to healthy controls, patients with AN showed a blunted startle response to the fear- but not to the sadness-eliciting stimulus. DISCUSSION: The findings support the assumption that underweight is associated with attenuated emotional reactivity to fear-eliciting material in AN. This is in line with the hypothesis that starvation and low body weight constitute a maladaptive mechanism of emotion regulation in AN, contributing to the maintenance of the disorder.

Measurement of food-related approach-avoidance biases: Larger biases when food stimuli are task relevant.

Strong implicit responses to food have evolved to avoid energy depletion but contribute to overeating in today's affluent environments. The Approach-Avoidance Task (AAT) supposedly assesses implicit biases in response to food stimuli: Participants push pictures on a monitor "away" or pull them "near" with a joystick that controls a corresponding image zoom. One version of the task couples movement direction with image content-independent features, for example, pulling blue-framed images and pushing green-framed images regardless of content ('irrelevant feature version'). However, participants might selectively attend to this feature and ignore image content and, thus, such a task setup might underestimate existing biases. The present study tested this attention account by comparing two irrelevant feature versions of the task with either a more peripheral (image frame color: green vs. blue) or central (small circle vs. cross overlaid over the image content) image feature as response instruction to a 'relevant feature version', in which participants responded to the image content, thus making it impossible to ignore that content. Images of chocolate-containing foods and of objects were used, and several trait and state measures were acquired to validate the obtained biases. Results revealed a robust approach bias towards food only in the relevant feature condition. Interestingly, a positive correlation with state chocolate craving during the task was found when all three conditions were combined, indicative of criterion validity of all three versions. However, no correlations were found with trait chocolate craving. Results provide a strong case for the relevant feature version of the AAT for bias measurement. They also point to several methodological avenues for future research around selective attention in the irrelevant versions and task validity regarding trait vs. state variables.

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

OBJECTIVE: It is unclear whether observed memory impairment in anorexia nervosa (AN) depends on the semantic structure (categorized words) of material to be encoded. We aimed to investigate the processing of semantically related information in AN. METHOD: Memory performance was assessed in a recall, learning, and recognition test in 27 adult women with AN (19 restricting, 8 binge-eating/purging subtype; average disease duration: 9.32 years) and 30 healthy controls using an extended version of the Rey Auditory Verbal Learning Test, applying semantically related and unrelated word stimuli. RESULTS: Short-term memory (immediate recall, learning), regardless of semantics of the words, was significantly worse in AN patients, whereas long-term memory (delayed recall, recognition) did not differ between AN patients and controls. DISCUSSION: Semantics of stimuli do not have a better effect on memory recall in AN compared to CO. Impaired short-term versus long-term memory is discussed in relation to dysfunctional working memory in AN. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

First-person Pronoun Use in Spoken Language as a Predictor of Future Depressive Symptoms: Preliminary Evidence from a Clinical Sample of Depressed Patients.

Several theories suggest that self-focused attention plays an important role in the maintenance of depression. However, previous studies have predominantly relied on self-report and laboratory-based measures such as sentence completion tasks to assess individual differences in self-focus. We present a prospective, longitudinal study based on a sample of 29 inpatients with clinical depression, investigating whether an implicit, behavioural measure of self-focused attention, i.e., the relative frequency of first-person singular pronouns in naturally spoken language, predicts depressive symptoms at follow-up over and above initial depression. We did not find a significant cross-sectional association between depressive symptoms and first-person singular pronoun use. However, first-person singular pronoun use significantly predicted depressive symptoms approximately 8 months later, even after controlling for depressive symptoms at baseline or discharge. Exploratory analyses revealed that this effect was mainly driven by the use of objective and possessive self-references such as 'me' or 'my'. Our findings are in line with theories that highlight individual differences in self-focused attention as a predictor of the course of depression. Moreover, our findings extend previous work in this field by adopting an unobtrusive approach of non-reactive assessment, capturing naturally occurring differences in self-focused attention. We discuss possible clinical applications of language-based assessments and interventions with regard to self-focus. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Naturally occurring individual differences in first-person singular pronoun use provide an unobtrusive way to assess patients' automatic self-focused attention. Frequent use of first-person singular pronouns predicts an unfavourable course of depression. Self-focused language might offer innovative ways of tracking and targeting therapeutic change.

Social cognition in anorexia nervosa: Specific difficulties in decoding emotional but not nonemotional mental states.

OBJECTIVE: Building on recent models of anorexia nervosa (AN) that emphasize the importance of impaired social cognition in the development and maintenance of the disorder, the present study aimed at examining whether women with AN have more difficulties with inferring other people's emotional and nonemotional mental states than healthy women. METHOD: Social cognition was assessed in 25 adult women with AN and 25 age-matched healthy women. To overcome limitations of previous research on social cognition in AN, the processing of social information was examined in a more complex and ecologically valid manner. The Movie for the Assessment of Social Cognition (MASC) reflects complex real-life social interaction and allows for disentangling emotional and non-emotional mental state inference as well as different types of errors in mentalizing. RESULTS: Women with AN showed poorer emotional mental state inference, whereas non-emotional mental state inference was largely intact. Groups did not differ in undermentalizing (overly simplistic theory of mind) and overmentalizing (overly complex or over-interpretative mental state reasoning). Performance in the MASC was independent of levels of eating disorder psychopathology and symptoms of depression and anxiety. DISCUSSION: The findings suggest that AN is associated with specific difficulties in emotional mental state inference despite largely intact nonemotional mental state inference. Upon replication in larger samples, these findings advocate a stronger emphasis on socio-emotional processing in AN treatment. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:883-890).

Social organization and space use of a wild mandrill (Mandrillus sphinx) group.

Mandrills (Mandrillus sphinx) are enigmatic Old World primates whose social organization and ecology remain poorly known. Previous studies indicated, for example, that groups are composed of only adult females and their young or that several units composed of one adult male and several females make up larger permanent social units. Here, we present the first data on group composition and male ranging patterns from the only habituated wild mandrill group and examine how home range size and daily path length varied with environmental and demographic factors over a 15-month period. Our study site is located in southern Gabon where we followed the group on a daily basis, collecting data on presence, ranging, behavior, and parasite load of its individual members. Throughout the study, the group was made up of about 120 individuals, including several non-natal and natal adult and sub-adult males. One-male units were never observed. The mandrills traveled an estimated 0.44-6.50 km/day in a home range area of 866.7 ha. Exploratory analyses revealed that precipitation, the number of adult males present, and the richness of protozoan parasites were all positively correlated with daily path length. These results clarify the social system of mandrills and provide first insights into the factors that shape their ranging patterns.

Approach bias and cue reactivity towards food in people with high versus low levels of food craving.

OBJECTIVE: Even though people suffering from high levels of food craving are aware of the negative consequences of binge eating, they cannot resist. Automatic action tendencies (i.e. approach bias) towards food cues that operate outside conscious control may contribute to this dysfunctional behavior. The present study aimed to examine whether people with high levels of food craving show a stronger approach bias for food than those with low levels of food craving and whether this bias is associated with cue-elicited food craving. METHOD: Forty-one individuals reporting either extremely high or extremely low levels of trait food craving were recruited via an online screening and compared regarding approach bias towards visual food cues by means of an implicit stimulus-response paradigm (i.e. the Food Approach-Avoidance Task). State levels of food craving were assessed before and after cue exposure to indicate food cue reactivity. RESULTS: As expected, high food cravers showed stronger automatic approach tendencies towards food than low food cravers. Also in line with the hypotheses, approach bias for food was positively correlated with the magnitude of change in state levels of food craving from pre-to post-cue exposure in the total sample. DISCUSSION: The findings suggest that an approach bias in early stages of information processing contributes to the inability to resist food intake and may be of relevance for understanding and treating dysfunctional eating behavior.

The temporal dynamics of cognitive reactivity and their association with the depression risk: an exploratory study.

BACKGROUND: Cognitive reactivity is the change in depressive thinking in response to negative mood. Previous research indicates that cognitive reactivity is an important variable in the etiology and course of depression. The present study tested which time interval after a negative mood induction is critical for the prediction of the depression risk. METHODS: Participants suffering from a major depressive disorder were recruited when entering inpatient treatment. At the end of inpatient treatment they completed an experimental procedure to assess their depressive thinking once before and twice after a negative mood induction. Subsequently, patients were followed up for 26 weeks. RESULTS: The immediate change in depressive thinking in response to the negative mood induction was negatively associated with future depression. The delayed change did not predict the depression risk. CONCLUSION: The negative association between the immediate change in depressive thinking and the depression risk is not in line with results from previous studies on cognitive reactivity. Previous research on emotion context insensitivity and the avoidance of negative thoughts offers hypotheses which could account for this result. Further research is needed to shed light on the processes underlying cognitive reactivity.

Approach Bias Modification in Food Craving-A Proof-of-Concept Study.

The aim of the present proof-of-concept study was to test a novel cognitive bias modification (CBM) programme in an analogue sample of people with subclinical bulimic eating disorder (ED) psychopathology. Thirty participants with high levels of trait food craving were trained to make avoidance movements in response to visual food stimuli in an implicit learning paradigm. The intervention comprised ten 15-minute sessions over a 5-week course. At baseline, participants showed approach and attentional biases towards high-caloric palatable food that were both significantly reduced and turned into avoidance biases after the training. Participants also reported pronounced reductions in both trait and cue-elicited food craving and in ED symptoms as well. The overall evaluation of the training by the participants was positive. The specific CBM programme tested in this pilot trial promises to be an effective and feasible way to alter automatic action tendencies towards food in people suffering from bulimic ED psychopathology.