Facing Eating Disorder Fears: An Open Trial Adapting Prolonged Exposure to the Treatment of Eating Disorders.

Eating disorders (EDs) are maintained by core fears, which lead to avoidance behaviors, such as food avoidance or compensatory behaviors. Previously tested exposure-based treatments for EDs have generally focused on proximal outcomes (e.g., food), rather than addressing core fears (e.g., fear of weight gain and its consequences). The current study tested the feasibility and initial clinical efficacy of 10 sessions of imaginal and in vivo exposure for core ED fears (termed "Facing Eating Disorder Fears"), mainly fear of weight gain and its associated consequences. Participants were 36 adults with anorexia nervosa (AN), bulimia nervosa, or other specified feeding and eating disorders determined by semistructured diagnostic interviews. ED symptoms, fears, and body mass index (BMI) were assessed at pretreatment, posttreatment, and 1-month follow-up. Treatment involved 10 sessions of imaginal and in vivo exposure to ED fears in combination with in vivo exposures to feared and avoided situations as homework. ED symptoms and fears decreased from pre- to posttreatment and at 1-month follow-up. BMI increased significantly from pre- to posttreatment, particularly for those with AN. Effect sizes ranged from small to very large. ED symptoms and fears decreased and BMI increased following exposure. Increases in BMI occurred without any direct intervention on eating, suggesting that weight gain can be achieved without a specific focus on food during ED treatment. Facing Eating Disorder Fears may be a feasible stand-alone intervention for EDs. Future research must test comparative efficacy through randomized controlled trials.

Binge Eating, Purging, and Restriction Symptoms: Increasing Accuracy of Prediction Using Machine Learning.

Eating disorders are severe mental illnesses characterized by the hallmark behaviors of binge eating, restriction, and purging. These disordered eating behaviors carry extreme impairment and medical complications, regardless of eating disorder diagnosis. Despite the importance of these disordered behaviors to every eating disorder diagnosis, our current models are not able to accurately predict behavior occurrence. The current study utilized machine learning to develop longitudinal predictive models of binge eating, purging, and restriction in an eating disorder sample (N = 60) using real-time intensive longitudinal data. Participants completed four daily assessments of eating disorder symptoms and emotions for 25 days on a smartphone (total data points per participant = 100). Using data, we were able to compute highly accurate prediction models for binge eating, restriction, and purging (.76-.96 accuracy). The ability to accurately predict the occurrence of binge eating, restriction, and purging has crucial implications for the development of preventative interventions for the eating disorders. Machine learning models may be able to accurately predict onset of problematic psychiatric behaviors leading to preventative interventions designed to disrupt engagement in such behaviors.

Personalizing eating disorder treatment using idiographic models: An open series trial.

OBJECTIVE: Treatments for adults with eating disorders (EDs) only work in about 50% of individuals, and for some diagnoses (e.g., anorexia nervosa; atypical anorexia nervosa), there are no existing evidence-based treatments. Part of the reason that treatments may only work in a subset of individuals is because of the high heterogeneity present in the EDs, even within diagnoses. Manualized treatments delivered in a standard format may not always address the most relevant symptoms for a specific individual. METHOD: The current open series trial recruited participants with transdiagnostic ED diagnoses (N = 79) to investigate the feasibility, acceptability, and initial clinical efficacy of a 10-session network-informed personalized treatment for eating disorders. This treatment uses idiographic (i.e., one-person) network models of ecological momentary assessment symptom data to match participants to evidence-based modules of treatment. RESULTS: We found that network-informed personalized treatment was highly feasible with low dropout rates, was rated as highly acceptable, and had strong initial clinical efficacy. ED severity decreased from pre- to posttreatment and at 1-year follow-up with a large effect size. ED cognitions, behaviors, clinical impairment, worry, and depression also decreased from pre- to posttreatment. CONCLUSIONS: These data suggest that network-informed personalized treatment has high acceptability and feasibility and can decrease ED and related pathology, possibly serving as a feasible alternative to existing treatments. Future randomized controlled trials comparing network-informed personalized treatment for ED to existing gold standard treatments are needed. Additionally, more research is needed on this type of personalized treatment both in the EDs, as well as in additional forms of psychopathology, such as depression. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Predicting eating disorder and anxiety symptoms using disorder-specific and transdiagnostic polygenic scores for anorexia nervosa and obsessive-compulsive disorder.

BACKGROUND: Clinical, epidemiological, and genetic findings support an overlap between eating disorders, obsessive-compulsive disorder (OCD), and anxiety symptoms. However, little research has examined the role of genetics in the expression of underlying phenotypes. We investigated whether the anorexia nervosa (AN), OCD, or AN/OCD transdiagnostic polygenic scores (PGS) predict eating disorder, OCD, and anxiety symptoms in a large developmental cohort in a sex-specific manner. METHODS: Using summary statistics from Psychiatric Genomics Consortium AN and OCD genome-wide association studies, we conducted an AN/OCD transdiagnostic genome-wide association meta-analysis. We then calculated AN, OCD, and AN/OCD PGS in participants from the Avon Longitudinal Study of Parents and Children to predict eating disorder, OCD, and anxiety symptoms, stratified by sex (combined N = 3212-5369 per phenotype). RESULTS: The PGS prediction of eating disorder, OCD, and anxiety phenotypes differed between sexes, although effect sizes were small. AN and AN/OCD PGS played a more prominent role in predicting eating disorder and anxiety risk than OCD PGS, especially in girls. AN/OCD PGS provided a small boost over AN PGS in the prediction of some anxiety symptoms. All three PGS predicted higher compulsive exercise across different developmental timepoints [ß = 0.03 (s.e. = 0.01) for AN and AN/OCD PGS at age 14; ß = 0.05 (s.e. = 0.02) for OCD PGS at age 16] in girls. CONCLUSIONS: Compulsive exercise may have a transdiagnostic genetic etiology, and AN genetic risk may play a role in the presence of anxiety symptoms. Converging with prior twin literature, our results also suggest that some of the contribution of genetic risk may be sex-specific.

Using individual networks to identify treatment targets for eating disorder treatment: a proof-of-concept study and initial data.

BACKGROUND: Eating disorders (EDs) are severe mental illnesses, with high morbidity, mortality, and societal burden. EDs are extremely heterogenous, and only 50% of patients currently respond to first-line treatments. Personalized and effective treatments for EDs are drastically needed. METHODS: The current study (N = 34 participants with an ED diagnosis collected throughout the United States) aimed to investigate best methods informing how to select personalized treatment targets utilizing idiographic network analysis, which could then be used for evidence based personalized treatment development. We present initial data collected via experience sampling (i.e., ecological momentary assessment) over the course of 15 days, 5 times a day (75 total measurement points) that were used to select treatment targets for a personalized treatment for EDs. RESULTS: Overall, we found that treatment targets were highly variable, with less than 50% of individuals endorsing central symptoms related to weight and shape, consistent with current treatment response rates for treatments designed to target those symptoms. We also found that different aspects of selection methods (e.g., number of items, type of centrality measure) impacted treatment target selection. CONCLUSIONS: We discuss implications of these data, how to use idiographic network analysis to personalize treatment, and identify areas that need future research. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04183894. Registered 3 December 2019-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04183894 . NCT04183894 (ClinicalTrials.gov identifier).

Eating disorders are severe psychiatric illnesses that carry high mortality, morbidity, and societal and personal burden. Treatments for eating disorders only work in 50% of patients, signifying a great need to improve treatments. One reason that treatments may not work, is because eating disorders vary substantially from one individual to the next, which existing treatments do not fully consider. The current study (N = 34 participants with an eating disorder diagnosis) uses a new modeling technique to identify which symptoms should be targeted in treatment in a personalized manner. As expected, we found that, using this modeling technique, symptoms that should be targeted in treatment vary considerably. We discuss how to use this modeling technique to identify individual treatment targets and ways in which the field can use this strategy to improve existing and create new treatments.

Social appearance anxiety moderates the relationship between thin-ideal internalization and eating disorder symptoms cross-sectionally and prospectively in adolescent girls.

PURPOSE: The sociocultural theory of eating disorders (EDs) posits that thin-ideal internalization may interact with social risk factors to influence ED development. Social appearance anxiety (SAA) is a potential social risk factor for EDs that may influence the relationship between thin-ideal internalization and EDs. METHODS: The current study (N = 525 adolescent females) examined whether SAA moderated the relationship between thin-ideal internalization and ED symptoms cross-sectionally and prospectively across one month. RESULTS: The interaction between thin-ideal internalization and SAA on ED symptoms was significant in both models, such that when SAA was higher, there was a significantly stronger relationship between thin-ideal internalization and ED symptoms. We also found that SAA uniquely, prospectively predicted ED symptoms. CONCLUSION: These results suggest that adolescents with high SAA and high thin-ideal internalization are more likely to exhibit higher ED symptoms. SAA both prospectively predicts ED symptoms and may amplify the relationship between thin-ideal internalization and EDs. This research highlights SAA as a social risk factor for ED development in adolescents. Interventions focused on SAA may optimize ED prevention in this population. LEVEL OF EVIDENCE: Level IV, evidence obtained from multiple time series with or without the intervention.

Eating disorder symptoms and core eating disorder fears decrease during online imaginal exposure therapy for eating disorders.

BACKGROUND: Few evidence-based treatments for eating disorders (EDs) exist. Imaginal exposure therapy is a key component of effective treatment for anxiety disorders and post-traumatic stress disorder. However, imaginal exposure has not been systematically tested as a treatment for EDs. The current study aimed to develop and test online imaginal exposure as a treatment for EDs. METHODS: The current study tested a four-week trial of online imaginal exposure for EDs (N = 229 participants with EDs recruited globally). Participants completed diagnostic interviews and four sessions of weekly online imaginal exposure, in which they wrote about and imagined a core ED fear (identified with a therapist). Participants completed measures of ED symptoms and fears (i.e., fear of weight gain, food) at pre-imaginal exposure, post-imaginal exposure, and six-month follow-up. Participants were recruited and participated in the protocol from November 2016 to October 2018. RESULTS: All primary outcomes (ED symptoms, ED fears) significantly decreased at study completion and six-month follow-up with medium-to-large effect sizes. State anxiety across the exposure and follow-ups significantly decreased, specifically from initial sessions to follow-up. Worry, but not depression, significantly decreased. LIMITATIONS: This study was an open case trial and did not include a control condition. CONCLUSIONS: Significant decreases in ED symptoms and fears occurred during the course of imaginal exposure treatment. Online imaginal exposure is a feasible treatment for EDs and is associated with decreases in core ED symptomatology, which are comparable in magnitude to decreases seen from other evidence-based treatments. A future randomized-controlled trial is needed. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov identifier NCT03712748.

Prospective associations between childhood neuropsychological profiles and adolescent eating disorders.

OBJECTIVE: Cross-sectional associations between eating disorders (EDs) and deficits in neuropsychological functioning have been well documented; however, limited research has examined whether neuropsychological functioning is prospectively associated with EDs. The current study investigated prospective associations between neuropsychological functioning in childhood (ages 8 and 10) and ED behaviours and disorders in adolescence (at ages 14, 16, and 18 years) in a population-based sample. METHOD: Participants (N = 4,803) were children enrolled in the Avon Longitudinal Study of Parents and Children, a population-based, prospective study of women and their children. Regression methods tested associations between facets of neuropsychological functioning (attention, working memory, and inhibition) and eating disorder symptoms and diagnoses. RESULTS: Better scores on working memory tasks in childhood were associated with decreased risk of fasting but increased risk of excessive exercise during adolescence. Better inhibitory control was associated with decreased risk for disordered eating at age 14, and attentional difficulties were associated with increased risk for binge eating disorder during adolescence among boys but not girls. CONCLUSIONS: Neuropsychological functioning may enhance risk for disordered eating behaviours in specific ways. Overall, effect sizes were small, and results did not support global associations between neuropsychological differences and ED risk in this sample.

Exploring the contribution of exercise dependence to eating disorder symptoms.

OBJECTIVE: Exercise dependence is a set of cognitive and behavioral symptoms that constitute a reliance on exercise and is related to eating disorder (ED) symptoms. There are seven components of exercise dependence: tolerance, withdrawal, continuance, lack of control, reduction in other activities, time, and intention effects. Exercising in response to negative affect (NA) is a key feature of dysfunctional exercise in the EDs. However, it is unknown which specific components of exercise dependence relate to ED symptoms, above and beyond NA. METHOD: The current study (N = 168 individuals with EDs) investigated which components of exercise dependence relate to ED symptoms both cross-sectionally and prospectively. RESULTS: In cross-sectional data, we found that withdrawal, tolerance, and time were associated with ED symptoms, above and beyond NA. Prospectively over 1 month, when adjusting for baseline ED symptoms and NA, we found that lack of control, withdrawal, and time positively predicted ED symptoms. DISCUSSION: These findings inform future research on how exercise dependence relates to ED symptoms, showing that withdrawal and time are uniquely associated with ED symptoms both cross-sectionally and over time.

Exploring Mechanisms of Action in Exposure-Based Cognitive Behavioral Therapy for Eating Disorders: The Role of Eating-Related Fears and Body-Related Safety Behaviors.

Evidence-based cognitive behavioral therapy for eating disorders includes a component of exposure therapy, which involves patients confronting feared eating and body-related stimuli while preventing safety behaviors. With recent research demonstrating that eating-related fears and safety behaviors are central to eating disorder pathology, there is increased emphasis on improving the efficacy of exposure therapy in eating disorders. Doing so will require a better understanding of important mechanisms of action in this treatment. The present study explored how changes during treatment in eating-related fears and avoidance as well as body-related safety behaviors influence overall treatment outcomes. Individuals with eating disorders (N = 71) receiving exposure-based treatment completed measures of global eating disorder severity at admission and discharge. Hypothesized mechanisms of action were also assessed at admission and discharge as well as at a 2-week time point after beginning treatment. Path modeling analyses showed that decreased eating-related cognitions (feared concerns about eating) and emotions (anxiety about eating) at the 2-week time point were prospectively predictive of lowered global eating disorder symptom severity at discharge. Additionally, reduced body checking and avoidance behaviors after 2 weeks of treatment were also associated with lower eating disorder severity at discharge. These findings highlight the importance of exposure-based therapy in eating disorders and the need to uniquely address eating-related fears and safety behaviors.

Intolerance of uncertainty moderates the relationship between high personal standards but not evaluative concerns perfectionism and eating disorder symptoms cross-sectionally and prospectively.

Two dimensions of perfectionism related to eating disorder (ED) symptoms are evaluative concerns and high standards. Evaluative concerns are consistently linked with ED symptoms, whereas there are conflicting results regarding high standards and ED symptoms. High standards are unrelated to ED symptoms in some studies and are linked to higher ED symptoms in others. Intolerance of uncertainty (IU) may influence the relation between high standards and ED symptoms; individuals elevated in both IU and high standards may find it distressing to be uncertain about future situations for fear of not living up to high expectations and use ED behaviors to cope with such uncertainty. In the current study (N = 216), we explored whether IU moderates the relationships between high standards and evaluative concerns and ED symptoms, both cross-sectionally and prospectively across two weeks. IU significantly moderated high standards and ED symptoms both cross-sectionally and across time while accounting for baseline ED symptoms, but did not moderate the relationship between evaluative concerns and ED symptoms. Higher standards were associated with greater ED symptoms in individuals higher, but not lower in IU. These findings suggest high standards may only contribute to ED symptoms when individuals are also high in IU.

Obsessions are strongly related to eating disorder symptoms in anorexia nervosa and atypical anorexia nervosa.

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are highly comorbid. However, little research has examined which specific cognitive-behavioral aspects (e.g., checking, obsessing) of OCD are most relevant in those with AN. Furthermore, there is no research examining aspects of OCD in Atypical AN. The current two studies (N = 139 and N = 115 individuals diagnosed with AN/Atypical AN) examined a) which aspects of OCD were most related to AN symptomatology and b) if there were differences in OCD between individuals diagnosed with AN vs Atypical AN. We found that obsessing was most related to AN symptoms. We also found that there were no substantial significant differences between AN and Atypical AN. These findings add to the literature suggesting minimal differences between AN and Atypical AN, specifically regarding OCD symptomatology. These findings clarify that obsessions (rather than compulsions) may be the specific aspect of OCD most warranting treatment intervention in AN and Atypical AN.

Sensor technology implementation for research, treatment, and assessment of eating disorders.

Sensor technology has made huge technological advances in the past decade. Many sensor technologies (e.g., wearable wristbands) have been integrated into health research with the ability to substantially improve health outcomes and reduce health care costs. Despite the rapid technological developments in sensor technology, little research has examined sensor technology in eating disorders (EDs). The overarching aim of the current article is to briefly review the literature on sensor technology and health outcomes, including EDs, and discuss several potential ideas for the application of sensor technology in the treatment, assessment, and diagnosis of EDs. We will also present data from a feasibility case study with an ED participant and healthy control providing a brief example of how wearable sensor technology might be implemented in ED research. Overall, we will discuss how sensor technology could be used to improve treatment and assessment of EDs and represents an idea in need of more research in the ED field.

Associations between eating expectancies and Eating disorder symptoms in men and women.

Eating expectancies, or learned expectations that an individual has about eating, prospectively predict eating disorder (ED) symptoms. Most studies examining eating expectancies have focused on one or two eating expectancies and their relation with bulimic symptoms. In addition, these studies have been conducted mostly in women. Thus, it is unclear whether: 1) associations between eating expectancies and ED symptoms vary between men and women, and 2) extend to ED symptoms other than bulimic symptoms. The current study (N = 197 undergraduate men and 246 undergraduate women) investigated sex variance in a model of eating expectancies and ED symptoms, including factors associated with ED symptoms (i.e., negative urgency, negative affect, alcohol use, drug use, and body mass index). Sex variance was tested using path analysis in a model including eating expectancies and associated factors, with excessive exercise, negative attitudes toward obesity, restricting, cognitive restraint, binge eating, purging, muscle building, and body dissatisfaction as dependent variables. Unconstrained (i.e., unconstrained paths across men and women) and constrained (i.e., constraining paths across men and women) models were tested. The unconstrained and constrained models differed significantly, indicating that the models varied by sex. For both sexes, eating expectancies were uniquely associated with ED symptoms. For men, Eating Manages Negative Affect was significantly associated with the most ED symptoms. In contrast, for women, Eating Leads to Feeling Out of Control was associated with the most ED symptoms. Previous findings regarding eating expectancies and ED symptoms in women may not generalize to men. Intervening on eating expectancies in a sex-specific way may help reduce specific ED symptoms.

Ethnic variance between Asian and European American women in a six month prospective model of eating disorder and social anxiety symptom comorbidity.

Eating disorders and social anxiety are highly comorbid. Understanding this comorbidity may improve treatment outcomes, as social anxiety can impair the ability to benefit from eating disorder treatment. The primary model of social anxiety and eating disorder comorbidity includes social appearance anxiety, high standards, and maladaptive perfectionism. In the current study, we tested for ethnic invariance between Asians (n = 82) and European Americans (n = 182) in a cross-sectional and prospective comorbidity model of social anxiety and eating disorder symptoms. Differences were found across ethnicity in eating disorder and social anxiety symptom comorbidity. Maladaptive perfectionism predicted social anxiety and eating disorder symptoms in European Americans, whereas social appearance anxiety predicted social anxiety and eating disorder symptoms in Asians. Our findings suggest that interventions for social anxiety and eating disorders in Asian populations may be improved by assessing and targeting social appearance anxiety, while maladaptive perfectionism should be targeted among European Americans.

Implementation of a dissonance-based, eating disorder prevention program in Southern, all-female high schools.

Adolescence represents a high-risk period for eating disorder development, and there is great need for effective prevention programs targeted at this population. The Body Project, a dissonance-based eating disorder prevention program, has robust literature showing reductions in body dissatisfaction and eating disorder symptoms. However, many additional factors (i.e., comorbid symptoms, transdiagnostic factors) have not yet been examined in relation to the Body Project. Additionally, there is little known about how to most effectively and broadly disseminate this intervention. The current study (N = 332 adolescents) examines eating disorder symptoms, comorbidities, and transdiagnostic risk factors pre- and post-Body Project and at 1-month follow-up. This study is the first examination of the effectiveness of the Body Project implemented within school programming in southern, all-female high schools. Social appearance anxiety, physical and social anxiety sensitivity, rumination, worry, perfectionism, and guilt, but not depression, cognitive anxiety sensitivity, shame, or exercise dependence, decreased pre- to post-intervention and/or 1-month follow-up. These results support the effectiveness of the Body Project in addressing eating disorder symptoms and suggest it may aid in the prevention of comorbid conditions. Additionally, the effectiveness of the intervention was comparable to past investigations, supporting its use in schools across the United States.

Repetitive negative thinking predicts eating disorder behaviors: A pilot ecological momentary assessment study in a treatment seeking eating disorder sample.

BACKGROUND: Repetitive negative thinking is a transdiagnostic process that occurs across several psychological disorders, including eating disorders. Individuals with eating disorders have higher levels of repetitive negative thinking than controls, and repetitive negative thinking is associated with eating disorder behaviors. However, no study has measured how momentary repetitive negative thinking may subsequently impact daily eating disorder behaviors and vice-versa. METHOD: In the current study (N = 66, recently treated individuals recruited from an eating disorder treatment center), we examined the relationship between repetitive negative thinking and subsequent eating disorder behaviors and vice-versa using ecological momentary assessment. RESULTS: We found that higher momentary repetitive negative thinking predicted higher subsequent weighing and body checking. We also found that higher momentary meal-specific repetitive negative thinking predicted higher subsequent weighing and lower subsequent compensatory behavior. We also found that higher repetitive negative thinking predicted higher eating disorder symptoms at one-month follow-up. CONCLUSION: There are short-term and long-term negative effects of repetitive negative thinking in the eating disorders. Targeting repetitive negative thinking may be important for decreasing eating disorder behaviors.

Associations between dimensions of anorexia nervosa and obsessive-compulsive disorder: An examination of personality and psychological factors in patients with anorexia nervosa.

OBJECTIVE: Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are highly comorbid. However, the factors that account for this comorbidity are poorly understood. We examined the core dimensions of AN and OCD and psychological and personality factors shared by both disorders. METHOD: In path analyses (N = 732 women with either current AN or recovered from AN), we examined which factors were uniquely and independently associated with the core dimensions of AN and OCD. We also examined recovery from AN as a moderator. RESULTS: When individuals with AN reported greater concern over mistakes, they endorsed more severity in both AN and OCD core dimensions. These unique associations existed above and beyond all other transdiagnostic personality and psychological factors and regardless of AN recovery status. CONCLUSIONS: Concern over mistakes partially accounts for severity in the core dimensions of both AN and OCD. Concern over mistakes may represent an important target in the aetiology of AN and OCD.

Longitudinal and personalized networks of eating disorder cognitions and behaviors: Targets for precision intervention a proof of concept study.

INTRODUCTION: Despite the high mortality and significant societal and personal costs associated with eating disorders (EDs) there are few evidence-based treatments. Part of the difficulty developing and implementing evidence-based treatments in EDs is due to the extremely high heterogeneity (e.g., variability in treatment outcome, symptom presentation etc) present. METHODS: To begin to identify specific symptom heterogeneity within persons, the current study used novel within and between group and intra-individual network analyses to create longitudinal and within-person networks of ED cognitions and behaviors (N = 66 individuals diagnosed with an ED). This article provides a proof of concept study for how to use between and within-person network analyses both for the EDs and other forms of psychopathology. RESULTS: We found that cognitions focused on desiring thinness played a likely maintaining role in ED pathology, across network type and across time. Furthermore, we showed that three individuals with the same diagnosis (anorexia nervosa) differed in which symptoms maintained the disorder. We use these participants to exemplify how to use intra-individual network analysis to personalize treatment focused on the primary maintaining symptoms. Finally, we found that amount of time (e.g., 4 hr vs. simultaneously) impacts how symptoms maintain each other. CONCLUSIONS: These findings have implications for the development of novel personalized evidence-based treatments for EDs, as well as implications for how the field understands how psychopathology maintains itself. These data represent a first-step towards using intra-individual network analyses in the ED field, as well as for hypotheses generation in future research.