Implication of Social Rejection in Cognitive Bias Modification Interpretation Training in Adolescents With Eating Disorders.

Objectives: Difficulties in interpersonal relationships intensify negative emotions and act as risk and maintenance factors for eating pathology in eating disorders. Rejection sensitivity refers to the tendency to react sensitively to a rejection. Patients with eating disorders experience difficulties in interpersonal relationships because of their high sensitivity to rejection. Cognitive bias modification interpretation (CBM-I) is a treatment developed to correct interpretation bias for social and emotional stimuli. In this review, we searched for research characteristics and trends through a systematic literature analysis of CBM-I for eating disorders. Methods: Five papers that met the selection and exclusion criteria were included in the final literature review and analyzed according to detailed topics (participant characteristics, design, and results). Results: The literature supports the efficacy of the CBM-I in reducing negative interpretation bias and eating disorder psychopathology in patients with eating disorders. CBM-I targets emotional dysregulation in adolescent patients with eating disorders and serves as an additional strengthening psychotherapy to alleviate eating disorder symptoms. Conclusion: The current findings highlight the potential of CBM-I as an individualized adjunctive treatment for adolescents with eating disorders and social functioning problems.

The effect of training to target cognitive biases towards social rejection in eating disorders.

OBJECTIVE: This study examined the effect of cognitive bias modification for interpretation (CBM-I) training in Korean women with eating disorders (EDs). METHOD: Sixty-three women with EDs participated in the study. Participants were randomly assigned to the intervention group where they received six sessions of CBM-I training (n = 31) in addition to treatment-as-usual or were put on a waiting list (n = 32). Participants' interpretation and attention biases, emotion regulation, affect, and ED psychopathology were assessed at baseline, end-of-intervention (4 weeks), and follow-up (8 weeks). RESULTS: Participants who completed the CBM-I training displayed greater reductions in negative interpretation bias (Δη2 = 0.107) and emotion dysregulation (Δη2  = 0.085) with medium to large effect sizes compared to the control group, which were maintained from baseline to follow-up. Disengagement from negative faces and a focus on positive faces was found in the intervention group with a moderate effect size at the end-of-intervention (Δη2  = 0.090). Both intervention and control groups showed improvements in ED psychopathology. Baseline neuroticism was positively correlated with CBM-I effect. DISCUSSION: The results suggest that modifying interpretation bias towards ambiguous social stimuli might be an effective adjuvant treatment to reduce negative expectations of social situations and improve emotion regulation in women with bulimia nervosa and anorexia nervosa.

Recovery-focused self-help intervention using vodcasts for patients with personality disorder: feasibility randomised controlled trial.

BACKGROUND: Availability of long-term psychological interventions for personality disorders is limited because of their high intensity and cost. Research in evidence-based, low-intensity interventions is needed. AIMS: This study aimed to examine the feasibility, acceptability and potential impact of a low-intensity, digital guided self-help (GSH) intervention that is focused on emotion regulation, recovery-oriented and provides in-the-moment delivery for patients with personality disorders. METHOD: We conducted a single-blind feasibility trial. A total of 43 patients with a personality disorder were recruited and randomly assigned to either a GSH arm (n = 22) or a treatment-as-usual arm (n = 21). The GSH intervention included a series of short videos offering psychoeducation and support, personalised feedback using text messages, and supportive telephone calls, for 4 weeks in addition to treatment as usual. Outcomes of emotional disturbance, emotion dysregulation, self-harm behaviours and decentring ability were measured at baseline, 4 weeks (end of intervention) and 8 weeks (follow-up). RESULTS: All patients who attended the first session continued until the last session. There was an interaction effect between time and group on anxiety (P = 0.027, Δη2 = 0.10), where the GSH group showed a significant reduction in anxiety at follow-up (P = 0.003, d = 0.25). The GSH group increased in decentring ability at the end of intervention (P = 0.007, d = -0.65), and the decrease in self-harm behaviours continued until follow-up (P = 0.02, d = 0.57). CONCLUSIONS: The results suggest that a personalised digital GSH with a focus on recovery could reduce anxiety and self-harm behaviours at short-term follow-up.

Effect of modifying negative interpretation bias toward ambiguous social stimuli across eating and personality disorders.

OBJECTIVE: Heightened sensitivity toward social rejection has been implicated in eating disorders (ED) and personality disorder (PD). This study examined the effect of a cognitive bias modification training (CBM-I) targeting the interpretation of ambiguous social situations in individuals with comorbid ED and PD. METHOD: A total of 128 participants [33 with ED and PD, 22 with ED-only, 22 with PD-only, and 51 healthy controls (HC)] were recruited from a hospital and university settings, and included in the final analyses. The participants were randomly assigned to a CBM-I task with benign resolutions or a control task with neutral resolutions in a counterbalanced order in two sessions using a within-subject design. Interpretation bias toward social stimuli was measured using the ambiguous sentence completion task before and after completing the assigned task. RESULTS: The CBM-I task increased benign and decreased negative interpretations with large effect sizes in the diagnostic groups, and with a moderate effect size in the HC group. Participants' anxiety levels were also reduced after the task. The size of the change in negative interpretation was positively associated with baseline negative affect, and negatively associated with baseline positive affect. DISCUSSION: The results suggest that modifying interpretation bias has the potential as a transdiagnostic target of treatment for ED and PD, and a fully powered clinical trial with consecutive sessions would be warranted. PUBLIC SIGNIFICANCE: Participants with eating disorders and/or personality disorder, and healthy controls completed a single session of a cognitive training intervention targeting rejection sensitivity. The training produced a large decrease in negative interpretation in the diagnostic groups, and a moderate effect in healthy controls. The findings indicate that training for positive processing of social information may be of value to augment treatment in conditions such as eating disorders and personality disorder, in which there are high levels of rejection sensitivity.

Atypical anorexia nervosa: Implications of clinical features and BMI cutoffs.

Atypical anorexia nervosa (atypical AN) appears to be a heterogeneous disorder under the current diagnostic system. Though the body mass index (BMI) cutoff point of 18.5 kg/m2 is a criterion that distinguishes atypical AN from AN, the cutoff may not be universally applicable as the norms for BMI vary and can be affected by several factors, including cross-country differences and social determinants. It is unfortunate that we do not yet have reliable or widely available criteria other than BMI for the diagnosis of atypical AN. Additional relevant markers of atypical AN are needed in future diagnostic systems.

Biochemical, hematologic, and skeletal features associated with underweight, overweight, and eating disorders in young Korean women: A population-based study.

Background: Extreme weight conditions in young women are associated with adverse health outcomes. Closely linked with extreme weight status, eating disorders (EDs) are associated with several medical complications and high mortality rates. Objective: The study aimed to investigate the biochemical, hematologic, and skeletal features of young Korean women with underweight (UW) and overweight/obesity (OW) conditions, and patients with anorexia nervosa (AN) and bulimia nervosa (BN) compared to women with normal-weight (NW). Method: A total of 808 women (mean age 22.3 ± 3.4 years) were recruited for the study, including 144 with UW status [body mass index (BMI) < 18.5 kg/m2], 364 with NW, 137 with OW or obesity (27 with obesity; BMI ≥ 25 kg/m2), 63 patients with anorexia nervosa (AN), and 100 with bulimia nervosa (BN). We measured blood pressure and performed biochemical, hematologic and bone mineral density (BMD) evaluations at the lumbar and femoral neck. Results: Blood pressure and triiodothyronine levels were found to be lower in both ED groups and higher in the OW group, but no difference in the UW group, compared to the NW group. The aminotransferases and total cholesterol levels were higher in the ED and OW groups, compared to the NW group. Blood cell counts were decreased in the AN group, while increased in the OW group, compared to the NW group. Blood urea nitrogen was elevated in both ED groups. The UW and AN groups had lower BMD, whereas the OW group had higher BMD, compared to the NW group. Conclusion: Our findings suggested that both ED groups were associated with decreases in the resting energy expenditure. OW status was associated with a risk of metabolic syndrome, and UW status with lower BMD in young women. Overall, the medical parameters in Korean patients with ED were similar to the patterns reported in Western samples in previous studies, with few exceptions such as potassium level in BN.

Feasibility and acceptability of a digital tele-guided intervention targeting components of the addictive appetite model for bulimia nervosa and binge-eating disorder in Korea.

OBJECTIVE: We aimed to evaluate the feasibility, acceptability, and potential impact of a tele-guided digital-based intervention based on the addictive appetite model of recurrent binge eating. METHOD: Female college students with bulimia nervosa (BN) or binge-eating disorder (BED) (n = 22) received a 6-week guided intervention targeting addictive processes and emotion regulation. The feasibility of the intervention was evaluated, and the outcomes were assessed at baseline, the end of the intervention, and 1-month follow-up. RESULTS: Of the participants, 86.4% (n = 19) completed the intervention. The self-help materials were viewed 6.03 ± 3.06 times per week, and the duration of using the self-help materials was 113.16 ± 160.19 min/week. The intervention group experienced a significant reduction with a moderate effect on binge eating at the end of the intervention (Hedges' g = 0.58), and the effects lasted through follow-up (Hedges' g = 0.82). DISCUSSION: The results suggest that the digital intervention targeting a maintenance mechanism of recurrent binge eating was feasible and acceptable for patients with BN and BED, proving the potential for symptom improvement. PUBLIC SIGNIFICANCE: The addictive appetite model provides the framework for new interventions to improve treatments for BN and BED. This study found that the digital intervention based on the model was feasible and acceptable for patients with BN and BED.

The Effect of Alcohol Drinking on Metabolic Syndrome and Obesity in Koreans: Big Data Analysis.

The purpose of this study was to assess the effect of alcohol consumption on metabolic syndrome (MetS) and obesity in Koreans by analysis of big data from the National Health Insurance Service health checkup database. A total of 26,991,429 subjects aged 20 years or older were included. Alcohol consumption was divided into five groups: nondrinkers, ≤7.0 g/d, 7.1-14.0 g/d, 14.1-28.0 g/d, ≥28.1 g/d. Logistic regression analyses were performed after adjusting for age, exercise, smoking, and income. The odds ratios (ORs) of MetS and obesity in men and women were lowest at ≤7.0 g/d, similar to that of the nondrinkers at 7.1-14.0 g/d, and increased with the alcohol consumption. At 7.1-14.0 g/d in older men, the ORs of metabolic syndrome and obesity were similar to those in the nondrinkers, but the OR of obesity was slightly increased in older women. This study suggests that the risk of MetS and obesity may be higher in Korean men, women, and the elderly who drink more than 14 g/d than the nondrinkers. In people with obesity or abdominal obesity, or those who need to manage their blood pressure, glucose, or triglyceride, drinking more than 7 g/d may increase the risk of MetS.

Negative emotion-related eating behaviours in young women with underweight status, overweight status, anorexia nervosa, and bulimia nervosa in Korea.

OBJECTIVE: This study aimed at investigating the negative emotion-related eating behaviours of young women with extreme weights or eating disorders (EDs). METHOD: A total of 808 young women participated including 144 with underweight (UW), 364 with normal-weight (NW) and 137 with overweight (OW; including 27 with obesity) from universities, and 63 patients with anorexia nervosa (AN), and 100 patients with bulimia nervosa (BN) from a hospital. Participants were interviewed and completed questionnaires on eating behaviours related to negative emotions. RESULTS: While both OW and BN groups ate more in response to negative emotions, UW and AN groups ate less compared to NW group. Negative feelings after overeating were prominent in OW group and patients with ED. In negative emotions, patients with EDs preferred sweet tastes, but BN group preferred spicy tastes less. Patients with EDs had increased external eating, and BN group also showed increased restrained eating. Neuroticism had indirect impacts on OW status via emotional eating unlike BN. CONCLUSIONS: The results suggest that UW and OW status were on the spectrum of emotional eating, and AN and BN were on the extremes of external eating, which may be integrated into the development of interventions targeting each status.

Factors Associated with Underweight, Overweight, and Eating Disorders in Young Korean Women: A Population-Based Study.

Both underweight (UW) and overweight (OW) conditions are problematic in young women. The aim of this study was to examine the factors associated with extreme weight status and eating disorders (EDs) in young Korean women. A total of 808 women (mean age 22.3 ± 3.4 years) participated, including 144 with UW [Body Mass Index (BMI) < 18.5kg/m2], 364 with NW, and 137 with OW or obesity (BMI ≥ 25kg/m2), and 63 patients with anorexia nervosa (AN) and 100 with bulimia nervosa (BN). Participants completed questionnaires regarding nutrients consumed, eating behaviors, health behaviors, body image, and obsessive-compulsive symptoms with face to face interviews. The associations between the status of participants and the data were analyzed with NW group as a reference. OW status was associated with overeating and with frequent eating. UW status was associated with less frequent overeating and with longer sleep duration. AN status was associated with less frequent consumption of alcohol. BN status was associated with a larger discrepancy between the ideal and current body shape. Both OW status and BN were associated with more obsessive-compulsive symptoms. The results suggested that certain dietary, health, and psychological factors are associated with extreme weight conditions and EDs.

Oxytocin: A Potential Therapeutic for Obesity.

Oxytocin is a neuropeptide involved in the homeostasis of food consumption and energy; it affects hedonic eating. Studies in obese or binge-eating patients reported the hypophagic effect of oxytocin, which reduced caloric intake after administration. Several studies have demonstrated the effect of oxytocin's increasing energy intake, decreasing food consumption, and contributing to weight loss. Oxytocin's effects on food intake and metabolism suggest its therapeutic potential for treating obesity and binge eating.

Personality Assessment Questionnaire for ICD-11 personality trait domains: Development and testing.

BACKGROUND: We aimed to develop a questionnaire suitable for the assessment of trait domains in the forthcoming International Classification of Diseases 11th Revision (ICD-11). This questionnaire, the Personality Assessment Questionnaire for ICD-11 (PAQ-11) personality trait domains, was intended as a short and reliable self-report measure. METHOD: The initial items were derived from the relevant traits of an established version of the Personality Assessment Schedule. In Phase 1, item selection and scale construction proceeded iteratively using data from 334 female university students and 75 psychiatric patients (combined N = 409) in Korea. In Phase 2, a validation study of the scale was conducted in a subset of the sample from Phase 1, who were deemed to be at high risk of personality disorders (N = 210). RESULTS: Exploratory and confirmatory factor analyses of the Personality Assessment Schedule items created a 17-item scale. This scale, PAQ-11, demonstrated adequate convergent and discriminant validity with the five-factor model, the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition traits model and emotional difficulties. The results were consistent with its underlying theoretical structure. CONCLUSIONS: The PAQ-11 appears to be potentially promising in terms of clinical utility to assess the five domains of ICD-11 personality disorders. More research must be conducted in other cultural backgrounds with gender-balanced populations. © 2020 John Wiley & Sons, Ltd.

Transcultural adaptation of cognitive behavioral therapy (CBT) in Asia.

BACKGROUND: Cognitive behavior therapy (CBT) is an evidence based therapy and is now recommended by national organizations in many high income countries. CBT is underpinned by the European values and therefore for it to be effective in other cultures it needs to be adapted. AIMS: This paper describes an evidence based approach to culturally adapt CBT in Asian context, areas of focus for such adaptation and lessons learned. METHODS: An environmental scan of the literature, description of local CBT associations and perspectives from these organizations. RESULTS: Cultural adaptation of CBT focuses on three main areas; 1 awareness of culture and related issues, 2 assessment and 3 adjustment in therapy techniques. CONCLUSIONS: The last decade has seen an increase in culturally adapted CBT in Asia, however, more work needs to be done to improve access to CBT in Asia.

Introduction to a special issue on eating disorders in Asia.

OBJECTIVE: It is our pleasure to introduce a special issue of the International Journal of Eating Disorders on eating disorders (EDs) in Asia. METHOD: We received such a robust response to the special edition that we were able to fill two issues. Contributions focused on seven main themes: (1) prevalence, (2) time trends, (3) healthcare systems, (4) treatment, (5) risk factors, (6) assessment, and (7) orthorexia. RESULTS: New prevalence and time trend data from China, Iran, Singapore, Japan, and Taiwan suggest that EDs are increasingly common in Asia but are not always detected in healthcare settings. Only a minority of individuals with EDs in Singapore receive treatment, and psychosocial treatment and prevention interventions that are evidence-based in the West may require cultural adaptation before they can be fully implemented in Japan, Singapore, China, and South Korea. Psychological risk factors for EDs are more similar than different in Iran, India, Japan, and China, but biological risk factors are understudied across the continent. Psychometrically sound assessment tools are available in many Asian languages. DISCUSSION: We hope this special issue provides a catalyst and blueprint for global collaboration to relieve the burden of suffering of EDs in Asia and beyond.

A school-based eating disorder prevention program (Me, You & Us) for young adolescents in Korea: A 3-year follow-up study.

OBJECTIVE: The study aimed to examine the feasibility and long-term effects of a school-based eating disorder prevention program for young adolescents in Korea. METHOD: We followed up the students (n = 133) who had participated in the prevention program at 3 years ago to evaluate changes in body esteem and self-esteem between postintervention and 3-year follow-up, with investigating whether gender moderated the effect of time. RESULTS: Boys showed no decline in body esteem and self-esteem from postintervention to 3-year follow-up, indicating that the prevention program alleviated decreases in body esteem and self-esteem over time. Girls showed decreases in body esteem and self-esteem from postintervention to 3-years follow-up. DISCUSSION: This study provides evidence supporting the feasibility of the school-based eating disorder prevention program targeting mixed-sex, young adolescents in Korea. Given the developmental trajectories of decrease in body esteem and self-esteem during adolescence, the program may be efficient for boys over time. Boosters and/or complementary prevention approaches across gender are needed.

A Retrospective Analysis Evaluating the Outcome of Parenteral Nutrition in the Treatment of Anorexia Nervosa in Korea.

The objective of this study was to investigate the clinical efficacy of parenteral nutrition (PN) as supplemental feeding for patients with anorexia nervosa (AN). This study was conducted by reviewing the medical records of patients with AN who were hospitalized at a non-specialized ward. A total of 129 patients with AN were recruited, consisting of 67 patients received PN with oral refeeding and 62 patients received oral refeeding alone. We compared the weight gain at discharge and after discharge between the groups. As a result, at admission, the patients given supplementary PN had lower body mass indices and lower caloric intake than the patients without PN. The mean duration of PN was 8.5 days, which amounted to about a third of the average hospital stay with no difference between the groups. Both groups had similar weight gains during hospitalization, but the patients with PN had higher weight gains than the patients without PN at one and three months after discharge. In conclusion, the results suggest that supplementary PN in the early stage of refeeding might initiate weight gain in AN when nasogastric tube feeding is not possible. Randomized controlled trials are needed to be further tested of PN in treatment of AN.

COVID Isolation Eating Scale (CIES): Analysis of the impact of confinement in eating disorders and obesity-A collaborative international study.

Confinement during the COVID-19 pandemic is expected to have a serious and complex impact on the mental health of patients with an eating disorder (ED) and of patients with obesity. The present manuscript has the following aims: (1) to analyse the psychometric properties of the COVID Isolation Eating Scale (CIES), (2) to explore changes that occurred due to confinement in eating symptomatology; and (3) to explore the general acceptation of the use of telemedicine during confinement. The sample comprised 121 participants (87 ED patients and 34 patients with obesity) recruited from six different centres. Confirmatory Factor Analyses (CFA) tested the rational-theoretical structure of the CIES. Adequate goodness-of-fit was obtained for the confirmatory factor analysis, and Cronbach alpha values ranged from good to excellent. Regarding the effects of confinement, positive and negative impacts of the confinement depends of the eating disorder subtype. Patients with anorexia nervosa (AN) and with obesity endorsed a positive response to treatment during confinement, no significant changes were found in bulimia nervosa (BN) patients, whereas Other Specified Feeding or Eating Disorder (OSFED) patients endorsed an increase in eating symptomatology and in psychopathology. Furthermore, AN patients expressed the greatest dissatisfaction and accommodation difficulty with remote therapy when compared with the previously provided face-to-face therapy. The present study provides empirical evidence on the psychometric robustness of the CIES tool and shows that a negative confinement impact was associated with ED subtype, whereas OSFED patients showed the highest impairment in eating symptomatology and in psychopathology.

A comparison of patients with anorexia nervosa and women who are constitutionally thin.

OBJECTIVE: Many of the clinical features of anorexia nervosa (AN) can be secondary problems associated with malnutrition, which mask the primary features of AN. This study aimed to investigate the intrinsic features of AN by comparing AN patients to women who are constitutionally thin (CT). METHOD: Twenty-six patients with AN and 53 CT women of similar body mass index (AN: 17.13 ± 1.73 kg/m2 , CT: 16.62 ± 0.61 kg/m2 ) participated in the study. We examined medical findings, psychiatric features, and disturbed body image between the two groups. RESULTS: Patients with AN had earlier menarche but less frequent menstrual periods compared to CT women. They had lower blood pressure, lower triiodothyronine, and fasting glucose levels than CT women. Patients with AN had more disturbed body images and restricted diet patterns and also had higher neuroticism compared to CT women. CONCLUSIONS: The patients with AN viewed their current body shape as fatter and had more restrained eating than the CT women. The results suggest that the disturbed body image may be a salient feature of AN differentiating from CT women, the underlying neural mechanism of which requires further study.

The Development of the ICD-11 Classification of Personality Disorders: An Amalgam of Science, Pragmatism, and Politics.

The nomenclature of personality disorders in the 11th revision of the International Classification of Diseases and Related Health Problems represents the most radical change in the classification history of personality disorders. A dimensional structure now replaces categorical description. It was argued by the Working Group that only a dimensional system was consistent with the empirical evidence and, in the spirit of clinical utility, the new system is based on two steps. The first step is to assign one of five levels of severity, and the second step is to assign up to five prominent domain traits. There was resistance to this structure from those who feel that categorical diagnosis, particularly of borderline personality disorder, should be retained. After lengthy discussion, described in detail here, there is now an option for a borderline pattern descriptor to be selected as a diagnostic option after severity has been determined.

Mobile Self-Help Interventions as Augmentation Therapy for Patients with Anorexia Nervosa.

Background: It has been suggested that patients with anorexia nervosa (AN) who are resistant to first-line treatment would benefit from second-level interventions targeting specific features, an adaptive form of intervention. Guided self-help programs administered via mobile technology have the dual focus of instigating behavior change and managing anxiety associated with eating disorders in the moment and in users' naturalistic environments. Introduction: We evaluated the feasibility, acceptability, and preliminary augmentative effects of mobile-based, guided self-help interventions (Recovery vodcasts) after initial unsuccessful first-line treatments for patients with AN. Materials and Methods: Patients with AN who were unsuccessful in their treatments were recruited to access Recovery vodcasts as augmentation treatment for 3 weeks in Korea. Acceptability and feasibility of the intervention were evaluated, and qualitative feedback was collected. Preliminary treatment effects of adding the Recovery vodcasts were assessed, including eating disorder pathology, anxiety and depression symptoms, and body mass index. Results: The Recovery vodcasts were acceptable for patients with AN. The patients' psychopathologies of eating disorders improved with augmentation of the vodcasts in their first-line treatments. In addition, there was a tendency toward improvement of affective symptoms. The participants' feedback suggested that the intervention could be improved. Conclusions: The study demonstrated that the Recovery vodcasts were well accepted by Korean patients with AN. Moreover, augmentation of the Recovery vodcasts could facilitate improvements in psychopathology of eating disorders, anxiety, and mood symptoms for patients with AN.