Sleep disorders in a naturalistic cohort of Dutch psychiatric outpatients: prevalence rates and associations with psychopathology symptom severity and well-being.

Sleep problems are very common in individuals with a mental disorder. Given the abundant evidence indicating the negative impact of disturbed sleep on mental health outcome, insight into the prevalence of all types of sleep disorders in specific mental disorders and neurodevelopmental conditions is of practical importance. Therefore, we estimated the prevalence of six types of sleep disorders with the Holland Sleep Disorders Questionnaire in an overall mental health sample (n = 1082) and separately for different mental and neurodevelopmental conditions. Furthermore, associations between specific sleep disorders, psychopathology and well-being were studied. The impact of the total number of sleep disorders on these associations was examined. Overall, 46.2% of all participants scored above the cut-off for having a sleep disorder. Specifically, 26.8% scored on insomnia, 12.1% on sleep breathing disorders, 9.7% on hypersomnia, 13.7% on circadian rhythm sleep-wake disorders, 11.2% on parasomnia, and 17.9% on sleep-related movement disorders. Most sleep disorders were associated with greater severity of psychopathology and lower well-being. These associations got stronger with an increasing number of sleep disorders. Our study revealed higher suspected prevalence of most sleep disorders in a mental disorder sample compared to the general population. Moreover, the presence of sleep disorder(s) was strongly associated with symptom severity and reduced well-being. These findings extend the notion that early detection and treatment of sleep disorders in mental health populations is essential for psychiatric outcome.

How do victims of bullying develop depression? Testing interpersonal style to explain the victimization-depression link.

This study tested to what extent the relation between bullying victimization and future symptoms of depression could be explained by victims being more hostile and less assertive than non-involved individuals. Data came from waves 2-4 of the Dutch TRacking Adolescents' Individual Lives Survey (TRAILS). Participants' bullying experiences were assessed at age 13, interpersonal style at age 16, and depression symptoms at age 19. Mediation analyses were performed primarily on 274 self-reported victims and 1498 non-involved peers. Self-reported victims had an increased risk for depression symptoms. About a third of that risk could be explained by victims' hostile style, which was also higher than those of non-involved peers. Although victims also reported lower levels of assertiveness than non-involved peers, this interpersonal style did not mediate the link between bullying victimization and depression. Our findings suggest that high hostility, but not low assertiveness, partly explains the increased depression risk of self-reported victims. Therefore, interventions could focus on addressing hostility, to help reduce the likelihood that adolescents who have experienced bullying victimization will have more interpersonal conflicts and mental health problems in the future. Supplementary materials also include analyses for bullies and bully-victims, and for peer-reported measures.

Interventions Targeting Negative Mental Imagery in Social Anxiety: A Systematic Review and Meta-Analysis of Characteristics and Outcomes.

Psychological treatment for social anxiety disorder (SAD) has been found to be less effective than for other anxiety disorders. Targeting the vivid and distressing negative mental images typically experienced by individuals with social anxiety could possibly enhance treatment effectiveness. To provide both clinicians and researchers with an overview of current applications, this systematic review and meta-analysis aimed to evaluate the possibilities and effects of imagery-based interventions that explicitly target negative images in (sub)clinical social anxiety. Based on a prespecified literature search, we included 21 studies, of which 12 studies included individuals with a clinical diagnosis of SAD. Imagery interventions (k = 28 intervention groups; only in adults) generally lasted one or two sessions and mostly used imagery rescripting with negative memories. Others used eye movement desensitization and reprocessing and imagery exposure with diverse intrusive images. Noncontrolled effects on social anxiety, imagery distress and imagery vividness were mostly large or medium. Meta-analyses with studies with control groups resulted in significant medium controlled effects on social anxiety (d = -0.50, k = 10) and imagery distress (d = -0.64, k = 8) and a nonsignificant effect on imagery vividness. Significant controlled effects were most evident in individuals with clinically diagnosed versus subclinical social anxiety. Overall, findings suggest promising effects of sessions targeting negative mental images. Limitations of the included studies and the analyses need to be considered. Future research should examine the addition to current SAD treatments and determine the relevance of specific imagery interventions. Studies involving children and adolescents are warranted.

Negative body image and avoidant retrieval of body-related autobiographical memories.

People with a negative body image may be more likely to recall negative memories of their body, but also be motivated to avoid retrieving specific memories to prevent triggering aversive emotions (e.g., disgust). Such inclination to retain at a global level of memory recall may hamper the correction of their negative body image. In previous research using Autobiographical Memory Tests (AMTs) with minimal instructions, we failed to find an overgeneral memory bias specific to individuals with a negative body image but observed low specificity overall in response to body cue words. In the present study (N = 153), we included the traditional AMT next to a minimal instructions AMT and explored the idea that sensory reliving may be relevant to avoidance by assessing sensory reliving ratings next to memory specificity. A negative body image was associated with more negative body memories. In both AMTs, the findings failed to support our prediction that a more negative body image would be associated with lower specificity or sensory reliving. The findings are consistent with the view that autobiographical memories might be an important factor in defining one's body image, yet cast doubt on the relevance of avoidant retrieval of body-related memories in non-clinical samples.

Subjective disgust and facial electromyography responses towards unedited and morphed overweight self-pictures in women with varying levels of eating disorder symptomatology.

Individuals with an eating disorder (ED) often report to be disgusted by their body. Body-related self-disgust could play an important role in the development and maintenance of EDs. We investigated if women with relatively high ED symptom scores indeed respond with disgust upon exposure to their body as indexed by facial electromyography (fEMG) of the m. levator labii superioris and self-report. Given that one's self-disgust may increase/decrease depending on the relative distance of the own body to the thin ideal, we also assessed women's disgust for overweight- and thin-morphs of their body. Female undergraduate students (N = 104) were photographed and presented with their (morphed) body pictures, next to disgust-relevant and overweight body control pictures. Higher levels of ED symptoms were associated with stronger self-reported disgust to unedited body-pictures and overweight-morphs. Disgust to thin-morphs was unrelated to ED symptoms. Participants generally showed heightened facial disgust towards overweight morphs, yet the strength of facial disgust was unrelated to ED symptoms. Thus, the findings provide evidence for the involvement of heightened body-related self-disgust in ED symptomatology, albeit only on the basis of self-report.

Punishment sensitivity and the persistence of anorexia nervosa: High punishment sensitivity is related to a less favorable course of anorexia nervosa.

OBJECTIVE: Cross-sectional research provides robust evidence that individuals with anorexia nervosa (AN) report higher punishment sensitivity (PS) than individuals without an eating disorder (ED). High PS might interfere with treatment motivation and the ability to learn from experience. The current study took a longitudinal approach to test predictions that follow from the proposed relevance of PS as a factor in the persistence of AN symptoms. More specifically we tested (1) if higher PS at the start of treatment was related to less improvement in ED symptoms after one year, and (2) if a decrease in ED symptoms was associated with a concurrent decrease in PS. METHOD: Participants were 69 adolescents with a diagnosis of AN at the start of treatment of whom 62 participated again one year later. ED symptom severity and PS were assessed at both time points. RESULTS: Findings showed that (1) higher PS at the start of treatment was related to less improvement in ED symptoms, and (2) an improvement in ED symptoms was related to a decrease in PS. DISCUSSION: These findings are consistent with the proposed relevance of PS in the persistence of AN and suggest that it might be beneficial to address high PS in treatment. PUBLIC SIGNIFICANCE: Consistent with the view that punishment sensitivity (PS) is related to the persistence of anorexia nervosa, high PS at the start of treatment was related to less improvement in eating disorder symptoms in patients with anorexia nervosa. Furthermore, an improvement in eating disorder symptoms was associated with a concurrent decrease in PS, suggesting that PS can be subject to change and may be a relevant target for treatment.

Satisfaction with normative life domains and the course of anorexia nervosa.

OBJECTIVE: Satisfaction with normative life domains has been proposed as an important factor in the persistence of anorexia nervosa (AN). Initial evidence from a cross-sectional study indicated that individuals with AN reported lower satisfaction with normative life domains than individuals without an eating disorder. As an important next step in understanding causal relations, the present study used a longitudinal design to examine whether an improvement in AN symptoms is paralleled by an increase in satisfaction with normative life domains from baseline to follow-up and whether relatively low satisfaction with normative life domains at baseline is related to less improvement in AN symptoms. METHODS: During baseline and at 1-year follow-up, adolescents with AN (N = 69) completed the Brief Multidimensional Students' Life Satisfaction Scale to measure satisfaction with normative life domains (e.g., friendships, school experience). Furthermore, eating disorder symptoms and BMI were measured. RESULTS: Improvement in eating disorder symptoms, but not in BMI, was paralleled by an increase in satisfaction with normative life domains. Relatively low satisfaction with normative life domains at baseline was not prospectively related to less improvement in eating disorder symptoms or BMI at follow-up. DISCUSSION: Our findings provide initial evidence that satisfaction with normative life domains is a malleable factor which fluctuates with symptom severity in AN. The results of this exploratory study point to the relevance of examining whether targeting satisfactory engagement with specific life domains optimizes treatment effectiveness. PUBLIC SIGNIFICANCE: We explored whether an improvement in anorexia nervosa symptoms from start of treatment to 1-year follow-up would be paralleled by an increase in satisfaction with normative life domains. Improvement in eating disorder symptoms (but not BMI) was indeed related to a concurrent increase in satisfaction with normative life domains. These preliminary results point to the promising possibility that targeting satisfactory engagement with specific life domains may potentially enhance treatment effectiveness.

Eating disorder-specific rumination moderates the association between attentional bias to high-calorie foods and eating disorder symptoms: Evidence from a reliable free-viewing eye-tracking task.

Cognitive theories of eating disorders implicate Attentional Bias (AB) towards food-related information in the development and maintenance of eating disorders. Empirical evidence for this proposal, however, has been inconsistent, and the measures used to examine AB to food-related stimuli typically showed poor reliability. The aim of the current study was twofold. Firstly, we aimed to examine the psychometric properties of a newly devised eye-tracking task for the assessment of AB in the context of eating disorders. Secondly, we examined the role of Eating Disorder-specific (ED-specific) rumination as a potential moderator of the association between attentional bias to food images and eating disorder symptoms. One hundred and three female students were recruited and completed an eye-tracking task comprising 21 matrices that each contained 8 low-calorie and 8 high-calorie food images. Each matrix was presented for 6 s. First fixation location, first fixation latency, and total dwell time were assessed for low and high-calorie food images and the dwell-time based AB measure showed good reliability based on Cronbach's alpha, McDonald's Omega, and split-half method. In addition, the results revealed that the ED-specific rumination plays the hypothesized moderating role. Specifically, while participants with high levels of ED-specific rumination exhibited a positive association between AB to high-calorie foods and eating disorder symptoms, this association was not present among participants with lower levels of ED-specific rumination. The employed free-viewing task seems a reliable measure of AB to food-related stimuli, and the moderation analysis emphasizes the critical role of ED-specific rumination for eating disorder symptoms. Implications, limitations, and directions for future research are discussed.

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

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

Low satisfaction with normative life domains in adolescents with anorexia nervosa.

OBJECTIVE: Low satisfaction with normative life domains might be an important factor in the persistence of anorexia nervosa (AN). Initial evidence in non-clinical samples showed that lower satisfaction with normative life domains was related to more intense eating disorder symptoms. As a critical next step, the current study examined satisfaction with normative life domains in a clinical sample. Specifically, the present study tested whether adolescents with AN reported lower satisfaction with normative life domains than adolescents without an eating disorder. METHOD: Adolescents with AN (n = 69) and adolescents without an eating disorder matched on age, gender and educational level (n = 69) completed the Brief Multidimensional Students' Life Satisfaction Scale to assess satisfaction with five life domains (family, friendships, school, self and living location) and life in general. RESULTS: Adolescents with AN reported significantly lower satisfaction with normative life domains than the comparison group. Subsequent analyses showed that this overall group difference was primarily driven by adolescents with AN reporting lower satisfaction with the self, school experience and life in general. CONCLUSIONS: Findings supported the hypothesis that adolescents with AN show relatively low satisfaction with meaningful, non-AN-related life domains. This points to the potential relevance of enhancing satisfaction with specific life domains to optimize treatment effectiveness.

The clinical relevance of early identification and treatment of sleep disorders in mental health care: protocol of a randomized control trial.

BACKGROUND: Sleep disorders are a risk factor for developing a variety of mental disorders, have a negative impact on their remission rates and increase the risk of relapse. Early identification and treatment of sleep disorders is therefore of paramount importance. Unfortunately, in mental health care sleep disorders are often poorly recognized and specific treatment frequently occurs late or not at all. This protocol-paper presents a randomized controlled trial investigating the clinical relevance of early detection and treatment of sleep disorders in mental health care. The two aims of this project are 1) to determine the prevalence of sleep disorders in different mental disorders, and 2) to investigate the contribution of early identification and adequate treatment of sleep disorders in individuals with mental disorders to their sleep, mental disorder symptoms, general functioning, and quality of life. METHODS: Patients newly referred to a Dutch mental health institute for psychiatric treatment will be screened for sleep disorders with the self-assessment Holland Sleep Disorders Questionnaire (HSDQ). Patients scoring above the cut-off criteria will be invited for additional diagnostic evaluation and, treatment of the respective sleep disorder. Participants will be randomly assigned to two groups: Immediate sleep diagnostics and intervention (TAU+SI-T0), or delayed start of sleep intervention (TAU+SI-T1; 6 months after inclusion). The effect of sleep treatment as add-on to treatment as usual (TAU) will be tested with regard to sleep disorder symptoms, general functioning, and quality of life (in collaboration with a psychiatric sleep centre). DISCUSSION: This trial will examine the prevalence of different sleep disorders in a broad range of mental disorders, providing information on the co-occurrence of specific sleep and mental disorders. Further, this study is the first to investigate the impact of early treatment of sleep disorders on the outcome of many mental disorders. Moreover, standard sleep interventions will be tailored to specific mental disorders, to increase their efficacy. The results of this trial may contribute considerably to the improvement of mental health care. TRIAL REGISTRATION: This clinical trial has been retrospectively registered in the Netherlands Trial Register (NL8389; https://www.trialregister.nl/trial/8389) on February 2th, 2020.

Influence of hunger on attentional engagement with and disengagement from pictorial food cues in women with a healthy weight.

Because of inconsistencies in the field of attentional bias to food cues in eating behavior, this study aimed to re-examine the assumption that hungry healthy weight individuals have an attentional bias to food cues, but satiated healthy weight individuals do not. Since attentional engagement and attentional disengagement have been proposed to play a distinct role in behavior, we used a performance measure that is specifically designed to differentiate between these two attentional processes. Participants were healthy weight women who normally eat breakfast. In the satiated condition (n = 54), participants were instructed to have breakfast just before coming to the lab. In the fasted condition (n = 50), participants fasted on average 14 h before coming into the lab. Satiated women showed no stronger attentional engagement or attentional disengagement bias to food cues than to neutral cues. Fasted women did show stronger attentional engagement to food cues than to neutral cues that were shown briefly (100 ms). They showed no bias in attentional engagement to food cues that were shown longer (500 ms) or in attentional disengagement from food cues. These findings are in line with the assumption that healthy weight individuals show an attentional bias to food cues when food stimuli are motivationally salient. Furthermore, the findings point to the importance of differentiating between attentional engagement and attentional disengagement.

Reinforcement sensitivity and restrained eating: the moderating role of executive control.

PURPOSE: As the prevalence of overweight and obesity are still increasing, it is important to help individuals who encounter difficulty with losing weight. The current study was set out to further investigate characteristics of individuals who are highly motivated to restrict their food intake to lose weight, but fail to do so (i.e., restrained eaters). The motivation to lose weight might stem from high punishment sensitivity, whereas the failure to succeed in restricting food intake might be the result of high reward sensitivity. Thus, it was examined whether restrained eaters are characterized by both high reward sensitivity and high punishment sensitivity. Additionally, this is the first study to examine executive control as a potential moderator of this relationship. METHODS: Female undergraduates (N = 60) performed a behavioral measure of executive control, and completed the Restraint Scale to index level of restrained eating as well as two questionnaires on reinforcement sensitivity; the Behavioral Inhibition Scale/Behavioral Activation Scale, and the Sensitivity to Punishment and Sensitivity to Reward Questionnaire. RESULTS: There was a positive relationship between restrained eating and punishment sensitivity as indexed by both questionnaires. Reward sensitivity as measured by both indices was not directly related to restrained eating. Executive control moderated the relation between reward responsivity (but not reward-drive) and restrained eating; specifically in women with relatively weak executive control there was a positive relationship between reward responsivity and restrained eating behavior. CONCLUSION: In women with low executive control, restrained eating is associated with both heightened sensitivity to punishment and heightened responsivity to reward.

Internet-based attentional bias modification training as add-on to regular treatment in alcohol and cannabis dependent outpatients: a study protocol of a randomized control trial.

BACKGROUND: The automatic tendency to attend to and focus on substance-related cues in the environment (attentional bias), has been found to contribute to the persistence of addiction. Attentional bias modification (ABM) interventions might, therefore, contribute to treatment outcome and the reduction of relapse rates. Based on some promising research findings, we designed a study to test the clinical relevance of ABM as an add-on component of regular intervention for alcohol and cannabis patients. DESIGN/METHODS: The current protocol describes a study which will investigate the effectiveness and cost-effectiveness of a newly developed home-delivered, multi-session, internet-based ABM (iABM) intervention as an add-on to treatment as usual (TAU). TAU consists of cognitive behavioural therapy-based treatment according to the Dutch guidelines for the treatment of addiction. Participants (N = 213) will be outpatients from specialized addiction care institutions diagnosed with alcohol or cannabis dependency who will be randomly assigned to one of three conditions: TAU + iABM; TAU + placebo condition; TAU-only. Primary outcome measures are substance use, craving, and rates of relapse. Changes in attentional bias will be measured to investigate whether changes in primary outcome measures can be attributed to the modification of attentional bias. Indices of cost-effectiveness and secondary physical and psychological complaints (depression, anxiety, and stress) are assessed as secondary outcome measures. DISCUSSION: This randomized control trial will be the first to investigate whether a home-delivered, multi-session iABM intervention is (cost-) effective in reducing relapse rates in alcohol and cannabis dependency as an add-on to TAU, compared with an active and a waiting list control group. If proven effective, this ABM intervention could be easily implemented as a home-delivered component of current TAU. TRIAL REGISTRATION: Netherlands Trial Register, NTR5497 , registered on 18th September 2015.

Attentional Bias for Pain and Sex, and Automatic Appraisals of Sexual Penetration: Differential Patterns in Dyspareunia vs Vaginismus?

INTRODUCTION: Current information processing models propose that heightened attention bias for sex-related threats (eg, pain) and lowered automatic incentive processes ("wanting") may play an important role in the impairment of sexual arousal and the development of sexual dysfunctions such as genitopelvic pain/penetration disorder (GPPPD). Differential threat and incentive processing may also help explain the stronger persistence of coital avoidance in women with vaginismus compared to women with dyspareunia. AIMS: As the first aim, we tested if women with GPPPD show (1) heightened attention for pain and sex, and (2) heightened threat and lower incentive associations with sexual penetration. Second, we examined whether the stronger persistence of coital avoidance in vaginismus vs dyspareunia might be explained by a stronger attentional bias or more dysfunctional automatic threat/incentive associations. METHODS: Women with lifelong vaginismus (n = 37), dyspareunia (n = 29), and a no-symptoms comparison group (n = 51) completed a visual search task to assess attentional bias, and single target implicit-association tests to measure automatic sex-threat and sex-wanting associations. RESULTS: There were no group differences in attentional bias or automatic associations. Correlational analysis showed that slowed detection of sex stimuli and stronger automatic threat associations were related to lowered sexual arousal. CONCLUSION: The findings do not corroborate the view that attentional bias for pain or sex contributes to coital pain, or that differences in coital avoidance may be explained by differences in attentional bias or automatic threat/incentive associations. However, the correlational findings are consistent with the view that automatic threat associations and impaired attention for sex stimuli may interfere with the generation of sexual arousal.

Is disgust sensitive to classical conditioning as indexed by facial electromyography and behavioural responses?

Earlier studies provided preliminary support for the role of classical conditioning as a pathway of disgust learning, yet this evidence has been limited to self-report. This study included facial electromyographical (EMG) measurements (corrugator and levator muscles) and a behavioural approach task to assess participants' motivation-to-eat the actual food items (conditioned stimuli, CS). Food items served as CS and film excerpts of a woman vomiting served as unconditioned stimuli (US). Following acquisition the CS+ (neutral CS paired with US disgust) was rated as more disgusting and less positive. Notably, the conditioned response was transferred to the actual food items as evidenced by participants' reported lowered willingness-to-eat. Participants also showed heightened EMG activity in response to the CS+ which seemed driven by the corrugator indexing a global negative affect. These findings suggest that classical conditioning as a pathway of disgust learning can be reliably observed in subjective but not in disgust-specific physiological responding.

Judgmental Biases of Individuals with a Fear of Blushing: The Role of Relatively Strict Social Norms.

Blushing-fearful individuals often expect that others will judge them negatively. In two studies, we tested if this could be explained by having relatively strict beliefs about what is appropriate social behaviour. Study 1 used a student sample (n = 74), whereas study 2 compared a clinical treatment-seeking sample of blushing-fearful individuals (n = 33) with a non-anxious control group (n = 31). In both studies, participants were asked to read descriptions of common behaviours that could be considered as breaching the prevailing social norms but not necessarily so. Participants indicated (i) to what extent they considered these behaviours as violating the prevailing norm and (ii) their expectation of observers' judgments. Study 1 showed that strict norms were indeed related to fear of blushing and that the tendency of fearful participants to expect negative judgments could at least partly explain this relationship. Study 2 showed that high-fearful and low-fearful individuals do indeed differ in the strictness of their norms and that especially the norms that individuals apply to themselves might be relevant. These findings may provide fresh clues for improving available treatment options. KEY PRACTITIONER MESSAGES: Blushing-fearful individuals attribute relatively strict social norms to other people about which behaviours are appropriate and which are not and have stricter personal norms as well. Blushing-fearful individuals' tendency to expect overly negative judgments in ambivalent social situations can partly be explained by their relatively strict social norms. Having relatively strict social norms may (also) explain why blushing-fearful individuals report to blush often and intensely. It may be worthwhile to address strict social norms in therapy for fear of blushing.

Binding Temporal Context in Memory: Impact of Emotional Arousal as a Function of State Anxiety and State Dissociation.

Encoding of stressful experiences plays an important role in the development of posttraumatic stress disorder. A crucial aspect of memory encoding is binding: the "gluing" of the temporal and spatial elements of an episode into a cohesive unit. This study investigated the effect of emotional arousal on temporal binding and examined whether temporal binding varied as a function of state anxiety and/or state dissociation. Participants saw picture sequences that varied in arousal and valence. After each sequence, participants were presented with all the pictures simultaneously and had to sort the pictures in the original order. Temporal context binding was indexed by sorting accuracy. Binding was generally lower for high than low arousing pictures. Reduced binding of arousing material was specifically pronounced in participants with high state anxiety, whereas it seemed independent of state dissociation. These findings point to the relevance of impaired temporal binding as a component of aberrant memory encoding in stressful situations.

Automatic approach/avoidance tendencies towards food and the course of anorexia nervosa.

OBJECTIVE: The aim of the present study was to investigate the role of automatic approach/avoidance tendencies for food in Anorexia Nervosa (AN). We used a longitudinal approach and tested whether a reduction in eating disorder symptoms is associated with enhanced approach tendencies towards food and whether approach tendencies towards food at baseline are predictive for treatment outcome after one year follow up. METHOD: The Affective Simon Task-manikin version (AST-manikin) was administered to measure automatic approach/avoidance tendencies towards high-caloric and low-caloric food in young AN patients. Percentage underweight and eating disorder symptoms as indexed by the EDE-Q were determined both during baseline and at one year follow up. RESULTS: At baseline anorexia patients showed an approach tendency for low caloric food, but not for high caloric food, whereas at 1 year follow up, they have an approach tendency for both high and low caloric food. Change in approach bias was neither associated with change in underweight nor with change in eating disorder symptoms. Strength of approach/avoidance tendencies was not predictive for percentage underweight. DISCUSSION: Although approach tendencies increased after one year, approach tendencies were neither associated with concurrent change in eating disorder symptoms nor predictive for treatment success as indexed by EDE-Q. This implicates that, so far, there is no reason to add a method designed to directly target approach/avoidance tendencies to the conventional approach to treat patients with a method designed to influence the more deliberate processes in AN.